Accelerated high fluence photoactivated chromophore for infectious keratitis—corneal cross-linking (PACK-CXL) at the slit lamp: a pilot study

Hagar Olshaker, Asaf Achiron, Alexander Chorny, Farhad Hafezi, Tal Yahalomi, Assaf Kratz, Erez Tsumi, Nan Ji Lu, Boris Knyazer

Research output: Contribution to journalArticlepeer-review


Introduction: Photoactivated Chromophore for Infectious Keratitis-Corneal Cross-Linking (PACK-CXL) has garnered substantial interest among researchers and ophthalmologists due to its high promise as a potential treatment for infectious keratitis. The aim of this study is to evaluate the efficacy and safety of high fluence PACK-CXL, using 10.0 J/cm2 (30 mW/cm2, 5 min, and 33 s) at the slit lamp. Methods: This prospective interventional, nonrandomized cohort study included 20 eyes of 20 patients with bacterial, fungal, or mixed origin keratitis who underwent high fluence PACK-CXL treatment as an adjunct therapy to conventional antimicrobial therapy per American Academy of Ophthalmology treatment guidelines. The re-epithelization time was recorded, and corneal endothelial cell density was counted before and after treatment. Results: The average re-epithelization time was 8.2 ± 2.8 days (range 3–14 days). After PACK-CXL treatment, eight patients (40%) were directly discharged, while the remained patients stayed in the hospital for an average of 5.6 ± 3.5 days. No eyes required keratoplasty. Endothelial cell density counts before and after the PACK-CXL procedure were 2,562.1 ± 397.3, and 2,564.8 ± 404.5 cells/mm2, respectively (p = 0.96). Conclusion: although it was not a randomized control trial, we conclude that high fluence PACK-CXL as an adjuvant therapy is safe with no complications observed, and efficient as time to re-epithelization was less than 14 days for all patients and no patients underwent tectonic keratoplasties. Further research is needed to compare it to the current standard of care.

Original languageEnglish
Article number1229095
JournalFrontiers in Pharmacology
StatePublished - 1 Jan 2023
Externally publishedYes


  • corneal cross-linking
  • high fluence
  • hypo-osmolar riboflavin
  • infectious keratitis
  • outcome

ASJC Scopus subject areas

  • Pharmacology
  • Pharmacology (medical)


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