Collagen cross-linking aftercare instructions

After surgery

To keep the corneal surface (epithelium) well lubricated, it is important to use the drops hourly on the first day. You do not need to use the drops during the night.

Do not rub your eye(s) after the procedure whilst the contact lens is in place. If you accidentally do so and the contact lens comes out, do not put it back in your eye. If you are concerned, please call our advice line on 0207 566 2345 or clinic 4 on 020 7566 2475. A&E is open 24 hours a day, seven days a week.

You have been given an additional eye drop for use as a painkiller, which should be used sparingly. This drop is called Proxymetacaine and is an anaesthetic eye drop.

Your vision in the first week will vary quite a bit, and you may be sensitive to light as a result of the procedure, so it is recommended that you do not plan too many activities during this period. After three or four days your vision should begin to slowly improve.

Discomfort in the eyes is normal for the first week, and we have provided you with all the eye drops you will need to minimise this discomfort. Your eye(s) may be painful at times, mainly in the first three days. After this, the sensation tends to be that of irritation and grittiness.

If you develop increasing pain and redness please contact the department or attend A&E.

Helpful ways of preventing the discomfort include taking oral analgesics: two paracetamol tablets every four hours, (maximum eight per day), plus oral Naproxen (250mg) twice a day or Ibuprofen 200mg three times per day for the first three days. It also helps to keep your eye drops in the fridge and to use ice packs or cool compresses over closed eyes, which soothes any discomfort or eyelid swelling.

If you have a history of cold sore infections in the eye (herpes simplex keratitis/ulcers), please let the doctor know on the day of the procedure. You will be provided with an extra anti-viral tablet (acyclovir) to take afterwards.

We suggest following the order that the drops are listed:

Day of surgery (day 0)

Day 1 to Day 3

Day 4 to Day 7

Week 2

Oral analgesia

Take Naproxen (250mg) twice a day (or Ibuprofen 200mg three times a day) for the first three days. You can also purchase paracetamol to use alongside this, taking two tablets up to four times a day. We advise against taking Naproxen or Nurofen if you have an aspirin allergy, are asthmatic or have a history of stomach ulcers as these painkillers can cause indigestion-like symptoms. If this occurs, please discontinue use.

Weeks 3 and 4

Discard any remaining preservative-free drops and start using the following: FML 0.1% eye drops: Use one drop four times a day for two weeks Hyabak: Use one drop four times a day as required

Advice points for after surgery

• It is normal for your sight to be blurred for the first few weeks after surgery. Using lots of Hyabak will help smooth the surface of the cornea and improve the focusing. You can use as much Hyabak as you wish – the more you use within the first few weeks, the quicker your vision will recover.
• Your vision is likely to vary for several months following the procedure. This is completely normal. Vision can also be affected by changes in light conditions, tiredness, computer use and dry eyes. In all cases, rest assured that these changes do not mean that the treatment has failed or that your condition is getting worse.
• We advise that you wear sunglasses for comfort and protection for at least one week when outdoors. Use the eye-shield when sleeping for the first week. Avoid disturbing or touching the front (cornea) of the eye in any way and steer clear of rubbing your eyes firmly or vigorously when they are itchy. If your eye(s) feels uncomfortable, put a drop of Hyabak in. Again, keeping these drops in the fridge will help further alleviate many symptoms of itching and discomfort.
• Do not use make-up around your eyes for the first week as removing it can be difficult and irritate your eyes. Following the first week, remove make-up with your eyelids open (look downwards when removing it from the top eyelid, and look upwards or forwards when removing it from the bottom lid). Avoid contact with the clear cornea where the surface is healing.
• You can return to work when you feel comfortable. After cross-linking, most patients need approximately one week (sometimes longer) off work. Please make sure you carefully use the eye drops as instructed above, to optimise the outcome after surgery. You are likely to experience changes in your vision for around one month which may in turn result in mild headaches. Use artificial tears every one - two hours when using a computer screen or reading in the first few weeks after surgery. Remember to take regular short breaks when using computers to prevent the onset of symptoms.
• Your spectacle prescription will likely vary for the first few months. This will usually be tested six months after your surgery. You may visit your own high- street optician for a spectacle update after the first month, but if you can manage with your existing spectacles this will avoid unnecessary costs for you. Although most spectacle prescriptions stabilise after three months, evidence suggests that for some patients it can take up to one year.
• If you wear soft contact lenses, these should not be worn until you have finished the FML drops (i.e. after four weeks). If you wear hard lenses (rigid gas permeable, RGP), you may re-insert these from the second week onwards so long as the eye has sufficiently healed. We will be able to advise you of this at your first follow up appointment one week after the procedure. You may need to gradually build up the wear time again-for example for a few hours initially, using lots of lubricants at the same time.
• For the first week, please avoid more strenuous exercise such as running and aerobics (in case of injury or sweat running into the eyes).
• Although you may shower or bath the evening following surgery, it is recommended to avoid getting water in your eyes until you have been checked at your one-week follow up appointment. For the first month you should also not swim in chlorinated water. Other non-contact sports can be resumed after the first week.
• We also advise that you do not take any long-haul flights within the first week. Please contact the booking centre if you are planning any flights within seven days of surgery.
• Driving may be resumed after vision meets the driving standard (please seek individual advice).
• Avoid dusty/smoky environments for the first two weeks. If you get dust, dirt or an eyelash in your eye, wash it out using any of your eye drops.

The weeks after cross-linking

If you run out of artificial teardrops (Hyabak), you can purchase it over the counter at any pharmacy. When drops are needed up to six times per day, a normal bottle can be used. When drops are needed more than six times per day, use preservative-free minims. This will reduce toxicity from preservatives in bottled drops. Recommended artificial tear drops after cross-linking are:

Review date: January 2020

Pain relief options

There are three pain relief options:

1. Proxymetacaine: a local anaesthetic drop applied directly on the eye. It starts working in less than a minute and can last for 15 minutes or longer. This should be used sparingly.
2. Paracetamol and ibuprofen: these come as tablets or syrup and you can give these to your child at the same time. They should be given regularly for a minimum of 2 days.
3. Oral morphine (Oramorph®): This is a very strong pain killer that comes as a liquid solution. You can give this if you have already given paracetamol and ibuprofen and your child is still in pain.

Correct doses of pain relief drugs

The correct dose depends on your child’s weight. It is very important that you follow the prescription regarding the amount that you can give, as well as the correct frequency.

Please speak to your nurse or doctor before you leave the hospital if you are unsure how much or how often you can give pain relief to your child.

What you need to know about oral morphine (Oramorph®)

Your doctor has prescribed your child oral morphine to take home if they need it for pain relief. It is very important that you give this medication as instructed by your doctor, and do not go over the maximum dose or frequency. You should give this medication if your child is experiencing pain, despite giving them paracetamol and ibuprofen first.

If you think you may have given your child too much, you should speak to your doctor immediately.

Oral morphine is very effective in reducing your child’s pain, however like all medication it can have side effects like the ones listed below:

• itching
• nausea and vomiting
• constipation: to combat this, ensure your child is well hydrated, and eating fruits and foods rich in fibre.
• urinary retention (not being able to wee): contact your doctor
• dizziness, sweating, red skin.

If any of the above are problematic, please call the ward for advice on 020 7566 2595.

Because of the small number of doses that have been prescribed, it is not possible to develop long term side effects like addiction and tolerance to morphine.

Some children may not be suitable to have oral morphine, for example those already taking sedative medications or experiencing obstructive sleep apnoea. This is because they may be at higher risk of complications. Your doctor will not prescribe it in that case, and will discuss alternatives.

Concerning signs for immediate medical attention

Provided that the safe dose and frequency of giving the medication is followed correctly, oral morphine is safe for children. You should seek immediate medical attention by calling an ambulance if:

• your child is having breathing problems, slow breathing or has stopped breathing
• your child is very drowsy or unable to be woken up.

Instructions on how to handle oral morphine (oramorph®)

Please keep oral morphine out of your child’s reach and sight. It should be stored in a cupboard away from sunlight.

Once you are happy that your child’s pain has reduced following their surgery (usually within 2-3 days), you should take any remaining oral morphine to your local pharmacy where it can be disposed of safely. Do not store it or give it to anyone else.

Summary table of eye drops and oral medication

Day of surgery (Day 0) to Day 2:  Eye drops

Day of surgery (Day 0) to Day 2:  Oral medication

 Day 3 to Day 7:  Eye drops

 Day 8 to Day 14:  Eye drops

 Day 15 to Day 28:  Eye drops

Review date: July 2025