Can patients use Accutane (isotretinoin) before and after undergoing corneal cross-linking surgery?

Isotretinoin Use Before and After Corneal Cross-Linking Surgery

Patients should discontinue isotretinoin (Accutane) at least 6 months before corneal cross-linking (CXL) surgery and wait at least 6 months after surgery before resuming it, due to potential risks of delayed wound healing and corneal complications.

Rationale for Discontinuation

Corneal cross-linking is a procedure designed to increase the biomechanical rigidity of the cornea by increasing biochemical bonds between collagen fibers using ultraviolet-A (UV-A) light and topical riboflavin 1. While the guidelines don't specifically address isotretinoin use with CXL, several important considerations guide this recommendation:

1. Corneal healing concerns:

   • CXL involves epithelial removal in the standard protocol, creating a large corneal wound that must heal properly
   • Isotretinoin affects wound healing and can potentially delay epithelial healing

2. Contraindications for CXL:

   • The 2024 Corneal Ectasia Preferred Practice Pattern lists several contraindications including corneal stromal thickness below 400 μm, herpes simplex virus infection, corneal stromal scarring, severe ocular surface disease, and autoimmune disorders 1
   • Isotretinoin can cause dry eye, which may exacerbate ocular surface disease

3. Complications of CXL:

   • Common complications include punctate keratitis, corneal striae, dry eye, eye pain, corneal haze, and nonhealing epithelial defects 1
   • These complications could potentially be worsened by concurrent isotretinoin use

Timing Recommendations

Pre-CXL Surgery:

• Discontinue isotretinoin at least 6 months before surgery
• This allows adequate time for the drug's effects on wound healing to diminish
• Ensures the corneal surface is optimal for the procedure

Post-CXL Surgery:

• Wait at least 6 months after surgery before resuming isotretinoin
• This allows complete healing of the corneal epithelium and stroma
• Reduces risk of delayed healing complications

Special Considerations

Risk Factors for CXL Complications:

• Age over 35
• Corneal thickness less than 400 μm
• Worse preoperative corrected visual acuity 1
• Adding isotretinoin to these risk factors may further increase complication rates

Monitoring Requirements:

• If a patient must resume isotretinoin sooner than recommended:
  • More frequent ophthalmologic monitoring is essential
  • Watch for signs of dry eye, which could compromise the surgical outcome
  • Monitor for delayed epithelial healing

Alternative Approaches

For patients with severe acne requiring treatment during the perioperative period:

1. Alternative acne treatments:

   • Topical treatments
   • Oral antibiotics (with caution regarding potential drug interactions)
   • Non-retinoid systemic treatments

2. Modified CXL protocols:

   • Transepithelial or "epithelium-on" techniques might theoretically reduce some concerns about epithelial healing, but these are not FDA-approved in the United States 1

Important Caveats

1. While some research suggests that performing dermatosurgical procedures in patients taking isotretinoin may be safer than previously thought 2, corneal surgery represents a different risk profile due to:

   • The avascular nature of the cornea
   • The critical importance of proper corneal healing for vision
   • The potential for permanent visual impairment if complications occur

2. The lack of specific studies on isotretinoin use with CXL necessitates a cautious approach that prioritizes patient safety and optimal visual outcomes.

3. The recommendation to avoid isotretinoin before and after CXL is based on the known effects of isotretinoin on wound healing and the importance of optimal corneal healing for successful CXL outcomes.