Archive for the ‘Corneal Cross-linking’ Category

Dr. Raymond Stein was one of four international surgeons interviewed by Review of Ophthalmology on the subject of Corneal Cross-linking (CXL)

Wednesday, March 21st, 2012

Dr Raymond Stein was one of four international surgeons interviewed by Review of Ophthalmology on the subject of Corneal Cross-linking (CXL).

The other surgeons interviewed were Dr Kanellopoulos (Greece), Dr Chayet (Mexico), and Dr Rubinfeld (United States). World-wide results have been very positive at preventing corneal ectasia. CXL is considered the standard of care around the globe for progressive keratoconus.

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FAQS on Corneal Crosslinking by Dr Raymond Stein- Toronto Eye Surgeon

Friday, March 16th, 2012

Corneal Crosslinking – Frequently Asked Questions

Is Corneal Crosslinking (CXL) a new treatment for keratoconus?
CXL was introduced in Canada by the surgeons of the Bochner Eye Institute over 4 years ago. In Europe, where the procedure was pioneered, it has been performed for over 14 years ago. There are many long-term studies that demonstrate the efficacy and safety of the procedure.

What is the main goal of CXL?
The purpose of the treatment is to strengthen corneas so as to prevent progressive bulging and thinning that can interfere with vision. With a stronger and more stable cornea the risk of requiring a corneal transplant is practically eliminated.

What is the success rate of CXL?
At the Bochner Eye Institute over 3,000 eyes have been treated with CXL over the past 4 years. This is more than any other centre in the world. Patients have travelled from all over North America. The success rate at preventing progressive bulging and thinning has been over 98%.

Can CXL be repeated?
In rare cases (less than 2%) where CXL is not successful in stabilizing a cornea, a repeat treatment can be performed. There is no charge for this procedure at the Bochner Eye Institute.

Is there an ideal age for CXL?
Usually, the younger the patient the greater the chance of preserving vision with CXL. Patients treated at the Bochner Eye Institute have ranged in age from 10 to 60 years age. With treatment, the corneal contour is preserved, and therefore it is best to have CXL when the shape is only mildly distorted. Patients with advanced disease can have CXL but the vision may be less than ideal with glasses or soft contact lens necessitating the use of a rigid contact lens.

Are some keratoconus patients not good candidates for CXL?
Patients must have satisfactory corneal thickness for the procedure to be performed. A thickness of 400 microns is required prior to the ultraviolet light application. Corneas with a thickness between 320 microns and less than 400 microns can usually be treated by using specialized hypotonic drops to swell the cornea to 400 microns or greater prior to the ultraviolet light application. Also, corneas with significant central scarring that interferes with vision are not good candidates for CXL.

Can vision be improved with CXL?
Although the main goal of CXL is to stabilize the cornea, 60% of patients actually have an improvement in their vision. This is due to the fact that the corneal surface becomes less irregular with CXL as the steep areas are flattened and the flat areas are steepened.

How is the procedure performed?
The procedure is divided into 3 steps. Most patients find the procedure very easy and are comfortable. Anesthetic drops are instilled, which numbs the surface of the eye, and makes the procedure pain free. The first step of the procedure is the removal of the central corneal epithelium. A very gentle brush is used to polish away the soft cells of the front of the cornea referred to as the epithelium. The second part of the procedure is the instillation of specialized drops containing Riboflavin. Drops are typically used for 20 minutes. The third part of the procedure is the use of ultraviolet light, which is typically used for 10 minutes.

Why does the ultraviolet light treatment time vary from clinic to clinic?
The original treatment protocol in Europe was the use of ultraviolet light for 30 minutes at an energy level of 3mw/cm2. With the development of new CXL devices the energy level can be increased which shortens the treatment time said Dr Raymond Stein.

Can the corneal epithelium be left intact or does it have to be removed?
The long-term clinical studies have shown outstanding results when the epithelium is removed prior to CXL. New techniques are being developed to perform a transepithelial CXL approach in which the epithelium is left intact. It is essential for the success of this technique that the Riboflavin drops penetrate an intact epithelium to reach the deeper layers of the cornea in a high enough concentration. Early results with this technique are encouraging but we do not know the long-term results.

What is required after the treatment?
Immediately after the procedure a soft bandage contact lens is inserted which is worn for approximately 5 days. This allows enhanced comfort and promotes healing of the corneal epithelium. An antibiotic drop is used for 5 days and a steroid drop is used for 2 weeks. Artificial tears can be used as needed for comfort.

Is the vision better immediately after the procedure?
Usually the vision is slightly blurrier during the first month and then gradually improves. The blurred vision is related to the healing time of the corneal epithelium. Initially when the epithelium becomes intact it tends to be somewhat rough. With times it undergoes thickening and thinning in different areas to smooth the corneal contour.

How do I know if the treatment is successful?
Repeat corneal mapping is performed to demonstrate corneal stability or flattening. The mapping is typically performed at 4 to 6 months postoperatively and then annually. Sophisticated mapping techniques can evaluate both the front and back surfaces of the cornea to determine stability, improvement, or progression.

What are the potential complications of the treatment?
The complication rate is extremely low with CXL. The risk of infection is rare. In fact ultraviolet light can be used to kill bacteria and parasites in patients with corneal infections. Occasionally there is a delay in the healing of the corneal epithelium, which can delay the return of best vision.

When can I start wearing contact lenses?
After the procedure it is best to wait 2 weeks before returning to contact lens wear. If you have never worn contact lenses and would like to start lens wear it is best to wait at least one month before a consistent refraction can be obtained and lenses fitted.

How can I improve my vision so that I do not need rigid contact lenses?
There are two surgical options to reduce the irregular astigmatism so that you can see better without rigid contact lenses. An intracorneal ring (Intacs) can be performed in which one or two rings are inserted into the cornea to flatten steep areas. The other option is a topographically-linked photorefractive keratectomy (PRK) in which an excimer laser is used to flatten the steep cornea and steepen the flat cornea to enhance vision. Both these procedures can be performed at the same time as CXL or at later date.

More about Dr Raymond Stein

Dr. Raymond Stein Discusses Corneal Crosslinking with Eye World

Wednesday, February 22nd, 2012

Dr Raymond Stein was recently interviewed on Corneal Crosslinking, which was published in Eye World an international publication of the American Society of Cataract & Refractive Surgery. Click here to read the entire article.

Dr. Raymond Stein Lectures On New Innovative Treatments

Monday, November 14th, 2011

Dr. Raymond Stein was an invited guest speaker to the Vision Institute’s annual meeting in Toronto on November 4, 2011. The title of his presentation was “The Future of Cataract and Refractive Surgery”. Dr. Stein discussed some of the new innovative treatments such as Laser Cataract Surgery, Corneal Inlays for presbyopia, Corneal cross-linking combined with topographic laser ablations, and Microwave technology for keratoconus. The audience was over 300 eye-care professionals.

Dr. Raymond Stein’s Session Entitled “Ask the Expert”

Monday, November 14th, 2011

Dr. Raymond Stein was invited to speak at the American Academy of Ophthalmology’s annual meeting in Orlando on October 21, 2011. His session was titled “Ask the Expert” and he spoke on the subject of Corneal Cross-Linking in Keratoconus.

Background of Raymond Stein

Thursday, May 5th, 2011

Dr. Raymond Stein, MD, FRCSC, is an esteemed global leader in refractive surgery who has successfully performed more than 80,000 vision correction procedures. He obtained his medical degree at the University of Toronto Medical School, where he currently serves as an Assistant Professor of Ophthalmology. Dr. Stein completed his ophthalmology residency at the world-renowned Mayo Clinic and a cornea and external disease fellowship at the prestigious Willis Eye Hospital in Philadelphia. He serves as the Medical Director of the renowned Bochner Eye Institute in Toronto.

Raymond Stein has established himself as an expert and pioneer in refractive and implant surgery and was the first surgeon in all of Canada to perform corneal cross linking with Riboflavin for keratoconus and ectasia. He was also the first eye surgeon in Canada to implant the ReSTOR and Tetraflex IOLs for improved distance, intermediate and near vision. Dr. Stein was the first surgeon in Canada to use the IntraLase IFS femtosecond laser for creation of the LASIK corneal flap.

Dr. Raymond Stein is frequently invited to lecture at medical conferences throughout the world. He has authored numerous published articles, more than 15 book chapters and books on various subjects pertaining to refractive surgery. In fact, Dr. Stein is the author of the first clinical textbook on laser vision correction for instruction on advanced surgical techniques.

As a testament to his prolific career and unsurpassed surgical skills, Dr. Stein was chosen to serve at the Chief Eye Surgeon for W Network’s Style by Jury, a popular makeover television show in Canada. He is also the editor of the prestigious scientific journal Clinical and Surgical Ophthalmology.

In recognition of his accomplishments in refractive surgery, Dr. Stein has been honored with numerous prestigious awards from both national and international professional organizations, including the American Academy of Ophthalmology, the International Intraocular Implant Club and the Contact Lens Association of Ophthalmologists. He has also served as the President of prestigious Canadian Society of Cataract and Refractive Surgery.
Dr. Stein is the Chief of Ophthalmology at the Scarborough Hospital in Toronto and Cornea Consultant at the Mount Sinai Hospital



University of Pennsylvania, Wharton School



Medical School:

Doctor of Medicine

University of Toronto Medical School




Mayo Clinic

1983 -1986


Fellowship Training:

Willis Eye Hospital, Philadelphia



Bochner Eye Institute

Medical Director, Eye Surgeon

1997- Present


Scarborough Hospital, Toronto

Chief of Ophthalmology, Ophthalmologist

1987- Present


Mount Sinai Hospital

Cornea Consultant, Ophthalmologist

1989 – Present


University of Toronto Medical School

Assistant Professor of Ophthalmology

Professional Affiliations:

Contact Lens Association of Ophthalmologists

Wills Eye Hospital Alumni Association
American Academy of Ophthalmology

Fellow of the Royal College of Surgeons
Mayo Clinic Alumni Association

Ontario Medical Association

International Society of Refractive Surgery

American Society of Cataract and Refractive Surgery
Canadian Society of Cataract and Refractive Surgery

International Implant Club

Academy of Ophthalmic Education

Raymond Stein, MD, Honors and Awards:

1987 – 1988 Award for most outstanding article of the year published in the University of Toronto Medical Journal, titles Lifesaving Ocular Signs.

1990- 1991 Award for outstanding teaching, Ophthalmology Residents Research Day, University of Toronto, Toronto, Ontario, April 1991.

1991 – 1992 Nominated for Atkinson award, outstanding undergraduate teaching, University of Toronto.

1993 – 1994 Award for outstanding undergraduate and post graduate teaching, Mount Sinai Hospital, University of Toronto.

1997 Honor award of American Academy of Ophthalmology

1997 Honor award of Contact Lens Association of Ophthalmologists

Best paper of session, American Society of Cataract and Refractive Society

2001 Awarded membership into International Intraocular Club

2003 Best paper of session, International Society of Refractive Surgery


1. Raymond M. Stein, Bernard J. Slatt, Harold A. Stein. A Premier in Ophthalmology: A Textbook for Students. Mosby.

2. Raymond M. Stein, Melvin I. Freeman, Harold A. Stein. The Ophthalmic Assistant: A Text for Allied and Associated Ophthalmic Personnel. Mosby, 2006.

3. Raymond Stein, Harold A. Stein, Melvin I. Freeman, Lynn D. Maund. Residents Contact Lens Curriculum Manual. Mosby.

4. Raymond Stein, Harold A. Stein, Melvin I. Freeman, Lynn D. Maund. Contact Lenses: Fundamentals and Clinical Use. Slack Incorporated, 1996.

5. Raymond Stein, Bernard J. Slatt, Harold A. Stein, Melvin I. Freeman. Fitting Guide for Rigid and Soft Contact Lenses: A Practical Approach. Mosby, 2002. 

6. Raymond Stein, Harold A. Stein, Albert Cheskes. Laser Vision Correction: Welcome to a World Without Glasses or Contact Lenses.

7. Raymond Stein, Harold A. Stein. Management of Ocular Emergencies. Medic International.

8. Raymond Stein, Bernard J. Slatt, Harold A. Stein. Ophthalmic Terminology: Speller and Vocabulary Builder. Mosby, 1991.

9. Editor. Raymond M. Stein. Proceedings of the External Eye Meeting. Medic International, 1995.

10. Raymond M. Stein, Harold A. Stein, Albert Cheskes. The Excimer Fundamentals and Clinical Use. Slack Incorporated, 1997.

Peer-Reviewed Research Papers and Articles:

1. Raymond M. Stein. Laser vision correction: 20 years of personal experience. ASCRS EyeWorld.

2. Raymond M. Stein. Corneal Collagen Cross-Linking with Riboflavin (C3-R) and other Surgical Options in the Management of Keratoconus. Academy of Ophthalmic Education (AOE).

3. Raymond M. Stein. Ten Pearls for Treating Hyperopic Astigmatism. Refractive Eyecare for Ophthalmologists.

4. Raymond Stein. Techniques for Advanced Surface Ablation. Refractive Eyecare for Ophthalmologists.

5. Raymond M. Stein. Phakic Implants Can Expand a Refractive Surgery Practice. Refractive Eyecare for Ophthalmologists.

6. Raymond M. Stein. Patients to Avoid Personality Screening. Refractive Eyecare for Ophthalmologists.

7. Raymond M. Stein. Keratoma-Assisted ASA. Refractive Eyecare for Ophthalmologists.

8. Raymond M. Stein. Defining Safety in Keratome Technology. Refractive Eyecare for Ophthalmologists.

9. Raymond M. Stein. Clinical Experience with the Allegretto Wave in Custom and Standard Treatments. Refractive Eyecare for Ophthalmologists.

10. Raymond M. Stein. Advances in Refractive Surgery. Ophthalmology Rounds.

Raymond Stein Reviews

Dr. Raymond Stein Speaks at ASCRS

Thursday, April 7th, 2011

Dr. Raymond Stein was an invited guest speaker to the annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS) in San Diego on March 28, 2011. He presented the results from the Bochner Eye Institute of Corneal Collagen Crosslinking with up to 3.5 years of follow-up. None of the treated patients have shown any progressive ectasia. Crosslinking has been shown to be a major advance in the treatment of keratoconus, pellucid marginal degeneration, and ectasia after refractive surgery. The surgeons at the Bochner Eye Institute have been pioneers with this technology in North America. To learn more about Raymond Stein, MD, & Bochner Eye Institute, please call (416) 960-2020.

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Dr Raymond Stein presented his outcomes of Corneal Cross-linking at the American Academy of Ophthalmology (AAO)

Monday, November 8th, 2010

Dr Raymond Stein presented his outcomes of Corneal Cross-linking at the American Academy of Ophthalmology (AAO) in Chicago on Oct 19, 2010. The AAO is the largest ophthalmological meeting in the world with an attendance of over 20,000. Dr Raymond Stein in Toronto is considered the most experienced surgeon with cross-linking in North America having treated over 1,500 eyes with keratoconus.



Raymond Stein talks about his past 20 years of Laser Vision Correction- As seen in EyeWorld

Wednesday, October 20th, 2010

“Over the past 20 years at the Bochner Eye Institute, every day has been an exciting day for our patients, our staff, and our surgeons. Patients’ lives are enhanced with a painless, quick, and safe procedure. The most common regret that patients tell us is they wish they had the surgery when they were younger. Today patients who have laser surgery range in age from 18-65 years. In the early days of laser vision correction, it was primarily the risk takers who underwent the procedure. Skydivers, bungee jumpers, and motorcycle riders were commonplace. Today I see a high percentage of chess players, actuaries, accountants, and surgeons who are undergoing the procedure. Many patients don’t have any specific problems with their glasses or contact lenses but want to be free to live their life without any optical aids.” from EyeWorld

Raymond Stein as seen in EyeWorld

Raymond Stein MD as seen in EyeWorld at recent ASCRS meeting in Chicago

More about Raymond Stein

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