Talk:Keratoconus/Archive 3

Rearrange Treatment Options
I don't believe the most invasive and severe treatment options(corneal transplant) should be first even if they are the most well-known, as the uneducated reader would be best served to learn about the best credible alternatives before moving on to other worst-case treatment options.

For instance, crosslinking is becoming a true hope for a cure for this disease and many patients are unaware of it as a treatment option.. --arpowers (talk) 19:08, 26 December 2008 (UTC)
 * Write a proper separate article on the crosslinking, and I will translate it into Russian. A link then could also be placed into Corneal transplantation's "alternatives" subsection. --CopperKettle (talk) 04:28, 8 January 2009 (UTC)

Additionally, Intacs (ICRS) have over 10 years of clinical research, hundreds of peer-reviewed articles and federally regulated clinical studies to reference when looking for a clinically studied keratoconus treatment to consider prior to PK techniques. I think the order is fine in that historically, Contact Lenses are the first line of treatment followed by PK & ICRS. We are just now learning about cross-linking and adequate due diligence should be observed so not to jump quickly into an unknown treatment option like cross-linking without adequate clinical evidence. --intacs —Preceding undated comment was added on 20:19, 24 February 2009 (UTC).

Anonymous contribution about rigid CL
I quote: "It's important to note that although the rigid contact lenses help to provide the best possible vision, they do not affect the rate of progression of the condition. --ref--http://www.rnib.org.uk --ref--" - the phrase is strangely built: "although it is good, it is good"; I doubt the rigid lenses do not affect the KC progression; the link given is too general. -- C opper K ettle  20:26, 19 January 2009 (UTC) Here's the diff. -- C opper K ettle  20:28, 19 January 2009 (UTC)
 * The given URL was wrong; I have corrected it. I also reworded the text, removing the "it's important to note" part: the reader should be able to decide for themselves whether something is important. &mdash; BillC talk 08:34, 20 January 2009 (UTC)

C3-R corrections
I deleted inaccurate statements about riboflavin penetration and what the FDA legally has jurisdiction over.

1. It is now clear that use of tetracaine opens up epithelial tight junctions to allow riboflavin to penetrate. At the December Crosslinking Congress, Wollensak discussed that his research has confirmed this to be true which corroborates cited studies by other doctors.

2. The newly cited Hayes study has many flaws including that it was performed in porcine (pig eyes) not human eyes. This is the citation for a letter to editor that reports quite a number of flaws in the Hayes study that render it essentially no applicable to living human cornea crosslinking.

Effect of epithelial debridement in corneal collagen crosslinking therapy in porcine and human eyes. Yuen L, Chan C, Boxer Wachler BS. J Cataract Refract Surg. 2008 Nov;34(11):1815-6; author reply 1816. No abstract available. PMID: 19006714 [PubMed - indexed for MEDLINE]

3. The FDA does not legally regulate surgical techniques using available surgical instrumentation. Debridement of epithelium is entirely legal within the United States. The FDA has no jurisdiction whatsoever over surgical techniques with available instruments. —Preceding unsigned comment added by Scubadiver99 (talk • contribs)
 * When conducting riboflavin treatment, is the epithelium most commonly abraded prior to treatment, or not? &mdash; BillC talk 06:11, 21 January 2009 (UTC)

The above poster forgot to say that their was 1/5 less crosslinking found with the epi on method with tetracaine and with out tetracaine with epi on was only 7%, it was also said only go by peer reviewed articles, as other articles are not accurate but only being used for marketing purposes. And boy, are they desperate indeed to do that and also at the same time confusing matters ! —Preceding unsigned comment added by 149.254.49.33 (talk) 09:11, 22 January 2009 (UTC)

I'm new to editing but wanted to add in that Dr. John Kanollopoulos in Athens has had success with something called partial PRK with CXL - the following is a reference http://www.osnsupersite.com/view.aspx?rid=31281 I need to learn how to properly cite but I wanted to provide a reference for this edit. - there will actually be a better article coming out in the next few weeks the Journal of Refractive Surgery that is being published in Sept 2009 - when the article comes out, it refers to this as topography guided PRK - —Preceding unsigned comment added by Gospeedracer (talk • contribs) 00:44, 6 September 2009 (UTC)

Possible Commercial Motivation For Edits
Studies have shown that the on epithelial treatment(C3-R) is not effective, when compared to the 'debrided' form of treatment (Hayes study)..

I feel this should be referenced in the article. What I had said was not conclusive only suggestive of these results.

Now I am very excited about the new crosslinking treatment developed in Germany, as it seems like it really does work. But in order for it to work the cornea needs to be abraded slightly for the riboflavin to penetrate. Read this published article summary: http://www.ncbi.nlm.nih.gov/pubmed/18361990

In the US this is not possible without clinical trials as it is invasive. (there may be other reasons, but I had spoken to someone at Wachler's office who did tell me abrasion was not possible due to the FDA)

The c3-r method that doesn't debride the cornea and is classified as a 'vitamin'. Studies have shown this approach as inneffective, but since they are charging around $2000/eye for it, it is quite the cash cow.

I believe someone has been editing this wiki article under the name "scubadiver99", to artificially support C3-R as a more effective treatment when compared to the German crosslinking method

Again, to be clear Crosslinking does work but only if the cornea is 'debrided', the C3-R 'vitamin' classified treatment does not work nearly as well This misleading marketing must be stopped.

___________________________________________________________________________

These above comments by this person are clearly inappropriate and are also without merit. It seems he or she has an axe to grind by the unprofessional tone and ad hominem attacks which are not appropriate in wikicommunity. The Hayes study this person cited is the exact study that Scubadiver99 referenced as having a number of flaws. I agree the Hayes study is problematic.

BillC, if possible to ban this unnamed person from wikicommunity, I would encourage that be considered. 24 January 2009 Corneadoc  —Preceding unsigned comment added by Corneadoc (talk • contribs) 10:22, 24 January 2009 (UTC)

Reply
OK, BillC thank you for your objective viewpoint and moderation. I will do my best to be objective.

Why was the discussion removed about the multiple 'sock-puppets' Scubadiver99/Corneadoc was using? I am not the first to bring up Scubadiver99's possible ties to Wachler and the C3-R treatment...

"CorneaDoc" is it a coincidence you have made only 1 contribution to Wikipedia so far and its a comment in this discussion? Why are you are already trying to get me banned?

why don't you let me know what your real name is and we can talk about this? I am more than willing to have a constructive debate, and I am open to any credible literature that supports your claims... '' the issue is that I have a strong suspicion of commercial motives for those edits.

I have no axe to grind other than the pursuit of what's best for those seeking treatment.

Arpowers (talk) 03:47, 25 January 2009 (UTC)

Proposed Revision To Cross-linking Section
I propose that the following be added back to the article:
 * 1) The difference between the CXL and C3-R procedures (i.e. removal of corneal epithelium)
 * 2) An explanation why cross-linking procedures with corneal abrasion can't currently be performed/marketed in the US.
 * 3) A reference to the results from studies that have concluded that the corneal epithelium should be removed for the procedure to work. For example, this  study(@ [Hayes Article http://www.ncbi.nlm.nih.gov/pubmed/18361990]) by Hayes et al which concluded that "Complete removal of the corneal epithelium is an essential component of riboflavin-UVA crosslinking therapy."

Suggested Text:
 * The corneal epithelium is usually surgically abraded beforehand in order to increase penetration of the riboflavin into the stroma(citation needed). Preliminary studies have shown that this helps enable adequate penetration of riboflavin and thus the effectiveness of treatment(hayes study).


 * In the US, FDA regulations do not currently allow procedures that include the removal of the corneal epithelium to be marketed (or performed? citation needed).


 * C3-R, a "vitamin" classified on-epithelial treatment method is available in the US outside clinical trials. Unfortunately, one study has concluded that this approach is likely much less effective than when using the removal technique(Hayes Study).

User:Arpowers (talk) 07:08, 27 January 2009 (UTC)

As also discussed above, it is not correct to say FDA regulation do not allow procedures that...to be marketed. This is just not correct. Legally, this is allowed. Arpowers has not provided any points to counter my comments above in "C3-R Corrections".

The Hayes article is discussed above in "C3-R Corrections" with my prior comment and has numerous flaws as cited and discussed above. Arpowers has not provided any information to counter the cited flaws in the study cited above (Yuen et al). Scubadiver99 —Preceding unsigned comment added by Scubadiver99 (talk • contribs) 05:59, 5 February 2009 (UTC)

response
To use something off-label is in fact correct, but are you trying to tell me that you could market a procedure that removes the corneal epithelium in the US outside of clinical trials? Isn't this what 'off-label' is all about? Marketing is considered labeling.

The reason I know that c3-r is a 'vitamin' classified treatment is because I heard it directly from Wachler's assistant... they also told me they couldn't do the removal technique outside of trials... That is how I figured out this whole gimmick in the first place. —Preceding unsigned comment added by 75.25.174.48 (talk) 08:42, 5 February 2009 (UTC)

Also the Yuen et al citation you are using is a comment on the Hayes study. Just that a comment, which is merely an opinion. And I believed a biased one as I see Wachler on the list of authors. Moderators can find it here: http://www.ncbi.nlm.nih.gov/pubmed/19006714

As a response to your point, porcine models are widely accepted in the scientific community.

''I have removed the edits by Scubadiver99, because it was irrelevant, unsupported, and only partially correct. (physicians can perform procedures off-label, but cannot market them as marketing is considered labeling)''

User:Arpowers (talk) 08:59, 5 February 2009 (UTC)

FACT-BASED CLARIFICATION

As I stated earlier, it is clear that Arpowers has an ax to grind, despite his denials. His arguments prove a clear bias, which is fine. Bias is bias, not everyone can be objective. His response consists of ASSERTIONS with no factual EVIDENCE. So by your opinion and accusations, EVERYTHING boxer wachler is biased? Where is your proof? I suggest you look at his cv on his website. he was the former director of UCLA's Jules Stein Eye Institute, won numerous awards, published tons of peer-reviewed articles in the field, delivered 100s of scientific lectures etc, etc. Arpowers has no data, only disparaging comments that come from no fact-based position and he conveniently ignores all the scientific contributions boxer wachler has made to the field over the past decade. That's right past 10 years as a contributor to the field of ophthalmology. If you wish to defame character, that's up to you, but I suggest you be careful because legally that puts you on risky footing and opens you up to exposure.

As for your reference 55 about FDA regs, no where in that reference you provided does it say anything about what you are asserting. Again, only assertions no proof. Therefore delete is recommended.

"marketing" is not considered "labeling". Off label procedures are legally allowed and can be marketed. If Boxer Wachler wished to perform epi removal and market it, yes, that is completely legal. Again, Arpowers is only asserting, no proof.

Yuen et al peer-reviewed and published response includes Drs. Chan and Boxer Wachler. Three doctors have cited flaws, significant flaws in Hayes study. Most notable is that Hayes study used DEAD PIG eyes and did not use the same crosslinking protocol used in epi on procedures on LIVING HUMANS. Pig cornea anatomy is vastly different than human cornea anatomy, most notable is the epithelium is twice as thick in pigs corneas as humans for example. Twice the distance for ribo to penetrate to get to stroma in pigs than humans. Hayes studied apples and then erroneously applies conclusions to oranges. Significant flaws prevent Hayes study having relevance to epi on crosslinking in HUMANs. Perhaps if pigs were having epi on crosslinking if could have valid points, but not to living humans.

Scubadiver99

Unnecessary detail
There is no need for the article to go into the level of detail that is engendering the passions above. Patients' ophthalmologists are there to advise them on this, not a general-purpose web-based encyclopaedia. I have trimmed back some of the detail in the section in the hope that we can avoid these problems. Perhaps I can ask you both: what level of detail do you each think is appropriate for an article of this length (50K), and aimed at Wikipedia's general lay audience to carry? &mdash; BillC talk 08:35, 6 February 2009 (UTC)


 * Bill, good question. I think the current level of detail is appropriate for the lay public.  Scubadiver99  —Preceding unsigned comment added by Scubadiver99 (talk • contribs) 15:57, 6 February 2009 (UTC)


 * When are the trails for "epi on" going to start ? have they completed ? thats why DR BBW is doing it ? —Preceding unsigned comment added by 149.254.57.136 (talk) 01:08, 8 February 2009 (UTC)

I've been following this discussion and it seems this Hayes study is now being quoted completely out of context. I have removed it and the preceding sentence. —Preceding unsigned comment added by 189.182.108.137 (talk) 06:11, 10 February 2009 (UTC) Anyone wants to comment on this study ? http://www.ncbi.nlm.nih.gov/pubmed/18361990?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed —Preceding unsigned comment added by 149.254.58.219 (talk) 00:02, 11 February 2009 (UTC)

Signing posts
Can participants here please sign their talkpage posts: type four tildes ( ~ ) at the end of your post and it will be automatically converted to a signature and timestamp. There is also a button above the edit box that will do the same thing. Thank you. &mdash; BillC talk 08:11, 11 February 2009 (UTC)

= Article By MedCompare on Cross-linking =

I wanted to add this article by MedCompare in the discussion: http://www.medcompare.com/featuredarticle.asp?articleid=409

In light of this I would like to add back the edits that scubadiver99 removed again:


 * 1) The difference between the CXL and C3-R procedures (i.e. removal of corneal epithelium)
 * 2) A note that the crosslinking procedure is currently in clinical trials in the US
 * 3) A reference to the results from studies that have concluded that the corneal epithelium should be removed for effectiveness. For example, this  study(@ [Hayes Article http://www.ncbi.nlm.nih.gov/pubmed/18361990]) by Hayes et al which concluded that "Complete removal of the corneal epithelium is an essential component of riboflavin-UVA crosslinking therapy."...

to quote Wollensok who pioneered this procedure: ''"The removal of the epithelium is essential for the homogeneous diffusion of riboflavin into the corneal stroma. Without epithelial removal (like in C3-R) the biomechanical effect is less than 50% of the standard crosslinking procedure." ''

With no replies to this note, I will add this section again in a day or two.

Also I think that anyone wanting to credibly participate in this discussion should reveal their real name and background or not participate at all

User:Arpowers (talk) 08:22, 19 February 2009 (UTC)

Good work AP, to me there has been great desperation from the "epi on" camp all along which is clear to see for everyone that there is over selling going on from them - its the whole world who know this as everywhere they are doing epi off.

About the "Names" used, yes if the content written is suspect then question the author in what their motives are. However Wikipedia allows me to type this with out having a "User Name" - as long as I can do this I will until the rules change, and by that time we must all register to write here. With out registering and being able to write here is a feature on Wikipedia and so allowed by default. We don't know if any of the names here are real, we don't have to have our passports checked to get an ID here or write here with out one, it is (only) the net after all.

Anyway not to let this detract from the purpose of this discussion page and the more important topics here. —Preceding unsigned comment added by 149.254.51.255 (talk • contribs)


 * Indeed, Wikipedia allows anonymous editing of talk and article pages by default. However, it is still required to sign talk page posts (by typing four tildes: ~ at the end of the post). Things will get very confusing on here very rapidly if people do not do that. Thank you for your consideration. &mdash; BillC talk 16:55, 22 February 2009 (UTC)

Obviouly it has not confused you Bill, why do you take it that it will confuse others ? Lets not play "Silly buggers" I was not told that their is requirement - look I'm typing away with out a requirement. Besides a "ID" does come up, if you look at the end of a message. Thats enough for me to write here otherwise I would not be able to.


 * Your ID did not come up at the end of a message. It is there because I went back into the history, found out who said what, and added the unsigned template afterwards. I will not have time to do that every time. The guideline on signing posts can be read here: WP:SIGN. Please consider signing your posts, I'd appreciate it, thanks. &mdash; BillC talk 23:32, 22 February 2009 (UTC)

How do I know that the guideline was not added after I posted last ? or you did it ? it only says its a guideline for "good practice" - they arn't going to arrest anyone - but If it makes you happy I sign as Robin Hood

Companys are not Associations or Groups
In light of unraveling that Epi on is/was getting marketed a lot, I am going to remove the boston sclerals site and the Snergey eyes and also a blog - all of where are not "associations or groups". What is the matterwith these people, can't they read ! —Preceding unsigned comment added by 149.254.51.255 (talk • contribs)

Removed c3-r from alternative names
As this is a trademarked term (http://tess2.uspto.gov/bin/showfield?f=doc&state=4002:681s7c.2.1) and a separate procedure from the one developed in Germany, that is undergoing clinical research.

User:Arpowers (talk) 09:33, 24 February 2009 (UTC)

I replaced both CCL and C3-R as crosslinking is well known by both terms regardless of trademarking status. In fact, the trademark confirms C3-R was the very first name for this procedure which pre-dates even CXR and CCL.

I also removed Hayes reference. For reasons, please see my detailed reasons outlines about as to why it was removed earlier. Scubadiver99 —Preceding unsigned comment added by Scubadiver99 (talk • contribs) 04:38, 25 February 2009 (UTC) I also edited language on epi removal and added reference for peer-reviewed study by Wachler et al regarding results of intact epithelium. Scubadiver99 (talk) 04:59, 25 February 2009 (UTC) By the way APowers, your Feb 19 comments of merely repeating your prior same points and ignoring the criticisms of those same points is not a productive move for moving this article forwardScubadiver99 (talk) 05:04, 25 February 2009 (UTC).


 * Look - trademarking a name means nothing, it was good for marketing, CR3 has not been proven - this is what your avoiding or dancing around - its soooo clear to see !!! signed RH


 * this quote is deceitful, as this study from Chan has been disproved ALREADY (please see te link above) "Some view the corneal epithelium removal as necessary in order to increase penetration of the riboflavin into the stroma[54] while a peer-reviewed study in patients showed crosslinking with intact epithelium was efficacious.[55]" (some real good great bull there!)

There is a desperation here by Scubby, and real big desperation to pevert things. I think he should be banned and banned a long time ago. Why didn't DR BW attened the CXL congress ? he didn't the years before either, what is is scared off ? Dr's laughing at him ? This muppet (Scubby) really needs watching !! signed RH

Civility
Please keep the conversations on this page civil. &mdash; BillC talk 18:19, 27 February 2009 (UTC)

Frustrating
Civil? This is getting really frustrating. The people who are advocating science and 'facts' are not getting paid to edit this article like scubadiver99 is. I don't understand why it is so hard to edit this article and really believe this lack of moderation is '''undermining Wikipedia as a resource for medical information. ''' Who is scubadiver99 and why hasn't he or his sock-puppets been banned? Maybe even a full name & background?

My arguments have been well cited and I have spent time making sure they are factual. I have given my name and background (and been threatened). I even reported the 'commercial motivation for edits' on the board...

Who has the power to change editing privileges on this article? BillC I will be civil, but I'm requesting some action be taken on this.

User:Arpowers (talk) 23:59, 28 February 2009 (UTC)
 * First off, Wikipedia really isn't a good resource for medical information, and makes that explicitly clear in WP:MEDICAL. Why would you trust advice that might very well have been made up by a bored schoolchild? Secondly, it's too bad that no one took any notice of your complaint at WP:COIN. Promotion of specific doctors and methods in this article has been a long-standing issue (see for example Suspected sock puppets/Scubadiver99), although it is not limited to Brian Boxer Wachler. I understand why you are frustrated. Semi-protection of the article would significantly reduce the questionable editing, but I wouldn't hold out much hope for that. I'll try to get some more eyes on the article and see if that helps.  Delicious carbuncle (talk) 01:09, 1 March 2009 (UTC)


 * If Wikipedia is not a good source for medical information, it should be clearly said by it being visible to any visitors to Wikipedia from the strat and on the start of any article on a subject- not a link to a page about it pull out as and when some wants to. Otherwise Wikipedia is trying to market themselves as something important but when the heat is on, they cave in and saying "oh but it say here that we are not medical information, take a look at this page which we have not made you aware off". The reason people are trying to twist the truth on Wikipedia pages like Scubby is, is because on search engines wikidepedia comes up more often than not. —Preceding unsigned comment added by 149.254.51.225 (talk) 14:46, 2 March 2009 (UTC)
 * There is a disclaimer link at the bottom of each and every page. While I agree with some of your points, this isn't the place to debate the issue. Delicious carbuncle (talk) 14:36, 4 March 2009 (UTC)

If Wikipedia allows Scubby to do this (for the Dr he markets) they are just as bad as Scubby. Does Wikipedia want to be the laughing stock of the world with also Dr Scubby doo ? May be Wikipedia takes money from Scubby ? There has been a catalog of bogus info. from Scubby over a very long time. Dear Scubby, you must think we are stupid, the Dr you promote must think that too, and so only has contempt for us our fellow patients which we are trying to bring awareness to such new depths people will go to (hence the scubber driver (scubby to us) name used here) signed RH —Preceding unsigned comment added by 149.254.51.225 (talk) 14:46, 2 March 2009 (UTC)
 * Please stop referring to User:Scubadiver99 as "Scubby". It makes your comments seem more like personal attacks, which won't help to solve this issue. Thanks. Delicious carbuncle (talk) 14:41, 4 March 2009 (UTC)

I have been following this dialogue and it seems that some parties have become rather emotional over this topic. I think it's best to maintain objectivity to provide clarity. In reviewing the cited articles, it's clear to me the data indicates that crosslinking with and without removal of corneal epithelium shows efficacy to patients. I would like to echo BillC's recommendation about civility. Corneadoc (talk) 03:33, 4 March 2009 (UTC)

reply to corneadoc
Corneadoc, didn't you along with scubadiver99 write/edit the Brian Boxer Wachler wikipedia article? Citing him as one of the "Best Doctors in America"? And didn't you try to get me banned for insinuating there was some wiki gaming going on? Well, I'm glad you decided to join the conversation but unfortunately I believe your opinion is biased.

User:Arpowers (talk) 08:05, 4 March 2009 (UTC)
 * I've started a sockpuppetry case at Sockpuppet investigations/Scubadiver99. Delicious carbuncle (talk) 15:02, 4 March 2009 (UTC)

Arpowers, sorry to disappoint you (yes there is more than one cornea specialist). I will be sure notify Dr. Boxer Wachler of your colorful discussions about him. I will also be sure to point out your libelous comments that you made about him as well in earlier comments that was already pointed out to you. Corneadoc (talk) 00:04, 5 March 2009 (UTC)
 * Are you saying that you know Boxer Wachler? If so, what's your relationship? Delicious carbuncle (talk) 03:50, 5 March 2009 (UTC)

CorneaDoc - can you stop the rhetoric, what patients want is proof and there are none valid, just rhetoric, can you show the opposite and of the same amount, of the links to studies already posted ? if not you are just talking "hot air", being a "know it all" pulling things out of "thin air"- how can "epi on" be the same as Epi removed to allow for better B2 diffusion in to the cornea ? - logic says the two are different, as they are from the out set and in studies already. This rhetoric is not a joke to us and has shown that there is over selling going on by a "fallen" Dr. Can any of you guys let me know about reporting this to the advertising standards authorities, I think a police arrest should be made Signed RH

I think we all have an interest in being sure accurate information is being represented. I have been around for a very, very long time, even before the days of myopic keratomileusis (a pre-lasik procedure) that some surgeons were performing and was not very effective. So I have seen alot come and go by the waistside. It is quite frankly hard to ignore the data that show patients are receiving benefit from crosslinking (regardless if the epithelium is or it not removed). Please see references #55 and #56 (I added 56). Summarizing the science is not supposed to be emotional as it seems to have become on this topic. If everyone can keep his or her "cool", we can all achieve what wiki is here for. Does that make sense to everyone? Corneadoc (talk) 02:16, 6 March 2009 (UTC)
 * Corneadoc, in case you missed my question to you above, let me ask again: Are you saying that you know Boxer Wachler? If so, what's your relationship? Thanks. Delicious carbuncle (talk) 03:18, 6 March 2009 (UTC)

This must be the greatest low on this discussion page with this utter nonsense - CorneaDoc, 56 - which you say you added, IS NOT A PER REVIEWED ARTICLE - HAVE YOU GOT THAT ? it is rhetoric, it is just marketing rhetoric and its a standard excuse and easy brush off in all you say. 55, has been disproved (and there was parts missing in how conclusion was jumped to - the longer version of the studies need to be read) by http://www.ncbi.nlm.nih.gov/pubmed/18361990?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed

THE ABOVE HAS BEEN POSTED BEFORE Another thing is, anyone can say they are a "CorneaDoc" - Drs because of responsibility use there real name and give what their education is also in conjunction with a real name (you don't even seem to think you should, which only goes to show you up even more - otherwise you have no creditability, you have none from the "wool being pulled over our eyes" shallow replies you give here - what depths you will go to is staggering. Did Dr BW do animal testing before offering epi on to patients ? or even do a comparitive study ? PLEASE ANSWER OUR QUESTIONS IN FULL< AS OTHERWISE YOU ARE PART OF THE PROBLEM signed RH —Preceding unsigned comment added by 149.254.51.17 (talk) 21:40, 6 March 2009 (UTC)

Delicious Carbuncle, no where does it say that only peer-reviewed articles can be posted on wiki. The Pinelli study is valid - it was controlled and groups were matched statistically preop. Unfortunately, his results do you support your obvious bias for epi-off crosslinking. The bias of you RH, and Arpowers against epi-on is more transparent than a new factory window. Scubadiver99 (talk) 04:54, 7 March 2009 (UTC)
 * Please re-read whatever prompted your accusation - I haven't made that statement. My only recent involvement here is to try to bring some resolution to the disputes that swirl around one small portion of this article. The comments by "RH" (who hops from IP to IP and refuses to sign their posts properly) are disruptive personal attacks as far as I'm concerned. I requested that the article and talk page be protected, but that was denied by an admin who didn't appear to grasp the situation. I will attempt to get some more admin eyes on this and the related sockpuppetry case so we can actually address the content concerns productively. Delicious carbuncle (talk) 17:12, 7 March 2009 (UTC)

Peer reviewed article is far more respected ok ? do you get that ? Besides the overwhelming evidence is for epi off in comparison, for epi on is negligible. That needs to be said on the article, what do the others say ? RH

Note: This talk page has been temporarily semi-protected. I encourage the editor who sometimes signs as RH to read WP:CIVIL. Having a username generally makes communication easier for other editors. Editing as an IP (i.e., without a username) is allowed, but the same rules and guidelines apply. In the meantime, could someone summarize the cross-linking dispute concisely and without attacking other editors so we can get this resolved? Thanks. Delicious carbuncle (talk) 18:19, 8 March 2009 (UTC)

Delicous Carbuncle, I stand corrected. My comment was in reponse to RH. Nonetheless, the comment is still valid.

I agree with you Delicious Carbuncle, there is clearly a problem with resolving this section. If an outside party reviews the comments in this Discussion, I think it will clear that there is a similar tone and attack style of both RH and Apowers against myself and anyone who puts forth information that shows another version of crosslinking works. How can it be investigated if this is the same person using an alias? It's very suspect and itself smells of Sockpuppetry, don't you think?

Additionally, the unprofessional, personal "attack dog" nature of RH and Apowers' comments cannot be ignored - they don't seem consistent with spirit of Wiki community. I think that is largely the problem. Do you agree? Perhaps RH and Apowers' comments stem from some kind of personal "intolerance" to others who have a different opinion. BillC what are your comments about this situation? We clearly need outside help. Scubadiver99 (talk) 16:37, 9 March 2009 (UTC)
 * Perhaps it would be more helpful, as I requested above, to briefly summarize the dispute. I doubt anyone is going to want to wade through the bickering, accusations, and counter-accusations on this talk page. For the record, I don't think "RH" and user:Arpowers are the same person (although you are aware that I believe you have used numerous accounts to push your particular view). Delicious carbuncle (talk) 16:51, 9 March 2009 (UTC)

Summaries
I'll give my summary view, if neither of the engaged parties will do so just yet. It is of course, my opinion, and I am no authority in keratoconus, ophthalmology or even medicine.


 * The dispute is centred around a recent treatment for keratoconus, in which the cornea is treated with a riboflavin solution, and illuminated with ultraviolet light for some minutes. The treatment encourages bonds to form in the cornea, strengthening it, and halting, or even reversing the effects of keratoconus. The dispute is principally over whether the corneal epithelium should be abraded before this treatment, or not. The on-Wiki dispute mirrors a real-life disagreement between practitioners. The treatment was pioneered in Germany, where the "epi-off" method is favoured, while in the United States, one prominent ophthalmologist by the name of Brian Boxer Wachler (BBW) favours the "epi-on" method. The epi-off party look askance at BBW's marketing of the epi-on method, question whether such marketing is at odds with American medical practice (such as in vivo human trials) and whether he has the right to name, even trademark, the treatment. BBW, in turn, has been defending himself in the technical press. I have avoided directly naming the treatment as this is also one of the facets of the dispute: the epi-off party prefer the name "CXL", while BBW prefers the name he has trademarked: "C3R".


 * The resulting on-Wiki dispute has become fraught, and at times uncivil, leading to a temporary semi-protection of the article talk page. has been accused of sockpuppetry and conflict of interest editing.

That is my current understanding, and I welcome correction and comment. &mdash; BillC talk 00:12, 10 March 2009 (UTC)

Additional Point
My viewpoint on this conflict is centered around the overwhelming amount of evidence supporting the fact that the epi-off method is much better than the epi-on method. While Scubadiver99 and corneadoc continually suggest I have added no evidence to support claims, I feel that I have supported myself amply.


 * Here is the supporting citations for the 'epi-off' camp:


 * http://www.medcompare.com/featuredarticle.asp?articleid=409
 * This is an article citing Wollensak, the creator of this procedure who states that: "The removal of the epithelium is essential for the homogeneous diffusion of riboflavin into the corneal stroma. Without epithelial removal (like in C3-R) the biomechanical effect is less than 50% of the standard crosslinking procedure."
 * This is an article citing Wollensak, the creator of this procedure who states that: "The removal of the epithelium is essential for the homogeneous diffusion of riboflavin into the corneal stroma. Without epithelial removal (like in C3-R) the biomechanical effect is less than 50% of the standard crosslinking procedure."


 * http://www.ncbi.nlm.nih.gov/pubmed/18361990


 * This published article summary discusses a formal study carried out to measure of epi-on versus epi-off. Concluding that: Complete removal of the corneal epithelium is an essential component of riboflavin-UVA crosslinking therapy as superficial epithelial trauma and tetracaine administration alone are not sufficient to permit the penetration of riboflavin into the corneal stroma. Failure to achieve adequate stromal absorption of riboflavin may impair the efficacy of the crosslinking process.

Additionally, I am a medical device professional and I have a good understanding of the difference between medical literature and marketing materials. Most articles provided to support the opposition come directly from websites created by Brian Boxer Wachler or his affiliates which makes them biased and not credible.


 * *My opinion: From my exposure to FDA regulations, it is my assumption that the "C3R" procedure was created to get around certain FDA marketing regulations for unapproved device indications (i.e. recommended uses)...
 * Having the procedure be epi-on means that it is a 'vitamin' treatment and therefore not required to be approved by FDA.
 * Having the procedure be epi-on means that it is a 'vitamin' treatment and therefore not required to be approved by FDA.


 * This allows the 'C3R' procedure to be marketed in the US and at a high margin because there are little or very few competitors.

User:Arpowers (talk) 05:41, 13 March 2009 (UTC)

Rich and startling history of XIX century surgical attempts
A wide array of attempted treatments is described in Ramón Castroviejo's article Keratoplasty for the Treatment of Keratoconus. As I understand, Castroviejo was the major inventor of modern keratoplasty. Maybe he too could be mentioned. There's an article about him at Spanish Wikipedia. -- C opper K ettle  16:19, 10 March 2009 (UTC)
 * Good find, CopperKettle. Interesting. &mdash; BillC talk 19:39, 10 March 2009 (UTC)
 * As to the CXL\C3R\whatever-its-named-riboflavin+UV-treatment, it is for some reason added in the Corneal transplantation. I think it is irrelevant there. -- C opper K ettle  21:24, 10 March 2009 (UTC)

Suggested Text for CXL section
This is something which has been put forward by Bill.

"One important element of NPOV is that of weight: the amount of coverage of a particular viewpoint should be in proportion its prominence."

And due to that you wrote:

"...the majority of practitioners in the field remove the epithelium first, but an American outfit is reporting success in a modified procedure which does not, and that this is an area of active dispute within the field."

Both sounds good to me. I will add it to the article once there is any feedback on this suggestion. RH —Preceding unsigned comment added by 149.254.49.16 (talk) 13:48, 30 March 2009 (UTC)

The above quotes do not really add to the article itself. The current article text appropriately cites that there are two techniques. Scubadiver99 (talk) 03:29, 2 April 2009 (UTC)
 * Welcome back, Scubadiver99. Can you look at the section above where the dispute here is outlined and weigh in with your view? Thanks. Delicious carbuncle (talk) 11:50, 2 April 2009 (UTC)

I just knew this would be the reply we would get from Scubadiver. Its he same as the story of when two mothers came to see King Salomon, each addition a baby was theirs. King Salomon in his wisdom, said the baby should then be cut in two. That's when one of the mothers wept and pleaded with the King not to do this. The other "mother" was gleefully happy.

The moral of this, that even though all that was proposed was that there is a dispute (which there is) the Epi on gang don't wish that to be made known from a neuitral web site, thus causing shame and putting the spot light on what is being falsely sold.

Those quotes was written by someone who we clearly know is trying to get to the truth, and the well thought out Wiki guideline is being followed.

I ask Wikipedians known to be good citizens of Wikipedia from everywhere they edit on Wikipedia (through those well known Wikipedians who come here - please put the word out to others like you if needed) to voice there thoughts on this matter. I very much welcome your input and a speedy end to this farce. Thank you RH

RH, no need for dramatics - it's most productive to play it straight. The present article section text is accurate. Scubadiver99 (talk) 05:37, 3 April 2009 (UTC)

Well your not right again, from the info I sent to another Wikipedia (who is not affiliated to me - so no accusations there - unlike you have had)this can be seen, that needs to go on the article as well, i mean why not ? (that question is for not for one person but all who read this)

And don't tell me how to write here, you certainly don't take note of anything yourself. RH —Preceding unsigned comment added by 149.254.56.42 (talk) 20:41, 3 April 2009 (UTC)

cc'ed from my talk page:


 * I should say that the text you [RH] praise about weight and prominence are not really mine, but are a paraphrase of a section on Wikipedia's Neutral Point of View, a central pillar of its content policy. BBW's site I have not read at all, let alone too much. You have said that the overwhelming majority of practitioners are removing the epithelium first: perhaps we can set some numbers to this. For example, how many besides BBW are doing the epi-on method, and how many worldwide are doing it by the epi-off way? This would definitely affect the way something gets described&mdash;or not mentioned at all&mdash;in a Wikipedia article. &mdash; BillC talk 13:26, 5 April 2009 (UTC)

I was thinking on those lines Bill, and knew you was paraphrasing the first quote, but did not want to write more than was needed for the subject text. Yours and the Wiki standards are good to see.

I will ask our good friend Scuberdiver to quote a figure and then back it up by some medical establishment verifying this figure (the name of the medical establishment and a document to which they put their name on, which is what would be required in the first stance. This would be good of you if you could manage that)

Scuberdiver will I predict - use a higher number than one or two by trying to smudge the issue (as already) by adding to the figure however else he can think of. So I will say now that the definition of epi off is where a surgical instrument of varying types, of may be more than one, is used to remove surgically the cells of the epithelium before commencing with treatment by which using surgical alcohol or not. RH —Preceding unsigned comment added by 149.254.51.92 (talk) 01:53, 6 April 2009 (UTC)


 * come on Scuberdriver, hurry up, why are you slow or too shy now to reply ? RH —Preceding unsigned comment added by 149.254.49.47 (talk) 17:25, 7 April 2009 (UTC)

BillC, I see your point of view. If the majority are in fact doing trans epi (epi off) vs epi on or visa versa, I don't see a value to cite proportions of doctors doing one way or the other way. Majorities are not always correct (ie slavery in the 1840s) and minorities are not always correct either (Jonestown, koolaid mass suicide). Citing doctor preferences is not really a reliable statistic especially. For example when the phacoemulsification technique for cataract surgery first was introduced by Dr. Charles Kelman of New York, most eye doctors thought he was a rebel since they were performing the original extracap type cataract surgery (more invasive and longer recovery). Thus the majority of doctors at that time were doing the inferior extracap technique. Time proved Dr. Kelman correct and now hardly any eye surgeons perform extracap, virtually all eye surgeons do phacoemulsification. To have said extracap was better than phacoemulsification simply because more eye surgeons were doing the extracap technique would be a gross travesty of the truth. Scubadiver99 (talk) 06:02, 8 April 2009 (UTC)


 * CAN YOU ANSWER THE QUESTION ? in stead of dancing around it, the WIki standard is as good as "one man one vote" (majority rule) and that's how democracy works if you did not know, its good enough for the free world so why not you ?, you are now trying to change what the free world excepts, all just because you will not answer the question. This is just time wasting by Scubberdiver. We have to draw the line somewhere with that, so what do others think the time set should be to answer with out "dancing around" ? come on Scubberdiver why is it so hard for you to answer simple questions ? RH


 * Scubadiver99, your example of a change in how cataract surgery is performed is not relevant to the issue. To quote from WP:FRINGE: "While currently accepted scientific paradigms may later be rejected, and hypotheses previously held to be controversial or incorrect sometimes become accepted by the scientific community (such as plate tectonics), it is not the place of Wikipedia to venture such projections. If the status of a given idea changes, then Wikipedia changes to reflect that change. Wikipedia primarily focuses on the state of knowledge today, documenting the past when appropriate (identifying it as such), and avoiding speculation about the future." It sounds like undue weight is being given to a procedure that is not generally used or considered anything over than experimental at this time. Unless you can find sources to show that it is used by more than a few doctors, I'm of the opinion that it should be removed from the article entirely, based on WP:UNDUE. Delicious carbuncle (talk) 14:31, 8 April 2009 (UTC)

Epi-on crosslinking is not "theory" and therefore "fringe theory" does not apply- epi on crosslinking is a real procedure that has cited results on real patients. Scubadiver99 (talk) 05:14, 14 April 2009 (UTC)


 * The word 'theory' is not relevant here: the same Wikipedia policy applies to any practice, undertaking, or school of thought. &mdash; BillC talk 07:06, 14 April 2009 (UTC)
 * Since Scubadiver99 has failed to provide supporting references, I'm comfortable removing the section on "epi-on crosslinking" from the article. Anyone else have any objection to me doing that? Delicious carbuncle (talk) 01:03, 15 April 2009 (UTC)

[Personal attack removed]. Please respect the talk page guidelines &mdash; BillC talk 18:04, 15 April 2009 (UTC)

It's just one blatantly bias attempt after another by RH and Delicious Carbuncle to remove any reference to epi on crosslinking. How convenient is it to blatantly ignore "supporting references" 57 and 58 that are currently in article. It is very clear there is an "ax to grind". Is there some personal vendetta you have and is this your way of retaliating? Scubadiver99 (talk) 05:40, 18 April 2009 (UTC)
 * I have no axe to grind and no vendetta to carry out. We seem to have a consensus here, albeit one with which you disagree. The supporting references you now point to after being asked repeatedly to provide evidence of wider use and acceptance don't seem relevant to this discussion. One is by Pinelli et al on Pinelli's experimental treatment of 10 patients (5 of which were a control group) and his experiments on rabbit eyes. Similarly the Boxer Wachler et al paper deals with a 21 patient experiment. I'm sure this discussion will be continued, but please take it to WP:3O or elsewhere. I'm hoping that we can finally be done with the constant bickering here over this small section. Delicious carbuncle (talk) 13:46, 18 April 2009 (UTC)


 * You have failed to answer the questions put to you again and again Scubadiver, why not just say how many Drs are doing Epi on ? why is it too hard for you to say ? You are being silly, and you know you are. I think we must reflect what the is going on, not what you would like to say is going on, or should be going on, or will be going on. The difference being "we" as in collectively. Why is it you seem to think you know ? is it because you work for the out-fit your promoting, go back and tell them its never washed with us or will wash with us this unnatural twisting of common sense and no answers to very simple questions. I do feel sorry for you as you don't seem to get it. RH —Preceding unsigned comment added by 149.254.49.23 (talk) 15:05, 18 April 2009 (UTC)

Delicous Carbuncle, making a blanket dismissal of two studies that show a technique that you do not support is clearly inappropriate.

Additionally, the original Wollensak study published in American Journal of Ophthalmology in 2004 had how many eyes? Answer: 23. Somehow in your opinion 21 eyes in the Boxer Wachler et al paper is invalid and should be 100% dismissed and buried. Gee, that makes sense and is completely fair (sarcasm here).

The Pinelli study was a study in patients, not rabbit eyes. 10 eyes were in each group of epi on vs epi off and the improvements in each group were the same.

I just have to wonder since if you don't have an ax to grind, then do you have some financial connection to UVX or the US FDA clinical trial that uses only epi off? Your insistence of burying anything and everything that scientifically supports epi on crosslinking is really suspect. Scubadiver99 (talk) 03:22, 22 April 2009 (UTC)
 * To answer your question, I have no financial connection to anything keratoconus or eye surgery-related. I have stated that before, but I'm willing to answer again or even to rephrase it if you don't think my answer was clear. I have no conflict of interest in this topic.


 * To return the discussion to the real issue, if general practice is to use epi-off, then Wikipedia needs to reflect that. In this case, the number of doctors using epi-on and the experimental nature of the treatment means that any inclusion gives epi-on unwarranted weight. I'm sure you disagree, but please attempt to use Wikipedia mechanisms for settling this rather than edit-warring. Thanks. 21:44, 26 April 2009 (UTC)
 * Delicious Carbuncle, I challenge your denial of financial interest. Why?  There is no other reason to explain why you are constantly trying to bury all references (even peer-reviewed) that show epi on works.  Second, you misleadingly tried to evoke "fringe theory" as justification to remove epi on from  article.  That was flat out incorrect and misleading.  At the recent 2009 ASCRS meeting, there was a lot of talk from international ophthalmologists who are now performing epi on crosslinking, not epi off.  It seems that more doctors are doing epi on than epi off.  Scubadiver99 (talk) 04:17, 28 April 2009 (UTC)
 * Please indent your comments so that it is easier for readers to follow the conversation (it is hard enough already). I have no response to your accusation since I've already stated that I have no financial interest in keratoconus treatment. Again, it has no bearing on the issue at hand. I would appreciate it if you could focus yourself on the discussion instead of attacking me. This is the last time I'll ask nicely.


 * I didn't say the epi-on was a "fringe theory", I merely quoted a relevant part of WP:FRINGE. However, that is probably a very good place to look to for guidance in this case, since the seem to be no sources indicating that the treatment is anything more than experimental at this stage. That isn't a criticism of the efficacy or future use of the treatment, just a statement of how things stand right now. I think we've been through this before. If you're not bringing anything new to this discussion, don't expect that I will continue to reply. Thanks. Delicious carbuncle (talk) 04:55, 28 April 2009 (UTC)

There are two references that were inappropriately deleted. I have replaced the published referenced sources and original wording in article as this is an appropriate represention of the current status of crosslinking: there are two techniques of crosslinking that have been shown to be effective. This reflects how things are right now. Corneadoc (talk) 16:29, 28 April 2009 (UTC)
 * And I have reverted to the previous state. I believe User:Corneadoc is an obvious sockpuppet of User:Scubadiver99. I will be re-opening the sockpuppetry cases (the previous ones were inconclusive). Sockpuppet or not, given the situation here, it is advisable to discuss any proposed changes regarding that section. Thanks. Delicious carbuncle (talk) 21:30, 28 April 2009 (UTC)

Yes, please share with the group the reasons these two references are not valid that you keep removing? These appear valid to me. I have reinstated my balanced edits to the article. By they way, I guess anyone who has anything positive to say about crosslinking with intact epithelium is a sockpuppet per your accusation. Corneadoc (talk) 00:39, 29 April 2009 (UTC)
 * Not at all. Here is the first SSP case from January 2008, and here is the case from March 2009. You will note that the common thread is single purpose accounts which edit topics related to Brian Boxer Wachler. The changes you are reverting were part of a consensus arrived at in this section. This has already been explained and you have been asked not to revert, so if you or Scubadiver99 reverts again I will ask for you to be blocked. Thanks. Delicious carbuncle (talk) 04:17, 29 April 2009 (UTC)

Delicious Carbuncle, I would like to propose a means to resolve this conflict. Please propose balanced and fair wording regarding that there are two types of crosslinking have been shown to be effective. I trust we all can intelligently come to an agreement and put this to rest. Scubadiver99 (talk) 01:18, 29 April 2009 (UTC)
 * Please don't address your questions solely to me. Re-read the above discussions - this isn't a question of wording. Please consider WP:3O or WP:RFC, which I have suggested to you before. Please think twice before adding anything else to this already protracted and unproductive discussion. Delicious carbuncle (talk) 04:28, 29 April 2009 (UTC)

The present wording is "The corneal epithelium skin cell removal is generally removed in order to increase penetration of the riboflavin into the stroma (the main body of the cornea)". We know that others are doing it with intact epithelium and are able to get ribo to penetrate through intact epi. http://www.eyeworld.org/article.php?sid=4837 shows a slitlamp photo of ribo in stroma with intact epi. It makes sense in article to mention that this technique exists. I propose this edit: "The corneal epithelium skin cell removal is generally removed (but not always) in order to increase penetration of the riboflavin into the stroma (the main body of the cornea)." I welcome comments. Corneadoc (talk) 23:27, 29 April 2009 (UTC)
 * I'm sorry, I don't see where you find that information in the article. Can you quote the relevant passage? Thanks. Delicious carbuncle (talk) 12:19, 30 April 2009 (UTC)

I would simplify wording: "The corneal epithelium may or may not be removed for the crosslinking procedure." Scubadiver99 (talk) 05:40, 30 April 2009 (UTC)
 * "RH" had "The corneal epithelium skin cell removal is necessary...". You seemed to want "Some view the corneal epithelium removal as necessary...". I changed it to the current "generally removed" version to placate you. Is removing the epithelium general practice? Delicious carbuncle (talk) 12:19, 30 April 2009 (UTC)

The reality is that no one really know what is general practice. As we all know the epithelium removal technique was the original technique, but more ophthalmologists are doing crosslinking without removing epithelium. It's certainly possible that a majority now are not removing epithelium based on conversations at the recent ASCRS meeting, but no one really knows. Corneadoc (talk) 00:01, 1 May 2009 (UTC)

What about simply saying "Crosslinking can be performed with or without removing epithelium". That's short and sweet. Everyone ok with that?Scubadiver99 (talk) 03:34, 5 May 2009 (UTC)

That's fine too. Unless anyone has any comments, fine to go ahead and post. Corneadoc (talk) 00:57, 6 May 2009 (UTC)
 * You have been asked and were unable to provide any kind of references showing that epi-on is anything other than an experimental practice. The repeated attempts here to insinuate it back into the article aren't productive and are becoming disruptive. I've asked you several times now to take the issue elsewhere if you are unsatisfied with the consensus here. Please stop this. Delicious carbuncle (talk) 02:41, 6 May 2009 (UTC)


 * The references were provided previously, but perhaps you did not see them:


 * 1) Chan CCK, Sharma M, Boxer Wachler BS. The effect of inferior segment Intacs with and without corneal collagen crosslinking with riboflavin (C3-R) on keratoconus. J Cataract Refract Surg 2007;33:75-80.


 * 2) http://www.eyeworld.org/article.php?sid=3797


 * Reference 2 above also shows slit lamp photos of riboflavin penetration through intact epithelium.


 * This is not experimental as an increasing number of doctors are using this in clinical practice, not under any clinical study protocols. In fact, I am not aware of any epi-on crosslinking being performed under a study protocol.  All ophthalmologists to my knowledge are using it in clinical practice.


 * DC, please choose revised wording you are comfortable with so this can be settled. Corneadoc (talk) 20:44, 6 May 2009 (UTC)
 * For the very last time - those references do not show that epi-on is anything other than an experimental practice (in fact they show the opposite. This isn't a question of wording. I have asked you repeatedly to take this somewhere else. If you or Scubadiver99 post here about epi-on again, I will ask for your account(s) to be blocked for disruption. Please properly indent your comments. Thanks. Delicious carbuncle (talk) 00:28, 7 May 2009 (UTC)


 * DC, you assert those references as being experimental, then you say they show the opposite (non-experimental). Frankly, you are not making any sense.
 * 1) The only "experiment" in crosslinking is the current US FDA clinical trial which uses epi-off. FDA clincal trials are by definition experimental. Therefore the only "experimental practice" is epi-off crosslinking if you wish to get into technicalities.
 * 2) At the April 2009 American Academy of Cataract and Refractive Surgeons Annual Meeting in San Francisco, quite a number of ophthalmologists are now performing epi-on crosslinking.
 * 3) The above references scientifically show epi-on crosslinking is effective.
 * 4) Reference 2 shows riboflavin penetration into stroma of cornea through intact epithelium when pre-treated with tetracaine drops which loosen the epithelial tight junctions to allow riboflavin to penetrate intact, yet loosened epithelium.
 * 5) Based on the above, it is fair and truthful to describe in the article there are two types of crosslinking, with and without epithelium. I have made that change.  Corneadoc (talk) 18:19, 7 May 2009 (UTC)


 * P.S. I also removed the comment about the procedure, with epithelium removed, is approved in Europe.  I deleted "with epithelium removed" because only devices are approved, procedures are not.  Corneadoc (talk) 18:24, 7 May 2009 (UTC)
 * I'm only replying here to let you know that I will be reverting and starting a thread at WP:ANI asking for you account to be blocked for disruption as I had said I would in previous comment. Delicious carbuncle (talk) 16:34, 8 May 2009 (UTC)
 * Please see . Thanks. Delicious carbuncle (talk) 17:15, 8 May 2009 (UTC)


 * DC, I am not surprised by your actions. First, you accused me of sockpuppetry, which was not supported.  Second, you now wish my account to be blocked.   Third, now you wish Corneadoc's account to be blocked only because he/she logically based on the solid data explains that epi-on crosslinking should be acknowledged.  It seems that there is a clear pattern of your attempts to bury anyone who wishes to have the other technique of crosslinking merely mentioned in this article.  Scubadiver99 (talk) 04:43, 9 May 2009 (UTC)
 * Since I clearly stated what I was going to do, I would hardly expect you to be surprised when I did it. I have asked for your accounts to be blocked because you continue to revert the changes and argue about wording here. Asking for you to take this to an appropriate forum to make your case is hardly "burying" anything. And please note that ANI is not that forum. Nonetheless, your comment probably belongs on my talk page, not here. Delicious carbuncle (talk) 11:09, 9 May 2009 (UTC)

I am following this discussion for several months and just registered. Sorry in advance if my formatting is not perfect. I am an ophthalmologist in Thailand and we have seen many cases of Keratoconus and Keratoectasia after Lasik and we have performed CXL with and without abrasion of epithelium. It is quite painful for patients when abraded epithelium. We now favor keeping the epithelium in place especially since the benefits of this techique with application of topical anesthetic eye drops permits permeation of riboflavin solution drops to enter the corneal stroma are stabilization of disease is not different from CXL with epithelium abraded. Many more ophthalmologists are doing this CXL with epithelium in place. For this section to be honest, I believe CXL with keeping epithelium in place needs to be included in this article. 00:21, 12 May 2009 (UTC)Lasiklady (talk)


 * Would someone like to volunteer to make this text change?Corneadoc (talk) 00:54, 12 May 2009 (UTC)
 * I'm not clear why you think any change is necessary. No new sources have been offered. No offence intended to User:Lasiklady, but this type of anecdotal evidence, while interesting and informative, cannot be considered reliable for the purposes of Wikipeda. Incidentally, have you seen the thread below about disruption of this talk page? Delicious carbuncle (talk) 01:40, 12 May 2009 (UTC)

I have read everything. I forgot my password and created modified username lasikladythai. I commented on disruption thread below. Please do not harbour any resentment towards me for my opinion. Lasikladythai (talk) 11:14, 15 May 2009 (UTC)


 * Your repeated, failed attempts to bury anyone and any comment that is at odds with your mission to exclusively have only epi off crosslinking in article is most evident. Your final, failed attempt to have anyone blocked who wishes to have both epi on and epi off represented in article is reflective of your motives.  Your request to block accounts of those who wish to have both types of crosslinking in article has been now purged from ANI tread and confirms the transparency of your mission.  I have made edit to article that there are two types of crosslinking which is the truth as represented by publications and general ophthalmology use.  Corneadoc (talk) 04:37, 15 May 2009 (UTC)

What is clearly suspect is your refusal to answer the questions again ! RH —Preceding unsigned comment added by 149.254.49.46 (talk) 13:31, 22 April 2009 (UTC) Also have you looked on Medline (pub-med site) it might surprise you how little there is on Epi on, and how there is lots on Epi off, that is how it is for all to see. RH —Preceding unsigned comment added by 149.254.58.66 (talk) 17:18, 22 April 2009 (UTC) I am just posting this to let you know that Scubberdiver will try to play games here and on the article, as seen already, please be aware. RH —Preceding unsigned comment added by 149.254.49.58 (talk) 18:19, 24 April 2009 (UTC)

Low alcohol dehydrogenase, TrkA-Sp3 etc.
- quite interesting. -- C opper K ettle  13:58, 21 April 2009 (UTC) An interesting link, I quote from OMIM: "Keratoconus is a common corneal dystrophy that leads to severe visual impairment. In keratoconus-affected corneas, Lambiase et al. (2005) found a strong increase in expression of the short isoforms of SP3 involved in gene repression and lack of the long SP3 isoform involved in gene activation. Associated with altered SP3 expression was a total absence of TRKA (NTRK1; 191315) expression and decreased expression of NGF (see NGFB; 162030) and p75(NTR) (NGFR; 162010). Furthermore, expression of short SP3 isoforms in human corneal keratocyte primary cultures resulted in downregulation of TRKA expression. Lambiase et al. (2005) hypothesized that an imbalance in SP transcription factor isoforms may play a role in controlling NGF signaling, thus contributing to the pathogenesis of keratoconus." Best regards, -- C opper K ettle  09:34, 22 April 2009 (UTC)
 * TrkA and Sp3:

Good data. Cristina Kenney, PhD has also found keratoconic corneas have abnormal activity of antioxident enzymes superoxide dismutase and catalase reflecting oxidative stress on the cornea. PMID: 15728537. Scubadiver99 (talk) 06:12, 24 April 2009 (UTC)

This is silly. Its just a theory, just like all the others, why does it happen ? can Kenney explain - has anyone asked her or raised this ? Anyone can have a theory, its got to be proven instead of promoting themselves otherwise. RH —Preceding unsigned comment added by 149.254.49.58 (talk) 20:15, 24 April 2009 (UTC)

Note on sources - It might be a good idea for everyone here to read (or re-read) WP:MEDRS. Delicious carbuncle (talk) 16:10, 26 April 2009 (UTC)

Kenney's conclusion is not theory, but from results from her study. Take the time to read the paper vs. just shoot off about it. Scubadiver99 (talk) 20:54, 26 April 2009 (UTC)


 * Its quite simple, if you read any study, any at all, the ones kindly posted by Copper Kettle or those you find on Med line or anywhere, HAS RESULTS and from that a conclusion. What makes Kenny's study any different ? You talking as if it is the silver bullet or that the conclusion has been proven, she may have got it wrong, its not the final word on it, it may only be a part of something else we don't know, there are big missing parts to it, which is as many as there are studies. Why this has to be explained, I don't know ! RH —Preceding unsigned comment added by 149.254.58.87 (talk) 06:52, 3 May 2009 (UTC)

Mental health and personality aspects of Keratoconus
"significantly more keratoconic patients had mental disorders: 35% vs. 22% of controls (P < .042), he said. Significantly more keratoconic patients also had experienced aggression (46%), sadness (49%) and suicidal thoughts (19%)" "MIPS showed keratoconus patients to be more pain avoiding, with more imaginative intuition, asocial withdrawal and anxious hesitation than the control group." How do you think, do these worth a mention? -- C opper K ettle  16:46, 23 April 2009 (UTC)
 * Keratoconus patients are more likely to have psychiatric disorders, study shows - Ocular surgery news; 2007
 * Psychological and social aspects of patients with keratoconus - ; 2007
 * Keratoconus personality is mentioned here.
 * On the other hand, in a book on keratoconus other studies are also mentioned that did not found personality traits specific to kc and the claims of "kc personality" are reported with a pinch of salt.

Well if you have vision troubles, you ain't going to be over the moon about it (whats the stats on other eye condition or any other condition ?), its the same with any vision loss. KC is not understood much, and there is a lot of mystery surround it, people says whats the problem ? wear you glasses ! as you look normal to people. Plus whats the trouble you have contact lenses and transplants (which are an success ?!). Its fustrating with correction, you can have painful vision, low vision even with corrective lenses, and how scary is rejection after a Translant ? and how long they will last ? you need contact lens mostly afterwards, so if your intolerant to contacts, its a bit of an over kill to remove and replace tissue with a dead persons. Also a wen questionaire of a small sample is not science at all. RH —Preceding unsigned comment added by 149.254.49.58 (talk) 18:16, 24 April 2009 (UTC)
 * You know, the pathways that are now being uncovered in KC (inflammatory cytokines, adhesion regulation, free radicals removal, NGF signaling etc.) may well affect neural function, and that could be interesting.. I know about painful experience, have two transplants. I agree that questionaires could be fishy. -- C opper K ettle  06:31, 26 April 2009 (UTC)

Malondiadlehyde and glucosamine
One study reports of an increased level of malondialdehyde (MDA) in KC corneas. Reading about MDA, I found that glucosamine (in vitro, alas: ) may have the ability to lower the MDA. Will read more; found this link interesting. -- C opper K ettle  02:20, 27 April 2009 (UTC)

Rare mutations linked to KC
Maybe it is worth to mention these two genes in the article? VSX1 is an "orphan" at this point. -- C opper K ettle  15:43, 29 April 2009 (UTC) It could go something like that: "Different genes could underlie each individual case of the disease. For example, keratoconus-associated mutations of SOD1 and VSX1 genes were reported, but a small study conducted later with the foreknowledge of these reports failed to find association of the two genes in another 18 families." -- C opper K ettle  16:46, 29 April 2009 (UTC)
 * SOD1: (familial keratoconus)
 * VSX1:, (de novo; dont know why they call them "mutations", probably because they affect highly conservative regions)

CopperKettle, I think that is appropriate to cite these genes may be linked.Corneadoc (talk) 00:37, 30 April 2009 (UTC)

True or false: Scubadiver99 and Corneadoc are behaving disruptively on this page
Arising from an item at ANI, I would like to get a sense of the distribution of opinions among people who participate here. I will make an assertion -- please indicate whether you agree or disagree with it, with no more than a brief explanation, one or two sentences at most. Please do not discuss other people's opinions here, open a new section if you think discussion is necessary. I will aggressively remove anything that clutters or obfuscates this section.

Assertion: Scubadiver99 and Corneadoc have been behaving disruptively on this page.

Do you agree or disagree? Looie496 (talk) 21:40, 9 May 2009 (UTC)
 * As the editor who raised the issue, I will agree with your assertion. See diffs presented here. Delicious carbuncle (talk) 23:18, 9 May 2009 (UTC)


 * I thought long and hard before responding here: I am afraid their behaviour has become disruptive, a complete refusal to get the point. There has been considerable goading of them, however, which itself has been highly disruptive. &mdash; BillC  talk 19:13, 10 May 2009 (UTC)


 * Yes, I agree. I am a medical professional and their commercial motivations have been clear to me for a long time. They have never provided evidence to support their perspective. User:Arpowers (talk) 06:18, 12 May 2009 (UTC)

I agree to everyone here. We must not stand for this abuse of the FREE Wikidepia service and the playing with the life's of those suffering from vision loss (that is an absolute sin which is a given fact that does not need to besaid - but is needed for Scubberdiver and his side kick cornea Doc). I think that the full force of what can be done to bring these people to justice should take place, lets see how they like being on the receiving end of their bully boy tactics (its absolutely idiotic to think they could pull the wool over patients eyes. Their ISP should be contacted (easy enough through their IP address, and matters told to them and then taken further through that (it can be the first test case of this kind where they are taught a lesson they will not forget, warding of others who think they can get away with the same kind of unethical commerial editing). I think its worth a mention on the article that it has come to this. I know the others here who has posted in this section have only fair play on their mind, but this trouble we have seen are motivated by greed, but not scientific facts. RH —Preceding unsigned comment added by 149.254.49.40 (talk) 15:11, 14 May 2009 (UTC)


 * The administrator case was purged after this summary was posted by Scubadiver99:

 Long confusing copy & paste I would like to summarize the pattern of strategies of Delicious Carbuncle to suppress any mention of epi-on crosslinking. All verbatim exerpts below are verifiable on Discussion page of Keratoconus article:
 * 1) Delicious Carbuncle accused me of sockpuppetry which was not supported after investigation.


 * 2) Then Delicious Carbuncle states epi-on crosslinking is fringe theory as justification for removing it from Keratoconus article. This was refuted:

To quote from WP:FRINGE: "While currently accepted scientific paradigms may later be rejected, and hypotheses previously held to be controversial or incorrect sometimes become accepted by the scientific community (such as plate tectonics), it is not the place of Wikipedia to venture such projections. If the status of a given idea changes, then Wikipedia changes to reflect that change. Wikipedia primarily focuses on the state of knowledge today, documenting the past when appropriate (identifying it as such), and avoiding speculation about the future."It sounds like undue weight is being given to a procedure that is not generally used or considered anything over than experimental at this time. Unless you can find sources to show that it is used by more than a few doctors, I'm of the opinion that it should be removed from the article entirely, based on WP:UNDUE. Delicious carbuncle (talk) 14:31, 8 April 2009 (UTC) Epi-on crosslinking is not "theory" and therefore "fringe theory" does not apply- epi on crosslinking is a real procedure that has cited results on real patients. Scubadiver99 (talk) 05:14, 14 April 2009 (UTC) The word 'theory' is not relevant here: the same Wikipedia policy applies to any practice, undertaking, or school of thought. —BillC talk 07:06, 14 April 2009 (UTC)
 * 3) Then Delicious Carbuncle states that I failed to provide references on epi-on crosslinking although I had previously provided them:

Since Scubadiver99 has failed to provide supporting references, I'm comfortable removing the section on "epi-on crosslinking" from the article. Anyone else have any objection to me doing that? Delicious carbuncle (talk) 01:03, 15 April 2009 (UTC) These were references I had provided, but seem to have been ignored:


 * a. Chan CCK, Sharma M, Boxer Wachler BS. The effect of inferior segment Intacs with and without corneal collagen crosslinking with riboflavin (C3-R) on keratoconus. J Cataract Refract Surg 2007;33:75-80.
 * b. Pinelli study http://www.eyeworld.org/article.php?sid=3797


 * 4) Then Delicious Carbuncle misrepresents articles data and methods and attempts to use misrepresentations as grounds for article dismissal:

One is by Pinelli et al on Pinelli's experimental treatment of 10 patients (5 of which were a control group) and his experiments on rabbit eyes. Similarly the Boxer Wachler et al paper deals with a 21 patient experiment. I'm sure this discussion will be continued, but please take it to WP:3O or elsewhere. I'm hoping that we can finally be done with the constant bickering here over this small section. Delicious carbuncle (talk) 13:46, 18 April 2009 (UTC) Delicous Carbuncle, making a blanket dismissal of two studies that show a technique that you do not support is clearly inappropriate. Additionally, the original Wollensak study published in American Journal of Ophthalmology in 2004 had how many eyes? Answer: 23. Somehow in your opinion 21 eyes in the Boxer Wachler et al paper is invalid and should be 100% dismissed and buried. Gee, that makes sense and is completely fair (sarcasm here). The Pinelli study was a study in patients, not rabbit eyes. 10 eyes were in each group of epi on vs epi off and the improvements in each group were the same. I just have to wonder since if you don't have an ax to grind, then do you have some financial connection to UVX or the US FDA clinical trial that uses only epi off? Your insistence of burying anything and everything that scientifically supports epi on crosslinking is really suspect. Scubadiver99 (talk) 03:22, 22 April 2009 (UTC)
 * 5) Delicious Carbuncle now tosses in this accusation sockpuppetry again merely because two people are making a similar point that appears to be in conflict with his/her passionate support for epi-off crosslinking:

I believe User:Corneadoc is an obvious sockpuppet of User:Scubadiver99. I will be re-opening the sockpuppetry cases (the previous ones were inconclusive). Delicious carbuncle (talk) 21:30, 28 April 2009 (UTC)
 * 6) Then Delicious Carbuncle says the two studies are experimental, then says they are just the opposite (very confusing and unclear what is actually meant by that comment). Comment includes intimidation to "be quiet or else I will ask for your accounts to be blocked":

those references do not show that epi-on is anything other than an experimental practice (in fact they show the opposite. If you or Scubadiver99 post here about epi-on again, I will ask for your account(s) to be blocked for disruption. Delicious carbuncle (talk) 00:28, 7 May 2009 (UTC) I do not know what path is motivating Delicious Carbuncle, but it does not appear to be following the path of the truth which is that there are two proven ways of performing crosslinking for keratoconus in patients- epi-on and epi-off. Scubadiver99 (talk) 05:38, 9 May 2009 (UTC)

In any case, the two references cited above (Pinelli and Chan et al) in Section 3 provide evidence that there is no distruptive editing by including epi off as well as epi on crosslinking in article.

How can one turn a blind eye to these two studies then accuse me of being disruptive for trying to represent truthful information in this article?

P.S. Why was this page purged from Administrator page and who purged it? P.P.S. RH and Apowers have always been unprofessional towards myself and Scubadiver99 and have been warned about that.

Corneadoc (talk) 05:12, 15 May 2009 (UTC)


 * Well, I was having some doubts, but that response makes it clear that something needs to be done. The IP editor, however, is strongly encouraged to go troll somewhere else. Looie496 (talk) 05:51, 15 May 2009 (UTC)

I respectfully disagree that there have been disruptive behaviour of Scubadiver99 and Corneadoc because it is truthful that these two studies indicate information of CXL without removal of epithelium should be mentioned in article. I changed my CXL technique after reading Dr. Roberto Pinelli's study published in Eyeworld and it works. Kindly please do not attack me for my opinion.10:15, 15 May 2009 (UTC)Lasikladythai (talk)


 * At this point, I don't think this problem is solvable without major changes to the article. It really needs to follow WP:MEDRS, which means relying on good review papers rather than primary research articles.  As it is, there's no principled way to decide on appropriate weight for any given study, and therefore no principled way to resolve disputes like this.  It's reasonably clear to me who is right, but that doesn't really help.


 * For what it's worth, I looked into the question of whether Scubadiver99 and Corneadoc are socks, but it seems pretty unlikely, because they have quite different time-of-day editing patterns. Neither has edited enough to allow really solid conclusions to be drawn, though.  Lasikladythai is a brand new account so it's impossible to say anything. Looie496 (talk) 15:42, 15 May 2009 (UTC)


 * Not to disagree with WP:MEDRS, but why are major changes required to the article? This area is the only one under dispute, and is one small part of one small section. The disputed section is a single 19-word sentence in a 4300-word article. Why are the required changes major? What is wrong with the sources and writing in the other 99.5% of the article? &mdash; BillC talk 16:42, 15 May 2009 (UTC)


 * Scanning through the references, out of 66 sources currently, I count 34 that look at first glance like primary research articles. Cleaning that up would be a significant effort.  Not cleaning it up makes problems like this hard to solve, because once you start admitting primary research articles, it becomes very difficult to say which ones should be admitted, how they should be described, and which are inappropriately weighted -- it's much better to leave that judgement to the experts who write review articles. Looie496 (talk) 17:37, 15 May 2009 (UTC)


 * As a new user, I respectfully submit this review article for consideration: http://www.keratoconusinserts.com/images/pdf/C3-RforKC.pdf  Lasikladythai (talk) 08:42, 17 May 2009 (UTC)


 * I have respectfully added this review article reference. Lasikladythai (talk) 05:45, 19 May 2009 (UTC)
 * Please stop this. We've been through weeks of discussion on this particular point and at least a year's worth of sockpuppetry by accounts related to Brian Boxer Wachler. I will be archiving these discussions shortly. You are encouraged to take this somewhere else, but I will be reverting further changes against consensus as vandalism and removing any new discussion here as disruptive. Feel free to report me to admins. Thanks. Delicious carbuncle (talk) 15:10, 19 May 2009 (UTC)

Reliable Sources
I think that we should add the following sentence to the section using the references:


 * a. Chan CCK, Sharma M, Boxer Wachler BS. The effect of inferior segment Intacs with and without corneal collagen crosslinking with riboflavin (C3-R) on keratoconus. J Cataract Refract Surg 2007;33:75-80.
 * b. Pinelli study http://www.eyeworld.org/article.php?sid=3797

This is a reliable source, and this information is directly relevent to the article. Lasikladythai (talk) 11:37, 15 May 2009 (UTC)
 * This has been discussed here at great length and there is no point in trying to rehash the discussion yet again. In fact, the persistent refusal to stop discussing it here has become disruptive. Please take this to WP:RFC or other appropriate forum. Thanks. Delicious carbuncle (talk) 11:57, 15 May 2009 (UTC)


 * I see that these articles were discussed and there is nothing at all wrong with them. It seems that you are asking for proof and these studies provide it with credibility - as much credibility as any other article used in this article of keratoconus.  If you wish to discount these two studies, then you must discount ALL studies used for reference in this article of keratoconus since the credibility of these two studies is no different from other cited studies.  There is nothing lacking in them. I have been encouraged to speak my opinion in this forum as being appropriate and am doing so. Lasikladythai (talk) 08:34, 17 May 2009 (UTC)


 * My position is that these are reliable sources which is a criteria put forth by wikipedia. Corneadoc (talk) 12:55, 17 May 2009 (UTC)
 * Please see Administrators%27 noticeboard/Incidents. Thanks. Delicious carbuncle (talk) 13:48, 17 May 2009 (UTC)

User:Scubadiver99 and User:Corneadoc blocked for sockpuppetry
Please see Sockpuppet investigations/Scubadiver99/Archive. Anyone object to archiving some of the lengthy discussions about epi-on/epi-off? Would it be appropriate to add some kind of disclaimer? I'm not bothered by the accusations made about me by those accounts, but I wouldn't want editors reading those archives to read the discussion without knowledge about the sockpuppetry. Delicious carbuncle (talk) 16:36, 18 May 2009 (UTC)
 * Archive the lot and post a link in it to the sockpuppetry case. &mdash; BillC talk 18:47, 18 May 2009 (UTC)


 * Hooray! Good work. Finally some progress can be made to this article about Crosslinking. Ironically, I think that these sockpuppets have significantly held back public awareness of this treatment. When I have some time I will put together something on the current state of the research and update the article. Alternatively, would it make sense to create a stand-alone article on Crosslinking?

User:Arpowers (talk) 03:44, 28 May 2009 (UTC)
 * A good stand-alone article on the subject is most welcomed! -- C opper K ettle  04:16, 28 May 2009 (UTC)


 * I would prefer that you leave the entire conversation, cumbersome as it is. I am researching keratoconus treatment options, and I found it very illuminating.  I am certainly much more skeptical and have done further reading as a result.  Also, I wholeheartedly agree with Arpowers.  I know it would open up a whole new can of worms, but this class of procedure really should have its own page, separate from more general information about keratoconus.  There will likely be even more information about this procedure sought by wiki readers after the completion of the ongoing US trial.Chrystelle88 (talk) 01:28, 21 August 2009 (UTC)
 * Thanks for the reminder. I had intended to archive this some time ago, but left it until sockpuppets stopped popping up on my talk page and then just forgot to come back and do it. I will do so now. There is no useful information for readers and it may be embarrassing to Dr Boxer Wachler. As for creating a separate page about keratoconus treatment options, please don't. It wouldn't be in keeping with other, similar articles, and it will cause problems. If you decide to ignore this advice, please make sure to notify editors at this page. Thanks. Delicious carbuncle (talk) 14:19, 21 August 2009 (UTC)
 * Wow, what an incredibly curt response. Please be civil.  I have no intention of creating a page for collagen cross-linking, because I am not qualified to do so. However, there certainly should be a page.  It very much would provide useful information to readers, and I don't see how it would run afoul of Wiki's objectives.  The procedure is now being performed in many countries world-wide. There is a page on LASIK and similar procedures.  I hope someone takes up this task.  —Preceding unsigned comment added by Chrystelle88 (talk • contribs) 21:33, 23 August 2009 (UTC)

Update - Following the blocks of Scubadiver99 and Corneadoc, the battle seems to have moved to Brian Boxer Wachler, but I have no doubt it will return here eventually unless some IP blocks get handed out. Although I was unaware of it, User:Arpowers, the anon IP contributor who signs themselves as "RH", and I were part of a sockpuppetry case (Sockpuppet_investigations/Arpowers/Archive). That case resulted in user User:Approach the Bench being blocked as another Scubadiver99 sockpuppet. I only found out about the case when it was noted in a new sockpuppetry case that I had filed for a another new Boxer Wachler sockpuppet. I am waiting to archive the above discussions until that case is closed, since I think they serve to illustrate the situation rather clearly. Delicious carbuncle (talk) 14:03, 2 June 2009 (UTC)