Ageing of the human corneal stroma: structural and biochemical changes

Selected parameters of the corneal deformation in the Corvis tonometer

Introduction

Contemporary ophthalmology knows many methods of measuring intraocular pressure, namely the methods of non-contact and impression applanation tonometry. In non-contact applanation tonometers, e.g. the Corvis, the corneal flattening is caused by an air puff. Image registration of the corneal deflection performed by a tonometer enables to determine other interesting biomechanical parameters of the eye, which are not available in the tonometer. The measurement of new selected parameters is presented in this paper.

Material and method

Images with an M × N × I resolution of 200 × 576 × 140 pixels were acquired from the Corvis device in the source recording format *.cst. A total of 13'400 2D images of patients examined routinely in the Clinical Department of Ophthalmology, in District Railway Hospital in Katowice, Poland, were analysed in accordance with the Declaration of Helsinki. A new method has been proposed for the analysis of corneal deflection images in the Corvis tonometer with the use of the Canny edge detection method, mathematical morphology methods and context-free operations.

Results

The resulting image analysis tool allows determination of the response of the cornea and the entire eyeball to an air puff. The paper presents the method that enables the measurement of the amplitude of curvature changes in the frequency range from 150 to 500 Hz and automatic designation of the eyeball movement direction. The analysis of these data resulted in 3 new features of dynamics of the eye reaction to an air puff. Classification of these features enabled to propose 4 classes of deformation. The proposed algorithm allows to obtain reproducible results fully automatically at a time of 5 s per patient using the Core i5 CPU M460 @ 2.5GHz 4GB of RAM.

Conclusions

The paper presents the possibility of using a profiled algorithm of image analysis, proposed by the authors, to measure additional cornea deformation parameters. The new tool enables automatic measurement of the additional new parameters when using the Corvis tonometer. A detailed clinical examination based on this method will be presented in subsequent papers.

Age-related changes in corneal pulsation: ocular dicrotism

PURPOSE

To evaluate age-related changes in the shape of corneal indentation pulse (CIP) in relation to simultaneously registered blood pulsation (BPL) and electrocardiogram (ECG) signals in healthy subjects.

METHODS

Seventy-seven subjects were recruited for the study, including 36 young subjects (aged 23 to 32 years) and 41 older subjects (aged 44 to 72 years) with no reported ocular and cardiovascular abnormalities and free of any systemic diseases. Corneal indentation pulse was measured with a noninvasive ultrasonic distance sensor. Simultaneously, BPL and ECG were acquired with a pulse oximeter placed on the earlobe and Eindhoven triangle setup, respectively. Correlation analysis was applied to identify the interactions between the parameters of the averaged signals, estimated with dedicated signal processing algorithms, for all subject measurements and separately for both considered groups.

RESULTS

Twenty-nine out of 41 older subjects showed evidence of a double peak-shaped CIP waveform that could be interpreted as ocular pulse dicrotism. None of the young subjects exhibited this phenomenon. For the young group, significant correlations (p < 0.05) were found between the CIP crest time of a single peak-shaped CIP waveform and the other shape parameters of the CIP, BPL, and ECG signals. Similarly, for the older group of subjects, significant corresponding correlations were only found between the preliminary crest time of a double peak-shaped CIP waveform.

CONCLUSIONS

Using noninvasive corneal indentation pulse measurement revealed, for the first time, an ocular pulse dicrotism. This might be a natural sign of aging or an early indication of hemodynamic aspects of cardiovascular diseases.

Effects and adverse events after CXL for keratoconus are independent of age: a 1-year follow-up study

PURPOSE

To compare the effect, failure rate and the risks of corneal cross-linking (CXL) in keratoconus patients aged ≥35 years to patients <35 years.

METHODS

In 141 eyes of 116 keratoconus patients we compared the changes in best phoropter-corrected visual acuity (BCVA) and maximum keratometry values (Kmax) before and 12 months after CLX in patients aged ≥35 years (n=34, 38 eyes) to the cohort of patients below 35 years of age.

RESULTS

Overall, CXL significantly improved BCVA from 0.487 logMAR (95% confidence interval (CI) 0.426-0.548) by -0.197 logMAR (95% CI -0.243 to -0.150; P<0.001) and reduced Kmax from 48.96 diopter (Dpt) by -1.33 Dpt (95% CI -1.85 to -0.81: P<0.001). Age ≥35 years had no effect on the changes of BCVA (-0.02 (95% CI -0.13 to 0.09); P=0.757) or Kmax (0.58 (95%CI -0.51 to 1.68); P=0.294) as compared with younger patients. In 54 patients (55 eyes, 38.5%) aged <35 years and in 18 patients (18 eyes, 47.4%) aged ≥35 years, BCVA increased by ≥2 Snellen lines. Failure (increase in Kmax ≥1 Dpt) was observed in 17 eyes (16.5%) of patients aged <35 years and in 3 eyes (7.9%) of patients aged ≥35 years during the 12-month follow-up period. Adverse outcomes (loss of ≥2 Snellen lines) occurred in 4 (3.9%) eyes of patients aged <35 years and 1 (2.6%) eye of a patient aged ≥35 years.

CONCLUSION

Effects and adverse events of CXL treatment do not seem to differ between subjects younger or older than 35 years.

Age-related decrease in human corneal γ-glutamyltranspeptidase activity

PURPOSE

To investigate age-related effects on human corneal γ-glutamyltranspeptidase (GGT) (ectoenzyme important to maintaining corneal hydration and antioxidant potential via glutathione recapture).

METHODS

Age-related differences between total, endothelial, and epithelial GGT activity and endothelial cell density were determined for corneas from 29 donors (mean age, 53 ± 17 years; age range, 13-83 years). GGT activity was determined using a standard colorimetric assay based on the transpeptidation reaction. Corneal GGT localization and expression was determined by immunohistochemistry.

RESULTS

Total corneal, endothelial, and epithelial GGT activities in the young (<50 years) donor corneas were 37% (P = 0.02), 44% (P = 0.001), and 36% (P = 0.06) higher, respectively, than in the senior (≥50 years) corneas. The age-related rates of decline for GGT activity were 1.0 unit per year for total cornea, 0.4 to 0.5 unit per year for endothelium, and 0.3 to 0.4 unit per year for epithelium. Notably, endothelial cell density in the young corneas was 14% (P = 0.001) higher than in the senior corneas declining about 100 cells per square millimeter per decade (0.3% per year). GGT activity per 10 endothelial cells decreased at about 0.2 units per year and GGT activity per 10 endothelial cells in the young corneas was 41% higher (P = 0.01) than in the senior corneas. Fewer immunoreactive GGT-positive epithelial cells were detected in senior cornea.

CONCLUSION

The age-related loss of human corneal GGT activity was associated with reductions in endothelial and epithelial GGT activity, being because of reduced number of GGT-positive endothelial and epithelial cells and reduced GGT activity per endothelial cell.

Comparison of the new rebound tonometer with Goldmann applanation tonometer in a clinical setting

PURPOSE

To evaluate the clinical usefulness of a new rebound tonometer, Icare(®) PRO (Icare PRO), by comparison with Goldmann applanation tonometry (GAT) in a study on patients with glaucoma.

METHODS

One hundred and seventy-two eyes of 86 subjects were enrolled in this study. All of the subjects were examined with an autorefractometer, Icare PRO, slit-lamp biomicroscope, GAT, ultrasound A-scan and pachymeter. Three intraocular pressure (IOP) measurements were obtained by Icare PRO and GAT. The intraobserver reliabilities were established by calculating the intraclass correlation coefficients. The Bland-Altman plot was used to compare the Icare PRO and GAT.

RESULTS

There was a good correlation between the IOP measurement by GAT and that by Icare PRO (r = 0.6995, p < 0.001). The intraclass correlation coefficients of Icare PRO and GAT were 0.778 and 0.955, respectively. The IOP differences between Icare PRO and GAT (mean: 1.92 mmHg; SD: 3.29 mmHg; 95% limit of agreement: -4.52 to 8.37 mmHg) did not vary over the wide range of central corneal thickness (p = 0.498), age (p = 0.248), axial length (p = 0.277) or spherical equivalent (p = 0.075).

CONCLUSIONS

Although IOP with Icare PRO was higher than that with GAT, especially at lower GAT IOP value, Icare PRO was found to be a reliable method and showed a good correlation with GAT. The IOP difference between Icare PRO and GAT was not affected by the central corneal thickness, age, axial length or spherical equivalent. Icare PRO can be expected not only to be a good screening tool but also to be a good substitute for GAT.

Development of diagnostic and treatment strategies for glaucoma through understanding and modification of scleral and lamina cribrosa connective tissue

Considerable evidence indicates that the state of ocular connective tissues and their response in glaucomatous disease affect the degree of glaucoma damage. Both experimental and clinical data suggest that improved diagnostic and prognostic information can be derived from the assessment of the mechanical responsiveness of the sclera and lamina cribrosa to intraocular pressure (IOP). Controlled mutagenesis of the sclera has produced a mouse strain that is relatively resistant to increased IOP. Alteration of the baseline scleral state can be accomplished through either increased cross-linking of fibrillar components or their reduction. The sclera is a dynamic structure, altering its structure and behavior in response to IOP change. The biochemical pathways that control these responses are fertile areas for new glaucoma treatments.

Corneal cross-linking in 9 horses with ulcerative keratitis

BACKGROUND

Corneal ulcers are one of the most common eye problems in the horse and can cause varying degrees of visual impairment. Secondary infection and protease activity causing melting of the corneal stroma are always concerns in patients with corneal ulcers. Corneal collagen cross-linking (CXL), induced by illumination of the corneal stroma with ultraviolet light (UVA) after instillation of riboflavin (vitamin B2) eye drops, introduces crosslinks which stabilize melting corneas, and has been used to successfully treat infectious ulcerative keratitis in human patients. Therefore we decided to study if CXL can be performed in sedated, standing horses with ulcerative keratitis with or without stromal melting.

RESULTS

Nine horses, aged 1 month to 16 years (median 5 years) were treated with a combination of CXL and medical therapy. Two horses were diagnosed with mycotic, 5 with bacterial and 2 with aseptic ulcerative keratitis. A modified Dresden-protocol for CXL could readily be performed in all 9 horses after sedation. Stromal melting, diagnosed in 4 horses, stopped within 24 h. Eight of nine eyes became fluorescein negative in 13.5 days (median time; range 4-26 days) days after CXL. One horse developed a bacterial conjunctivitis the day after CXL, which was successfully treated with topical antibiotics. One horse with fungal ulcerative keratitis and severe uveitis was enucleated 4 days after treatment due to panophthalmitis.

CONCLUSIONS

CXL can be performed in standing, sedated horses. We did not observe any deleterious effects attributed to riboflavin or UVA irradiation per se during the follow-up, neither in horses with infectious nor aseptic ulcerative keratitis. These data support that CXL can be performed in the standing horse, but further studies are required to compare CXL to conventional medical treatment in equine keratitis and to optimize the CXL protocol in this species.

Corneal biomechanics in iatrogenic ectasia and keratoconus: A review of the literature

The Ocular Response Analyzer (ORA) (Reichert Ophthalmic Instruments, Buffalo, NY) allows direct measurement of corneal biomechanical properties. Since its introduction, many studies have sought to elucidate the clinical applications of corneal hysteresis (CH) and corneal resistance factor (CRF). More recently, detailed corneal deformation signal waveform analysis (WA) has potentially expanded the diagnostic capabilities of the ORA. In this review, the role of CH, CRF, and WA are examined in keratoconus (KC) and iatrogenic ectasia (IE). The PubMed database was searched electronically for peer-reviewed literature in July 2012 and August 2012 without date restrictions. The search strategy included medical subject heading (MeSH) and natural language terms to retrieve references on corneal biomechanics, CH, CRF, corneal deformation signal WA, IE, and KC. The evidence suggests that while CH and CRF are poor screening tools when used alone, increased sensitivity and specificity of KC and IE screening result when these parameters are combined with tomography and topography. Recent advances in WA are promising, but little is currently understood about its biomechanical and clinical relevance. Future studies should seek to refine the screening protocols for KC and IE as well as define the clinical applicability of WA parameters.

Multimodal Highlighting of Structural Abnormalities in Diabetic Rat and Human Corneas

PURPOSE

This study aimed to highlight structural corneal changes in a model of type 2 diabetes, using in vivo corneal confocal microscopy (CCM). The abnormalities were also characterized by transmission electron microscopy (TEM) and second harmonic generation (SHG) microscopy in rat and human corneas.

METHODS

Goto-Kakizaki (GK) rats were observed at age 12 weeks (n = 3) and 1 year (n = 6), and compared to age-matched controls. After in vivo CCM examination, TEM and SHG microscopy were used to characterize the ultrastructure and the three-dimensional organization of the abnormalities. Human corneas from diabetic (n = 3) and nondiabetic (n = 3) patients were also included in the study.

RESULTS

In the basal epithelium of GK rats, CCM revealed focal hyper-reflective areas, and histology showed proliferative cells with irregular basement membrane. In the anterior stroma, extracellular matrix modifications were detected by CCM and confirmed in histology. In the Descemet's membrane periphery of all the diabetic corneas, hyper-reflective deposits were highlighted using CCM and characterized as long-spacing collagen fibrils by TEM. SHG microscopy revealed these deposits with high contrast, allowing specific detection in diabetic human and rat corneas without preparation and characterization of their three-dimensional organization.

CONCLUSION

Pathologic findings were observed early in the development of diabetes in GK rats. Similar abnormalities have been found in corneas from diabetic patients.

TRANSLATIONAL RELEVANCE

This multidisciplinary study highlights diabetes-induced corneal abnormalities in an animal model, but also in diabetic donors. This could constitute a potential early marker for diagnosis of hyperglycemia-induced tissue changes.

Corneal crosslinking with riboflavin and ultraviolet A. I. Principles

Changes in the biomechanical properties of the human cornea play an important role in the pathogenesis of corneal ectatic diseases. Biomechanical investigation shows significant differences between human ectatic corneas and normal corneas, including decreased stiffness and reduction of collagen crosslinks in the ectatic cornea. Induction of crosslinks is a well-established procedure in polymer chemistry to increase the elastic modulus of materials. Crosslinking (CXL) in connective tissue can occur during aging and as a side effect of diabetes mellitus. CXL has been used medically to increase stability and reduce the biodegradation of collagen-based biomaterials for bioprostheses. CXL of the cornea using riboflavin and UVA light with a wavelength of 370 nm and a dosage of 5.4 J/cm² is a new approach that increases the mechanical and biochemical stability of stromal tissue. This technique combines the principles of CXL (chemical and nonenzymatic) and the biochemical mechanisms of photo-oxidative CXL with riboflavin as a photosensitizer. In this review, the enrichment of riboflavin in the stroma by standard (epi-off) and transepithelial (epi-on) CXL is discussed. The theoretical and experimental measurements of the absorption of UV light explain the stronger CXL effect in the anterior stroma and its importance for the prevention of damage to the endothelial cells. UV devices are described. Changes of the physical properties after CXL, as well as the cellular changes, are discussed. From these basic investigations, treatment parameters for effective and safe CXL are identified.

The effect of riboflavin/UVA collagen cross-linking therapy on the structure and hydrodynamic behaviour of the ungulate and rabbit corneal stroma

Purpose

To examine the effect of riboflavin/UVA corneal crosslinking on stromal ultrastructure and hydrodynamic behaviour.

Methods

One hundred and seventeen enucleated ungulate eyes (112 pig and 5 sheep) and 3 pairs of rabbit eyes, with corneal epithelium removed, were divided into four treatment groups: Group 1 (28 pig, 2 sheep and 3 rabbits) were untreated; Group 2 (24 pig) were exposed to UVA light (3.04 mW/cm²) for 30 minutes and Group 3 (29 pig) and Group 4 (31 pig, 3 sheep and 3 rabbits) had riboflavin eye drops applied to the corneal surface every 5 minutes for 35 minutes. Five minutes after the initial riboflavin instillation, the corneas in Group 4 experienced a 30 minute exposure to UVA light (3.04 mW/cm²). X-ray scattering was used to obtain measurements of collagen interfibrillar spacing, spatial order, fibril diameter, D-periodicity and intermolecular spacing throughout the whole tissue thickness and as a function of tissue depth in the treated and untreated corneas. The effect of each treatment on the hydrodynamic behaviour of the cornea (its ability to swell in saline solution) and its resistance to enzymatic digestion were assessed using in vitro laboratory techniques.

Results

Corneal thickness decreased significantly following riboflavin application (p<0.01) and also to a lesser extent after UVA exposure (p<0.05). With the exception of the spatial order factor, which was higher in Group 4 than Group 1 (p<0.01), all other measured collagen parameters were unaltered by cross-linking, even within the most anterior 300 microns of the cornea. The cross-linking treatment had no effect on the hydrodynamic behaviour of the cornea but did cause a significant increase in its resistance to enzymatic digestion.

Conclusions

It seems likely that cross-links formed during riboflavin/UVA therapy occur predominantly at the collagen fibril surface and in the protein network surrounding the collagen.

Inhibition effect of curcumin on TNF-α and MMP-13 expression induced by advanced glycation end products in chondrocytes

AIMS

Accumulation of advanced glycation end products (AGEs) plays a pivotal role in the mechanism by which aging contributes to osteoarthritis (OA). In the present study, we examined the effect of curcumin, a pharmacologically safe phytochemical agent, on AGE-induced tumor necrosis factor-α (TNF-α) and matrix metalloproteinase-13 (MMP-13) in rabbit chondrocytes.

METHODS

Chondrocytes were derived from rabbit articular cartilage by enzymatic digestion. TNF-α and MMP-13 mRNA was monitored by RT-PCR. TNF-α protein was determined using cytokine-specific ELISA. The reactive oxygen species was determined by the fluorescent probe 29,79-dichlorofluorescein diacetate. The phosphorylation and nuclear translocation of the nuclear factor-ĸB (NF-ĸB) system were studied by Western blot and immunofluorescence respectively.

RESULTS

Curcumin significantly decreased AGE-stimulated TNF-α and MMP-13 mRNA and suppressed the NF-ĸB activation via inhibition of ĸBα (I-ĸBα) phosphorylation, I-ĸBα degradation and p65 nuclear translocation.

CONCLUSIONS

These novel pharmacological actions of curcumin on AGE-stimulated chondrocytes provide new suggestions that curcumin has nutritional potential as a naturally occurring anti-inflammatory agent for treating OA.

Age-related variations in the biomechanical properties of human sclera

This study examined age-related changes in biomechanical behaviour in the anterior, equatorial and posterior regions of the human sclera (white of the eye). Circumferential strip specimens were extracted from areas close to the limbus, equator and posterior pole in 45 donor scleras ranging in age between 51 and 84 years. The strips were subjected to cycles of uniaxial tension loading at a strain rate of 8% per minute while monitoring their load-deformation behaviour. All specimens demonstrated nonlinear behaviour with an initially low tangent modulus (a measure of material stiffness) increasing under higher stresses. The average ratios between the tangent modulus at a high stress of 1 MPa and that at a low stress of 0.05 MPa were 11.2±1.7, 12.0±1.7 and 12.4±1.5 for anterior, equatorial and posterior specimens, respectively. Stiffening was observed with age in all regions, but it was statistically significant only in the anterior region (P<0.01). Anterior specimens showed the largest stiffness growth with advancing age in both the initial, matrix regulated phase of behaviour (0.32 MPa/decade), and the final, collagen regulated phase (3.97 MPa/decade), followed by equatorial (0.27 and 2.15 MPa/decade) then posterior specimens (0.14 and 0.26 MPa/decade). The stress-strain behaviour of scleral tissue exhibits increasing stiffness with higher age. In addition to a regional variation of material stiffness, the rate of stiffness growth with age also varies between regions.

Relative importance of factors affecting corneal hysteresis measurement

PURPOSE

To evaluate the relative influences of several demographic, ocular, and systemic parameters on corneal hysteresis (CH).

METHODS

This is a prospective, observational, cross-sectional study using subjects recruited from consecutive Albuquerque VAMC eye clinic patients. We classified eligible subjects as primary open-angle glaucoma (POAG), ocular hypertension, glaucoma suspect, or normal. We used the Ocular Response Analyzer, Pascal Dynamic Contour Tonometer, and Goldmann applanation tonometer to obtain intraocular pressure (IOP), CH, corneal resistance factor, and ocular pulse amplitude values. We also obtained corneal curvature, central corneal thickness (CCT), axial length, retinal nerve fiber layer thickness, clinical cup/disc ratio (CDR) estimates, and standard automated perimetry metrics (mean defect, pattern standard deviation). We gathered glycosylated hemoglobin (A1C) data through chart review. Multivariate regression analyses were used to determine independent relationships between CH and the other parameters.

RESULTS

Three hundred seventeen eyes in 317 subjects were studied (116 POAG, 87 ocular hypertension, 47 glaucoma suspect, and 67 normal). In univariate regression analysis, CH varied directly with CCT (β = 0.39, p < 0.001), corneal curvature (β = 0.16, p = 0.01), corneal resistance factor (β = 0.57, p < 0.001), A1C (β = 0.15, p = 0.01), mean defect (β = 0.29, p < 0.001), and retinal nerve fiber layer (β = 0.31, p < 0.001). Factors inversely related to CH were age (β = -0.22, p < 0.001), IOP (β = -0.29, p < 0.001), ocular pulse amplitude (β = -0.11, p = 0.04), CDR (β = -0.34, p < 0.001), and pattern standard deviation (β = -0.29, p < 0.001). CH was lower in POAG compared with the other diagnostic groups. In multivariate analysis, CH was independently associated with age, IOP, CCT, A1C, glaucoma diagnosis, and CDR. Of these factors, CCT and IOP demonstrated twice as much influence on CH compared with the other four factors.

CONCLUSIONS

Although this study identified six separate variables that independently influence CH values, the overall r value indicates that these variables together only explain 40% of CH variability. These results suggest that other significant sources of variability exist and deserve investigation.

Birefringence of the central cornea in children assessed with scanning laser polarimetry

Corneal birefringence is a well-known confounding factor with all polarization-sensitive technology used for retinal scanning and other intraocular assessment. It has been studied extensively in adults, but little is known regarding age-related differences. Specifically, no information is available concerning corneal birefringence in children. For applications that are geared towards children, such as retinal birefringence scanning for strabismus screening purposes, it is important to know the expected range of both corneal retardance and azimuth in pediatric populations. This study investigated central corneal birefringence in children (ages three and above), by means of scanning laser polarimetry (GDx-VCC™, Carl Zeiss Meditec, Inc.). Children's measures of corneal retardance and azimuth were compared with those obtained in adults. As with previous studies in adults, corneal birefringence was found to vary widely in children, with corneal retardance ranging from 10 to 77 nm, and azimuth (slow axis) ranging from -11° to 71° (measured nasally downward). No significant differences in central corneal birefringence were found between children and adults, nor were significant age-related differences found in general. In conclusion, establishing knowledge of the polarization properties of the central cornea in children allows better understanding, exploitation, or bypassing of these effects in new polarization-sensitive pediatric ophthalmic applications.

Biomechanical and Refractive Results of Transepithelial Cross-linking Treatment in Keratoconic Eyes

Purpose

To analyze change in visual acuity (VA), refractive outcomes, corneal compensated intraocular pressure (IOPcc), corneal hysteresis (CH) and cornea resistance factor (CRF) after transepithelial cross-linking (CXL) treatment.

Setting

Kudret Eye Hospital, Ankara, Turkey

Materials and methods

A total of 32 eyes of 22 patients diagnosed with keratoconus were included in this retrospective study. Changes in VA, spheric and cylinderic refraction for all eyes were analyzed before and 3 months after transepithelial CXL. In addition, a subset of 14 eyes had data acquired using the ocular response analyzer (ORA), and for these eyes, IOPcc, CH and CRF were recorded as well as a measurement of the amplitude of the first peak in the infrared signal (peak 1), used to identify the inward applanation event. The ORA parameters were also compared before and 3 months after treatment.

Results

Uncorrected and best corrected VA increased 1.76 and 1.61 Snellen lines (p < 0.05); spheric and cylinderic refractions improved 0.74 and 0.43 D (p > 0.05) respectively. Mean changes in IOPcc, CRF and CH were not significantly different (p > 0.05). However, mean peak 1 signal value increased significantly (p < 0.05).

Conclusion

Transepithelial CXL is effective in VA improvement in the short-term with an increase in the peak 1 signal value which is consistent with an increase in stiffness of cornea, whereas IOPcc, CRF and CH values remained the same.

How to cite this article

Klllç A, Roberts CJ. Biomechanical and Refractive Results of Transepithelial Cross-linking Treatment in Keratoconic Eyes. Int J Kerat Ect Cor Dis 2012;1(2):75-78.

Cross-linking with ultraviolet-a and riboflavin reduces corneal permeability

PURPOSE

To investigate the effect of cross-linking treatment on corneal permeability in a live animal model.

METHODS

Rabbit eyes were selected at random to be left unoperated or to undergo epithelial debridement with or without treatment consisting of cross-linking (CXL) with riboflavin and ultraviolet-A. Nine eyes received a total dose of 3.6 J/cm² and after epithelial healing the corneas were placed in a two-chamber system for quantification of the diffusion of fluorescein compared with controls. Thirty eyes received a total dose of 5.4 J/cm² and, after epithelial healing, in vivo corneal permeability was quantified as the pupillary response over a 30-minute period to a dose of topical pilocarpine compared with controls.

RESULTS

In the ex vivo assay, the mean permeability coefficient in the CXL group (2.42 × 10⁻⁷) was reduced when compared with the unoperated controls (3.73 × 10⁻⁷; P = 0.007) and to the eyes that received epithelial debridement alone (3.74 × 10⁻⁷; P = 0.01). In the in vivo permeability assay, the change in pupillary diameter at 30 minutes after pilocarpine administration was smaller in the CXL group (-1.9 mm), compared with the epithelial debridement group (-2.6 mm; P < 0.001) and with the unoperated controls (-2.7 mm; P = 0.003).

CONCLUSIONS

Corneal cross-linking with ultraviolet-A and riboflavin results in a statistically significant reduction in corneal permeability. These findings suggest that dosing of topical medications may need to be increased in eyes with a history of CXL to achieve expected therapeutic effects, and they may have implications for the long-term health of the cornea.

Variance of speed of sound and correlation with acoustic impedance in canine corneas

The clinical standard for measuring corneal thickness is ultrasound pachymetry that assumes a constant speed of sound. The purpose of this study was to examine the variance of speed of sound and its relationship with acoustic impedance in healthy eyes of canines with a large age span. Corneal speed of sound and acoustic impedance were measured in 34 canine eyes at room temperature (21 ± 1°C). The mean speed of sound was 1577 ± 10 m/s ranging from 1553 to 1594 m/s. There was a strong correlation between speed of sound and acoustic impedance (R = 0.84, p < 0.001). Corneal speed of sound had a small variance in healthy canines over 1-year-old, but was significantly lower in younger canines suggesting an age effect. The strong correlation between corneal speed of sound and acoustic impedance may offer a potential means to noninvasively detect abnormal speed of sound for more accurate corneal thickness estimation.

Ultraviolet light-induced cyclobutane pyrimidine dimers in rabbit eyes

Sunlight exposure of the eye leads to pathologies including photokeratitis, cortical cataracts, pterygium, actinic conjunctivitis and age-related macular degeneration. It is well established that exposure to ultraviolet (UV) radiations leads to DNA damage, mainly cyclobutane pyrimidine dimers (CPDs). CPD formation is the principal factor involved in skin cancer. However, the exact mechanism by which sunlight induces ocular pathologies is not well understood. To shed light on this issue, we quantified the CPD formation onto DNA of rabbit ocular cells following UVB exposure. We found that CPDs were induced only in the structures of the ocular anterior chamber (cornea, iris and lens) and were more concentrated in the corneal epithelium. Residual UVB that pass through the cornea are completely absorbed by the anterior layers of the iris. CPDs were also detected in the central portion of the lens that is not protected by the iris (pupil). By determining the UV-induced DNA damage formation in eyes, we showed that anterior ocular structures are a reliable physical barrier that protects the subjacent structures from the toxic effects of UV. Although the corneal epithelium is the structure where most of the CPDs were detected, no cancer is related to solar exposure.

The role of nonenzymatic glycation and carbonyls in collagen cross-linking for the treatment of keratoconus

PURPOSE

Corneal cross-linking (CXL) is a treatment for keratoconus that eliminates the need for keratoplasty in most patients. However, its molecular mechanisms remain under study. Advanced glycation end products (AGEs) have been suggested by many studies as the causative strengthening agent during CXL, though no studies to date have directly tested this hypothesis.

METHODS

Corneas of young rabbits and sharks were pretreated with pyridoxal hydrochloride and copper ions before CXL. Two known inhibitors of AGE formation, aminoguanidine and rifampicin, were applied during CXL in the treatment solution. Tensile strength tests were conducted after these experiments to detect diminished or accentuated corneal stiffening after CXL. SDS-PAGE was performed on type I collagen cross-linked in the absence and presence of AGE inhibitors.

RESULTS

Pretreatment with pyridoxal hydrochloride resulted in significantly higher corneal stiffening after CXL. AGE inhibitors significantly diminished cross-linking as detected by both tensile strength measurements using whole corneas and gel electrophoresis of in vitro cross-linking of type I collagen in solution, in the presence and absence of the inhibitors. Rifampicin inhibited CXL more significantly than aminoguanidine in gel electrophoresis and tensile strength tests, confirming recent findings on its efficacy as an AGE inhibitor.

CONCLUSIONS

Data presented here suggest that CXL is carbonyl dependent and involves the formation of AGE cross-links. Six possible cross-linking mechanisms are discussed.

Riboflavin/UVA collagen cross-linking-induced changes in normal and keratoconus corneal stroma

Purpose

To determine the effect of Ultraviolet-A collagen cross-linking with hypo-osmolar and iso-osmolar riboflavin solutions on stromal collagen ultrastructure in normal and keratoconus ex vivo human corneas.

Methods

Using small-angle X-ray scattering, measurements of collagen D-periodicity, fibril diameter and interfibrillar spacing were made at 1 mm intervals across six normal post-mortem corneas (two above physiological hydration (swollen) and four below (unswollen)) and two post-transplant keratoconus corneal buttons (one swollen; one unswollen), before and after hypo-osmolar cross-linking. The same parameters were measured in three other unswollen normal corneas before and after iso-osmolar cross-linking and in three pairs of swollen normal corneas, in which only the left was cross-linked (with iso-osmolar riboflavin).

Results

Hypo-osmolar cross-linking resulted in an increase in corneal hydration in all corneas. In the keratoconus corneas and unswollen normal corneas, this was accompanied by an increase in collagen interfibrillar spacing (p<0.001); an increase in fibril diameter was also seen in two out of four unswollen normal corneas and one unswollen keratoconus cornea (p<0.001). Iso-osmolar cross-linking resulted in a decrease in tissue hydration in the swollen normal corneas only. Although there was no consistent treatment-induced change in hydration in the unswollen normal samples, iso-osmolar cross-linking of these corneas did result in a compaction of collagen fibrils and a reduced fibril diameter (p<0.001); these changes were not seen in the swollen normal corneas. Collagen D-periodicity was not affected by either treatment.

Conclusion

The observed structural changes following Ultraviolet-A cross-linking with hypo-osmolar or iso-osmolar riboflavin solutions are more likely a consequence of treatment-induced changes in tissue hydration rather than cross-linking.

Collagen cross-linking: Strengthening the unstable cornea

Corneal ectasia, a weakening of corneal integrity, occurs both due to acquired and congenital conditions such as keratoconus. It is a progressing condition that affects both visual acuity, and corneal stability. Various methods exist for correcting this impairment, however none address the inherit pathology, an increase laxity of the corneal stroma. Collagen cross-linking, a new, minimally invasive method, aims to strengthen the stroma by inducing cross links between neighboring collagen fibers. This method results in an increase in corneal tensile strength, with no medium term adverse effects on its normal architecture. Clinically, treated patients display improvement in both visual acuity and keratometric readings. This method may provide clinicians with easily accessible tools to stop the progression, and even correct visual deterioration due to corneal ectasia. Here we review the current information regarding this new method, as well as discuss its potential benefits and downfalls.

Determinants of corneal biomechanical properties in an adult Chinese population

PURPOSE

To investigate variations in corneal hysteresis (CH) and corneal resistance factor (CRF) and their ocular and systemic associations in Chinese adults.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

We included 1136 subjects of Chinese origin from an ongoing population-based study.

METHODS

All subjects in this population-based study underwent a standardized ocular examination including keratometry (corneal radius of curvature), intraocular pressure (IOP) measurement with Goldmann applanation tonometry, central corneal thickness (CCT), and axial length (AL) assessments. The CH and CRF were measured with the Ocular Response Analyzer. Participants underwent a detailed interview and laboratory investigations that included estimation of nonfasting serum glucose, glycosylated hemoglobin, and lipid profile.

MAIN OUTCOME MEASURES

We assessed CH, CRF, and their associations with demographic, ocular, and systemic factors.

RESULTS

The mean age of study subjects was 55.3±8.4 years and 51.2% were females. The mean CH and CRF were 10.6±1.5 and 10.1±1.6 mmHg, respectively. Women had higher mean CH (10.8 vs 10.4 mmHg; P<0.001) and CRF (10.4 vs. 9.8 mmHg; P<0.001) than men. After adjusting for age, gender, IOP, CCT, keratometry, AL, and diabetes, CH was negatively associated with age (β = -0.034; P<0.001), IOP (β = -0.037; P = 0.01), corneal radius of curvature (β = -0.963; P<0.001), and AL (β = -0.106; P = 0.001); and positively associated with female gender (β = 0.308; P<0.001) and CCT (β = 0.020; P<0.001). The CRF showed a negative association with age (β = -0.023; P<0.001) and corneal radius of curvature (β = -0.771; P<0.001), and was positively associated with female gender (β = 0.368; P<0.001), IOP (β = 0.134; P<0.001) and CCT (β = 0.024; P<0.001). Subjects with diabetes had a higher CH (β = 0.324; P<0.001) and CRF (β = 0.396; P = 0.002) compared with those without diabetes.

CONCLUSIONS

With advancing age, the CH and CRF in adult Chinese decreased. Women and subjects with diabetes had greater CH and CRF. Corneal biomechanical properties of hysteresis and resistance factor are significantly influenced by IOP, CCT, corneal radius of curvature, and AL.

Characterization of age-related variation in corneal biomechanical properties

An experimental study has been conducted to determine the stress-strain behaviour of human corneal tissue and how the behaviour varies with age. Fifty-seven well-preserved ex vivo donor corneas aged between 30 and 99 years were subjected to cycles of posterior pressure up to 60 mm Hg while monitoring their behaviour. The corneas were mechanically clamped along their ring of scleral tissue and kept in physiological conditions of temperature and hydration. The tissue demonstrated hyper-elastic pressure-deformation and stress-strain behaviour that closely matched an exponential trend. Clear stiffening (increased resistance to deformation) with age was observed in all loading cycles, and the rate of stiffness growth was nonlinear with bias towards older specimens. With a strong statistical association between stiffness and age (p < 0.05), it was possible to develop generic stress-strain equations that were suitable for all ages between 30 and 99 years. These equations, which closely matched the experimental results, depicted corneal stiffening with age in a form suitable for implementation in numerical simulations of ocular biomechanical behaviour.

Collagen cross-linking: a new treatment paradigm in corneal disease - a review

The last 2 years has seen a marked increase in the prominence of corneal collagen cross-linking as a treatment strategy for progressive keratoconus. This interest has arisen from a body of laboratory evidence documenting the biomechanical and cellular changes induced by cross-linking. The findings of this research provide a plausible rationale for its use in keratoconus to retard the progression of this common disease. The rapidly growing number of clinical reports suggests, not only a consistent stabilizing effect of cross-linking, but that a variable improvement in corneal shape and visual function may also occur in some patients. However, the marked variation in the clinical course of keratoconus, together with the challenges of accurately evaluating refractive error, visual acuity and even corneal shape in this condition, demands further evidence from randomized controlled clinical trials. The aim of this review is to summarize the theoretical basis and risks of corneal collagen cross-linking, along with the available evidence for its use in keratoconus and other corneal disease states.

Intraocular pressure measurement precision with the Goldmann applanation, dynamic contour, and ocular response analyzer tonometers

OBJECTIVE

To examine the repeatability and reproducibility of intraocular pressure (IOP) measurements obtained with the Goldmann applanation tonometer (GAT), the Pascal dynamic contour tonometer (DCT; Swiss Microtechnology AG, Port, Switzerland), and the Reichert Ocular Response Analyzer (ORA; Reichert Ophthalmic Instruments, Buffalo, NY). A secondary objective was to assess agreement between the devices.

DESIGN

Evaluation of technology.

PARTICIPANTS

One hundred participants; a mixture of glaucoma suspects, patients, and control volunteers.

METHODS

The IOP measurements were obtained with the GAT, DCT, and ORA by 2 of 3 experienced clinicians. Keratometry (CC) measurements were made using the IOLMaster (Carl Zeiss Meditech, AG, Jena, Germany). Three ORA corneal compensated IOP (IOPcc) measurements were obtained before the instillation of anesthesia, after which 2 GAT IOP and 3 DCT IOP measurements were obtained in a randomized order. Central corneal thickness (CCT) was measured using an ultrasound pachymeter. The average ORA corneal response factor (CRF) and the average DCT ocular pulse amplitude (OPA) were determined. Intraobserver variability was calculated by the repeatability coefficient. Interobserver variability (measurement reproducibility) and device agreement were calculated by Bland-Altman analysis (mean difference [bias] and 95% limits of agreement [LoA]). The effect of corneal characteristics (CC, CCT, and CRF) on the IOP measurement differences between tonometers also was determined.

MAIN OUTCOME MEASURES

Repeatability and reproducibility of the GAT, DCT, and ORA IOPcc and agreement between tonometers.

RESULTS

The repeatability coefficients for GAT, DCT, and ORA were 2.2, 2.3, and 4.3 mmHg, respectively. The intraobserver variability of ORA measurements was shown to be significantly associated with OPA and to a lesser degree with the quality of ORA waveform scans. The interobserver bias (95% LoA) was -0.8 (+/-3.9) mmHg for GAT -0.2 (+/-2.8) mmHg for DCT and -0.3 (+/-3.9) mmHg for ORA IOPcc. On average, GAT under-read both DCT and ORA IOP measurements by approximately 2 mmHg. The IOP measurement differences were better predicted by CRF than CCT.

CONCLUSIONS

The DCT shows excellent measurement precision, displaying the best repeatability and reproducibility of the 3 tonometers. Corneal stiffness, as defined using CRF, was associated significantly with agreement between devices. The IOP measurements with each device are not interchangeable.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Effect of aging on corneal biomechanical parameters using the ocular response analyzer

PURPOSE

To assess the effect of aging on corneal biomechanical parameters in a normal population.

METHODS

We prospectively examined 204 normal eyes of 204 healthy Japanese volunteers (68 men, 136 women; mean age 46.7+/-19.4 years [range: 19 to 89 years]). Corneal hysteresis, corneal resistance factor, corneal-compensated intraocular pressure (IOP(cc)), and Goldmann-correlated intraocular pressure (IOP(G)) were qualitatively assessed using a Reichert Ocular Response Analyzer. Central corneal thickness was measured using an ultrasound pachymeter. This measurement was performed 3 times, and the mean value obtained was used for statistical analysis. The relationships between patient age and corneal biomechanical parameters, or age and intraocular pressure (IOP), were investigated.

RESULTS

Mean corneal hysteresis and corneal resistance factor were 10.1+/-1.5 mmHg and 10.1+/-1.6 mmHg, respectively. Mean central corneal thickness was 539.1+/-30.9 microm. A weak, but significant, negative correlation was found between age and corneal hysteresis (Pearson's correlation coefficient r=-0.17, P=.02) and corneal resistance factor (r=-0.18 P=.01). On the other hand, no significant correlation was found between age and central corneal thickness (r=-0.06, P=.41), age and IOP(cc) (r=-0.02, P=.82), or age and IOP(G) (r=-0.11, P=.11).

CONCLUSIONS

Corneal biomechanical parameters are significantly decreased by aging without significant changes in central corneal thickness or IOP, suggesting that age-related structural changes resulting from collagen cross-linking may lead to a reduction of corneal biomechanical variables independent of central corneal thickness or IOP.

Assessment of Corneal Biomechanical Properties and Their Variation with Age

PURPOSE

The aim of this study was to determine the stress-strain behavior of corneal tissue and how the behavior was affected by age.

METHODS

Human corneal specimens ranging in age between 50 and 95 years were tested under inflation conditions to determine their stress-strain behavior. The corneas were subjected to two load rates that represent dynamic and static loading conditions. The pressure-deformation results were analyzed using shell theory to derive the stress-strain behavior.

RESULTS

The corneas demonstrated clear nonlinear behavior with an initial low stiffness stage and a final high stiffness stage. The transition between the two stages coincided with intraocular pressures between 12 and 20 mmHg. There was a considerable increase in stiffness associated with both age and load rate. Equations were derived to describe the nonlinear stress-strain relationship of corneal tissue for any age between 50 and 95 years, and these equations are presented in a form suitable for use in numerical simulations.

CONCLUSIONS

The cornea demonstrates considerable stiffening with age with the behavior closely fitting an exponential power function typical of collagenous tissue. The increase in stiffness could be related to the additional age-related nonenzymatic cross-linking affecting the stromal collagen fibrils.

Corneal collagen-its role in maintaining corneal shape and transparency

Corneal collagen has a number of properties that allow it to fulfil its role as the main structural component within the tissue. Fibrils are narrow, uniform in diameter and precisely organised. These properties are vital to maintain transparency and to provide the biomechanical prerequisites necessary to sustain shape and provide strength. This review describes the structure and arrangement of corneal collagen from the nanoscopic to the macroscopic level, and how this relates to the maintenance of the form and transparency of the cornea.

The role of advanced glycation end products in retinal ageing and disease

The retina is exposed to a lifetime of potentially damaging environmental and physiological factors that make the component cells exquisitely sensitive to age-related processes. Retinal ageing is complex and a raft of abnormalities can accumulate in all layers of the retina. Some of this pathology serves as a sinister preamble to serious conditions such as age-related macular degeneration (AMD) which remains the leading cause of irreversible blindness in the Western world. The formation of advanced glycation end products (AGEs) is a natural function of ageing but accumulation of these adducts also represents a key pathophysiological event in a range of important human diseases. AGEs act as mediators of neurodegeneration, induce irreversible changes in the extracellular matrix, vascular dysfunction and pro-inflammatory signalling. Since many cells and tissues of the eye are profoundly influenced by such processes, it is fitting that advanced glycation is now receiving considerable attention as a possible pathogenic factor in visual disorders. This review presents the current evidence for a pathogenic role for AGEs and activation of the receptor for AGEs (RAGE) in initiation and progression of retinal disease. It draws upon the clinical and experimental literature and highlights the opportunities for further research that would definitively establish these adducts as important instigators of retinal disease. The therapeutic potential for novel agents that can ameliorate AGE formation of attenuate RAGE signalling in the retina is also discussed.

Effects of laser irradiation on collagen organization in chemically induced degenerative annulus fibrosus of lumbar intervertebral disc

BACKGROUND AND OBJECTIVE

The number of in vitro experimental studies was carried out with the use of intact tissues to establish a mechanism of laser-tissue interaction. However, in the process of degeneration, both biochemical composition and behavior of the disc were altered drastically. The objective of this study was to evaluate the role of the main matrix components in laser modification of annulus fibrosus (AF) under IR laser irradiation.

STUDY DESIGNS/MATERIALS AND METHODS

The samples of AF in a motion segment after hyaluronidase treatment, trypsin digestion and glycation by glyceraldehyde were heated in hydrothermal bath (95 degrees C, 2 min) or irradiated by laser at 1.56 microm. Specimens were imaged by cross-polarization optical coherence tomography (CP-OCT), and then analyzed by differential scanning calorimery (DSC).

RESULTS AND DISCUSSION

According to CP-OCT and DSC data non-significant alteration was revealed in AF after hyaluronidase treatment, glycation led to stabilization of annulus collagen and trypsin digestion resulted in a noticeable impairment of collagen fibrils. Laser treatment induced subsequent damages of AF matrix but these damages cannot be explained by laser heating only. The specificity of chemical modification of AF matrix has an influence on a character of collagen network alteration due to IR laser effect. Minimal and maximal alterations are observed for hyaluronidase and trypsin treated samples respectively. Glyceraldehyde fixed samples showed failure of the collagen structure after moderate laser treatment; at the same time thermal denaturation of collagen macromolecules was negligible. We assume that a mechanical effect of laser irradiation plays an important role in laser-induced annulus collagen modification and propose the scheme of physico-chemical process occurring under non-uniform IR laser treatment in AF tissue.

CONCLUSION

CP-OCT and DSC techniques allow us to record the alteration of collagen network organization as a result of chemical modification. There were detected significant and specific effects of the biochemical composition and material properties on the response of AF collagen network on laser irradiation. The results go in accordance with our hypothesis that the primary effect of laser influence on collagen network under tension is the mechanical damage of collagen fiber.

Non-invasive biometric assessment of ocular rigidity in glaucoma patients and controls

PURPOSE

To determine in vivo whether a pharmacologically induced change in intraocular pressure (IOP) leads to measurable changes in axial eye length and whether there is a difference between glaucoma patients and control subjects.

METHODS

42 subjects (19 patients with primary open angle glaucoma and 23 control patients matched for age and gender) underwent axial eye length measurement using partial coherence laser interferometry and measurement of IOP using dynamic contour tonometry before and 2 h after oral intake of 500 mg acetazolamide. Student's t-test was used to compare differences in the means.

RESULTS

An identical drop in IOP was induced in both the glaucoma (mean+/-SEM: 2.90+/-0.44 mmHg, n=19) and the control group (mean+/-SEM: 3.17+/-0.32 mmHg, n=23). The change in axial eye length was significantly smaller (P=0.026) in the glaucoma group (mean+/-SEM: -14.2+/-3.2 microm, n=19) compared with the control group (mean+/-SEM: -23.0+/-2.98 microm, n=23).

CONCLUSIONS

Our results strongly suggest that the ocular rigidity is increased in patients with established glaucoma in comparison to control subjects. Ocular rigidity could play a role in the pathogenesis and pathophysiology of glaucoma. Determination of ocular rigidity could be helpful in detection of glaucoma.

Stabilization of scleral collagen by glycerol aldehyde cross-linking

The paper aims at the evaluation of prospects for using glyceraldehyde as a cross-linking agent for the scleral tissue. Stability parameters (denaturation temperature, Young's modulus, ultimate tensile stress, proteolytic resistance) and analytical parameter (fluorescence intensity) were determined during the glycation process of isolated rabbit sclera. The analysis of fluorescence spectral characteristic provided information about some glycation products. The glyceraldehyde treatment was resulted in a significant increase in thermal stability, proteolytic resistance and improvement of biomechanical characteristics (Young's modulus, ultimate tensile stress). Unique properties of the reaction between scleral collagen and glyceraldehyde are observed at short cross-linking times. The appearance of intermediate collagen fraction with lowest thermal and proteolytic stability was detected.