Hydration dependent viscoelastic tensile behavior of cornea

Determining the Relationship Between Corneal Stiffening and Tissue Dehydration After Corneal Cross-Linking

Purpose

To quantify corneal cross-linking (CXL)-induced stiffening via mechanical testing to estimate the impact of changes in hydration levels (H) and evaluate depth-dependent tissue hydration after CXL.

Methods

Eighty-three porcine corneal buttons were divided into three groups: Standard protocol CXL (S-CXL), accelerated CXL (A-CXL), and untreated (nonirradiated riboflavin-only) controls. Samples were hydrated or dehydrated to modulate H and dynamic mechanical analyzer compression tests were performed to measure Young's modulus (E). To extract the solid tissue network modulus, the cornea was modeled as a biphasic material after measuring E at different H. Corneal hydration was correlated with depth-dependent tissue thickness characterized by confocal reflection microscopy (CRM).

Results

Young's modulus increased fourfold after S-CXL (0.72 ± 0.1 MPa) and threefold after A-CXL E (0.53 ± 0.12 MPa) versus controls (0.17 ± 0.045 MPa). However, H decreased from 4.07 ± 0.35 in controls to 2.06 ± 0.2 after S-CXL and 2.79 ± 0.12 after A-CXL. After H modulation and biphasic mechanical modeling, Young's modulus for corneal solid tissue network showed only a 1.8-fold increase after S-CXL (2.25 MPa) and 1.5-fold increase after A-CXL (1.85 MPa) versus controls (1.22 MPa). With CRM, the overall thickness of the corneal tissue was found to linearly correlate to hydration H as expected. No appreciable depth dependence of hydration-induced thickness changes throughout the corneal buttons were observed.

Conclusions

Corneal tissue hydration changes significantly impact measured corneal stiffness after CXL using mechanical testing. Not considering H leads to major overestimation of the stiffening effect of the CXL procedure. Depth-dependence of corneal thickness because of changing hydration is strongly dependent on the integrity of the tissue.

Evaluation of Corneal Biomechanics Using Brillouin Microscopy in Chinese Adults With Myopia

PURPOSE

To evaluate the corneal biomechanical metrics of Chinese adults with myopia and identify relevant factors of Brillouin microscopy.

METHODS

In this cross-sectional study, corneal biomechanics in Chinese adults with myopia were quantified and analyzed using Brillouin microscopy and the Corvis ST (CST) (Oculus Optikgeräte GmbH) and analyzed. Univariate linear regression was used with potential factors including age, sex, spherical equivalent (SE), intraocular pressure (IOP), central corneal thickness (CCT), and mean keratometry (Kmean).

RESULTS

The study included 87 eyes of 87 participants (mean age: 24.47 ± 6.27 years). Central, Mean, maximum (Max), minimum (Min), standard deviation, and Max-Min Brillouin modulus (BM) values obtained from Brillouin microscopy exhibited values of 2.826 ± 0.039, 2.827 ± 0.027, 2.864 ± 0.034, 2.790 ± 0.038, 0.108 ± 0.042, and 0.074 ± 0.041 GPa, respectively. No significant correlations were found between BM parameters and age, sex, SE, IOP, or CCT. However, the Mean (β = -0.251, P = .019), Min (β = -0.315, P = .003), and Max-Min (β = 0.229, P = .033) BM values were significantly associated with Kmean. The Central, Mean, Min, and Max BM values negatively correlated with the Tomographic Biomechanical Index measured by CST (Spearman's r = -0.24, -0.35, -0.29, and -0.23, respectively, all P < .05).

CONCLUSIONS

Brillouin microscopy accurately reflects corneal biomechanical parameters in Chinese adults with myopia, independent of IOP and CCT, with a good correlation with CST. Concurrent evaluation of the corneal curvature is imperative when employing Brillouin microscopy in clinical practice. [J Refract Surg. 2024;40(10):e768-e776.].

Planar biaxial testing of CXL strengthening effects

The stiffening effect of corneal crosslinking (CXL) treatment, a therapeutic approach for managing the progression of keratoconus, has been primarily investigated using uniaxial tensile experiments. However, this testing technique has several drawbacks and is unable to measure the mechanical response of cornea under a multiaxial loading state. In this work, we used biaxial mechanical testing method to characterize biomechanical properties of porcine cornea before and after CXL treatment. We also investigated the influence of preconditioning on measured properties and used TEM images to determine microstructural characteristics of the extracellular matrix. The conventional method of CXL treatment was used for crosslinking the porcine cornea. The biaxial experiments were done by an ElectroForce TestBench system at a stretch ratio of 1:1 and a displacement rate of 2 mm/min with and without preconditioning. The experimental measurements showed no significant difference in the mechanical properties of porcine cornea along the nasal temporal (NT) and superior inferior (SI) direction. Furthermore, the CXL therapy significantly enhanced the mechanical properties along both directions without creating anisotropic response. The samples tested with preconditioning showed significantly stiffer response than those tested without preconditioning. The TEM images showed that the CXL therapy did not increase the diameter of collagen fibers but significantly decreased their interfibrillar spacing, consistent with the mechanical property improvement of CXL treated samples.

Corneal biomechanics and diagnostics: a review

PURPOSE

Corneal biomechanics is an emerging field and the interest into physical and biological interrelations in the anterior part of the eye has significantly increased during the past years. There are many factors that determine corneal biomechanics such as hormonal fluctuations, hydration and environmental factors. Other factors that can affect the corneas are the age, the intraocular pressure and the central corneal thickness. The purpose of this review is to evaluate the factors affecting corneal biomechanics and the recent advancements in non-destructive, in vivo measurement techniques for early detection and improved management of corneal diseases.

METHODS

Until recently, corneal biomechanics could not be directly assessed in humans and were instead inferred from geometrical cornea analysis and ex vivo biomechanical testing. The current research has made strides in studying and creating non-destructive and contactless techniques to measure the biomechanical properties of the cornea in vivo.

RESULTS

Research has indicated that altered corneal biomechanics contribute to diseases such as keratoconus and glaucoma. The identification of pathological corneas through the new measurement techniques is imperative for preventing postoperative complications.

CONCLUSIONS

Identification of pathological corneas is crucial for the prevention of postoperative complications. Therefore, a better understanding of corneal biomechanics will lead to earlier diagnosis of ectatic disorders, improve current refractive surgeries and allow for a better postoperative treatment.

The relationship between keratan sulfate glycosaminoglycan density and mechanical stiffening of CXL treatment

The corneal stroma is primarily composed of collagen fibrils, proteoglycans, and glycosaminoglycans (GAGs). It is known that corneal crosslinking (CXL) treatment improves mechanical properties of the cornea. However, the influence of stromal composition on the strengthening effect of CXL procedure has not been thoroughly investigated. The primary objective of the present research was to characterize the effect of keratan sulfate (KS) GAGs on the efficacy of CXL therapy. To this end, the CXL method was used to crosslink porcine corneal samples from which KS GAGs were enzymatically removed by keratanase II enzyme. Alcian blue staining was done to confirm the successful digestion of GAGs and uniaxial tensile experiments were performed for characterizing corneal mechanical properties. The influence of GAG removal and CXL treatment on resistance of corneal samples against enzymatic pepsin degradation was also quantified. It was found that removal of KS GAGs significantly softened corneal tensile properties (P < 0.05). Moreover, the CXL therapy significantly increased the tensile stiffness of GAG-depleted strips (P < 0.05). GAG-depleted corneal buttons were dissolved in the pepsin digestion solution significantly faster than control samples (P < 0.05). The CXL treatment significantly increased the time needed for complete pepsin digestion of GAG-depleted disks (P < 0.05). Based on these observations, we concluded that KS GAGs play a significant role in defining tensile properties and structural integrity of porcine cornea. Furthermore, the stiffening influence of the CXL treatment does not significantly depend on the density of corneal KS GAGs. The findings of the present study provided new information on the relation between corneal composition and CXL procedure mechanical effects.

Finite Deformation of Scleral Tissue under Electrical Stimulation: An Arbitrary Lagrangian-Eulerian Finite Element Method

The sclera is considered as the principal load-bearing tissue within the eye. The sclera is negatively charged; thus, it exhibits mechanical response to electrical stimulation. We recently demonstrated the electroactive behavior of sclera by performing experimental measurements that captured the deformation of the tip of scleral strips subjected to electric voltage. We also numerically analyzed the electromechanical response of the tissue using a chemo-electro-mechanical model. In the pre-sent study, we extended our previous work by experimentally characterizing the deformation profile of scleral strips along their length under electrical stimulation. In addition, we improved our previous mathematical model such that it could numerically capture the large deformation of samples. For this purpose, we considered the transient variability of the fixed charge density and the coupling between mechanical and chemo-electrical phenomena. These improvements in-creased the accuracy of the computational model, resulting in a better numerical representation of experimentally measured bending angles.

Modeling and experimental investigation of electromechanical properties of scleral tissue; a CEM model using an anisotropic hyperelastic constitutive relation

The sclera is a soft tissue primarily consisting of collagen fibers, elastin, and proteoglycans. The proteoglycans are composed of a core protein and negatively charged glycosaminoglycan side chains. The fixed electric charges inside the scleral extracellular matrix play a key role in its swelling and are expected to cause the tissue to deform in response to an electric field. However, the electroactive response of the sclera has not yet been investigated. The present work experimentally demonstrates that sclera behaves similar to an anionic electrosensitive hydrogel and develops a chemo-electro-mechanical (CEM) mathematical framework for its electromechanical response. In the numerical model, a hyperelastic constitutive law with distributed collagen fibers is used to capture the nonlinear mechanical properties of the sclera, and the coupled Poisson-Nernst-Planck equations represent the distribution of mobile ions throughout the domain. After calibrating the proposed numerical CEM model against the experimental measurements, we employ it to investigate the effects of different parameters on the scleral electromechanical response including the voltage and fixed charge density. The experimental and numerical findings of the present study confirm that sclera behaves as an electroactive hydrogel and provide new insight into the mechanical response of this ocular tissue.

Experimental and numerical analysis of electroactive characteristics of scleral tissue

The sclera provides mechanical support to retina and protects internal contents of the eye against external injuries. The scleral extracellular matrix is mainly composed of collagen fibers and proteoglycans (PGs). At physiological pH, collagen molecules are neutral but PGs contain negatively charged glycosaminoglycan chains. Thus, the sclera can be considered as a polyelectrolyte hydrogel and is expected to exhibit mechanical response when subjected to electrical stimulations. In this study, we mounted scleral strips, dissected from the posterior part of porcine eyes, at the center of a custom-designed container between two electrodes. The container was filled with NaCl solution and the bending deformation of scleral strips as a function of the applied electric voltage was measured experimentally. It was found that scleral strips reached to an average bending angle of 3°, 10° and 23° when subjected to 5V, 10V, and 15V, respectively. We also created a chemo-electro-mechanical finite element model for simulating the experimental measurements by solving coupled Poisson-Nernst-Plank and equilibrium mechanical field equations. The scleral fixed charge density and modulus of elasticity were found by fitting the experimental data. The ion concentration distribution inside the domain was found numerically and was used to explain the underlying mechanisms for the scleral electroactive response. The numerical simulations were also used to investigate the effects of various parameters such as the electric voltage and fixed charge density on the scleral deformation under an electric field. STATEMENT OF SIGNIFICANCE: This manuscript investigates the electroactive response of scleral tissue. It demonstrates that the sclera deforms mechanically when subjected to electrical stimulations. A chemo-electro-mechanical model is also presented in order to numerically capture the electromechanical response of the sclera. This numerical model is used to explain the experimental observations by finding the ion distribution inside the tissue under an electric field. This work is significant because it shows that the sclera is an electroactive polyanionic hydrogel and it provides new information about the underlying mechanisms governing its mechanical and electrical properties.

Biomechanical Effects of Deep Anterior Lamellar Keratoplasty and Penetrating Keratoplasty for Keratoconus: A Finite Element Analysis

Purpose

To theoretically compare corneal displacement and the von Mises (VM) stress distribution of deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) for keratoconus (KC) and to evaluate the effects of residual stromal thickness (RST) and intraocular pressure (IOP) on postoperative corneal biomechanics.

Methods

We performed DALK and PK simulations using Ansys by employing anisotropic nonlinear hyperelastic corneal material properties. We analyzed corneal displacement and VM stress in DALK and PK models under IOPs of 10, 15, 20, and 25 mmHg. We established two DALK models: The ideal-type DALK ensured that postoperative central corneal thickness was constant at 560 µm and the corneal graft thickness varied with RST. The clinical-type DALK ensured that corneal grafts had the same thickness (500 µm) regardless of RST. Then we analyzed the effects of RST and IOP on postoperative corneal displacement and VM stress.

Results

Corneal displacement and VM stress were lower in the DALK than in the PK model. In the ideal-type DALK model, an increase in RST was associated with increased deformation and decreased VM stress in the healing zone, except for a RST of 0 µm. In the clinical-type DALK model, deformation and VM stress in the healing zone decreased with an increase in RST, except for a RST of 0 µm.

Conclusions

DALK showed more stability than PK. For the ideal-type DALK model, an increase in RST resulted in decreased postoperative corneal biomechanics in the healing zone. For the clinical-type DALK model, corneal deformation and VM stress decreased with an increase in RST, which provides numerical evidence for the design of corneal transplantation for patients with KC.

Translational Relevance

In this computational modeling study, we first theoretically compared corneal biomechanics between DALK and PK for KC. Then, the effects of RST and IOP on postoperative corneal biomechanics were investigated. Our findings provide novel insights into the optimal design for corneal transplantation for patients with KC.

Tensile Viscoelastic Properties of the Sclera after Glycosaminoglycan Depletion

PURPOSE

Fibrillar collagen network and glycosaminoglycans (GAGs) are the primary components of extracellular matrix (ECM) of the sclera. The main goal of this study was to investigate the possible structural roles of GAGs in the scleral tensile properties as a function of preconditioning and displacement rate.

METHODS

Four-step uniaxial stress-relaxation tests were used for characterizing the viscoelastic tensile response of the posterior porcine sclera with and without enzymatic GAG removal. The scleral strips were divided into different groups based on the displacement rate and the presence or absence of a preconditioning step in the loading protocol. The groups were (1) displacement rate of 0.2 mm/min without preconditioning, (2) displacement rate of 1 mm/min without preconditioning, (3) displacement rate of 0.2 mm/min with preconditioning, and (4) displacement rate of 1 mm/min with preconditioning. The peak stress, equilibrium stress, and the equilibrium elastic modulus were calculated for all specimens and compared against each other.

RESULTS

Increasing the displacement rate from 0.2 mm/min to 1.0 mm/min was found to cause an insignificant change in the equilibrium stress and equilibrium elastic modulus of porcine scleral strips. Removal of GAGs resulted in an overall stiffer tensile behavior independent of the displacement rate in samples that were not preconditioned (P < .05). The behavior of preconditioned samples with and without GAG removal was not significantly different from each other.

CONCLUSIONS

The experimental measurements of the present study showed that GAGs play an important role in the mechanical properties of the posterior porcine sclera. Furthermore, using a preconditioning step in the uniaxial testing protocol resulted in not being able to identify any significant difference in the tensile behavior of GAG depleted and normal scleral strips.

Constitutive Modeling of Corneal Tissue: Influence of Three-Dimensional Collagen Fiber Microstructure

The cornea, the transparent tissue in the front of the eye, along with the sclera, plays a vital role in protecting the inner structures of the eyeball. The precise shape and mechanical strength of this tissue are mostly determined by the unique microstructure of its extracellular matrix. A clear picture of the 3D arrangement of collagen fibrils within the corneal extracellular matrix has recently been obtained from the secondary harmonic generation images. However, this important information about the through-thickness distribution of collagen fibrils was seldom taken into account in the constitutive modeling of the corneal behavior. This work creates a generalized structure tensor (GST) model to investigate the mechanical influence of collagen fibril through-thickness distribution. It then uses numerical simulations of the corneal mechanical response in inflation experiments to assess the efficacy of the proposed model. A parametric study is also done to investigate the influence of model parameters on numerical predictions. Finally, a brief comparison between the performance of this new constitutive model and a recent angular integration (AI) model from the literature is given.

Individualized Characterization of the Distribution of Collagen Fibril Dispersion Using Optical Aberrations of the Cornea for Biomechanical Models

Purpose

The spatial distribution of collagen fibril dispersion has a significant impact on both corneal biomechanical and optical behaviors. The goal of this study was to demonstrate a novel method to characterize collagen fibril dispersion using intraocular pressure (IOP)-induced changes in corneal optical aberrations for individualized finite-element (FE) modeling.

Methods

The method was tested through both numerical simulations and ex vivo experiments. Inflation tests were simulated in FE models with three assumed patterns of collagen fibril dispersion and experimentally on three rhesus monkey corneas. Geometry, matrix stiffness, and the IOP-induced changes in wavefront aberrations were measured, and the collagen fibril dispersion was characterized. An individualized corneal model with customized collagen fibril dispersion was developed, and the estimated optical aberrations were compared with the measured data.

Results

For the theoretical investigations, three assumed distributions of fibril dispersion were all successfully characterized. The estimated optical aberrations closely matched the measured data, with average root-mean-square (RMS) differences of 0.29, 0.24, and 0.10 µm for the three patterns, respectively. The overall features of the IOP-induced changes in optical aberrations were estimated for two ex vivo monkey corneas, with average RMS differences of 0.57 and 0.43 µm. Characterization of the fibril dispersion in the third cornea might have been affected by corneal hydration, resulting in an increased RMS difference, 0.8 µm.

Conclusions

A more advanced corneal model with individualized distribution of collagen fibril dispersion can be developed and used to improve our ability to understand both biomechanical and optical behaviors of the cornea.

Biomechanical effect of ultraviolet-A-riboflavin cross-linking on simulated human corneal stroma model and its correlation with changes in corneal stromal microstructure

In this study, we established an experimental human corneal stroma model of simulated cornea tissue composed of thin anterior cornea strips layers obtained from small incision lenticular extraction (SMILE) surgery. We investigated the biomechanical effect of ultraviolet-A- riboflavin cross-linking at different depths of corneal stroma model and correlated it with stromal microstructural changes examined by transmission electron microscopy (TEM). Corneal strips were harvested from fresh human corneal lenticules obtained after SMILE surgery. Experimental models (n = 34) were established by superimposing the corneal lenticule strips until their thickness reached close to 500 μm. Corneal cross-linking (CXL) was performed subsequently using standard or accelerated protocol. Elasticity and viscosity were quantified using stress-strain extensometer. TEM was used to visualize the collagen fiber diameter and interfibrillar spacing. The relative change in Young's modulus (rel. ΔE) decreased nonlinearly with increasing stromal depth both in the standard and accelerated groups. Compared to the sham controls, the rel. ΔE in standard and accelerated CXL groups increased significantly in the anterior 400 μm and 275 μm depth, respectively. Also, the relative change in stress (rel. ΔS) was significantly lower after standard and accelerated CXL compared to sham controls. Depth analysis showed similar results for the elastic effect. TEM images showed a small, non-significant increase in fibril diameter. The interfibrillar spacing decreased significantly after standard and accelerated CXL in the anterior-mid stromal region. We noted that the increase of corneal stiffness correlated with decrease in interfibrillar spacing after CXL. The stiffening effect was depth dependent. The effect of accelerated CXL was less in the deep corneal stromal regions compared to standard CXL.

Keratoconus prognosis study for patients with corneal external mechanical stress mode

PURPOSE

To demonstrate the correlation between excessive eye rubbing and corneal degeneration for Keratoconus patients.

MATERIALS AND METHODS

Keratoconus (KC) patients who regularly rub their eyes had shown a rapid degeneration rate of their affected corneas. This observation is experimentally and numerical discussed and developed based on clinical data of 8 of KC Patients with a mean age of 26.5 ± 9.4 years old, and four healthy individuals with a mean age of 24.33 ± 5 years old at the baseline. Corneal topography was used to measure both central corneal thickness (CCT) and its total refractive power. The registered data had been exploited to assess the progression of the disease, and the final results were embedded in a finite element model of human corneas to simulate their response to eye rubbing at different stages of the pathology. Corneal lifetime prognosis using multi-layer perceptron was then established to estimate the number of eye rubbing cycles for each stage of KC.

RESULTS

The survey of KC patients who declared stopping eye rubbing had shown a decrease in CCT loss rate, followed by a durable stability. Mechanical stresses numerical simulations had shown different corneal behaviours in term of shape deformity, apical raise and corneal applanation between healthy and KC stages models. Apical rise ranged from 0.122 to 0.389 mm for an applied intraocular pressure that equals to 15 mmHg. A normal stress of 5 kPa provoked a corneal applanation that ranged from 0.27 mm in healthy cases to 1.173 mm in severe stages of the disease. The application of 2.5 kPa biaxial stress had resulted normal and tangential applanations that successively ranged from 0.152 and 0.173 mm in healthy corneas to 0.446 mm and 0.458 mm in severe KC stages. An adopted prognosis algorithm was able to predict the current stage of the disease and to estimate the remaining number of eye rubbing cycles before failure.

CONCLUSION

Eye rubbing was proven to be a considerable contributing factor in KC patient's corneal degeneration. The progression of this pathology could be decreased or halted by stopping eye rubbing at early stages.

The contribution of sGAGs to stress-controlled tensile response of posterior porcine sclera

Despite the significant progress in characterizing mechanical functions of individual scleral extracellular matrix (ECM) components, the biomechanical contribution of sulfated glycosaminoglycans (sGAGs) is still poorly understood. The primary purpose of this study was to determine the possible function of sGAGs in scleral mechanical response by characterizing the tensile behavior of normal and sGAG-depleted samples. We used chondroitinase ABC solution to remove sGAGs from scleral samples that were dissected from posterior porcine eyes. We performed biochemical analyses for assessing the efficacy of sGAG removal protocol. Furthermore, we conducted stress-controlled uniaxial tensile tests to characterize the influence of sGAG removal on mechanical properties of sclera. The tensile behavior of scleral strips right after dissection and after being soaked in buffer was also determined. Biochemical analyses confirmed that 18 hour incubation in 0.125 U/ml Chondroitinase ABC solution removed over 90% of chondroitin and dermatan sGAGs. No significant difference was observed in the thickness/hydration of samples because of enzyme- and buffer-treated samples. Furthermore, it was found that sGAG depletion did not significantly alter the tangent modulus, energy dissipation, and peak strain of posterior scleral strips. It was concluded that sGAGs did not influence the stress-controlled viscoelastic tensile response of sclera.

Effects of Corneal Hydration on Brillouin Microscopy In Vivo

Purpose

To investigate how corneal hydration affects the Brillouin frequency of corneal stroma.

Methods

From a simple analytical model considering the volume fraction of water in corneal stroma, we derived the dependence of Brillouin frequency on hydration and hydration-induced corneal thickness variation. The Brillouin frequencies of fresh ex vivo porcine corneas were measured as their hydration was varied in dextran solution and water. Healthy volunteers (8 eyes) were scanned in vivo repeatedly over the course of 9 hours, and the diurnal variations of Brillouin frequency and central corneal thickness (CCT) were measured.

Results

The measured dependence of Brillouin frequency on hydration, both ex vivo and in vivo, agreed well with the theoretical prediction. The Brillouin frequencies of human corneas scanned immediately after waking were on average ∼25 MHz lower than their daytime average values. For stabilized corneas, the typical variation of Brillouin frequency was ± 7.2 MHz. With respect to CCT increase or swelling, the Brillouin frequency decreased with a slope of −1.06 MHz/μm in vivo.

Conclusions

The ex vivo and in vivo data agree with our theoretical model and support that the effect of corneal hydration on Brillouin frequency comes predominantly from the dependence of the tissue compressibility on the water. Corneal hydration correlates negatively with the Brillouin frequency. During daytime activities, the influence of physiological hydration changes in human corneas is < ± 10 MHz. The sensitivity to hydration may potentially be useful in detecting abnormal hydration change in patients with endothelial disorders.

Relationship between initial corneal hydration and stiffening effects of corneal crosslinking treatment

PURPOSE

To characterize the mechanical property improvement of riboflavin and ultraviolet light corneal crosslinking (CXL) procedure in artificially swollen human and porcine corneas.

SETTING

Computational Biomechanics Research Laboratory, Mechanical and Industrial Engineering Department, University of Illinois at Chicago, Illinois, USA.

DESIGN

Experimental study.

METHODS

Porcine and human donor corneas were crosslinked at different hydration levels using riboflavin-dextran solutions of different osmolality. Four porcine groups (H_w [hydration in mg H₂O/mg dry tissue] = 3.3 ± 0.2 [SD]; 4.0 ± 0.1; 5.1 ± 0.1; 5.6 ± 0.1) and 3 human groups (H_w = 3.2 ± 0.1; 3.9 ± 0.2; 5.3 ± 0.3) were considered. The mechanical properties were measured by uniaxial tensile experiments during which the hydration of samples was the same as the hydration at which they were crosslinked. Tensile properties of 2 porcine groups (H_w = 5.1 ± 0.1; 5.6 ± 0.1) were also measured when their average hydration was lowered to 4.0 mg H₂O/mg dry tissue.

RESULTS

The CXL procedure significantly increased tensile properties of both human and porcine samples in each hydration group (P < .05). The improvement in tensile properties was hydration-dependent, that is, samples crosslinked at higher hydration levels showed lower maximum tensile stress. The behavior of samples crosslinked at different initial hydration but tested mechanically at similar hydration showed insignificant difference (P = .7).

CONCLUSION

Increasing the hydration of porcine and human corneal samples before the CXL treatment had insignificant influence on tensile property improvement, as measured by testing specimens at similar hydration.

UVA/riboflavin collagen crosslinking stiffening effects on anterior and posterior corneal flaps

The UVA/riboflavin collagen crosslinking (CXL) is one of the treatment procedure for stopping the progression of keratoconus. The inclusion criterion for this procedure is a minimum corneal thickness of 400 μm, which is not often met in patients with advanced keratoconus. Preoperatively swelling thin corneas was shown to stabilize the keratectasia without any postoperative endothelial damage. Recently, we have shown that swelling porcine corneas prior to the CXL treatment had no significant effect on the resulting improvement in their tensile properties. In the present study, we extended this previous study and characterized the stiffening effects of CXL on anterior and posterior flaps as a function of their hydration. A DSAEK system was used to excise 10 mm corneal flaps from 80 porcine corneas. Individual flaps were crosslinked at different initial hydration levels by using riboflavin solutions composed of different dextran concentrations; the thickness was taken as a measure of flap hydration. A DMA machine was used to measure the tensile properties either immediately after the CXL treatment or after the thickness (hydration) of the crosslinked samples was brought down to a specific value. The average thickness of anterior groups was 670 μm, 540 μm, and 410 μm, and the average thickness of posterior groups was 845 μm, 650 μm, and 440 μm. It was found that although CXL significantly increased the tensile properties of all anterior groups, it had an insignificant effect on the stiffness of posterior flaps. Furthermore, except for the posterior flaps in 845 μm and 650 μm thickness groups, decreasing the hydration significantly increased the tensile modulus (p < 0.05). Finally, the anterior flaps that were crosslinked at higher hydration, i.e. swollen before CXL, showed significantly less amount of stiffening in comparison with those crosslinked at lower hydration when the tensile property measurement was done at similar hydration (p < 0.05).

Perilimbal sclera mechanical properties: Impact on intraocular pressure in porcine eyes

There is extensive knowledge on the relationship of posterior scleral biomechanics and intraocular pressure (IOP) load on glaucomatous optic neuropathy; however, the role for biomechanical influence of the perilimbal scleral tissue on the aqueous humor drainage pathway, including the distal venous outflow system, and IOP regulation is not fully understood. The purpose of this work is to study the outflow characteristics of perfused porcine eyes relative to the biomechanical properties of the perilimbal sclera, the posterior sclera and the cornea. Enucleated porcine eyes from eleven different animals were perfused with surrogate aqueous at two fixed flow rates while monitoring their IOP. After perfusion, mechanical stress-strain and relaxation tests were conducted on specimens of perilimbal sclera, posterior sclera, and cornea from the same perfused eyes. Statistical analysis of the data demonstrated a strong correlation between increased tangent modulus of the perilimbal sclera tissues and increased perfusion IOP (R² = 0.74, p = 0.0006 at lower flow rate and R² = 0.71, p = 0.0011 at higher flow rate). In contrast, there were no significant correlations between IOP and the tangent modulus of the other tissues (Posterior sclera: R² = 0.17 at lower flow rate and R² = 0.30 at higher flow rate; cornea: R² = 0.02 at lower flow rate and R²<0.01 at higher flow rate) nor the viscoelastic properties of any tissue (R² ≤ 0.08 in all cases). Additionally, the correlation occurred for IOP and not net outflow facility (R² ≤ 0.12 in all cases). These results provide new evidence that IOP in perfused porcine eyes is strongly influenced by the tangent modulus, sometimes called the tissue stiffness, of the most anterior portion of the sclera, i.e. the limbus.

Depth-Dependent Out-of-Plane Young's Modulus of the Human Cornea

Purpose/Aim: Despite their importance in accurate mechanical modeling of the cornea, the depth-dependent material properties of the cornea have only been partially elucidated. In this work, we characterized the depth-dependent out-of-plane Young's modulus of the central and peripheral human cornea with high spatial resolution.

MATERIALS AND METHODS

Central and peripheral corneal buttons from human donors were subjected to unconfined axial compression followed by stress relaxation for 30 min. Sequences of fluorescent micrographs of full-thickness corneal buttons were acquired throughout the experiment to enable tracking of fluorescently labeled stromal keratocyte nuclei and measurements of depth-dependent infinitesimal strains. The nominal (gross) out-of-plane Young's modulus and drained Poisson's ratio for each whole specimen was computed from the equilibrium stress and overall tissue deformation. The depth-dependent (local) out-of-plane Young's modulus was computed from the equilibrium stress and local tissue strain based on an anisotropic model (transverse isotropy).

RESULTS

The out-of-plane Young's modulus of the cornea exhibited a strong dependence on in-plane location (peripheral versus central cornea), but not depth. The depth-dependent out-of-plane Young's modulus of central and peripheral specimens ranged between 72.4-102.4 kPa and 38.3-58.9 kPa. The nominal out-of-plane Young's modulus was 87 ± 41.51 kPa and 39.9 ± 15.28 kPa in the central and peripheral cornea, while the drained Poisson's ratio was 0.05 ± 0.02 and 0.07 ± 0.04.

CONCLUSIONS

The out-of-plane Young's modulus of the cornea is mostly independent of depth, but not in-plane location (i.e. central vs. peripheral). These results may help inform more accurate finite element computer models of the cornea.

3D Characterization of corneal deformation using ultrasound speckle tracking

The three-dimensional (3D) mechanical response of the cornea to intraocular pressure (IOP) elevation has not been previously reported. In this study, we use an ultrasound speckle tracking technique to measure the 3D displacements and strains within the central 5.5 mm of porcine corneas during the whole globe inflation. Inflation tests were performed on dextran-treated corneas (treated with a 10% dextran solution) and untreated corneas. The dextran-treated corneas showed an inflation response expected of a thin spherical shell, with through-thickness thinning and in-plane stretch, although the strain magnitudes exhibited a heterogeneous spatial distribution from the central to more peripheral cornea. The untreated eyes demonstrated a response consistent with swelling during experimentation, with through-thickness expansion overriding the inflation response. The average volume ratios obtained in both groups was near 1 confirming general incompressibility, but local regions of volume loss or expansion were observed. These results suggest that biomechanical measurements in 3D provide important new insight to understand the mechanical response of ocular tissues such as the cornea.

Corneal biomechanical properties in healthy children measured by corneal visualization scheimpflug technology

Background

The aim of this study was to evaluate corneal biomechanical properties in a population of healthy children in China using corneal visualization Scheimpflug technology (CST).

Methods

All children underwent complete bi-ocular examinations. CST provided intraocular pressure (IOP) and corneal biomechanical parameters, including time, velocity, length and deformation amplitude at first applanation (A1T, A1V, A1L, A1DA), at second applanation (A2T, A2V, A2L, A2DA), highest concavity time (HCT), maximum deformation amplitude (MDA), peak distance (PD), and radius of curvature (RoC). Pearson correlation analysis was used to assess the impacts of demographic factors, central corneal thickness (CCT), spherical equivalent (SE), and IOP on corneal biomechanics.

Results

One hundred eight subjects (32 girls and 76 boys) with the mean age of 10.80 ± 4.13 years (range 4 to18 years) were included in the final analyses. The right and left eyes were highly symmetrical in SE (p = 0.082), IOP (p = 0.235), or CCT (p = 0.210). Mean A1T of the right eyes was 7.424 ± 0.340 ms; the left eyes 7.451 ± 0.365 ms. MDA was 0.993 ± 0.102 mm in the right eyes and 0.982 ± 0.100 mm in the left eyes. Mean HCT of the right eyes was 16.675 ± 0.502 ms; the left eyes 16.735 ± 0.555 ms. All CST parameters of both eye were remarkably symmetrical with the exception of A2L (p = 0.006), A1DA (p = 0.025). The majority of CST parameters of both eyes were significantly correlated with CCT and IOP (p < 0.05). However, age, SE, and sex exert little influence on the CST measurements.

Conclusions

This study found interocular symmetry in corneal biomechanics in healthy children eyes. Several CST biomechanical parameters in children are modified by CCT and IOP.

Comparison of Two Cap Thickness in Small Incision Lenticule Extraction: 100μm versus 160μm

PURPOSE

To compare the changes of biomechanical properties, endothelial cell density (ECD), and posterior corneal elevation (PCE) after femtosecond small incision lenticule extractions (SMILEs) with 100μm versus 160μm cap thicknesses.

METHODS

A total of 12 rabbits were randomly assigned into two groups of 6 each. SMILE was performed at a depth of either 160μm (160-cap group) or 100μm (100-cap group). Corneal biomechanics, PCE, ECD were evaluated pre-operatively, 1week, 1 month, 2 months, 3 months, and 4 months post-operatively by Pentacam, Corvis ST, in vivo confocal microscopy (IVCM) respectively. The Young's modulus was obtained by strip-extensometry test 4 months after surgery.

RESULTS

At each time point, the second applanation time (A2T) was similar between the groups with the exception of 4 months after surgery (22.66±0.16 ms in the 160-cap group versus 21.75±0.29 ms in the 100-cap group, p = 0.004). Neither deformation amplitude (DA) nor the first applanationtime (A1T) were significantly different between the two groups. The postoperative posterior surface did not shift forward, the changes of PCE and ECD were not significantly different between the two groups at any observation time. Young's modulus was higher in the 160-cap group than that in the 100-cap group with no statistical significance (P>0.05). Regression analyses showed that the PCE changes and Young's modulus were not affected by cap thickness (CT) or residual stromal bed thickness (RBT) (All P>0.05).

CONCLUSIONS

The differences of corneal biomechanics, posterior surface elevation, or ECD changes were quite small when using 100μm or 160μm cap thicknesses in SMILE.

Finite Element Analysis of Descemet's Stripping Automated Endothelial Keratoplasty (DSAEK) Surgery Allograft to Predict Endothelial Cell Loss

PURPOSE

To develop high fidelity finite element (FE) models of the Descemet's stripping automated endothelial keratoplasty (DSAEK) allograft to estimate the stress distributions generated on the allograft during its deformed state in popular allograft insertion configurations and qualitatively correlate the stress distributions to postsurgical endothelial cell (EC) loss.

MATERIALS AND METHODS

Corneal allograft simulation was performed using ANSYS (Canonsburg, PA, USA) utilizing isotropic nonlinear hyperelastic corneal material properties to evaluate the stress distributions generated on the DSAEK allograft during popular allograft insertion configurations, namely forceps, taco, and double-coil insertion configurations. The gathered FE simulation results were qualitatively compared with published clinical studies to verify the simulation results.

RESULTS

The FE simulation results demonstrate that high stress regions predicted by FE model results correctly predict the areas of postsurgical EC loss as published in the studies available in open literature. The FE simulation stress magnitude results suggest that highest EC loss due to mechanical bending trauma occurs in double-coil configuration followed by forceps and then taco configuration.

CONCLUSIONS

The results of the presented FE simulation study highlight that allograft regions with high stress distribution demonstrate postsurgical EC loss in clinical studies. The modeling procedures presented in this research can be utilized to develop novel surgical devices/techniques that can modulate the postsurgical EC loss due to mechanical bending trauma and facilitate allograft unfolding inside the AC, thereby improving the results of the DSAEK surgical procedure.

A Biphasic Transversely Isotropic Poroviscoelastic Model for the Unconfined Compression of Hydrated Soft Tissue

The unconfined compression experiments are commonly used for characterizing the mechanical behavior of hydrated soft tissues such as articular cartilage. Several analytical constitutive models have been proposed over the years to analyze the unconfined compression experimental data and subsequently estimate the material parameters. Nevertheless, new mathematical models are still required to obtain more accurate numerical estimates. The present study aims at developing a linear transversely isotropic poroviscoelastic theory by combining a viscoelastic material law with the transversely isotropic biphasic model. In particular, an integral type viscoelastic model is used to describe the intrinsic viscoelastic properties of a transversely isotropic solid matrix. The proposed constitutive theory incorporates viscoelastic contributions from both the fluid flow and the intrinsic viscoelasticity to the overall stress-relaxation behavior. Moreover, this new material model allows investigating the biomechanical properties of tissues whose extracellular matrix exhibits transverse isotropy. In the present work, a comprehensive parametric study was conducted to determine the influence of various material parameters on the stress–relaxation history. Furthermore, the efficacy of the proposed theory in representing the unconfined compression experiments was assessed by comparing its theoretical predictions with those obtained from other versions of the biphasic theory such as the isotropic, transversely isotropic, and viscoelastic models. The unconfined compression behavior of articular cartilage as well as corneal stroma was used for this purpose. It is concluded that while the proposed model is capable of accurately representing the viscoelastic behavior of any hydrated soft tissue in unconfined compression, it is particularly useful in modeling the behavior of those with a transversely isotropic skeleton.

Interrelation of Hydration, Collagen Cross-Linking Treatment, and Biomechanical Properties of the Cornea

PURPOSE

The present study was designed to investigate the effects of hydration and collagen cross-linking treatment on biomechanical properties of the cornea.

METHODS

The original corneal collagen cross-linking protocol was used to induce cross-links in bovine corneas. The thickness of samples was used as a measure of their hydration and five different thickness groups (n = 5 each) were considered. The cross-linked corneal strips were allowed to hydrate/dehydrate until their thickness reached 500, 700, 900, 1100, and 1500 μm. The tensile behavior of specimens in each thickness group was characterized by conducting uniaxial tensile experiments. The experiments were done in mineral oil in order to keep the thickness of samples constant and minimize hydration changes.

RESULTS

It was observed that collagen cross-linking treatment significantly increased both the maximum tensile stress and the equilibrium (relaxed) stress of the bovine cornea (p < 0.01). Furthermore, with increasing the thickness (hydration) of the collagen cross-linked samples, their tensile stiffness significantly decreased (p < 0.01). An exponential relation and a logarithmic expression successfully represented experimentally measured stress-strain behavior and relaxation response of all groups (r(2 )> 0.99), respectively.

CONCLUSION

Hydration and collagen cross-linking treatment concomitantly affect biomechanical properties of the cornea. Therefore, an accurate estimate of stiffening effects of collagen cross-linking treatment option using uniaxial tensile experiments is only possible if the hydration of specimens is fully controlled.

Collagen cross-linking treatment effects on corneal dynamic biomechanical properties

Cornea is a soft tissue with the principal function of transmitting and refracting light rays. The objective of the current study was to characterize possible effects of the riboflavin/UVA collagen cross-linking on corneal dynamic properties. The original corneal cross-linking protocol was used to induce cross-links in the anterior portion of the bovine cornea. A DMA machine was used to conduct mechanical tensile experiments at different levels of tensile strains. The samples were divided into a control group (n = 5) and a treated group (n = 5). All specimens were first stretched to a strain of 5% and allowed to relax for twenty minutes. After completion of the stress-relaxation experiment, a frequency sweep test with oscillations ranging from 0.01 to 10 Hz was performed. The same procedure was repeated to obtain the stress-relaxation and dynamic properties at 10% strain. It was observed that the collagen cross-linking therapy significantly increased the immediate and equilibrium tensile behavior of the bovine cornea (P < 0.05). Furthermore, for all samples in control and treated groups and throughout the whole range of frequencies, a significantly larger tensile storage modulus was measured at an axial strain of 10% compared to what was obtained at a tensile strain of 5%. Finally, it was noted that although this treatment procedure resulted in a significant increase in the storage and loss modulus at any axial strain and frequency (P < 0.05), it significantly reduced the ratio of the dissipated and stored energy during a single cycle of deformation. Therefore, it was concluded that while the riboflavin/UVA collagen cross-linking increased significantly corneal stiffness, it decreased significantly its damping capability and deformability. This reduced damping ability might adversely interfere with corneal mechanical performance.

Stiffening effects of riboflavin/UVA corneal collagen cross-linking is hydration dependent

The collagen cross-linking is a relatively new treatment option for strengthening the cornea, delaying, and in some cases stopping the progression of keratoconus. The uniaxial tensile experiments are among the most commonly used techniques to assess the effectiveness of this therapeutic option in enhancing tensile properties. In the present study, we investigated the possible effects of hydration on stiffening effects of corneal collagen cross-linking procedure, as measured by the uniaxial tensile testing method. For this purpose, after cross-linking bovine corneas, we let the strips to dehydrate in air or swell in a solution until their thickness reached an average thickness of 0.5, 0.7, 0.9, 1.1, and 1.5 mm. Using thickness as a representative of hydration, we divided corneal strips into five different groups and measured their stress-strain behavior by conducting uniaxial tensile experiments in mineral oil. It was observed that the collagen cross-linking treatment and hydration together affect the tensile behavior of the bovine cornea. While corneal collagen cross-linking resulted in a significant increase in the tensile stress-strain response of each thickness group (P<0.01), less hydrated collagen cross-linked samples showed a significantly stiffer response (P<0.01). A master curve was found for representing the tensile behavior of the collagen cross-linked bovine cornea at different levels of hydration. The results of the present research confirmed that the amount of mechanical stiffening of the corneal collagen cross-linking, as measured by uniaxial tensile testing, strongly depends on the hydration. Therefore, it is concluded that uniaxial tensile experiments could only be used to assess stiffening effects of the collagen cross-linking treatment if the hydration of specimens is fully controlled.