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Borchert GA, Kandel H, Watson SL. Epithelium-on versus epithelium-off corneal collagen crosslinking for keratoconus: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol 2024; 262:1683-1692. [PMID: 37938377 PMCID: PMC11106102 DOI: 10.1007/s00417-023-06287-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/10/2023] [Accepted: 10/21/2023] [Indexed: 11/09/2023] Open
Abstract
PURPOSE Corneal collagen crosslinking (CXL) is the primary treatment for progressive keratoconus which has a significant impact on vision and quality of life. Our study aimed to compare the efficacy and safety of epithelium-on versus epithelium-off CXL to treat keratoconus. METHODS We searched PubMed, Medline, Embase, Web of Science, and Scopus databases. We included studies that compared standard epithelium-off with epithelium-on CXL. The primary outcome measures were changes in corrected distance visual acuity (CDVA) and maximum keratometry (Kmax), and the secondary outcomes were uncorrected distance visual acuity (UDVA), central corneal thickness (CCT), and adverse events. A meta-analysis was performed on the primary and secondary outcomes based on the weighted mean differences between baseline to 12-month follow-up. RESULTS The search retrieved 887 publications with 27 included in the systematic review. A total of 1622 eyes (1399 patients; age 25.51 ± 4.02 years) were included in comparisons of epithelium-off to epithelium-on CXL in keratoconus. Epithelium-off CXL treated 800 eyes and epithelium-on CXL for 822 eyes. At 12-month follow-up, CDVA and Kmax showed no significant difference between the epithelium-off and epithelium-on CXL. The secondary outcomes showed that UDVA was better in epithelium-off CXL (- 0.11D, 95% CI - 0.12, - 0.1; p < 0.001) and there was more thinning in CCT in epithelium-off CXL (- 3.23 μm, 95% CI - 4.64, - 1.81; p <0.001). CONCLUSION Epithelium-off and epithelium-on CXL were both effective to treat progressive keratoconus. Further research is needed to compare the long-term outcomes and safety of both CXL protocols for adaptation into clinical practice.
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Affiliation(s)
- Grace A Borchert
- The University of Sydney, Save Sight Institute, Sydney, New South Wales, Australia.
| | - Himal Kandel
- The University of Sydney, Save Sight Institute, Sydney, New South Wales, Australia
| | - Stephanie L Watson
- The University of Sydney, Save Sight Institute, Sydney, New South Wales, Australia
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Ahmet S, Yayla Akincilar G, Kirgiz A, Kandemir Besek N, Kemer Atik B, Topcu H, Gumus Kasapoglu G. Long-term results of accelerated corneal collagen crosslinking in paediatric patients with progressive keratoconus: 10-year follow-up. Eye (Lond) 2024:10.1038/s41433-024-03064-7. [PMID: 38609652 DOI: 10.1038/s41433-024-03064-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 03/06/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVES To evaluate the 10-year visual, refractive, and tomographic outcomes of epithelium-off accelerated corneal collagen cross-linking (ACCL) in paediatric patients with progressive keratoconus (KC) and to compare the stages in terms of re-progression. METHODS Patients under 18 years of age with progressive KC who underwent ACCL between 2010 and 2012 and completed at least 10 years of follow-up were included in this retrospective study. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive errors, and corneal tomography parameters were evaluated preoperatively and at 1, 5, and 10 years postoperatively. The effect of stage and age on re-progression was analysed. RESULTS The study included 175 eyes of 97 patients (mean age: 14.46 ± 2.17 years). Improvement in UDVA and CDVA was observed in all postoperative periods compared to the preoperative period (each p-value < 0.05). The increase in spherical equivalent (SE), flattening of keratometry values, and decrease in thinnest corneal thickness (TCT) were statistically significant in the tenth year compared to preoperatively (each p-value < 0.05). Re-progression was observed in 16 eyes (9.14%). Haze was observed in 13 eyes (7.43%), 4 of which were permanent. Deep anterior lamellar keratoplasty was performed in 3 eyes (1.7%) and a second ACCL in 3 eyes (1.7%). CONCLUSIONS ACCL is an effective and safe long-term strategy to prevent progression of KC in paediatric patients. In the light of this study with a 10-year follow-up re-progression rate of 9.14%, long-term follow-up of patients after ACCL for possible re-progression and the need for re-CCL or keratoplasty may be recommended.
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Affiliation(s)
- Sibel Ahmet
- University of Health Sciences, Beyoglu Eye Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey.
| | - Gizem Yayla Akincilar
- University of Health Sciences, Beyoglu Eye Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
| | - Ahmet Kirgiz
- University of Health Sciences, Beyoglu Eye Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
| | - Nilay Kandemir Besek
- University of Health Sciences, Beyoglu Eye Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
| | - Burcu Kemer Atik
- University of Health Sciences, Beyoglu Eye Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
| | - Husna Topcu
- University of Health Sciences, Beyoglu Eye Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
| | - Gunes Gumus Kasapoglu
- University of Health Sciences, Beyoglu Eye Training and Research Hospital, Department of Ophthalmology, Istanbul, Turkey
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Somohano K, Alzaga-Fernandez AG. Controversies in Corneal Collagen Crosslinking: A Review of Investigational Crosslinking Protocols and Its Off-label Application. Int Ophthalmol Clin 2022; 62:51-62. [PMID: 36170222 DOI: 10.1097/iio.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Preliminary Characterization of Predictive Factors of the Visual Change after Epi-On and Epi-Off Corneal Collagen Crosslinking Techniques. J Ophthalmol 2021; 2021:9680253. [PMID: 34917415 PMCID: PMC8670975 DOI: 10.1155/2021/9680253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/04/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose To investigate the potential predictive factors of the visual change achieved with accelerated epi-on and epi-off corneal collagen crosslinking (CXL) in keratoconus. Methods This retrospective comparative study analyzed 67 eyes treated with an accelerated epithelium-on (epi-on group) and epithelium-off (epi-off group) CXL. The clinical outcomes were evaluated and compared during a 1-year follow-up. Likewise, the relationship of the change achieved with both CXL techniques in the corrected distance visual acuity (CDVA) with different preoperative data was investigated. Results The mean CDVA change at 3 months postoperatively was −0.04 ± 0.19 and −0.07 ± 0.25 in the epi-on and epi-off groups, respectively (p = 0.809). In the epi-on group, this change was significantly correlated with the preoperative apical (r = −0.375, p = 0.045) and central corneal thickness (r = −0.402, p = 0.031). In the epi-off group, the CDVA change was significantly correlated with not only the preoperative apical (r = 0.402, p = 0.028) and central corneal thickness (r = 0.367, p = 0.046) but also with some topometric and aberrometric indices (r ≤ −0.374, p ≤ 0.042). Furthermore, the change in CDVA in the epi-on group could be predicted from age, preoperative refractive astigmatism J45 component, anterior corneal asphericity, and posterior corneal high order aberration root mean square (p = 0.002, R2 = 0.503). In the epi-off group, the CDVA change could be predicted from the preoperative minimum corneal thickness and magnitude of the vertical anterior corneal primary coma component (p = 0.001, R2 = 0.446). Conclusions Clearly, different predictive factors of the visual change induced with the accelerated epi-on and epi-off CXL techniques are present, suggesting a different mechanism of action for stiffening the cornea and inducing changes in this structure.
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Arance-Gil Á, Villa-Collar C, Pérez-Sanchez B, Carracedo G, Gutiérrez-Ortega R. Epithelium-Off vs. transepithelial corneal collagen crosslinking in progressive keratoconus: 3 years of follow-up. JOURNAL OF OPTOMETRY 2021; 14:189-198. [PMID: 32883647 PMCID: PMC8093524 DOI: 10.1016/j.optom.2020.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 06/30/2020] [Accepted: 07/15/2020] [Indexed: 05/07/2023]
Abstract
PURPOSE To compare the efficacy of epithelium-off corneal collagen crosslinking (CXL) with transepithelial CXL in patients with progressive keratoconus with a follow-up of 3 years, taking into account the patients' age and the location of the corneal ectasia. METHODS In this prospective study participated 64 eyes with progressive keratoconus were included in this long-term study, of which 31 eyes were treated by epithelium-off CXL and 33 by transepithelial CXL. All of the patients with a follow-up of 36 months were evaluated for visual variables (corrected distance visual acuity (CDVA), corneal aberrations, and corneal densitometry), structure variables (astigmatism, keratometry, corneal asphericity, maximum posterior elevation, corneal thickness, and corneal volume), and keratoconus index variables. RESULTS After corneal CXL, CDVA improved significantly in both central and paracentral keratoconus, with greater improvement in the centrals (p = 0.001), asphericity at 6 mm improved in central keratoconus (p = 0.047). In the epi-off group, there was a significant improvement in coma-like (p = 0.038), higher-order aberrations (p = 0.036), asphericity at 8 mm (p = 0.049), asphericity at 10 mm (p = 0.049), and index of surface variance (p = 0.049). CONCLUSION Although both techniques halted and stabilized the progression of keratoconus, epithelium-off CXL was more effective. In addition, after the corneal CXL, there was a greater degree of regularization of the corneal surface and, therefore, a greater improvement in the CDVA with central keratoconus than with paracentral keratoconus.
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Affiliation(s)
| | - César Villa-Collar
- Clínica Novovisión, Madrid, Spain; Department of Pharmacy, Biotechnology, Nutrition, Optics and Optometry, Faculty of Biomedical and Health Sciences, European University of Madrid, Madrid, Spain.
| | - Belén Pérez-Sanchez
- Department of Statistics, Mathematics and Informatics, Miguel Hernández University, Elche, Spain.
| | - Gonzalo Carracedo
- Department of Optometry and Vision, Faculty of Optic and Optometry, Complutense University of Madrid, Madrid, Spain.
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Ng SM, Ren M, Lindsley KB, Hawkins BS, Kuo IC. Transepithelial versus epithelium-off corneal crosslinking for progressive keratoconus. Cochrane Database Syst Rev 2021; 3:CD013512. [PMID: 33765359 PMCID: PMC8094622 DOI: 10.1002/14651858.cd013512.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Keratoconus is the most common corneal dystrophy. It can cause loss of uncorrected and best-corrected visual acuity through ectasia (thinning) of the central or paracentral cornea, irregular corneal scarring, or corneal perforation. Disease onset usually occurs in the second to fourth decade of life, periods of peak educational attainment or career development. The condition is lifelong and sight-threatening. Corneal collagen crosslinking (CXL) using ultraviolet A (UVA) light applied to the cornea is the only treatment that has been shown to slow progression of disease. The original, more widely known technique involves application of UVA light to de-epithelialized cornea, to which a photosensitizer (riboflavin) is added topically throughout the irradiation process. Transepithelial CXL is a recently advocated alternative to the standard CXL procedure, in that the epithelium is kept intact during CXL. Retention of the epithelium offers the putative advantages of faster healing, less patient discomfort, faster visual rehabilitation, and less risk of corneal haze. OBJECTIVES To assess the short- and long-term effectiveness and safety of transepithelial CXL compared with epithelium-off CXL for progressive keratoconus. SEARCH METHODS To identify potentially eligible studies, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 1); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature database (LILACS); ClinicalTrials.gov; and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not impose any date or language restrictions. We last searched the electronic databases on 15 January 2020. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which transepithelial CXL had been compared with epithelium-off CXL in participants with progressive keratoconus. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. MAIN RESULTS We included 13 studies with 723 eyes of 578 participants enrolled; 13 to 119 participants were enrolled per study. Seven studies were conducted in Europe, three in the Middle East, and one each in India, Russia, and Turkey. Seven studies were parallel-group RCTs, one study was an RCT with a paired-eyes design, and five studies were RCTs in which both eyes of some or all participants were assigned to the same intervention. Eleven studies compared transepithelial CXL with epithelium-off CXL in participants with progressive keratoconus. There was no evidence of an important difference between intervention groups in maximum keratometry (denoted 'maximum K' or 'Kmax'; also known as steepest keratometry measurement) at 12 months or later (mean difference (MD) 0.99 diopters (D), 95% CI -0.11 to 2.09; 5 studies; 177 eyes; I2 = 41%; very low certainty evidence). Few studies described other outcomes of interest. The evidence is very uncertain that epithelium-off CXL may have a small (data from two studies were not pooled due to considerable heterogeneity (I2 = 92%)) or no effect on stabilization of progressive keratoconus compared with transepithelial CXL; comparison of the estimated proportions of eyes with decreases or increases of 2 or more diopters in maximum K at 12 months from one study with 61 eyes was RR 0.32 (95% CI 0.09 to 1.12) and RR (non-event) 0.86 (95% CI 0.74 to 1.00), respectively (very low certainty). We did not estimate an overall effect on corrected-distance visual acuity (CDVA) because substantial heterogeneity was detected (I2 = 70%). No study evaluated CDVA gain or loss of 10 or more letters on a logarithm of the minimum angle of resolution (logMAR) chart. Transepithelial CXL may result in little to no difference in CDVA at 12 months or beyond. Four studies reported that either no adverse events or no serious adverse events had been observed. Another study noted no change in endothelial cell count after either procedure. Moderate certainty evidence from 4 studies (221 eyes) found that epithelium-off CXL resulted in a slight increase in corneal haze or scarring when compared to transepithelial CXL (RR (non-event) 1.07, 95% CI 1.01 to 1.14). Three studies, one of which had three arms, compared outcomes among participants assigned to transepithelial CXL using iontophoresis versus those assigned to epithelium-off CXL. No conclusive evidence was found for either keratometry or visual acuity outcomes at 12 months or later after surgery. Low certainty evidence suggests that transepithelial CXL using iontophoresis results in no difference in logMAR CDVA (MD 0.00 letter, 95% CI -0.04 to 0.04; 2 studies; 51 eyes). Only one study examined gain or loss of 10 or more logMAR letters. In terms of adverse events, one case of subepithelial infiltrate was reported after transepithelial CXL with iontophoresis, whereas two cases of faint corneal scars and four cases of permanent haze were observed after epithelium-off CXL. Vogt's striae were found in one eye after each intervention. The certainty of the evidence was low or very low for the outcomes in this comparison due to imprecision of estimates for all outcomes and risk of bias in the studies from which data have been reported. AUTHORS' CONCLUSIONS Because of lack of precision, frequent indeterminate risk of bias due to inadequate reporting, and inconsistency in outcomes measured and reported among studies in this systematic review, it remains unknown whether transepithelial CXL, or any other approach, may confer an advantage over epithelium-off CXL for patients with progressive keratoconus with respect to further progression of keratoconus, visual acuity outcomes, and patient-reported outcomes (PROs). Arrest of the progression of keratoconus should be the primary outcome of interest in future trials of CXL, particularly when comparing the effectiveness of different approaches to CXL. Furthermore, methods of assessing and defining progressive keratoconus should be standardized. Trials with longer follow-up are required in order to assure that outcomes are measured after corneal wound-healing and stabilization of keratoconus. In addition, perioperative, intraoperative, and postoperative care should be standardized to permit meaningful comparisons of CXL methods. Methods to increase penetration of riboflavin through intact epithelium as well as delivery of increased dose of UVA may be needed to improve outcomes. PROs should be measured and reported. The visual significance of adverse outcomes, such as corneal haze, should be assessed and correlated with other outcomes, including PROs.
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Affiliation(s)
- Sueko M Ng
- Department of Ophthalmology, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Mark Ren
- Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristina B Lindsley
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Barbara S Hawkins
- Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Irene C Kuo
- Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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The Use of Autologous Serum Eye Drops after Epithelium-off Corneal Collagen Crosslinking. Optom Vis Sci 2021; 97:300-304. [PMID: 32304540 DOI: 10.1097/opx.0000000000001500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE After epithelium-off crosslinking (CXL), epithelial closure time and post-operative pain are an important issue in terms of possible complications and patient comfort. We report a prospective randomized study about the use of autologous serum eye drops after CXL. PURPOSE This study aims to evaluate the effect of autologous serum eye drops on epithelial healing and post-operative pain after CXL. METHODS Sixty patients diagnosed as having progressive keratoconus and treated with accelerated CXL (9 mW/cm for 10 minutes) randomly received 20% autologous serum eye drops (autologous serum group, n = 30) or artificial tears (control group, n = 30). Patients were evaluated every day after the surgery, and the day of epithelial closure was recorded. All patients were asked to report the maximum pain level using the Wong-Baker FACES Pain Rating Scale at the end of each day until the epithelial closure was completed. The change in topographic parameters and haze were recorded at 6 months. RESULTS The mean epithelial closure time was significantly lower in the autologous serum group than in the control group (2.37 ± 0.49 and 2.67 ± 0.47 days, respectively; P = .02). There was a statistically significant difference between the pain scores in the first and second days of surgery between the two groups (first-day autologous serum autologous serum group: 2.80 ± 0.66 and control group: 3.50 ± 0.82, P = .01; second-day autologous serum group: 1.73 ± 0.69 and control group: 2.20 ± 0.76, P = .02). Pre-operative and post-operative topographic parameters and haze at 6 months were similar between the two groups (P > .05 for all). CONCLUSIONS Use of autologous serum eye drops after CXL accelerates epithelial healing and reduces post-operative pain. Shortening the duration of epithelial closure would be beneficial in reducing possible complications and increasing patient comfort.
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Comparison of Standard and Transepithelial Corneal Cross-Linking for the Treatment of Keratoconus: A Meta-analysis. J Ophthalmol 2021; 2021:6679770. [PMID: 33575037 PMCID: PMC7864754 DOI: 10.1155/2021/6679770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/03/2021] [Accepted: 01/18/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose To compare the clinical results of standard corneal cross-linking (SCXL) with transepithelial corneal cross-linking (TECXL) in progressive keratoconus using a meta-analysis. Methods PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched up to June 2020 to identify relevant studies. The PRISMA guidelines were followed. Primary outcomes were change in uncorrected distance visual acuity and maximum keratometry (Kmax) after CXL. Secondary outcomes were change in corrected distance visual acuity, mean refractive spherical equivalent (MRSE), spherical and cylindrical error, endothelial cells density (ECD), and central corneal thickness (CCT). Results Sixteen studies with a total of 690 eyes (SCXL: 332 eyes; TECXL: 358 eyes) were included. At the last follow-up, SCXL provided a greater decrease in maximum keratometry (Kmax) than TECXL (weighted mean difference (WMD) −1.12; 95% confidence interval (CI) −1.96, −0.29). For the other outcomes, there were no statistically significant differences. Conclusions Except for a greater decrease in Kmax with SCXL group, both groups have a comparable effect on visual, pachymetric, and endothelial parameters at 24 months after surgery. Larger studies with a longer follow-up time are necessary to determine whether these techniques are comparable in the long term.
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Corneal Cross-linking: Epi-On vs. Epi-Off Current Protocols, Pros, and Cons. CURRENT OPHTHALMOLOGY REPORTS 2020. [DOI: 10.1007/s40135-020-00241-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kuo IC, Hawkins BS, Ren M, Lindsley KB. Transepithelial versus epithelium-off corneal crosslinking for progressive keratoconus. Hippokratia 2020. [DOI: 10.1002/14651858.cd013512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Irene C Kuo
- Wilmer Eye Institute, The Johns Hopkins University School of Medicine; Department of Ophthalmology; 4924 Campbell Blvd #100 Baltimore Maryland USA 21236
| | - Barbara S Hawkins
- The Johns Hopkins University School of Medicine; Wilmer Eye Institute; 550 North Broadway, 9th floor Baltimore Maryland USA 21205-2010
| | - Mark Ren
- The Johns Hopkins University School of Medicine; Wilmer Eye Institute; 550 North Broadway, 9th floor Baltimore Maryland USA 21205-2010
| | - Kristina B Lindsley
- IBM Watson Health; Life Sciences, Oncology, & Genomics; Baltimore Maryland USA
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Corneal crosslinking: Current protocols and clinical approach. J Cataract Refract Surg 2019; 45:1670-1679. [DOI: 10.1016/j.jcrs.2019.06.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 05/19/2019] [Accepted: 06/21/2019] [Indexed: 12/18/2022]
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12
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Valera-Cornejo DA, Vega-Estrada A, Alio JL. Invasive Pharmacology Outcomes with Different Corneal Cross-Linking Protocols: A Review. J Ocul Pharmacol Ther 2019; 35:475-490. [DOI: 10.1089/jop.2018.0144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
| | - Alfredo Vega-Estrada
- Miguel Hernandez University, Alicante, Spain
- VIssum Ophthalmic Corporation, Alicante, Spain
| | - Jorge L. Alio
- Miguel Hernandez University, Alicante, Spain
- VIssum Ophthalmic Corporation, Alicante, Spain
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13
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Wen D, Li Q, Song B, Tu R, Wang Q, O'Brart DPS, McAlinden C, Huang J. Comparison of Standard Versus Accelerated Corneal Collagen Cross-Linking for Keratoconus: A Meta-Analysis. Invest Ophthalmol Vis Sci 2019; 59:3920-3931. [PMID: 30073363 DOI: 10.1167/iovs.18-24656] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To systematically compare epithelial-off standard (SCXL) to accelerated corneal collagen cross-linking (ACXL) for the treatment of keratoconus. Methods PubMed, Embase, the Cochrane Library, and the US trial registry were searched for trials comparing SCXL and ACXL for keratoconus up to October 2017. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated. Primary outcomes were changes in uncorrected distance visual acuity, maximum keratometry (Kmax), and mean keratometry (mean K). Secondary outcomes were changes in corrected distance visual acuity, mean refractive spherical equivalent, central corneal thickness (CCT), and endothelial cell density (ECD). Results Eleven trials were included. For primary outcomes, SCXL showed a greater reduction in Kmax (SMD 0.32; 95% CI 0.16, 0.48) than ACXL. For secondary outcomes, the decrease in CCT (SMD 0.32; 95% CI 0.03, 0.61) and ECD (SMD 0.26; 95% CI 0.06, 0.46) was less with ACXL than with SCXL. For the other outcomes, there were no statistically significant differences. Conclusions SCXL has a greater effect in terms of reduction in Kmax than ACXL, while ACXL induces less reduction in CCT and ECD than SCXL. Further well-designed randomized controlled trials comparing ACXL and SCXL are indicated.
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Affiliation(s)
- Daizong Wen
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qi Li
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Benhao Song
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ruixue Tu
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qinmei Wang
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China.,Key Laboratory of Vision Science, Ministry of Health People's Republic of China, Wenzhou, Zhejiang, China
| | - David P S O'Brart
- Department of Ophthalmology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom.,King's College, London, United Kingdom
| | - Colm McAlinden
- Department of Ophthalmology, Glangwili Hospital, Hywel Dda University Health Board, Carmarthen, United Kingdom
| | - Jinhai Huang
- School of Ophthalmology and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China.,Key Laboratory of Vision Science, Ministry of Health People's Republic of China, Wenzhou, Zhejiang, China
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14
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Al Zubi K, Albakar Y, Nasser R. Transepithelial versus Epithelium off Crosslinking for Treating Keratoconus among Jordanians. Open Ophthalmol J 2019. [DOI: 10.2174/1874364101913010008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
The progression of keratoconus is stabilized with the help of corneal collagen cross-linking (CXL) supported through photosynthesized riboflavin.
Objective:
This study aims to compare the effectiveness of the transepithelial procedure and epithelium off procedure of corneal collagen crosslinking among keratoconus patients in Jordan.
Methods:
The study recruited 80 patients suffering from progressive keratoconus, from a tertiary care setting in Jordan. These participants were randomly divided into two groups; group 1 with 40 participants subjected to transepithelial (Corneal collagen cross-linking) CXL; and 40 participants in group 2 received conventional epithelium off CXL.
Results:
Improvement was observed in the mean contact lens, which corrected distance visual acuity (CDVA) from logMAR 0.332 ± 0.09 (group 1), 0.35 ± 0.09 (group 2) to 0.241 ± 0.07 (group 1), 0.21 ± 0.07 (group 2), respectively at the end of follow-up (12 months). The mean pachymetry improved from 429.81 ± 18.96 μm (group 1), 430.08 ± 17.05 μm (group 2) to 436.5 ± 15.49 μm (group 1), 436.44 ± 12.53 μm (group 2), respectively, after twelve months. Additionally, the mean Sim K astigmatism declined from 7.0 ± 2.0 (group 1), 6.73 ± 1.98 (group 2) to 5.97 ± 1.88 (group 1), 5.53 ± 0.08 (group 2) respectively at twelve months post-treatment. Majority of the patients in group 2 experienced more pain as compared to group 1 participants.
Conclusion:
The effectiveness of a cross-linking procedure related to keratometry readings and corneal thickness showed that conventional (epithelium off) CXL method is more effective than transepithelial CXL.
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Iqbal M, Elmassry A, Tawfik A, Abou Samra W, Elgharieb M, Elzembely H, Soliman A, Saad H, El Saman I, Saeed A, Farouk M, Tawfik T, Abou Ali A, Fawzy O. Analysis of the Outcomes of Combined Cross-Linking with Intracorneal Ring Segment Implantation for the Treatment of Pediatric Keratoconus. Curr Eye Res 2018; 44:125-134. [PMID: 30362837 DOI: 10.1080/02713683.2018.1540706] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE To analyze the visual and refractive outcomes of combined accelerated cross-linking with femtosecond laser intracorneal ring segment implantation for the treatment of pediatric keratoconus. MATERIALS AND METHODS This retrospective multicenter noncomparative clinical study included 63 eyes of 37 patients (age, 9-17 years) who underwent between August and September 2016 combined cross-linking with intracorneal ring segment implantation for keratoconus. Preoperative and postoperative (6, 12, and 18 months) uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), subjective refractions, keratometry (K), and pachymetry measurements were compared. RESULTS The postoperative spherical equivalent refraction was within ±1 D, ±2 D, and ±3 D in 19 (30.2%), 27 (42.9%), and 37 (58.8%) eyes, respectively. Only 27 eyes achieved the attempted preoperative spherical equivalent refraction. The mean spherical equivalent refraction significantly improved from -6.01 ± 2.97 to -3.13 ± 2.78 D postoperatively (P < 0.0001). The mean K average reading significantly decreased from 48.75 ± 4.25 to 46.65 ± 3.89 D postoperatively (P < 0.0001). The mean postoperative myopic, astigmatic, and spherical equivalent corrections were -2.17 ± 2.19, -1.52 ± 2.03, and -2.93 ± 2.35 D, respectively. The mean UDVA and CDVA showed significant improvements (0.89 ± 0.33 to 0.40 ± 0.28, P < 0.0001; 0.35 ± 0.31 to 0.25 ± 0.24, P = 0.004; respectively) at 18 months postoperatively. Keratoconus progression, segment migration, and segment extrusion were seen in four (6.4%), one (1.6%), and three (4.7%) eyes, respectively, probably contributing to the lower mean postoperative CDVA. CONCLUSION Cross-linking plus is only partially effective for pediatric keratoconus. Despite some improvements in vision and keratometry measures, it resulted in complications such as keratoconus progression, segment extrusion, and segment migration that affected the vision in some patients. These findings suggest an assessment of standard epithelium-off collagen cross-linking as a sole procedure to treat pediatric keratoconus in future studies.
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Affiliation(s)
- Mohammed Iqbal
- a Department of Ophthalmology, Faculty of Medicine , Sohag University , Sohag , Egypt
| | - Ahmed Elmassry
- b Department of Ophthalmology, Faculty of Medicine , Alexandria University , Alexandria , Egypt
| | - Ahmed Tawfik
- c Department of Ophthalmology, Faculty of Medicine , Zagazig University , Zagazig , Egypt
| | - Waleed Abou Samra
- d Department of Ophthalmology, Faculty of Medicine , Mansoura University , Mansoura , Egypt
| | - Mervat Elgharieb
- e Department of Ophthalmology, Faculty of Medicine , Suez Canal University , Suez , Egypt
| | - Hosam Elzembely
- f Department of Ophthalmology, Faculty of Medicine , Minia University , Minia , Egypt
| | - Ashraf Soliman
- g Department of Ophthalmology, Faculty of Medicine , Ain Shams University , Cairo , Egypt
| | - Hisham Saad
- h Department of Ophthalmology, Faculty of Medicine , Tanta University , Tanta , Egypt
| | - Islam El Saman
- a Department of Ophthalmology, Faculty of Medicine , Sohag University , Sohag , Egypt
| | - Ahmed Saeed
- i Department of Ophthalmology, Faculty of Medicine , Banha University , Banha , Egypt
| | - Mahmoud Farouk
- a Department of Ophthalmology, Faculty of Medicine , Sohag University , Sohag , Egypt
| | - Tarek Tawfik
- i Department of Ophthalmology, Faculty of Medicine , Banha University , Banha , Egypt
| | - Amin Abou Ali
- a Department of Ophthalmology, Faculty of Medicine , Sohag University , Sohag , Egypt
| | - Omar Fawzy
- j Department of Ophthalmology , Sohag Eye Hospital , Sohag , Egypt
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Transepithelial versus epithelium-off corneal crosslinking for corneal ectasia. J Cataract Refract Surg 2018; 44:1507-1516. [PMID: 30314751 DOI: 10.1016/j.jcrs.2018.08.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/14/2018] [Accepted: 08/19/2018] [Indexed: 01/24/2023]
Abstract
This review compared the clinical results of transepithelial corneal crosslinking (CXL) to epithelium-off (epi-off) CXL in progressive corneal ectasia using a metaanalysis. The Cochrane databases and Medline were searched for randomized controlled trials (RCTs). Seven RCTs involving 505 eyes that met the eligibility criteria were identified. The epi-off CXL group showed significantly better outcomes in postoperative changes in maximum keratometry (K) during 1-year observation periods. Transepithelial CXL resulted in significantly greater post-treatment central corneal thickness and best spectacle-corrected visual acuity (BSCVA). The presence of a postoperative demarcation line was significantly more frequent after epi-off CXL than that after transepithelial CXL. No statistically significant difference was found between other parameters. Although patients in the transepithelial CXL group demonstrated a greater improvement in BSCVA compared with patients in the epi-off CXL group at the 1 year follow-up, transepithelial CXL had less impact on halting progressive corneal ectasia in terms of maximum K than epi-off CXL.
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Nattis A, Donnenfeld ED, Rosenberg E, Perry HD. Visual and keratometric outcomes of keratoconus patients after sequential corneal crosslinking and topography-guided surface ablation: Early United States experience. J Cataract Refract Surg 2018; 44:1003-1011. [DOI: 10.1016/j.jcrs.2018.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/01/2018] [Accepted: 05/25/2018] [Indexed: 10/28/2022]
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Comparison of Epithelium-Off Versus Transepithelial Corneal Collagen Cross-Linking for Keratoconus: A Systematic Review and Meta-Analysis. Cornea 2018; 37:1018-1024. [PMID: 29847492 DOI: 10.1097/ico.0000000000001632] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE To systematically compare standard epithelium-off corneal collagen cross-linking (SCXL) and transepithelial corneal collagen cross-linking (TECXL) for treating keratoconus. METHODS PubMed, EMBASE, the Cochrane Library, the US trial registry (ClinicalTrials.gov), VIP Database, Wanfang Databse, and China National Knowledge Infrastructure searches up to February 2017 were conducted. Primary outcomes were changes at 1 year in uncorrected distance visual acuity, maximum keratometry (Kmax), and mean keratometry (mean K). Secondary outcomes were changes at 1 year in corrected distance visual acuity, mean refractive spherical equivalent, central corneal thickness, endothelial cell density, and the occurrence of adverse events. RESULTS Eight studies with a total of 455 eyes were included. For primary outcomes, SCXL showed a greater reduction in mean K [standardized mean difference (SMD) 0.28; 95% confidence interval (CI), 0.03-0.53; P = 0.03] compared with TECXL. Subgroup analysis indicated that SCXL had a comparable effect on reducing mean K with TECXL protocols using chemical enhancers (SMD 0.05; 95% CI, -0.36 to 0.45; P = 0.82) but a greater reduction in mean K compared with TECXL with current iontophoretic protocols (SMD 0.43; 95% CI, 0.10-0.75; P = 0.01). For the other outcomes, there were no statistically significant differences. CONCLUSIONS With the exception of less reduction in mean K with current iontophoretic protocols, analysis of the limited number of comparative studies available seems to demonstrate that SCXL and TECXL have a comparable effect on visual, refractive, pachymetric, and endothelial parameters at 1 year after surgery. Further follow-up is required to determine whether these techniques are comparable in the long-term.
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Three-Year Outcomes of Cross-Linking PLUS (Combined Cross-Linking with Femtosecond Laser Intracorneal Ring Segments Implantation) for Management of Keratoconus. J Ophthalmol 2018; 2018:6907573. [PMID: 29576880 PMCID: PMC5822772 DOI: 10.1155/2018/6907573] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 10/11/2017] [Accepted: 11/12/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose To analyze the results of three-year outcomes of combined epithelium-on cross-linking with femtosecond laser ICRS (cross-linking PLUS) for keratoconus management. Design A retrospective multicenter clinical study. Methods 43 eyes of 38 patients were subjected to preoperative and postoperative UCVA, BCVA, refraction, Pentacam pachymetry, and keratometry examinations at 3-, 6-, 12-, 24-, and 36-month follow-up period. Results The preoperative and postoperative mean UCVA was 1.30 ± 0.48 (logMAR ± SD) and 0.82 ± 0.22 respectively. The preoperative and postoperative mean BCVA was 0.90 ± 0.40 and 0.60 ± 0.30, respectively. The preoperative and postoperative mean K average was 50.63 ± 0.87 (D ± SD) and 45.56 ± 0.98, respectively. The preoperative and postoperative mean pachymetry was 471 ± 92.36 (μm ± SD) and 423 ± 39.58, respectively. The preoperative and postoperative mean astigmatism was 7.55 ± 1.75 and 3.39 ± 1.26, respectively. One eye showed ICRS edge exposure while 6 eyes showed progression of keratoconus. Conclusion CXL PLUS was proved to be a successful procedure to halt progression (mainly by CXL) and to correct the refractive status of the keratoconic eye (mainly by ICRS). CXL PLUS performed a synergistic action correcting and maintaining the correction of both myopic and astigmatic components of keratoconus.
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Efficacy of Epithelium-Off and Epithelium-On Corneal Collagen Cross-Linking in Pediatric Keratoconus. Eye Contact Lens 2017; 43:155-161. [PMID: 26925536 DOI: 10.1097/icl.0000000000000255] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the efficacy of riboflavin/ultraviolet A epithelium-off (epi-off) and epithelium-on (epi-on) corneal collagen cross-linking (CXL) in progressive pediatric keratoconus. METHODS Thirty-six eyes of 27 patients aged 18 years or younger (12-18 years) diagnosed with progressive keratoconus and treated with epi-off (n=18 eyes) or epi-on (n=18 eyes) CXL were included in this study. All patients were followed up for 24 months postoperatively. RESULTS At 24-month follow-up, the mean corrected distance visual acuity (CDVA) improved from 0.24±0.17 to 0.17±0.11 logMAR in the epi-off group (P=0.032). In the epi-on group, CDVA improved from 0.33±0.23 to 0.26±0.20 logMAR (P=0.012), but the improvement was not significantly different between groups (P>0.05). In the epi-off group, all mean K values improved: K1 (Δ=-0.63 D, P=0.024), K2 (Δ=-0.73 D, P=0.008), and Kmax (Δ=-1.4 D, P=0.035), whereas in the epi-on group, Kmax and K2 did not change significantly and K1 (Δ=0.68 D, P=0.029) significantly worsened. Postoperative mild corneal haze occurred in 5 eyes (28%) in the epi-off group. No postoperative complications were observed in the epi-on group. In 94.4% of the epi-off group, keratoconus regressed (44.4%) or stabilized (50.0%), whereas in the epi-on group, only 66.6% regressed (33.3%) or stabilized (33.3%), and the difference was significant (P=0.038). CONCLUSIONS The efficacy of the epi-on procedure in terms of its ability to halt keratoconus progression appears to be 0.70 of the efficacy of epi-off CXL.
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Vastardis I, Pajic-Eggspuehler B, Nichorlis C, Mueller J, Pajic B. Recent Innovations in Collagen Corneal Cross-linking; a Mini Review. Open Ophthalmol J 2017; 11:217-224. [PMID: 28932338 PMCID: PMC5585451 DOI: 10.2174/1874364101711010217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/13/2017] [Accepted: 06/14/2017] [Indexed: 11/22/2022] Open
Abstract
Background: The introduction of corneal cross-linking (CXL) with ultraviolet-A (UVA) and Riboflavin photosensitizer (Vit B2) from Seiler et al., revolutionized the treatment of Keratoconus and other corneal ectatic diseases. Today, the commonly known epithelium off Dresden protocol is in clinical use for the last 15 years with great success and regarded by many as the golden standard. Methods: With several studies demonstrating its simplicity, efficacy and safety this revolutionary method, paved the way for new therapies and strategies in the treatment of corneal ectatic diseases and changed our understanding in corneal biomechanics. Recent scientific and technological advances enabled the creation of various modifications of the initial CXL protocol and the formation of new ones. Conclusion: This work highlights the recent advances of CXL, such as the role of oxygen, higher fluence and shorter irradiation times as well as the various clinical applications and updates of this method.
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Affiliation(s)
- Iraklis Vastardis
- Swiss Eye Research Foundation, Eye Clinic ORASIS, Titlisstrasse 44, 5734 Reinach, Switzerland
| | | | - Charis Nichorlis
- Swiss Eye Research Foundation, Eye Clinic ORASIS, Titlisstrasse 44, 5734 Reinach, Switzerland
| | - Jörg Mueller
- Swiss Eye Research Foundation, Eye Clinic ORASIS, Titlisstrasse 44, 5734 Reinach, Switzerland.,University of Novi Sad, Faculty of Physics, Novi Sad, Serbia
| | - Bojan Pajic
- Swiss Eye Research Foundation, Eye Clinic ORASIS, Titlisstrasse 44, 5734 Reinach, Switzerland.,University of Novi Sad, Faculty of Physics, Novi Sad, Serbia.,Medical faculty, Military Medical Academy, University of defence Belgrade, Serbia
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Liu Y, Liu Y, Zhang YN, Li AP, Zhang J, Liang QF, Jie Y, Pan ZQ. Systematic review and Meta-analysis comparing modified cross-linking and standard cross-linking for progressive keratoconus. Int J Ophthalmol 2017; 10:1419-1429. [PMID: 28944203 DOI: 10.18240/ijo.2017.09.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 06/26/2017] [Indexed: 11/23/2022] Open
Abstract
AIM To compare the effectiveness and safety between modified cross-linking (MC) and standard cross-linking (SC) in mild or moderate progressive keratoconus. METHODS Eligible studies were retrieved from four electronic databases, including CENTRAL, Clinical Trials gov, PupMed and OVID MEDLINE. We set post-surgical maximum K value (Kmax) as the primary outcome. In addition, uncorrected and corrected distant visual acuity (UDVA and UDVA), spherical equivalent (SE), endothelial cell density (ECD), central cornea thickness (CCT) and depth of demarcation line (DDL) were Meta-analyzed as secondary outcomes. Mean differences for these outcomes were pooled through either a random-effect model or fixed-effect model according to data heterogeneity. RESULTS Twenty-four comparative studies either on accelerated cross-linking (AC) compared with SC or on trans-epithelial cross-linking (TC) compared with SC were included and pooled for analysis. The results indicated that MC was significantly inferior to SC at delaying Kmax deterioration [AC vs SC 0.49 (95% CI: 0.04-0.94, I2=75%, P=0.03); TC vs SC 1.15 (95% CI: 0.54-1.75, I2=50%, P=0.0002)]. SE decreased significantly for SC when compared to AC [0.62 (95% CI: 0.38-0.86, I2=22%, P<0.00001)]. DDL of SC was more significantly deeper than that of TC [-133.49 (95% CI: -145.94 to -121.04, I2=33%, P<0.00001)]. Other outcomes demonstrated comparable results between MC and SC. CONCLUSION SC is more favorable at halting the progression of keratoconus, but visual acuity improvement showed comparable results between MCs and SC.
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Affiliation(s)
- Yang Liu
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Yi Liu
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Ying-Nan Zhang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Ai-Peng Li
- Department of Ophthalmology, First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Jing Zhang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Qing-Feng Liang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Ying Jie
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Zhi-Qiang Pan
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
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Evaluation of Iontophoretic Collagen Cross-linking for Early Stage of Progressive Keratoconus Compared to Standard Cross-linking: A Non-Inferiority Study. Ophthalmol Ther 2017; 6:147-160. [PMID: 28160249 PMCID: PMC5449295 DOI: 10.1007/s40123-017-0076-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Indexed: 11/29/2022] Open
Abstract
Introduction The purpose of this study was to evaluate the efficacy and safety of iontophoretic collagen cross-linking (I-CXL) compared to epithelium-off standard collagen cross-linking (CXL) in treating the early stages of progressive keratoconus. Methods This retrospective cohort study at Oftaprof Clinic, Iasi, Romania included 40 eyes of 40 patients with progressive keratoconus stage I according to the Amsler classification who underwent I-CXL and the results were compared with a matched group of 40 eyes from 40 patients who received standard CXL. The follow-up period was 24 months. Uncorrected (UCVA) and corrected (CDVA) distance visual acuities, corneal topography, and pachymetry were evaluated in all patients. Results The mean patient age was 26.52 ± 3.77 years for the standard CXL group and 28.32 ± 4.91 for the I-CXL group. The mean UCVA and CDVA improved significantly in both groups. At 12 months, the improvement of UCVA was greater in the I-CXL group (P < 0.05). There was a statistically significant different trend in CDVA between groups with a more favorable outcome for the standard CXL group (P < 0.01). The manifest cylinder decreased by a mean of 0.962 ± 0.114 D in the epithelium-off CXL group and by 0.831 ± 0.082 D in the I-CXL group (P < 0.001). At 24 months, the Kmax values improved by 1.2 ± 0.199 D in the standard group and by 0.908 ± 0.177 D in the I-CXL group (P < 0.001). Conclusion All parameters either improved or remained unchanged after the iontophoretic collagen cross-linking intervention. I-CXL was found to be as effective as the standard technique. Electronic supplementary material The online version of this article (doi:10.1007/s40123-017-0076-8) contains supplementary material, which is available to authorized users.
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Akbar B, Intisar-Ul-Haq R, Ishaq M, Fawad A, Arzoo S, Siddique K. Comparison of transepithelial corneal crosslinking with epithelium-off crosslinking (epithelium-off CXL) in adult Pakistani population with progressive keratoconus. Taiwan J Ophthalmol 2017; 7:185-190. [PMID: 29296550 PMCID: PMC5747228 DOI: 10.4103/tjo.tjo_38_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE: The purpose of this study is to compare the safety and efficacy of transepithelial corneal crosslinking (CXL) with epithelium-off crosslinking (epithelium-off CXL) in the treatment of progressive keratoconus in adult Pakistani population. MATERIALS AND METHODS: Sixty-four eyes of 64 consecutive patients of progressive keratoconus were included in this quasi-experimental study. Thirty-two eyes received transepithelial CXL with Peschke TE (0.25% riboflavin (Vitamin B2), 1.2% hydroxypropyl methylcellulose (HPMC), 0.01% benzalkonium chloride) and 32 eyes received epithelium-off CXL with Peschke M (0.1% riboflavin (Vitamin B2) 0.1%, HPMC 1.1%.) The cornea was then exposed to ultraviolet A light at an irradiance of 3 mW/cm2 for 30 min. The primary outcome measure, clinical stabilization of keratoconus was defined as an increase of no more than 1D in Kmax at 1 year. Other parameters evaluated at baseline and 3, 6, 12, and 18 months postoperatively were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE), astigmatism (Ast), simulated keratometry, steep keratmetry (steep K), and corneal thickness at thinnest point (pachy thin). RESULTS: Both epithelium-off CXL and transepithelial CXL groups showed a significant reduction in Kmax, steep K, simulated K, corneal pachymetry at all test points (P < 0.05) with significantly greater reductions achieved in epithelium-off CXL group at 18 months follow-up. The mean UDVA, CDVA, SE, Ast significantly improved in both groups (P < 0.05). The mean postoperative UDVA and CDVA between the groups were not significant at 12 months (P = 0.650, 0.018, respectively). Clinical stabilization was achieved in 94% of eyes in epithelium-off CXL and 75% of eyes in transepithelial CXL. In epithelium-off CXL, three eyes exhibited stromal haze resolved by corticosteroid treatment. No complication was documented in transepithelial CXL group. CONCLUSION: Transepithelial CXL is not recommended to be replaced completely by standard epithelium-off CXL due to continued ectatic progression in 25% of cases. However, thin corneas, unfit for standard epithelium-off CXL, can benefit from transepithelial CXL.
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Affiliation(s)
- Bushra Akbar
- Department of Ophthalmology, Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan
| | - Rana Intisar-Ul-Haq
- Department of Ophthalmology, Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan
| | - Mazhar Ishaq
- Department of Ophthalmology, Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan
| | - Ayesha Fawad
- Department of Ophthalmology, Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan
| | - Sabahat Arzoo
- Department of Ophthalmology, Armed Forces Institute of Ophthalmology, Rawalpindi, Pakistan
| | - Kashif Siddique
- Biostatistics, King Salman Armed Forces Hospital, Tabuk, KSA Academic Affairs (Research Unit), Saudi Arabia
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Corneal collagen crosslinking for corneal ectasias: a review. Eur J Ophthalmol 2016; 27:253-269. [PMID: 28009397 DOI: 10.5301/ejo.5000916] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To review the published literature on corneal collagen crosslinking (CXL). METHODS Importance has been placed on seminal publications, systemic reviews, meta-analyses, and randomized controlled clinical trials. Where such evidence was not available, cohort studies, case-controlled studies, and case series with follow-up greater than 12 months were examined. RESULTS Corneal collagen crosslinking with riboflavin and ultraviolet A (UVA) 370 nm radiation appears to be capable of arresting the progression of ectatic corneal disorders, with most studies reporting significant improvements in visual, keratometric, and topographic measurements. Its mode of action at the molecular level is undetermined. Follow-up is limited to 5-10 years but suggests sustained stability and enhancement in corneal shape with time. Nearly all published long-term data and comparative studies are with epithelium-off techniques. Epithelium-on investigations suggest some efficacy but less than with epithelium-off treatments and long-term data are unavailable. Accelerated techniques with higher UVA fluencies and shorter treatments times, delivering the same UVA energy dosage, are the subject of recent investigation, with some laboratory and clinical studies suggesting reduced efficacy compared to the standard 3 mW/cm2 for 30 minutes irradiation procedure. Combined methodologies of CXL with techniques such as photorefractive keratectomy and intrastromal rings show promise but long-term follow-up is indicated. Sight-threatening complications of CXL are rare. CONCLUSIONS Studies of epithelium-off CXL with irradiation at 3 mW/cm2 for 30 minutes support its efficacy. Refinement in techniques may allow for safer and more rapid procedures with less patient discomfort but require further investigation.
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Aldahlawi NH, Hayes S, O'Brart DPS, O'Brart ND, Meek KM. An investigation into corneal enzymatic resistance following epithelium-off and epithelium-on corneal cross-linking protocols. Exp Eye Res 2016; 153:141-151. [PMID: 27765574 PMCID: PMC5131611 DOI: 10.1016/j.exer.2016.10.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/10/2016] [Accepted: 10/14/2016] [Indexed: 11/28/2022]
Abstract
The aim of this study was to investigate corneal enzymatic resistance following epithelium off and on riboflavin/UVA cross-linking (CXL). One hundred and fourteen porcine eyes were divided into four non-irradiated control groups and seven CXL groups. The latter comprised; (i) epithelium-off, 0.1% iso-osmolar riboflavin, 9 mW UVA irradiation for 10 min, (ii) disrupted epithelium, 0.1% hypo-osmolar riboflavin, 9 mW UVA for 10 min, (iii) epithelium-on, 0.25% hypo-osmolar riboflavin with 0.01% benzylalkonium chloride (BACS), 9 mW UVA for 10 min, (iv) epithelium-on, 5 min iontophoresis at 0.1 mA for 5 min with 0.1% riboflavin solution, 9 mW UVA for 10 min or (v) 12.5 min, (vi) epithelium-on, prolonged iontophoresis protocol of 25 min with 1.0 mA for 5 min and 0.5 mA for 5 min with 0.25% riboflavin with 0.01% BACS, 9 mW UVA for 10 min or (vii) 12.5 min. Enzymatic resistance was assessed by daily measurement of a corneal button placed in pepsin solution and measurement of corneal button dry weight after 11 days of digestion. This study revealed that the enzymatic resistance was greater in CXL corneas than non-irradiated corneas (p < 0.0001). Epithelium-off CXL showed the greatest enzymatic resistance (p < 0.0001). The prolonged iontophoresis protocol was found to be superior to all other trans-epithelial protocols (p < 0.0001). A 25% increase in UVA radiance significantly increased corneal enzymatic resistance (p < 0.0001). In conclusion, although epithelium-on CXL appears to be inferior to epithelium-off CXL in terms of enzymatic resistance to pepsin digestion, the outcome of epithelium-on CXL may be significantly improved through the use of higher concentrations of riboflavin solution, a longer duration of iontophoresis and an increase in UVA radiance. Epi-off CXL is superior to epi-on CXL in terms of enzymatic resistance. Epi-on CXL effectiveness can be improved by using a prolonged iontophoresis protocol. Higher riboflavin concentrations and increased UVA radiance may also enhance epi-on CXL.
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Affiliation(s)
- Nada H Aldahlawi
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ, UK
| | - Sally Hayes
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ, UK
| | - David P S O'Brart
- Keratoconus Research Institute, Department of Ophthalmology, St Thomas Hospital, London, SE1 7EH, UK
| | - Naomi D O'Brart
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ, UK
| | - Keith M Meek
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ, UK.
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Gatzioufas Z, Raiskup F, O'Brart D, Spoerl E, Panos GD, Hafezi F. Transepithelial Corneal Cross-linking Using an Enhanced Riboflavin Solution. J Refract Surg 2016; 32:372-7. [DOI: 10.3928/1081597x-20160428-02] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 02/04/2016] [Indexed: 02/07/2023]
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Nicholas DL, Gillian WD. Corneal cross-linking methods and outcomes: A review. AFRICAN VISION AND EYE HEALTH 2016. [DOI: 10.4102/aveh.v75i1.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The prevalence of corneal ectasias such as keratoconus has been widely documented. Keratoconus may lead to detrimental changes in visual acuity, which can often be corrected in the early stages but requires more invasive treatment as the condition progresses. Corneal cross-linking has become a treatment method of choice in early keratoconic patients and is used to stabilise the condition and prevent further progression of the disease. The principle behind this procedure is the creation of additional bonds within the corneal structure in order to enhance its mechanical properties and thereafter halt the progression of the condition. There are disagreements within the literature as to how these procedures can be performed, and there are various alternative methods. It can be concluded that corneal cross-linking is an effective treatment method for keratoconus and has been shown to produce various beneficial effects in terms of ocular structure and function.
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Çerman E, Toker E, Ozarslan Ozcan D. Transepithelial versus epithelium-off crosslinking in adults with progressive keratoconus. J Cataract Refract Surg 2016; 41:1416-25. [PMID: 26287880 DOI: 10.1016/j.jcrs.2014.10.041] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 09/24/2014] [Accepted: 10/11/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the efficacy of epithelium-off corneal collagen crosslinking (CXL) with transepithelial CXL in patients with progressive keratoconus. SETTING Department of Ophthalmology, Marmara University School of Medicine, Istanbul, Turkey. DESIGN Retrospective cohort study. METHODS Eyes that had transepithelial CXL were compared with eyes treated with epithelium-off CXL. All patients with a follow-up of 18 months were evaluated for uncorrected (UDVA) and corrected (CDVA) distance visual acuities, corneal topography, aberrometry, and pachymetry (Pentacam). RESULTS The mean patient age was 22.8 years ± 4.7 (SD) (range 18 to 31 years) in the transepithelial group (30 eyes) and 23.7 ± 3.9 years (range 18 to 30 years) in the epithelium-off group (30 eyes). The mean UDVA and CDVA significantly improved in both groups (P < .001). There was no significant difference in the CDVA gain between the 2 groups. In the epithelium-off group, significant improvements occurred in spherical error (P = .002), spherical equivalent (P = .004), maximum keratometry (K), flat K (P = .036), and steep K (P < .001). The reductions in flat K, steep K, and maximum K were greater in the epithelium-off group (P = .004 for flat K; P < .001 for steep K and maximum K). In the transepithelial group, significant improvements occurred in the cylindrical error (P = .009) and in the index of surface variance and index of surface asymmetry (both P < .001). CONCLUSION Although transepithelial CXL seemed to have reduced effectiveness in inducing improvement in topographic indices, its effect on visual acuity is likely to be similar to that of epithelium-off CXL. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.
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Affiliation(s)
- Eren Çerman
- From the Marmara University School of Medicine, Department of Ophthalmology, Istanbul, Turkey.
| | - Ebru Toker
- From the Marmara University School of Medicine, Department of Ophthalmology, Istanbul, Turkey
| | - Deniz Ozarslan Ozcan
- From the Marmara University School of Medicine, Department of Ophthalmology, Istanbul, Turkey
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Maurin C, Daniel E, Bonnin N, Pereira B, Monneyron N, Peltier C, Monier F, Chiambaretta F. [Assessment of postoperative pain after corneal collagen cross-linking by iontophoresis vs the rapid epithelium-off technique in progressive keratoconus patients]. J Fr Ophtalmol 2015; 38:904-11. [PMID: 26542679 DOI: 10.1016/j.jfo.2015.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 05/02/2015] [Accepted: 05/13/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Cross-linking (CXL) increases corneal biomechanical strength in progressive keratoconus. Since riboflavin cannot penetrate intact corneal epithelium, removal of epithelium is necessary for the classic CXL procedure (epi-off), but can cause severe postoperative pain. To avoid this problem, a method preserving the epithelium (epi-on) is used. In this study, we aimed to evaluate and compare postoperative pain after epi-off CXL and epi-on CXL. MATERIALS AND METHODS We present a retrospective study assessing the level of pain postoperatively in 38 patients between the age of 12 and 53 years who underwent CXL procedures at the University Hospital of Clermont-Ferrand from July 2013 to May 2014. Epi-off consisted of manual corneal de-epithelialization and riboflavin instillation for 20minutes, followed by UVA exposure for 9minutes. The epi-on technique used an applicator on the eye, filled with riboflavin, and a generator delivered a continuous low-level current for 5minutes. The duration of light exposure was similar in both groups. Postoperative medications were the same for both techniques. Assessment of pain and analgesic intake were reported by the patient on paper questionnaires. Pain was evaluated from preoperatively up until the end of the month. Statistical analyses were performed in bilateral formulation to an alpha type I and error risk of 5%. RESULTS Twenty-three epi-off patients and 15 epi-on patients. Twenty-nine men and 9 women (76.3%/23.7%). Mean age: 28 years. Reference base time was the return from the operating room. In the epi-off group, pain increased significantly until the morning of D2 and did not return to its intraoperative level until noon D2, 1.8±2.0 vs 2.5±2.5 (P=0.12). Pain remained stable until the morning of D4. From noon D4 until D30, it was significantly less than intraoperatively 1.8±2.0 vs 0.7±1.4 (P=0.01). In the epi-on group, pain was significantly higher than intraoperatively until noon of D1 2.5±2.2 vs 3.8±2.5 (P=0.01). From the evening of D1, it returned to its intraoperative level until the evening of D2 2.5±2.2 vs 2±1.7 (P=0.34). From the morning of D3 it was significantly less than intraoperatively 2.5±2.2 vs 0.8±0.9 (P=0.001). Considering all measurement times, there was no significant difference between the two groups (P=0.75), except from evening of D2 until evening of D3 in favor of iontophoresis: 1.9±2.3 vs 1.0±1.3 (P=0.038). DISCUSSION Epi-on seems less painful in the short term (up to noon of D1 for epi-on vs morning of D2 for epi-off) and with a shorter duration than epi-off. This can be explained by the absence of corneal de-epithelialization. However, the reduction in pain is not significant at all postoperative times, and a risk of epithelial abrasion during placement and removal of the corneal applicator may exist. CONCLUSION Iontophoresis maintains the corneal epithelium, decreases pain and improves patient comfort. A new study involving more patients and strict monitoring of medication intake would strengthen the validity of these results.
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Affiliation(s)
- C Maurin
- Service d'ophtalmologie, CHU de Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand cedex, France.
| | - E Daniel
- Service d'ophtalmologie, CHU de Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand cedex, France
| | - N Bonnin
- Service d'ophtalmologie, CHU de Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand cedex, France
| | - B Pereira
- Délégation recherche clinique et innovation, CHU de Clermont-Ferrand, Villa annexe IFSI, 58, rue Montalembert, 63003 Clermont-Ferrand cedex, France
| | - N Monneyron
- Service d'ophtalmologie, CHU de Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand cedex, France
| | - C Peltier
- Service d'ophtalmologie, CHU de Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand cedex, France
| | - F Monier
- Service d'ophtalmologie, CHU de Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand cedex, France
| | - F Chiambaretta
- Service d'ophtalmologie, CHU de Clermont-Ferrand, 58, rue Montalembert, 63003 Clermont-Ferrand cedex, France
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Iontophoretic transepithelial corneal cross-linking to halt keratoconus in pediatric cases: 15-month follow-up. Cornea 2015; 34:512-5. [PMID: 25789695 DOI: 10.1097/ico.0000000000000410] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To report the results 15 months after transepithelial corneal cross-linking by iontophoresis of riboflavin performed in pediatric patients affected by keratoconus. METHODS Fourteen eyes of 14 pediatric patients [mean age 13 ± 2.4 (SD) years; range, 10-18 years] were treated. Riboflavin solution was administered by iontophoresis for 5 minutes, and then UVA irradiation (10 mW/cm) was performed for 9 minutes. The corrected distance visual acuity measured as decimal number, spherical equivalent, refractive astigmatism, simulated K, corneal coma, spherical aberration, and high-order aberrations for 5.0-mm pupil and the thinnest point were measured preoperatively and 3, 6, 12, and 15 months postoperatively. The endothelial cell density was evaluated. The paired Student t test was used to compare data during the follow-up. RESULTS Fifteen months after the procedure, the corrected distance visual acuity improved from 0.7 ± 1.7 to 0.8 ± 1.8 (P = 0.005). Spherical equivalent and refractive astigmatism as well as topographic and aberrometric data did not show significant changes. Also, the mean thinnest point and the endothelial cell density remained unchanged. The optical coherence tomography showed a nonhomogeneous but deep hyperreflective band with a fading effect extending through the anterior 180 μm of the cornea. No side effects were recorded. CONCLUSIONS Transepithelial collagen cross-linking by iontophoresis, unlike other transepithelial techniques, seems to halt pediatric keratoconus progression over 15 months. However, we did not record significant improvement in higher-order aberrations and topographic indices.
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Corneal Collagen Cross-linking Combined With Simulation of Femtosecond Laser–Assisted Refractive Lens Extraction. Cornea 2015; 34:550-6. [DOI: 10.1097/ico.0000000000000376] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Intraoperative Optical Coherence Tomography Using the RESCAN 700: Preliminary Results in Collagen Crosslinking. BIOMED RESEARCH INTERNATIONAL 2015; 2015:572698. [PMID: 25945339 PMCID: PMC4402560 DOI: 10.1155/2015/572698] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 10/20/2014] [Accepted: 10/30/2014] [Indexed: 11/17/2022]
Abstract
Purpose. To compare the penetration of riboflavin using a microscope-integrated real time spectral domain optical coherence tomography (ZEISS OPMI LUMERA 700 and ZEISS RESCAN 700) in keratoconus patients undergoing accelerated collagen crosslinking (ACXL) between epithelium on (epi-on) and epithelium off (epi-off). Methods. Intraoperative images were obtained during each of the procedures. Seven keratoconus patients underwent epi-on ACXL and four underwent epi-off ACXL. A software tool was developed using Microsoft.NET and Open Computer Vision (OpenCV) libraries for image analysis. Pre- and postprocedure images were analyzed for changes in the corneal hyperreflectance pattern as a measure of the depth of riboflavin penetration. Results. The mean corneal hyperreflectance in the epi-on group was 12.97 ± 1.49 gray scale units (GSU) before instillation of riboflavin and 14.46 ± 2.09 GSU after AXCL (P = 0.019) while in the epi-off group it was 11.43 ± 2.68 GSU and 16.98 ± 8.49 GSU, respectively (P = 0.002). The average depth of the band of hyperreflectance in the epi-on group was 149.39 ± 15.63 microns and in the epi-off group it was 191.04 ± 32.18 microns. Conclusion. This novel in vivo, real time imaging study demonstrates riboflavin penetration during epi-on and epi-off ACXL.
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Parker JS, van Dijk K, Melles GRJ. Treatment options for advanced keratoconus: A review. Surv Ophthalmol 2015; 60:459-80. [PMID: 26077628 DOI: 10.1016/j.survophthal.2015.02.004] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/17/2015] [Accepted: 02/20/2015] [Indexed: 10/23/2022]
Abstract
Traditionally, the mainstay of treatment for advanced keratoconus (KC) has been either penetrating or deep anterior lamellar keratoplasty (PK or DALK, respectively). The success of both operations, however, has been somewhat tempered by potential difficulties and complications, both intraoperatively and postoperatively. These include suture and wound-healing problems, progression of disease in the recipient rim, allograft reaction, and persistent irregular astigmatism. Taken together, these have been the inspiration for an ongoing search for less troublesome therapeutic alternatives. These include ultraviolet crosslinking and intracorneal ring segments, both of which were originally constrained in their indication exclusively to eyes with mild to moderate disease. More recently, Bowman layer transplantation has been introduced for reversing corneal ectasia in eyes with advanced KC, re-enabling comfortable contact lens wear and permitting PK and DALK to be postponed or avoided entirely. We offer a summary of the current and emerging treatment options for advanced KC, aiming to provide the corneal specialist useful information in selecting the optimal therapy for individual patients.
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Affiliation(s)
- Jack S Parker
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands; UAB Callahan Eye Hospital, Birmingham, Alabama, USA
| | - Korine van Dijk
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands
| | - Gerrit R J Melles
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands; Amnitrans EyeBank, Rotterdam, The Netherlands.
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Neue Behandlungsprotokolle der Hornhautvernetzung (Corneal Crosslinking). SPEKTRUM DER AUGENHEILKUNDE 2015. [DOI: 10.1007/s00717-015-0257-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Robert MC, Arafat SN, Ciolino J. Collagen cross-linking of the Boston keratoprosthesis donor carrier to prevent corneal melting in high-risk patients. Eye Contact Lens 2014; 40:376-81. [PMID: 25320957 PMCID: PMC8487267 DOI: 10.1097/icl.0000000000000081] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the clinical relevance and pathophysiology of Boston keratoprosthesis (B-KPro)-related corneal keratolysis (cornea melt) and to describe a novel method of preventing corneal melt using ex vivo crosslinked cornea tissue carrier. METHODS A review of B-KPro literature was performed to highlight cases of corneal melt. Studies examining the effect of corneal collagen cross-linking (CXL) on the biomechanical properties of corneal tissue are summarized. The use of crosslinked corneal tissue as a carrier to the B-KPro is illustrated with a case. RESULTS Corneal melting after B-KPro is a relatively rare event, occurring in 3% of eyes during the first 3 years of postoperative follow-up. The risk of post-KPro corneal melting is heightened in eyes with chronic ocular surface inflammation such as eyes with Stevens-Johnson syndrome and mucous membrane pemphigoid. This chronic inflammation results in high tear levels of matrix metalloproteinases, the enzymes responsible for collagenolysis and corneal melt. Crosslinked corneal tissue has been shown to have stiffer biomechanical properties and to be more resistant to degradation by collagenolytic enzymes. We have previously optimized the technique for ex vivo corneal CXL and are currently studying its impact on the prevention of corneal melting after B-KPro surgery in high-risk eyes. Crosslinked carrier tissue was used in a 52-year-old man with familial aniridia and severe post-KPro corneal melt. The patient maintained his visual acuity and showed no evidence of corneal thinning or melt in the first postoperative year. CONCLUSION Collagen crosslinking was previously shown to halt the enzymatic degradation of corneal buttons ex vivo. This study demonstrates the safety and potential benefit of using crosslinked corneal grafts as carriers for the B-KPro, especially in eyes at higher risk of postoperative melt.
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Affiliation(s)
- Marie-Claude Robert
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, 02114
| | - Samer N Arafat
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, 02114
| | - Joseph Ciolino
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, 02114
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