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Lombardo M, Serrao S, Bernava GM, Lombardo G. Spatial targeted delivery of riboflavin with a controlled corneal iontophoresis delivery system in theranostic-guided UV-A light photo-therapy. JOURNAL OF BIOPHOTONICS 2024; 17:e202400068. [PMID: 38697616 DOI: 10.1002/jbio.202400068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/23/2024] [Accepted: 04/09/2024] [Indexed: 05/05/2024]
Abstract
Seven human donor eye globes underwent corneal cross-linking using theranostic UV-A device with accessory corneal iontophoresis system for patterned delivery of a 0.22% riboflavin solution. Theranostic-guided UV-A light illumination assessed riboflavin distribution and treated corneas at 10 mW/cm2 for 9 min with a 5.0-mm beam size. Corneal topography maps were taken at baseline and 2-h post-treatment. Analysis utilized corneal topography elevation data, with results showing controlled riboflavin delivery led to a consistent gradient, with 40% higher levels centrally (248 ± 79 μg/cm3) than peripherally (180 ± 72 μg/cm3 at ±2.5 mm from the center). Theranostic-guided UV-A light irradiation resulted in significant changes in corneal topography, with a decrease in best-fit sphere value (-0.7 ± 0.2 D; p < 0.001) and consistent downward shift in corneal elevation map (-11.7 ± 3.7 μm). The coefficient of variation was 2.5%, indicating high procedure performance in achieving significant and reliable corneal flattening.
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Affiliation(s)
- Marco Lombardo
- Studio Italiano di Oftalmologia, Rome, Italy
- Vision Engineering Italy srl, Rome, Italy
| | - Sebastiano Serrao
- Studio Italiano di Oftalmologia, Rome, Italy
- Vision Engineering Italy srl, Rome, Italy
| | | | - Giuseppe Lombardo
- Studio Italiano di Oftalmologia, Rome, Italy
- CNR-IPCF, Istituto per i Processi Chimico-Fisici, Messina, Italy
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Cortina MS, Greiner MA, Kuo AN, Li JY, Miller DD, Shtein RM, Veldman PB, Yin J, Kim SJ, Shen JF. Safety and Efficacy of Epithelium-Off Corneal Collagen Cross-Linking for the Treatment of Corneal Ectasia: A Report by the American Academy of Ophthalmology. Ophthalmology 2024:S0161-6420(24)00282-3. [PMID: 38935041 DOI: 10.1016/j.ophtha.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/03/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE To review the evidence on the safety and effectiveness of epithelium-off corneal collagen cross-linking (CXL) for the treatment of progressive corneal ectasia. METHODS A literature search of the PubMed database was most recently conducted in March 2024 with no date restrictions and limited to studies published in English. The search identified 359 citations that were reviewed in abstract form, and 43 of these were reviewed in full text. High-quality randomized clinical trials comparing epithelium-off CXL with conservative treatment in patients who have keratoconus (KCN) and post-refractive surgery ectasia were included. The panel deemed 6 articles to be of sufficient relevance for inclusion, and these were assessed for quality by the panel methodologist; 5 were rated level I, and 1 was rated level II. There were no level III studies. RESULTS This analysis includes 6 prospective, randomized controlled trials that evaluated the use of epithelium-off CXL to treat progressive KCN (5 studies) and post-laser refractive surgery ectasia (1 study), with a mean postoperative follow-up of 2.4 years (range, 1-5 years). All studies showed a decreased progression rate in treated patients compared with controls. Improvement in the maximum keratometry (Kmax) value, corrected distance visual acuity (CDVA), and uncorrected distance visual acuity (UDVA) was observed in the treatment groups compared with control groups. A decrease in corneal thickness was observed in both groups but was greater in the CXL group. Complications were rare. CONCLUSIONS Epithelium-off CXL is effective in reducing the progression of KCN and post-laser refractive surgery ectasia in most treated patients with an acceptable safety profile. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Maria S Cortina
- Department of Ophthalmology and Visual Science, University of Illinois College of Medicine, Chicago, Illinois
| | - Mark A Greiner
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Anthony N Kuo
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer Y Li
- UC Davis Eye Center, University of California, Davis, California
| | - Darby D Miller
- Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida
| | - Roni M Shtein
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Peter B Veldman
- Department of Ophthalmology & Visual Science, The University of Chicago, Chicago, Illinois
| | - Jia Yin
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Stephen J Kim
- Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Joanne F Shen
- Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
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Roszkowska AM, Scorcia V, Mencucci R, Giannaccare G, Lombardo G, Alunni Fegatelli D, Vestri A, Bifezzi L, Bernava GM, Serrao S, Lombardo M. Assessment of the Predictive Ability of Theranostics for Corneal Cross-linking in Treating Keratoconus: A Randomized Clinical Trial. Ophthalmology 2024:S0161-6420(24)00367-1. [PMID: 38908553 DOI: 10.1016/j.ophtha.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/29/2024] [Accepted: 06/13/2024] [Indexed: 06/24/2024] Open
Abstract
PURPOSE To validate the ability of theranostic imaging biomarkers in assessing corneal cross-linking (CXL) efficacy in flattening the maximum keratometry (Kmax) index. DESIGN Prospective, randomized, multicenter, masked clinical trial (ClinicalTrails.gov identifier, NCT05457647). PARTICIPANTS Fifty patients with progressive keratoconus. INTERVENTION Participants were stratified to undergo epithelium-off (25 eyes) and epithelium-on (25 eyes) CXL protocols using an ultraviolet A (UV-A) medical device with theranostic software. The device controlled UV-A light both for performing CXL and assessing the corneal riboflavin concentration (riboflavin score) and treatment effect (theranostic score). A 0.22% riboflavin formulation was applied onto the cornea for 15 minutes and 20 minutes in epithelium-off and epithelium-on protocols, respectively. All eyes underwent 9 minutes of UV-A irradiance at 10 mW/cm2. MAIN OUTCOME MEASURES The primary outcome measure was validation of the combined use of theranostic imaging biomarkers through measurement of their accuracy (proportion of correctly classified eyes) and precision (positive predictive value) to classify eyes correctly and predict a Kmax flattening at 1 year after CXL. Other outcome measures included change in Kmax, endothelial cell density, uncorrected and corrected distance visual acuity, manifest spherical equivalent refraction and central corneal thickness 1 year after CXL. RESULTS Accuracy and precision of the theranostic imaging biomarkers in predicting eyes that had >0.1 diopter (D) of Kmax flattening at 1 year were 91% and 95%, respectively. The Kmax value significantly flattened by a median of -1.3 D (IQR, -2.11 to -0.49 D; P < 0.001); both the uncorrected and corrected distance visual acuity improved by a median of -0.1 logarithm of the minimum angle of resolution (logMAR; IQR, -0.3 to 0.0 logMAR [P < 0.001] and -0.2 to 0.0 logMAR [P < 0.001], respectively). No significant changes in endothelial cell density (P = 0.33) or central corneal thickness (P = 0.07) were noted 1 year after surgery. CONCLUSIONS The study demonstrated the efficacy of integrating theranostics in a UV-A medical device for the precise and predictive treatment of keratoconus with epithelium-off and epithelium-on CXL protocols. Concentration of riboflavin and its UV-A light mediated photoactivation in the cornea are the primary factors determining CXL efficacy. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Anna Maria Roszkowska
- Ophthalmology Unit, Gaetano Martino Hospital, University of Messina, Messina, Italy; Department of Ophthalmology, Andrzej Frycz Modrzewski University, Krakow, Poland
| | - Vincenzo Scorcia
- Ophthalmology Unit, Renato Dulbecco Hospital, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Rita Mencucci
- Ophthalmology Unit, Careggi Hospital, University of Firenze, Firenze, Italy
| | - Giuseppe Giannaccare
- Eye Clinic, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | | | - Danilo Alunni Fegatelli
- Department of Public Health and Infectious Diseases, University of Roma "La Sapienza," Rome, Italy; Department of Life Sciences, Health and Health Professions, Link Campus University, Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Diseases, University of Roma "La Sapienza," Rome, Italy
| | - Luca Bifezzi
- Ophthalmology Unit, Renato Dulbecco Hospital, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Li N, Fan Z, Peng X. Analysis of the effect of calcium ions on promoting the penetrability of riboflavin into the corneal stroma by iontophoresis. Int Ophthalmol 2024; 44:89. [PMID: 38366000 DOI: 10.1007/s10792-024-03031-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/11/2024] [Indexed: 02/18/2024]
Abstract
PURPOSE To investigate the effect of calcium ions on promoting the penetrability of riboflavin into the corneal stroma by iontophoresis and to analyse the possible mechanism. METHODS Forty rabbits were divided into five groups randomly: 0.1% riboflavin-balanced salt solution (BSS) by iontophoresis group, 0.1% riboflavin-saline solution by iontophoresis group, 0.1% riboflavin-zinc gluconate solution by iontophoresis group, 0.1% riboflavin-calcium gluconate solution by iontophoresis group and classical riboflavin instillation after corneal de-epithelialization as the control group. The riboflavin concentrations in corneal stroma were determined and compared by high-performance liquid chromatography (HPLC) after removing epithelium and endothelium. RESULTS Iontophoretic delivery of a 0.1% riboflavin-calcium gluconate solution was the closest to the effect of classical de-epithelialization. The other solvents were unsufficient at enhancing the permeability of the riboflavin. CONCLUSION Calcium ions can promote the penetrability of riboflavin into the corneal stroma by iontophoresis.
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Affiliation(s)
- Na Li
- Department of Ophthalmology, The Third Medical Center of Chinese, PLA General Hospital, Yongding Road 69, Beijing, 100039, China.
| | - Zhengjun Fan
- Department of Ophthalmology, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, 100048, China
| | - Xiujun Peng
- Department of Ophthalmology, The Sixth Medical Center of Chinese, PLA General Hospital, Beijing, 100048, China
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Roszkowska AM, Oliverio GW, Hydzik-Sajak K, De Crescenzo M, Aragona P. Five-year results of iontophoresis-assisted transepithelial corneal cross-linking for keratoconus. Int Ophthalmol 2023; 43:3601-3607. [PMID: 37395906 PMCID: PMC10504154 DOI: 10.1007/s10792-023-02768-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE To assess long-term efficacy and safety of iontophoresis-assisted transepithelial corneal cross-linking (I-CXL) for keratoconus. PATIENTS AND METHODS Twenty-seven eyes of 21 patients (15 M, 6F) affected by progressive keratoconus were evaluated. All subjects were treated with iontophoresis-assisted transepithelial CXL. The patients were examined at baseline and each 6 months after the CXL procedure. Only subjects who completed the follow-up of 5 years were considered in this study. The main outcome measures were uncorrected visual acuity (UCVA), corrected visual acuity (CDVA), corneal transparency and corneal parameters such as K-max, central corneal thickness (CCT) and at the thinnest point, and high-order ocular aberrations (HOAs). The ABCD system was used to determine the progression and re-progression of ectasia. SETTING Ophthalmology Clinic, University Hospital of Messina, Messina, Italy. RESULTS At 5 years, significant improvements of UCVA from 0.53 ± 0.33 logMAR to 0.4 ± 0.33 logMAR (p = 0.001) and HOAs (p = 0.01) were registered. No significant changes of CDVA (p = 0.4), K-max (p = 0.75), CCT (p = 0.5) were observed at the end of follow-up period. The ABCD system showed re-progression in 25.9% of eyes after 5 years. No adverse events such as corneal opacities and infections were reported. CONCLUSIONS Iontophoresis-assisted transepithelial CXL resulted to be safe and effective to stabilize progressive keratoconus in adults at a long-term follow-up.
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Affiliation(s)
- Anna Maria Roszkowska
- Ophthalmology Clinic, Department of Biomedical Sciences, University of Messina, Messina, Italy.
- Ophthalmology Clinic, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland.
| | | | - Katarzyna Hydzik-Sajak
- Ophthalmology Clinic, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Kraków University, Kraków, Poland
| | - Michele De Crescenzo
- Ophthalmology Clinic, Department of Biomedical Sciences, University of Messina, Messina, Italy
| | - Pasquale Aragona
- Ophthalmology Clinic, Department of Biomedical Sciences, University of Messina, Messina, Italy
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Gustafsson I, Ivarsen A, Hjortdal J. Early findings in a prospective randomised study on three cross-linking treatment protocols: interruption of the iontophoresis treatment protocol. BMJ Open Ophthalmol 2023; 8:e001406. [PMID: 37739426 PMCID: PMC10533787 DOI: 10.1136/bmjophth-2023-001406] [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: 07/21/2023] [Accepted: 09/03/2023] [Indexed: 09/24/2023] Open
Abstract
PURPOSE To present the outcome of the interrupted iontophoresis-assisted treatment arm in an ongoing randomised clinical trial (NCT04427956). METHODS A randomised clinical study of corneal cross-linking (CXL) using continuous UV-A irradiation at a rate of 9 mW/cm2 and three different types of riboflavin and riboflavin delivery mode: (1) iso-osmolar dextran-based riboflavin (epithelium-off), (2) hypo-osmolar dextran-free riboflavin (epithelium-off) and (3) iontophoresis-assisted delivery of riboflavin (epithelium-on) for the treatment of progressive keratoconus. Inclusion criteria were an increase in the maximum keratometry value (Kmax) of 1.0 dioptre over 12 months or 0.5 dioptre over 6 months. The primary outcome in evaluating treatment efficacy was Kmax. Recently presented stratified detection limits were used post hoc to confirm the enrolment of patients with truly progressive keratoconus and in the assessment of the need for re-CXL. RESULTS Thirteen patients had been randomised to iontophoresis-assisted CXL when the treatment arm was interrupted; two patients dropped out. Of the remaining 11 patients, 7 were deemed as having truly progressive disease according to the more recent stratified detection limits. The disease continued to progress in three patients according to the original definition (increase in Kmax≥1 D), necessitating re-CXL with epithelium-off CXL. This progression was confirmed by post hoc analysis using the stratified detection limits for progression. CONCLUSIONS The iontophoresis-assisted CXL protocol failed to halt further disease progression in 27% of the patients. The failure rate increased to 38% when considering only the patients deemed to have truly progressive disease using the stratified detection limits.
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Affiliation(s)
- Ingemar Gustafsson
- Ophthalmology, Lund University, Lund, Sweden
- Ophthalmology, Skåne University Hospital Lund, Lund, Sweden
| | - Anders Ivarsen
- Ophthalmology, Aarhus University Hospital, Aarhus N, Denmark
| | - Jesper Hjortdal
- Ophthalmology, Aarhus University Hospital, Aarhus N, Denmark
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Deshmukh R, Ong ZZ, Rampat R, Alió del Barrio JL, Barua A, Ang M, Mehta JS, Said DG, Dua HS, Ambrósio R, Ting DSJ. Management of keratoconus: an updated review. Front Med (Lausanne) 2023; 10:1212314. [PMID: 37409272 PMCID: PMC10318194 DOI: 10.3389/fmed.2023.1212314] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Keratoconus is the most common corneal ectatic disorder. It is characterized by progressive corneal thinning with resultant irregular astigmatism and myopia. Its prevalence has been estimated at 1:375 to 1:2,000 people globally, with a considerably higher rate in the younger populations. Over the past two decades, there was a paradigm shift in the management of keratoconus. The treatment has expanded significantly from conservative management (e.g., spectacles and contact lenses wear) and penetrating keratoplasty to many other therapeutic and refractive modalities, including corneal cross-linking (with various protocols/techniques), combined CXL-keratorefractive surgeries, intracorneal ring segments, anterior lamellar keratoplasty, and more recently, Bowman's layer transplantation, stromal keratophakia, and stromal regeneration. Several recent large genome-wide association studies (GWAS) have identified important genetic mutations relevant to keratoconus, facilitating the development of potential gene therapy targeting keratoconus and halting the disease progression. In addition, attempts have been made to leverage the power of artificial intelligence-assisted algorithms in enabling earlier detection and progression prediction in keratoconus. In this review, we provide a comprehensive overview of the current and emerging treatment of keratoconus and propose a treatment algorithm for systematically guiding the management of this common clinical entity.
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Affiliation(s)
- Rashmi Deshmukh
- Department of Cornea and Refractive Surgery, LV Prasad Eye Institute, Hyderabad, India
| | - Zun Zheng Ong
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
| | - Radhika Rampat
- Department of Ophthalmology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jorge L. Alió del Barrio
- Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain
- Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain
| | - Ankur Barua
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
| | - Marcus Ang
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Jodhbir S. Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Dalia G. Said
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Harminder S. Dua
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Renato Ambrósio
- Department of Cornea and Refractive Surgery, Instituto de Olhos Renato Ambrósio, Rio de Janeiro, Brazil
- Department of Ophthalmology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
- Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Darren Shu Jeng Ting
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Lombardo M, Bernava GM, Serrao S, Roszkowska AM, Lombardo G. Predicting corneal cross-linking treatment efficacy with real-time assessment of corneal riboflavin concentration. J Cataract Refract Surg 2023; 49:635-641. [PMID: 36745847 DOI: 10.1097/j.jcrs.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/30/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess predictability of tissue biomechanical stiffening induced by UV-A light-mediated real-time assessment of riboflavin concentration during corneal crosslinking (CXL) of human donor tissues. SETTING Studio Italiano di Oftalmologia, Rome, Italy. DESIGN Laboratory study. METHODS 20 sclerocorneal tissues were randomly stratified to undergo CXL with either the epithelium intact (n = 12) or removed (n = 8). Samples underwent corneal soaking with 0.22% riboflavin formulation (RitSight) with dosing time of t = 10 minutes and t = 20 minutes in epithelium-off and epithelium-on protocols, respectively. All tissues underwent 9-minute UV-A irradiance at 10 mW/cm 2 using theranostic device (C4V CHROMO4VIS). The device used controlled UV-A light irradiation to induce both imaging and treatment of the cornea, providing a real-time measure of corneal riboflavin concentration and treatment efficacy (ie, theranostic score) during surgery. Tissue biomechanics were assessed with an air-puff device (Corvis), which was performed before and after treatment. A 3-element viscoelastic model was developed to fit the corneal deformation response to air-puff excitation and to calculate the mean corneal stiffness parameter (k c ). RESULTS Significant corneal tissue stiffening ( P < .05) was induced by the theranostic UV-A device in either CXL treatment protocol. Significant correlation was found between the theranostic score and the increase in k c ( R = 0.75; P = .003). The score showed high accuracy (94%) and precision (94%) to predict correctly samples that had improved tissue biomechanical strengthening. CONCLUSIONS Real-time assessment of corneal riboflavin concentration provided a predictive and precise approach for significant improvement of tissue strength on individual corneas, regardless of CXL treatment protocol.
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Affiliation(s)
- Marco Lombardo
- From the Studio Italiano di Oftalmologia, Rome, Italy (M. Lombardo, Serrao, G. Lombardo); Vision Engineering Italy srl, Rome, Italy (M. Lombardo); CNR-IPCF, Istituto per i Processi Chimico-Fisici, Messina, Italy (Bernava, G. Lombardo); Clinica Oculistica, Dipartimento di Scienze Biomediche, Università degli Studi di Messina, Messina, Italy (Roszkowska); Ophthalmology Department, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Poland (Roszkowska)
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Gustafsson I, Vicente A, Bergström A, Stenevi U, Ivarsen A, Hjortdal JØ. Current clinical practice in corneal crosslinking for treatment of progressive keratoconus in four Nordic countries. Acta Ophthalmol 2023; 101:109-116. [PMID: 35811357 PMCID: PMC10084360 DOI: 10.1111/aos.15213] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/24/2022] [Accepted: 06/26/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate clinical practice in the diagnosis and treatment of progressive keratoconus with corneal crosslinking (CXL) in four Nordic countries. METHODS A questionnaire was sent to all centres at which keratoconus patients are evaluated and CXL is performed in Sweden, Denmark, Norway and Iceland. Nineteen of 20 centres participated. RESULTS CXL is performed approximately 1300 times per year in these four Nordic countries with a population of around 21.7 million (2019). In most cases, progression is evaluated using the Pentacam HR, and the maximum keratometry reading (Kmax ) is considered the most important parameter. The most frequently used treatment protocol in Scandinavia is the 9 mW/cm2 epi-off protocol, using hydroxylpropyl methylcellulose riboflavin (HPMC-riboflavin). The participants deemed the following areas to be in most need of improvement: adaptation of the CXL protocol to individual patients (5/19), the development of effective epi-on treatment protocols (4/19), optimal performance of CXL in thin corneas (4/19), improvement of the definition of progression (2/19), and diagnosis of the need for re-treatment (2/19). CONCLUSIONS We concluded that the diagnosis of progressive keratoconus and the diagnostic equipment used are similar. Treatment strategies are also similar but are suitably different to provide an interesting basis for the comparison of treatment outcomes. The high degree of participation in this survey indicates the possibility of future scientific collaboration on CXL focusing on the areas deemed to need improvement. It would also be of interest to evaluate the possibility of creating a Nordic CXL Registry. The high number of CXL treatments performed ensures sufficient statistical power to solve many questions. Such a registry could be an important contribution to evidence-based care and would allow for longitudinal evaluation.
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Affiliation(s)
- Ingemar Gustafsson
- Department of Clinical Sciences, Department of Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - André Vicente
- Department of Clinical Sciences, Department of Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anders Bergström
- Department of Clinical Sciences, Department of Ophthalmology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ulf Stenevi
- Department of Ophthalmology, Sahgrenska University Hospital, Mölndal, Sweden
| | - Anders Ivarsen
- Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
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Roszkowska AM, Lombardo G, Mencucci R, Scorcia V, Giannaccare G, Vestri A, Alunni Fegatelli D, Bernava GM, Serrao S, Lombardo M. A randomized clinical trial assessing theranostic-guided corneal cross-linking for treating keratoconus: the ARGO protocol. Int Ophthalmol 2022:10.1007/s10792-022-02628-4. [PMID: 36587174 DOI: 10.1007/s10792-022-02628-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/20/2022] [Indexed: 01/01/2023]
Abstract
The Assessment of theranostic guided riboflavin/UV-A corneal cross-linking for treatment of keratoconus (ARGO; registration number NCT05457647) clinical trial tests the hypothesis that theranostic-guided riboflavin/UV-A corneal cross-linking (CXL) can provide predictable clinical efficacy for halting keratoconus progression, regardless of treatment protocol, i.e., either with or without epithelial removal. Theranostics is an emerging therapeutic paradigm of personalized and precision medicine that enables real-time monitoring of image-guided therapy. In this trial, the theranostic software module of a novel UV-A medical device will be validated in order to confirm its accuracy in estimating corneal cross-linking efficacy in real time. During CXL procedure, the theranostic UV-A medical device will provide the operator with an imaging biomarker, i.e., the theranostic score, which is calculated by non-invasive measurement of corneal riboflavin concentration and its UV-A light mediated photo-degradation. ARGO is a randomized multicenter clinical trial in patients aged between 18 and 40 years with progressive keratoconus aiming to validate the theranostic score by assessing the change of the maximum keratometry point value at 1-year postoperatively. A total of 50 participants will be stratified with allocation ratio 1:1 using a computer-generated stratification plan with blocks in two treatment protocols, such as epithelium-off or epithelium-on CXL. Following treatment, participants will be monitored for 12 months. Assessment of safety and performance of theranostic-guided corneal cross-linking treatment modality will be determined objectively by corneal tomography, corneal endothelial microscopy, visual acuity testing and slit-lamp eye examination.
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Affiliation(s)
- Anna Maria Roszkowska
- Ophthalmology Department, Faculty of Medicine, Health Sciences of Andrzej Frycz Modrzewski Krakow University, Gustawa Herlinga-Grudzińskiego 1, 30-705, Krakow, Poland. .,Dipartimento BIOMORF, Università di Messina, Via Consolare Valeria 1, 98100, Messina, Italy.
| | - Giuseppe Lombardo
- CNR-IPCF, Istituto per I Processi Chimico-Fisici, Viale F. Stagno D'Alcontres 37, 98158, Messina, Italy
| | - Rita Mencucci
- SOD Oculistica, AOU Careggi, Università di Firenze, Largo Brambilla 3, 50134, Florence, Italy
| | - Vincenzo Scorcia
- UO Oculistica, AOU Mater Domini, Università Magna Graecia di Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Giuseppe Giannaccare
- UO Oculistica, AOU Mater Domini, Università Magna Graecia di Catanzaro, Viale Europa, 88100, Catanzaro, Italy
| | - Annarita Vestri
- Dipartimento di Sanità Pubblica e Malattie Infettive, Università di Roma "La Sapienza", Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Danilo Alunni Fegatelli
- Dipartimento di Sanità Pubblica e Malattie Infettive, Università di Roma "La Sapienza", Piazzale Aldo Moro 5, 00185, Rome, Italy
| | - Giuseppe Massimo Bernava
- CNR-IPCF, Istituto per I Processi Chimico-Fisici, Viale F. Stagno D'Alcontres 37, 98158, Messina, Italy
| | | | - Marco Lombardo
- Studio Italiano di Oftalmologia, Via Livenza 3, 00198, Rome, Italy
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11
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Bhattacharyya A, Sarma P, Kaur H, Hafezi F, Bhattacharyya J, Kirubakaran R, Prajapat M, Medhi B, Das K, Prakash A, Singh A, Kumar S, Singh R, Reddy D, Kaur G, Sharma S. Short- and long-term safety and efficacy of corneal collagen cross-linking in progressive keratoconus: A systematic review and meta-analysis of randomized controlled trials. Taiwan J Ophthalmol 2022. [PMID: 37484615 PMCID: PMC10361434 DOI: 10.4103/2211-5056.361974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The purpose of the study is to evaluate the safety and outcomes of corneal collagen cross-linking (CXL) and different CXL protocols in progressive keratoconus (PK) population at short and long-term. MATERIALS AND METHODS A systematic review and meta-analysis was conducted. A total of eight literature databases were searched (up to February 15, 2022). Randomized controlled trials (RCTs) comparing CXL versus placebo/control or comparing different CXL protocols in the PK population were included. The primary objective was assessment of outcomes of CXL versus placebo and comparison of different CXL protocols in terms of maximum keratometry (Kmax) or Kmax change from baseline (Δ), spherical equivalent, best corrected visual acuity (BCVA), and central corneal thickness (CCT) in both at short term (6 months) and long term (1st, 2nd, and 3rd year or more). The secondary objective was comparative evaluation of safety. For the meta-analysis, the RevMan5.3 software was used. RESULTS A total of 48 RCTs were included. Compared to control, CXL was associated with improvement in Δ Kmax at 1 year (4 RCTs, mean difference [MD], -1.78 [-2.71, -0.86], P = 0.0002) and 2 and 3 years (1 RCT); ΔBCVA at 1 year (7 RCTs, -0.10 [-0.14, -0.06], P < 0.00001); and Δ CCT at 1 year (2 RCTs) and 3 years (1 RCT). Compared to conventional CXL (C-CXL), deterioration in Δ Kmax, ΔBCVA and endothelial cell density was seen at long term in the transepithelial CXL (TE-CXL, chemical enhancer). Up to 2 years, there was no difference between TE-CXL using iontophoresis (T-ionto) and C-CXL. At 2 and 4 years, C-CXL performed better compared to accelerated CXL (A-CXL) in terms of improving Kmax. Although CCT was higher in the A-CXL arm at 2 years, there was no difference at 4 years. While exploring heterogeneity among studies, selection of control eye (fellow eye of the same patient vs. eye of different patient) and baseline difference in Kmax were important sources of heterogeneity. CONCLUSION CXL outperforms placebo/control in terms of enhancing Kmax and CCT, as well as slowing disease progression over time (till 3 years). T-ionto protocol, on the other hand, performed similarly to C-CXL protocol up to 2 years.
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12
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Drakon AK, Pateyuk LS, Sheludchenko VM, Korchazhkina NB. [Ocular iontophoresis]. Vestn Oftalmol 2021; 137:119-127. [PMID: 34965077 DOI: 10.17116/oftalma2021137061119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Iontophoresis in medicine is a combined pharmacological and physical method of treatment that unites the therapeutic effect of an electric current with the pharmacological effect of medicinal substances administered at the same time via an electric current. The article describes the physical basis of the therapeutic effect of direct electric current on biological tissues, and highlights the physical and chemical mechanisms of target administration of pharmaceutical substances into the human body through intact skin or mucous membrane by means of direct electric current. In addition, it presents the results of international as well as Russian domestic scientific studies on the clinical effectiveness of iontophoresis in ophthalmology.
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Affiliation(s)
- A K Drakon
- Research Institute of Eye Diseases, Moscow, Russia
| | - L S Pateyuk
- Research Institute of Eye Diseases, Moscow, Russia
| | | | - N B Korchazhkina
- Russian Scientific Center of Surgery named after Academician B.V. Petrovsky, Moscow, Russia
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13
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Ultraviolet crosslinking of corneal collagen in patients with thin cornea. Literature review. ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.6-1.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
For the treatment of progressive keratoconus in the early stages, corneal collagen crosslinking is currently actively used. This technique is based on the stabilization of the pathological process by increasing the biomechanical properties of the own cornea. The thickness of the cornea less than 400 microns significantly limits the possibility of a standard cross-linking procedure performing.The article analyzes the literature data on the use of various methods of corneal crosslinking with a corneal thickness of less than 400 microns, which signifi cantly limits the possibilities of the standard procedure.It is known, that during crosslinking, at the initial stage, de-epithelialization of the cornea is performed, which, in the postoperative period, leads to a pronounced corneal syndrome. This determined the direction of the fi rst modifi cations of the technique associated with the use of partial de-epithelialization or its complete absence. Later, during cross-linking of “thin” corneas, techniques with the use of additional covering materials were actively used in order to replenish the missing corneal tissue of the patient during the UV irradiation procedure. Among them are the use of a soft contact lens without an ultraviolet fi lter, the use of a corneal lenticule obtained after SMILE surgery, the use of a protective fl ap of the donor cornea obtained using a femtosecond laser from the residual stroma of the corneal disc after descemet membrane transplantation or posterior lamellar keratoplasty. The variety of the proposed modifications and the ongoing search for better options indicate the demand for this technology and the need for further research, taking into account the individual characteristics of the patient’s ectasia.
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14
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Borroni D, Bonzano C, Hristova R, Rachwani-Anil R, Sánchez-González JM, de Lossada CR. Epithelial Flap Corneal Cross-linking. J Refract Surg 2021; 37:741-745. [PMID: 34756139 DOI: 10.3928/1081597x-20210802-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare standard epithelium-off corneal cross-linking (standard Epi-Off CXL) to corneal cross-linking with an epithelial flap (Epi-Flap CXL). METHODS Patients who had undergone sequential bilateral CXL for progressive keratoconus were included in this comparative interventional case series. One eye was treated with the Epi-Off CXL technique and the fellow eye with the Epi-Flap CXL technique. Postoperative pain was measured using the Verbal Rating Scale and corneal densitometry using a Scheimpflug camera. Sex, age, corrected distance visual acuity, keratometry, and corneal thickness were also recorded. RESULTS Twenty-four eyes of 12 patients with keratoconus with a mean age of 27.15 ± 5.15 years were included. The Verbal Rating Scale scores were significantly lower in patients who had Epi-Flap CXL on the first (1.00 [interquartile range (IQR): 0.00 to 1.00] vs 3.00 [IQR: 3.00 to 3.75], P = .01) and third (0.00 [IQR: 0.00 to 1.00] vs 1.00 [IQR: 0.00 to 1.00], P = .01) postoperative day compared to the Epi-Off CXL group. No pain was observed in both groups after the third day. After 12 months, the Epi-Flap CXL group showed significantly less anterior corneal haze (measured as corneal densitometry) compared to the patients treated with Epi-Off CXL (P = .01). Both groups demonstrated stability of keratometry and corneal thickness at 12 months after CXL (P < .01). CONCLUSIONS Epi-Flap CXL is associated with less postoperative pain and anterior stromal haze in patients undergoing CXL for progressive keratoconus with no loss of efficacy. [J Refract Surg. 2021;37(11):741-745.].
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15
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Transepithelial Diluted Alcohol and Iontophoresis-Assisted Corneal Crosslinking for Progressive Keratoconus in Adults: 4-Year Clinical Results. Cornea 2021; 41:462-469. [PMID: 34743098 DOI: 10.1097/ico.0000000000002821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/29/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to compare the 4-year clinical outcomes of transepithelial diluted alcohol and iontophoresis-assisted corneal crosslinking (DAI-CXL) and standard corneal crosslinking (S-CXL) in adults with progressive keratoconus. METHODS This retrospective study included 36 eyes of 36 keratoconic patients who underwent DAI-CXL (n = 18) or S-CXL (n = 18). Best spectacle-corrected visual acuity (BSCVA) and corneal topography parameters were analyzed at baseline and at 1, 2, 3, and 4 years of follow-up. Corneal demarcation line depth (DLD) at 1 month was measured, and the relation of DLD with corneal thickness (DL%) was assessed. RESULTS BSCVA improved significantly only in S-CXL (P = 0.01). A significant decrease in maximum keratometry and mean keratometry occurred at 4 years in both groups (all P < 0.05), and these changes were similar in both groups (all P > 0.05). There was a significant reduction in the thinnest corneal thickness in S-CXL (P = 0.01); however, the mean thinnest corneal thickness in DAI-CXL remained stable (P = 0.094). Higher-order aberrations and coma aberration decreased significantly in both groups at 4 years (all P < 0.05), with a higher decrease in S-CXL (all P < 0.05). Spherical aberration showed a significant reduction only in S-CXL (P = 0.005). In contrast to the similar mean DLD in both groups, DL% in DAI-CXL was significantly greater than that in S-CXL (P = 0.032). There were no correlations between the improvement in BSCVA, maximum keratometry, mean keratometry, higher-order aberrations, and the mean DLD and DL% (all P > 0.05). CONCLUSIONS DAI-CXL was as effective as S-CXL in arresting the progression of keratoconus and showed similar clinical results to S-CXL at the 4-year follow-up.
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Ng SM, Hawkins BS, Kuo IC. Transepithelial Versus Epithelium-Off Corneal Crosslinking for Progressive Keratoconus: Findings From a Cochrane Systematic Review. Am J Ophthalmol 2021; 229:274-287. [PMID: 34048801 PMCID: PMC8599612 DOI: 10.1016/j.ajo.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to summarize key findings from a systematic review of the effectiveness and safety of transepithelial corneal crosslinking (CXL) compared with epithelium-off CXL for progressive keratoconus. DESIGN Cochrane systematic review. METHODS We included in our review only randomized controlled trials (RCTs) in which transepithelial and epithelium-off CXL had been compared among participants with progressive keratoconus. The primary outcome was keratoconus stabilization based on post-operative maximum keratometry (Kmax). We adhered to Cochrane methods for trial selection, data extraction, risk of bias evaluation, and data synthesis. RESULTS Thirteen RCTs with 567 participants (661 eyes) were included; 11 studies compared non-iontophoresis-assisted transepithelial with epithelium-off CXL. Keratoconus stabilization was described as an outcome in 2 studies. The estimated difference in Kmax means (ie, the "mean difference," MD) from meta-analysis of 177 eyes in 5 RCTs indicated that there were no differences between intervention groups in Kmax at 12 months or later (MD: 0.99 diopter [D]; 95% confidence interval: -0.11 to 2.09). Meta-analysis of keratometry and visual acuity outcomes at 12 months or longer after surgery from 2 studies that had compared transepithelial CXL using iontophoresis provided no conclusive evidence of an advantage over epithelium-off CXL. CONCLUSIONS Lack of precision due to small sample sizes, indeterminate risk of bias due to inadequate reporting, and inconsistency in how outcomes were measured and reported among studies make it difficult to state with confidence whether transepithelial CXL confers an advantage over epithelium-off CXL for patients with progressive keratoconus with respect to stabilization of keratoconus, visual acuity, or patient-reported outcomes based on available data.
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Affiliation(s)
- Sueko M Ng
- From the Department of Ophthalmology (S.M.N.), School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Barbara S Hawkins
- and the Department of Ophthalmology (B.S.H., I.C.K.), Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Irene C Kuo
- and the Department of Ophthalmology (B.S.H., I.C.K.), Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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17
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D'Oria F, Palazón A, Alio JL. Corneal collagen cross-linking epithelium-on vs. epithelium-off: a systematic review and meta-analysis. EYE AND VISION (LONDON, ENGLAND) 2021; 8:34. [PMID: 34565473 PMCID: PMC8465763 DOI: 10.1186/s40662-021-00256-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 08/08/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The purpose of the study was to determine the advantages and disadvantages of epi-on corneal cross-linking (CXL) techniques compared with standard epi-off CXL. METHODS We searched MEDLINE and EMBASE for randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) and we evaluated the selected papers according to the Cochrane risk of bias tool. We considered, as primary outcomes, average Kmax flattening, changes in uncorrected and corrected distance visual acuity (UDVA and CDVA); as secondary outcomes, we considered changes in pachymetry values and endothelial cell density (ECD). We also investigated adverse events related to the treatments and treatment failure. Meta-analysis was conducted with a fixed or random-effects model using weighted mean difference (MD) with 95% confidence interval (CI) as the effect size. RESULTS A total of 15 studies were included and among these 15 trials, 9 were RCTs and 6 were NRSIs, but only 4 studies showed no high risk of bias and were included in this meta-analysis. Our analysis revealed significant postoperative differences in CDVA (MD = 0.07; 95% CI 0.04 to 0.10; P < 0.001), and no significative differences in UDVA, Kmax, central corneal thickness (CCT) and ECD (P > 0.05). Epi-on CXL protocol was found to be significantly less prompt to have risks of delay in epithelial healing (P = 0.035) and persistent stromal haze (P = 0.026). CONCLUSION Epi-on CXL is as effective as epi-off CXL. Except for a higher significant improvement in CDVA with current epi-on protocols, our meta-analysis demonstrates that epi-on and epi-off CXL have comparable effects on visual, topographic, pachymetric, and endothelial parameters. Epi-on CXL has clinical advantages in terms of comfort and avoidance of complications as it reduces the risk of developing delay in epithelial healing and persistent stromal haze.
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Affiliation(s)
- Francesco D'Oria
- Vissum Innovation, c/ Cabañal, 1, 03016, Alicante, Spain
- Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
- Section of Ophthalmology, Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Antonio Palazón
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| | - Jorge L Alio
- Vissum Innovation, c/ Cabañal, 1, 03016, Alicante, Spain.
- Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain.
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18
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Daniell M. Iontophoresis for corneal collagen crosslinking. Clin Exp Ophthalmol 2021; 49:223-224. [PMID: 33843117 DOI: 10.1111/ceo.13921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mark Daniell
- Department of Surgery, University of Melbourne, East Melbourne, Victoria, Australia.,Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia.,Centre for Eye Research Australia, East Melbourne, Victoria, Australia
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19
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Topo-Pachimetric Accelerated Epi-On Cross-Linking Compared to the Dresden Protocol Using Riboflavin with Vitamin E TPGS: Results of a 2-Year Randomized Study. J Clin Med 2021; 10:jcm10173799. [PMID: 34501248 PMCID: PMC8432027 DOI: 10.3390/jcm10173799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022] Open
Abstract
In the present study (clinical trial registration number: NCT05019768), we compared the clinical outcome of corneal cross-linking with either the standard Dresden (sCXL) or the accelerated custom-fast (aCFXL) ultraviolet A irradiation protocol using riboflavin–D-α-tocopheryl poly(ethylene glycol)-1000 succinate for progressive keratoconus. Fifty-four eyes of forty-one patients were randomized to either of the two CXL protocols and checked before treatment and at the 2-year follow-up. The sCXL group was subjected to CXL with 30 min of pre-soaking and 3 mW/cm2 UVA irradiation for 30 min. The aCFXL group was subjected to CXL with 10 min of pre-soaking and UVA irradiation of 1.8 ± 0.9 mW/cm2 for 10 min ± 1.5 min. In both groups, a solution of riboflavin–vitamin E TPGS was used. Uncorrected distance visual acuity, corrected distance visual acuity, pachymetry, Scheimpflug tomography, and corneal hysteresis were performed at baseline and after 24 months. Both groups showed a statistically significant improvement in corrected distance visual acuity, and keratometric and corneal hysteresis compared to baseline conditions; no statistically significant differences in outcomes between the two groups were observed. Improvement in refractive, topographic, and biomechanical parameters were observed after sCXL and aCFXL, making the riboflavin–VE-TPGS solution an effective option as a permeation enhancer in CXL procedures. Deeper stromal penetration of riboflavin could be complemented by photo-protection against UVA and free radicals formed during photoinduced processes.
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20
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Metzger M, Navel V, Barrière JV, Kwiatkowski F, Hébraud J, Mulliez A, Béral L, Chiambaretta F, Dutheil F. Benefits of using corneal topography to choose subjective refraction technique in keratoconus (RE-CON): a prospective comparative crossover clinical study. Graefes Arch Clin Exp Ophthalmol 2021; 260:197-207. [PMID: 34415365 DOI: 10.1007/s00417-021-05382-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE In prospective no-masking, comparative, crossover monocenter clinical trial, we aimed to evaluate whether the optimal subjective refraction technique varies with the keratoconus topography and to identify relevant topographic criteria. METHOD This study included 72 keratoconus eyes with impaired visual acuity. Each eye tested three methods of refraction (Jackson cylinder, astigmatism dial, stenopeic slit), resulting in three eyeglass lenses. Patients were assigned to the group corresponding to the eyeglass lens offering the best visual acuity. Five topographical characteristics were collected via the Pentacam: mean keratometry (Km), maximum keratometry (Kmax), distance from corneal center to Kmax (dKmax), Belin/Ambrosio Display (BAD_D), and index of surface variance (ISV). RESULTS Forty-six eyes were included in the dial group (64.8%), 23 eyes in the cylinder group (32.4%), and only 2 eyes in the slit group (2.8%); thus, we only compared dial and cylinder groups. The main analysis retrieved a significant probability to choose dial technic for BAD_D (p = 0.024); when BAD_D is > 9.71 (ROC threshold), the positive predictive value (PPV) = 89.5%, and for ISV, p = 0.012; when ISV is > 77, PPV = 89.1%. The sub-analysis of patients with different visual acuities between cylinder and dial confirmed these results with slightly different thresholds: the probability to choose dial technic was for BAD_D, p = 0.03; when BAD_D is > 7.55, PPV = 90%, and for ISV, p = 0.0084; when ISV is > 71, PPV = 88.5%. CONCLUSION Refraction method is linked to topographic indices ISV and BAD_D. A BAD_D > 7.55 indicates the dial method. In addition to keratoconus screening and diagnosis, this study suggests a new application of the topographer to select a suitable refraction method for eyeglass prescription. TRIAL REGISTRATION Study registered on the ClinicalTrials.gov database under n°: NCT04174209.
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Affiliation(s)
- Margaux Metzger
- CHU, Clermont-Ferrand, University Hospital of Clermont-Ferrand, Ophthalmology, Clermont-Ferrand, France.
| | - Valentin Navel
- Université Clermont Auvergne, CNRS, INSERM, GReD, Translational Approach To Epithelial Injury and Repair, CHU Clermont-Ferrand, University Hospital of Clermont-Ferrand, 63000, Ophthalmology, France.
| | - Jean-Vincent Barrière
- CHU, Clermont-Ferrand, University Hospital of Clermont-Ferrand, Ophthalmology, Clermont-Ferrand, France
| | - Fabrice Kwiatkowski
- Laboratory of Mathematics, Université Clermont Auvergne, Blaise Pascal, Clermont-Ferrand, France
| | - Jérémy Hébraud
- Intensive Care Unit, CHU Clermont-Ferrand, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélien Mulliez
- CHU Clermont-Ferrand, University Hospital of Clermont-Ferrand, Biostatistics, Clermont-Ferrand, France
| | - Laurence Béral
- CHU Pointe-À-Pitre Abymes, University Hospital of Pointe-À-Pitre Abymes, Ophthalmology, Pointe-à-Pitre, France
| | - Frédéric Chiambaretta
- Université Clermont Auvergne, CNRS, INSERM, GReD, Translational Approach To Epithelial Injury and Repair, CHU Clermont-Ferrand, University Hospital of Clermont-Ferrand, 63000, Ophthalmology, France
| | - Frédéric Dutheil
- CNRS, LaPSCo, Physiological and Psychosocial Stress, University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Preventive and Occupational Medicine, WittyFit, Université Clermont Auvergne, Clermont-Ferrand, France
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21
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Ouyang BW, Ding H, Wang H, Yang ZD, Zhong T, Fan HM, Zhong XW. Comparison of corneal biological parameters between transepithelial and epithelium-off corneal cross-linking in keratoconus. Int J Ophthalmol 2021; 14:998-1005. [PMID: 34282383 DOI: 10.18240/ijo.2021.07.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 04/08/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To evaluate the differences in corneal biological parameters between transepithelial and epithelium-off corneal cross-linking in keratoconus. METHODS In our prospective clinical trial, 40 patients (60 eyes) with progressive keratoconus were randomized to undergo corneal cross-linking with transepithelial (TE group, n=30) or epithelium-off (EO group, n=30) keratoconus. Examinations comprised topography, corneal biomechanical analysis and specular microscopy at 6mo postoperatively. RESULTS The keratometer values were not significantly different between the TE and EO corneal cross-linked groups in different periods (each P>0.05). The corneal thickness of the EO group was greater than that of the TE group at 1wk after the operation (each P<0.05). Regarding corneal biomechanical responses, the EO group showed a longer second applanation length than TE group (P=0.003). Regarding the corneal endothelial function, standard deviation of the endothelial cell size, and coefficient of variation in the cell area, the values of EO group were larger than those of TE group at 1wk (P=0.011, 0.026), and the percentage of hexagonal cells in EO group was lower than that in TE group at 1 and 6mo (P=0.018, 0.019). CONCLUSION Epithelium-off corneal cross-linking may strengthen corneal biomechanics better than TE procedure can. However, the TE procedure with a lower ultraviolet-A irradiation intensity would be safer for corneal endothelial function.
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Affiliation(s)
- Bo-Wen Ouyang
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Hui Ding
- Hainan Eye Hospital, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou 570311, Hainan Province, China
| | - Han Wang
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Zhen-Duo Yang
- Hainan Eye Hospital, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou 570311, Hainan Province, China
| | - Tan Zhong
- Hainan Eye Hospital, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou 570311, Hainan Province, China
| | - Hong-Ming Fan
- Hainan Eye Hospital, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou 570311, Hainan Province, China
| | - Xing-Wu Zhong
- Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China.,Hainan Eye Hospital, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou 570311, Hainan Province, China
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22
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Chen Y, Miao X, Gao M, Song L. Comparison of modified corneal cross-linking with intrastromal voriconazole for the treatment of fungal corneal ulcer. Exp Ther Med 2021; 22:786. [PMID: 34055085 PMCID: PMC8145909 DOI: 10.3892/etm.2021.10218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 03/01/2021] [Indexed: 01/14/2023] Open
Abstract
The present study aimed to evaluate the efficacy of modified corneal cross-linking (CXL) for the treatment of fungal corneal ulcers compared with that following intrastromal voriconazole injection. In total, 31 patients with fungal corneal ulcers treated at The General Hospital of Northern Theater Command between October 2017 and October 2019 were enrolled. Among them, 10 eyes were treated with ultraviolet A (UV-A)/riboflavin CXL (CXL group), whilst 21 eyes were treated with debridement combined with intrastromal voriconazole (stromal injection group). Preoperative microbiological examination was performed in both groups, and evaluated using Fisher's exact test. Postoperatively, infection control and total efficacy rates, localized lesion, ulcer healing rate 1 week after surgery, visual acuity and complications were evaluated using Fisher's exact test, however visual acuity was analyzed by mixed-model ANOVA. The results showed that the pre-operative species distribution between the CXL and stromal injection groups did not significantly differ. The infection control rate in the CXL group was notably higher compared with that in the stromal injection group (P=0.04). Furthermore, the total efficacy rate in the CXL group was also markedly higher compared with that in the stromal injection group, though no statistically significant differences were observed. Localized lesions were observed in nine eyes (90.0%) in the CXL group and nine eyes (42.9%) in the stromal injection group (P=0.02). However, the rate of ulcer healing at 1 week postoperatively and the logarithm of the minimum angle of resolution (logMAR) of visual acuity were not found to be significantly different between the two groups. In terms of complications, with the exception of one patient in the CXL group exhibiting loss of corneal transparency and one patient in the stromal injection group presenting with partial corneal thinning, no other forms of complications were observed. In conclusion, the present study suggested that CXL could have a beneficial impact for treating fungal corneal ulcers in the aspects of infection control, localized lesions and accelerated epithelialization. In addition, except the loss of corneal transparency, this treatment approach could be applied with reduced risks of adverse events.
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Affiliation(s)
- Yingxin Chen
- Department of Ophthalmology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, P.R. China
| | - Xingya Miao
- Department of Ophthalmology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, P.R. China
| | - Minghong Gao
- Department of Ophthalmology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, P.R. China
| | - Lixin Song
- Department of Dermatology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, P.R. China
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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: 12] [Impact Index Per Article: 4.0] [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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Wan KH, Ip CKY, Kua WN, Chow VWS, Chong KKL, Young AL, Cheng GPM, Jhanji V. Transepithelial corneal collagen cross‐linking using iontophoresis versus the Dresden protocol in progressive keratoconus: A meta‐analysis. Clin Exp Ophthalmol 2021; 49:228-241. [DOI: 10.1111/ceo.13918] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 02/01/2023]
Affiliation(s)
- Kelvin H. Wan
- Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong Kowloon Hong Kong
- Hong Kong Eye Hospital Kowloon Hong Kong
| | - Christina K. Y. Ip
- Department of Ophthalmology and Visual Sciences Prince of Wales Hospital Shatin Hong Kong
| | - Wee Nie Kua
- Department of Ophthalmology Tuen Mun Hospital Tuen Mun Hong Kong
| | - Vanissa W. S. Chow
- Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong Kowloon Hong Kong
- Hong Kong Eye Hospital Kowloon Hong Kong
| | - Kelvin K. L. Chong
- Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong Kowloon Hong Kong
- Department of Ophthalmology and Visual Sciences Prince of Wales Hospital Shatin Hong Kong
| | - Alvin L. Young
- Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong Kowloon Hong Kong
- Department of Ophthalmology and Visual Sciences Prince of Wales Hospital Shatin Hong Kong
| | - George P. M. Cheng
- Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong Kowloon Hong Kong
- Hong Kong Laser Eye Centre Central Hong Kong
| | - Vishal Jhanji
- Department of Ophthalmology University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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New perspectives in keratoconus treatment: an update on iontophoresis-assisted corneal collagen crosslinking. Int Ophthalmol 2021; 41:1909-1916. [PMID: 33590372 DOI: 10.1007/s10792-021-01713-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/09/2021] [Indexed: 10/22/2022]
Abstract
Keratoconus is a bilateral, asymmetric and progressive corneal disease. It usually results in apical thinning and steepening with corneal deformation and impaired vision. Since the early 1990 s, corneal collagen crosslinking (CXL) has remained the primary treatment to stabilize the progression of the disease. Iontophoresis-assisted CXL (I-CXL) has been proposed as a non-invasive alternative to standard epithelium-off technique, showing promising results. In this article, we review up to date literature to provide state of art knowledge and future perspectives of I-CXL.
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Helmy AM. Overview of recent advancements in the iontophoretic drug delivery to various tissues and organs. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2021.102332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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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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28
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Nath S, Shen C, Koziarz A, Banfield L, Nowrouzi-Kia B, Fava MA, Hodge WG. Transepithelial versus Epithelium-off Corneal Collagen Cross-linking for Corneal Ectasia: A Systematic Review and Meta-analysis. Ophthalmology 2020; 128:1150-1160. [PMID: 33383093 DOI: 10.1016/j.ophtha.2020.12.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 01/19/2023] Open
Abstract
TOPIC To evaluate the safety and efficacy of transepithelial corneal cross-linking in comparison with the established epithelium-off technique for corneal ectasia. CLINICAL RELEVANCE Considerable debate exists regarding whether transepithelial and epithelium-off cross-linking are comparable in their safety and efficacy. METHODS We searched 16 electronic databases, including Medline, Embase, Web of Science, and the grey literature, current to July 8, 2020, for randomized controlled trials comparing transepithelial and epithelium-off cross-linking for corneal ectasia. We excluded studies evaluating cross-linking for nonectatic indications, as well as non-randomized controlled trials. Our primary outcome was the change in maximal keratometry (Kmax) at 12 months after cross-linking, and we considered additional topographic, visual, and safety outcomes. We summarized our analyses by calculating weighted mean differences (MDs) with associated 95% confidence intervals (CIs) for continuous outcomes and relative risks (RRs) with corresponding 95% CIs for dichotomous outcomes. We conducted trial sequential analysis to determine whether the required information size was met for each outcome. The quality of individual trials was evaluated using the Cochrane Collaboration's risk of bias assessment tool, and the evidence was assessed at an outcome level using the Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS Twelve studies totaling 966 eyes were eligible. A significant difference was found between transepithelial and epithelium-off cross-linking groups in the change in Kmax at 12 months (MD, 0.75; 95% CI, 0.23-1.28; P = 0.004; primary outcome) and at longest follow-up (MD, 1.20; 95% CI, 0.62-1.77; P < 0.001; secondary outcome) after treatment. No significant difference was found between the 2 groups when examining uncorrected distance visual acuity (MD, 0.04; 95% CI, -0.06 to 0.14; P = 0.386) or corrected distance visual acuity (MD, 0.01; 95% CI, -0.06 to 0.09; P = 0.732). Transepithelial cross-linking was associated with significantly fewer complications than the epithelium-off approach (RR, 0.22; 95% CI, 0.06-0.79; P = 0.020), although it was associated with an increased rate of disease progression at 12 months after treatment (RR, 4.49; 95% CI, 1.24-16.25; P = 0.022). The required information size was met for our primary outcome and trial sequential analysis supported the conventional meta-analysis. The quality of evidence was rated as moderate using the Grading of Recommendations Assessment, Development, and Evaluation methodology. DISCUSSION The efficacy of transepithelial cross-linking remains inferior to the epithelium-off approach, although it is significantly safer.
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Affiliation(s)
- Siddharth Nath
- Department of Ophthalmology and Visual Sciences, McGill University, Montréal, Canada.
| | - Carl Shen
- Division of Ophthalmology, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Alex Koziarz
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Canada
| | - Behnam Nowrouzi-Kia
- Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Mark A Fava
- Division of Ophthalmology, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - William G Hodge
- Department of Ophthalmology, Ivey Eye Institute, Schulich School of Medicine and Dentistry, Western University, London, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Canada
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Saad S, Saad R, Jouve L, Kallel S, Trinh L, Goemaere I, Borderie V, Bouheraoua N. Corneal crosslinking in keratoconus management. J Fr Ophtalmol 2020; 43:1078-1095. [DOI: 10.1016/j.jfo.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/09/2020] [Accepted: 07/30/2020] [Indexed: 01/04/2023]
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Transepithelial corneal cross-linking assisted by two continuous cycles of iontophoresis for progressive keratoconus in adults: retrospective 5-year analysis. Graefes Arch Clin Exp Ophthalmol 2020; 259:239-246. [PMID: 32725404 PMCID: PMC7790794 DOI: 10.1007/s00417-020-04861-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/18/2020] [Accepted: 07/23/2020] [Indexed: 10/25/2022] Open
Abstract
PURPOSE The aim of this study is to compare the long-term effects of transepithelial corneal crosslinking with two continuous cycles of iontophoresis (EI-CXL) and conventional corneal crosslinking (C-CXL) in adults with progressive keratoconus. METHODS A retrospective analysis was conducted in adults who underwent C-CXL or EI-CXL between 2013 and 2015. Visual acuity, corneal tomography, anterior segment optical coherence tomography, in vivo corneal confocal microscopy (IVCM), and endothelial cell count (ECC) were performed preoperatively and 5 years postoperatively. RESULTS Sixty-eight patients with a mean age of (24.3 ± 3.8) years were included, 34 for each group. After CXL, UCVA or BCVA remained stable, while the spherical diopter, cylinder diopter, spherical equivalent, and Kmax significantly decreased at 1, 2, and 3 years in both groups than baseline (P < 0.05). No significant differences were found in any refractive or tomographic parameters as well as the minimal corneal thickness between groups during follow-up. At 5 years, Kmax was slightly higher in EI-CXL group (58.16 ± 6.28) than that of C-CXL group (57.46 ± 4.98). At 3 and 5 years, the minimal corneal thickness in C-CXL group was still significantly lower than baseline (P < 0.05). IVCM demonstrated the demarcation zone at a mean depth of (302.0 ± 41.7) μm after C-CXL, and at (251.2 ± 28.1) μm after EI-CXL (P < 0.001). Keratocyte repopulation was detectable at all follow-up timepoint in both groups. Postoperative complications including progression were recorded in 6 patients (11.7%) after C-CXL and 3 patients (8.8%) after EI-CXL. ECC remained stable in both groups. CONCLUSION EI-CXL showed approximate efficacy with C-CXL in stabilizing progressive keratoconus in adults. EI-CXL has the potential to be a preferable transepithelial protocol.
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Zhang X, Sun L, Tian M, Shen Y, Li M, Zhao J, Zhou X. Accelerated (45 mW/cm 2) Transepithelial Corneal Cross-Linking for Progressive Keratoconus Patients: Long-Term Topographical and Clinical Outcomes. Front Med (Lausanne) 2020; 7:283. [PMID: 32637419 PMCID: PMC7318888 DOI: 10.3389/fmed.2020.00283] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/21/2020] [Indexed: 11/30/2022] Open
Abstract
Aims: We characterized long-term clinical outcomes of accelerated (45 mW/cm2) transepithelial corneal cross-linking (ATE-CXL) for the treatment of progressive keratoconus. Methods: Forty-two eyes from 37 patients treated for keratoconus were observed. ATE-CXL was performed using riboflavin and pulsed-light ultraviolet treatment (45 mW/cm2, 7.2 J/cm2). Structural and functional measurements were made after 1 week and 1, 3, 6, 12, 24, 36, and 48 months subsequently. Corneal topographic parameters were observed using Scheimpflug topography (Pentacam software). Results: Surgery was uneventful in all subjects. Mean uncorrected (UDVA) and corrected distance visual acuity (CDVA) (logMAR) were 0.99 ± 0.58 and 0.44 ± 0.27 (P = 0.022), 0.24 ± 0.29 and 0.27 ± 0.35 (P = 0.601), at baseline and last follow-up, respectively. The pre-operative mean maximum keratometry (Kmax) value was 57.29 ± 9.13 diopters (D), and the thinnest corneal thickness (TCT) was 456.21 ± 44.66 μm. Mean Kmax was 56.67 ± 9.36 D, 4 years post-operatively (P = 0.781). TCT changed to 453.17 ± 46.76 μm at 4 years post-operatively (P = 0.780). Multiple linear regression indicated that patients with thinner pre-operative TCT (≤ 450 μm) showed decreasing post-operative average keratometry (Kavg) and increasing post-operative TCT. Patients with posterior central elevation (PCE) >80 μm showed decreasing post-operative Kavg as well as post-operative PCE. No complications were observed during follow-up. Conclusion: Stabilization after ATE-CXL was achieved for the treatment of keratoconus. The clinical efficacy of ATE-CXL in advanced keratoconus patients with thin corneal thickness and greater PCE will require further investigation.
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Affiliation(s)
- Xiaoyu Zhang
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China.,Department of Ophthalmology, The Eye and ENT Hospital of Fudan University, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Ling Sun
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China.,Department of Ophthalmology, The Eye and ENT Hospital of Fudan University, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Mi Tian
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China.,Department of Ophthalmology, The Eye and ENT Hospital of Fudan University, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Yang Shen
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China.,Department of Ophthalmology, The Eye and ENT Hospital of Fudan University, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Meiyan Li
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China.,Department of Ophthalmology, The Eye and ENT Hospital of Fudan University, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Jing Zhao
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China.,Department of Ophthalmology, The Eye and ENT Hospital of Fudan University, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
| | - Xingtao Zhou
- NHC Key Laboratory of Myopia, Fudan University, Shanghai, China.,Department of Ophthalmology, The Eye and ENT Hospital of Fudan University, Shanghai, China.,Shanghai Research Center of Ophthalmology and Optometry, Shanghai, China
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Lombardo G, Serrao S, Lombardo M. Comparison between standard and transepithelial corneal crosslinking using a theranostic UV-A device. Graefes Arch Clin Exp Ophthalmol 2020; 258:829-834. [PMID: 31900647 DOI: 10.1007/s00417-019-04595-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/20/2019] [Accepted: 12/27/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To assess corneal concentration of riboflavin in two different corneal crosslinking protocols performed by a novel image-guided therapeutic (or "theranostic") UV-A device. METHODS Ten human eye bank donor tissues were used in this work. The tissues underwent corneal cross-linking according to the conventional treatment protocol (n = 5; 30 min of stromal soaking followed by 30 min of 3 mW/cm2 UV-A irradiance) and the iontophoresis-assisted transepithelial protocol (n = 5; soaking for 5 min at 1 mA/min and 9 min of 10 mW/cm2 UV-A irradiance) using a theranostic UV-A device (Vision Engineering Italy srl, Italy). The device provided real time assessment of riboflavin concentration by hyperspectral image analysis of the cornea. A 0.1% riboflavin hypotonic solution (Ricrolin+, Sooft Italia Spa, Italy) was used in all cases. RESULTS Manual application of hypotonic riboflavin for 30 min into the stroma achieved greater corneal riboflavin concentration (425 ± 77 μg/cm3) than transepithelial delivery of riboflavin by corneal iontophoresis (195 ± 35 μg/cm3; P = 0.001). In both UV-A irradiation protocols, corneal riboflavin concentration decreased exponentially with a constant energy rate of 2.3 ± 0.5 J/cm2 and 1.8 ± 0.3 J/cm2 respectively. At the end of treatment, the average corneal concentration of riboflavin decreased by ≥ 85%, with values of 54 ± 29 μg/cm3 and 31 ± 9 μg/cm3 (P = 0.11), respectively. CONCLUSION Manual application of riboflavin onto the stroma achieved almost 50% greater concentration of riboflavin than transepithelial delivery by corneal iontophoresis. The theranostic UV-A device provided a novel approach to estimate corneal concentration of riboflavin non-invasively during treatment.
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Affiliation(s)
- Giuseppe Lombardo
- Vision Engineering Italy srl, Via Livenza 3, 00198, Rome, Italy.,CNR-IPCF, Istituto per i Processi Chimico-Fisici, Viale F. Stagno D'Alcontres 37, 98158, Messina, Italy
| | | | - Marco Lombardo
- Vision Engineering Italy srl, Via Livenza 3, 00198, Rome, Italy. .,Studio Italiano di Oftalmologia, Via Livenza 3, 00198, Rome, Italy.
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Perez VL, Wirostko B, Korenfeld M, From S, Raizman M. Ophthalmic Drug Delivery Using Iontophoresis: Recent Clinical Applications. J Ocul Pharmacol Ther 2019; 36:75-87. [PMID: 31755807 DOI: 10.1089/jop.2019.0034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Iontophoresis is a noninvasive delivery system designed to overcome barriers to ocular penetration of topical ophthalmic medications by employing a low-amplitude electrical current to promote the migration of a charged drug substance across biological membranes. Trans-scleral iontophoresis of dexamethasone phosphate has demonstrated dramatically increased intraocular concentrations of dexamethasone in rabbit ocular tissues compared with topical instillation, including 50- to 100-fold greater aqueous humor concentrations. Methods: This article reviews available data on recent clinical applications of iontophoretic ophthalmic drug delivery. Results: The EyeGate II delivery system (EGDS) is a trans-scleral iontophoresis system that has been used in conjunction with EGP-437, a proprietary-charged formulation of dexamethasone phosphate for iontophoretic delivery. In patients with noninfectious anterior uveitis, EGP-437, delivered through 2 iontophoretic treatments using the EGDS, demonstrated similar efficacy to topical prednisolone acetate 1% eye drops instilled 8 times daily over 28 days, suggesting the potential to decrease or eliminate the need for daily dosing of topical steroids in this patient population. Other applications for EGP-437 delivered through the EGDS that have been explored in clinical trials include treatment of dry eye, postsurgical inflammation and pain, and scleritis. In addition, transcorneal iontophoresis has been used outside of the United States to enhance riboflavin penetration in patients undergoing corneal cross-linking as therapy for progressive keratoconus. Conclusions: The reviewed studies demonstrate the feasibility of using iontophoresis to enhance drug delivery to ocular tissues and support the potential of this noninvasive technique across a range of ophthalmic indications.
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Affiliation(s)
| | - Barbara Wirostko
- EyeGate Pharmaceuticals, Inc., Waltham, Massachusetts.,Department of Ophthalmology Moran Eye Center, and Bio Medical Engineering, University of Utah, Salt Lake City, Utah
| | | | - Stephen From
- EyeGate Pharmaceuticals, Inc., Waltham, Massachusetts
| | - Michael Raizman
- Ophthalmic Consultants of Boston, Boston, Massachusetts.,New England Eye Center, Tufts University School of Medicine, Boston Massachusetts
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Baenninger PB, Bodmer NS, Bachmann LM, Iselin K, Kaufmann C, Belin MW, Thiel MA. Keratoconus Characteristics Used in Randomized Trials of Surgical Interventions—A Systematic Review. Cornea 2019; 39:615-620. [DOI: 10.1097/ico.0000000000002202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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35
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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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Vinciguerra P, Rosetta P, Legrottaglie EF, Morenghi E, Mazzotta C, Kaye SB, Vinciguerra R. Iontophoresis CXL With and Without Epithelial Debridement Versus Standard CXL: 2-Year Clinical Results of a Prospective Clinical Study. J Refract Surg 2019; 35:184-190. [PMID: 30855096 DOI: 10.3928/1081597x-20190128-01] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 01/24/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare the 2-year follow-up outcomes of three groups of patients with keratoconus treated with transepithelial iontophoresis (I-CXL), iontophoresis with epithelial removal (I-SCXL), and standard epithelium-off (S-CXL) CXL for progressive keratoconus. METHODS Sixty eyes of 60 patients treated with CXL for progressive keratoconus were included in this comparative, prospective clinical study. Twenty patients were included in each group (I-CXL, I-SCXL, and S-CXL). Corrected distance visual acuity (CDVA), refraction, corneal topography, Scheimpflug tomography, and aberrometry were assessed at baseline and at 1, 3, 6, 12, and 24 months of follow-up. To assess the long-term safety and efficacy of these treatments, the preoperative values were compared with the values at 24 months of follow-up. RESULTS The main outcome of the study was the non-statistically significant difference between the three protocols in induced change in most of the parameters, including visual acuity (P = .665), topographic indexes (all P > .05), and maximum keratometry (P = .611) after 2 years of follow-up. There were no significant differences in the change in refractive error following CXL in all groups or between groups (all P > .05). Conversely, I-CXL induced significantly less corneal thinning (P = .0299 and .0121) and a significantly greater reduction of higher order aberrations and coma (all P < .0001) compared to S-CXL and I-SCXL. All protocols induced a significant increase in visual acuity (S-CXL P = .0004, I-SCXL P = .0045, and I-CXL P = .004). CONCLUSIONS The 2-year results of this comparative, prospective clinical study demonstrate the efficacy and safety of I-CXL to treat progressive keratoconus and overcome the limitations of CXL with epithelial debridement. [J Refract Surg. 2019;35(3):184-190.].
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Deshmukh R, Hafezi F, Kymionis GD, Kling S, Shah R, Padmanabhan P, Sachdev MS. Current concepts in crosslinking thin corneas. Indian J Ophthalmol 2019; 67:8-15. [PMID: 30574883 PMCID: PMC6324097 DOI: 10.4103/ijo.ijo_1403_18] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Corneal cross-linking (CXL), introduced by Wollensak et al. in 2003, is a minimally invasive procedure to halt the progression of keratoconus. Conventional CXL is recommended in eyes with corneal thickness of at least 400 microns after de-epithelialization to prevent endothelial toxicity. However, most of the keratoconic corneas requiring CXL may not fulfill this preoperative inclusion criterion. Moderate-to-advanced cases are often found to have a pachymetry less than this threshold. There are various modifications to the conventional method to circumvent this issue of CXL thin corneas while avoiding the possible complications. This review is an update on the modifications of conventional CXL for thin corneas.
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Affiliation(s)
- Rashmi Deshmukh
- Cornea, Cataract and Refractive Services, Centre for Sight Hospital, New Delhi, India
| | - Farhad Hafezi
- ELZA Institute, Dietikon/Zurich; Laboratory for Ocular Cell Biology, University of Zurich, Zurich, Switzerland; University of Southern California, Roski Eye Institute, Los Angeles, CA, USA; Department of Ophthalmology, University of Wenzhou, Wenzhou, China
| | - George D Kymionis
- Athens Medical School, University of Athens, Athens, Greece; Jules Gonin Eye Hospital, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Sabine Kling
- Ophthalmic Personalized treatment and imaging cluster (OPTIC), Department of Information Technology and Electrical Engineering Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
| | - Rupal Shah
- Centre for Sight Hospital, Vadodara, India
| | - Prema Padmanabhan
- Department of Cornea and Refractive Surgery, Sankara Nethralaya, Chennai, India
| | - Mahipal S Sachdev
- Cornea, Cataract and Refractive Services, Centre for Sight Hospital, New Delhi, India
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Lombardo M, Serrao S, Lombardo G, Schiano-Lomoriello D. Two-year outcomes of a randomized controlled trial of transepithelial corneal crosslinking with iontophoresis for keratoconus. J Cataract Refract Surg 2019; 45:992-1000. [PMID: 31003798 DOI: 10.1016/j.jcrs.2019.01.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the 2-year clinical outcomes of corneal crosslinking (CXL) using transepithelial iontophoresis CXL (T-ionto CXL) in comparison with standard CXL for the treatment of progressive keratoconus. SETTING Single-site study. DESIGN Randomized controlled clinical trial with identifier code NCT02117999. METHODS The eyes of the participants were randomized to have either T-ionto CXL and/or standard CXL. Assessments of uncorrected (UDVA) and corrected (CDVA) distance visual acuities (logarithm of the minimum angle of resolution [logMAR]), manifest refraction spherical equivalent, maximum simulated keratometry (K) (diopters [D]), corneal higher-order aberrations (HOAs), central corneal thickness (CCT), and endothelial cell density (ECD) were performed at 3 days, 7 days, and 1, 3, 6, 12, and 24 months postoperatively. RESULTS The study comprised 34 eyes (25 patients). There were 22 eyes in the T-ionto CXL group and 12 eyes in the standard CXL group. Two years after T-ionto CXL and standard CXL, the mean maximum K flattened by -1.05 ± 1.20 D (P = .07) (20 eyes) and -1.51 ± .89 D (P < .001) (11 eyes), respectively. Two study cases (10%) and no control showed maximum K steepening of more than 1.0 D at 24 months postoperatively. The mean change in CDVA was -0.08 ± 0.15 logMAR (P = .04) and -0.02 ± 0.06 logMAR (P = .34) after T-ionto CXL and standard CXL, respectively. A significant average decrease in the myopic defocus (+0.81 D; P < .05) was found in both groups. No significant differences in the outcome measures between treatments were found at 24 months. The corneal HOAs, CCT, and ECD values did not change significantly in any group at 2 years postoperatively. CONCLUSIONS Clinically significant topographic, visual, and refractive improvements were found 2 years after T-ionto CXL; standard CXL showed more significant corneal apex flattening than the transepithelial iontophoresis protocol.
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Affiliation(s)
- Marco Lombardo
- Vision Engineering Italy srl, Rome, Italy; Studio Italiano di Oftalmologia, Rome, Italy.
| | | | - Giuseppe Lombardo
- Vision Engineering Italy srl, Rome, Italy; Consiglio Nazionale delle Ricerche, Istituto per i Processi Chimico-Fisici, Messina, Italy
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Liao K, Hu M, Chen F, Li P, Song P, Zeng QY. Clinical and microstructural changes with different iontophoresis-assisted corneal cross-linking methods for keratoconus. Int J Ophthalmol 2019; 12:219-225. [PMID: 30809476 DOI: 10.18240/ijo.2019.02.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/25/2018] [Indexed: 11/23/2022] Open
Abstract
AIM To compare the clinical and microstructural changes induced by different transepithelial iontophoresis-assisted corneal cross-linking (I-CXL) methods for keratoconus. METHODS A total of 42 eyes of 42 patients with progressive keratoconus were divided into two groups. Group A received I-CXL for 5min, while group B received I-CXL for 10min. Visual acuity, optical coherence tomography (OCT), specular microscopy and confocal microscopy were evaluated preoperatively and at 1, 3, 6, and 12mo postoperatively. RESULTS Twelve months after the operation, uncorrected visual acuity (UCVA) and corrected distance visual acuity (CDVA) were improved in both groups, with a better outcome in the I-CXL 10min group (P=0.025, 0.021, respectively). Kmax values decreased by 0.94±3.00 D in the I-CXL 10min group (P=0.033) but increased by 1.87±3.29 D in the I-CXL 5min group (P=0.012). OCT scans showed that the demarcation line was most visible and substantially deeper in the I-CXL 10min group. Confocal microscopy showed greater anterior stromal keratocyte decreases in the I-CXL 10min group than in the I-CXL 5min group at 3 and 6mo postoperatively (P<0.001); however, anterior stromal keratocytes and subbasal nerve density were not significantly different between the two groups at 12mo postoperatively. CONCLUSION I-CXL for 10min more effectively halts the progression of keratoconus than I-CXL for 5min after 12mo of follow-up. However, long-term studies are needed to evaluate the efficacy and safety of I-CXL.
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Affiliation(s)
- Kai Liao
- Aier School of Ophthalmology, Central South University, Changsha 410000, Hunan Province, China
| | - Min Hu
- Aier School of Ophthalmology, Central South University, Changsha 410000, Hunan Province, China
| | - Fen Chen
- Aier School of Ophthalmology, Central South University, Changsha 410000, Hunan Province, China
| | - Pei Li
- Aier School of Ophthalmology, Central South University, Changsha 410000, Hunan Province, China
| | - Peng Song
- Aier School of Ophthalmology, Central South University, Changsha 410000, Hunan Province, China
| | - Qing-Yan Zeng
- Aier School of Ophthalmology, Central South University, Changsha 410000, Hunan Province, China.,Hankou Aier Eye Hospital, Wuhan 430000, Hubei Province, China
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Quantitative Analysis of the Corneal Collagen Distribution after In Vivo Cross-Linking with Second Harmonic Microscopy. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3860498. [PMID: 30756083 PMCID: PMC6348900 DOI: 10.1155/2019/3860498] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/24/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022]
Abstract
Corneal cross-linking (CXL) is a surgical procedure able to modify corneal biomechanics and stabilize keratoconus progression. Although it is known that CXL produces changes in corneal collagen distribution, these are still a topic of discussion. Here we quantitatively compare the corneal stroma architecture between two animal models four weeks after in vivo conventional CXL treatment, with second harmonic generation (SHG) imaging microscopy and the structure tensor (ST). The healing stage and the stroma recovery were also analyzed by means of histological sections. Results show that the CXL effects depend on the initial arrangement of the corneal collagen. While the treatment increases the order in corneas with a low level of initial organization, corneas presenting a fairly regular pattern are hardly affected. Histological samples showed active keratocytes in anterior and middle stroma, what means that the recovery is still in progress. The combination of SHG imaging and the ST is able to objectively discriminate the changes suffered by the collagen arrangement after the CXL treatment, whose effectiveness depends on the initial organization of the collagen fibers within the corneal stroma.
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Selected Medicines Used in Iontophoresis. Pharmaceutics 2018; 10:pharmaceutics10040204. [PMID: 30366360 PMCID: PMC6320882 DOI: 10.3390/pharmaceutics10040204] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 12/26/2022] Open
Abstract
Iontophoresis is a non-invasive method of systemic and local drug delivery using an electric field. Iontophoresis enables diffusion of the selected drug via skin, mucosa, enamel, dentin, and other tissues. The amount of delivered therapeutic molecules is about 10⁻2000 times greater than conventional forms of delivery. Among other fields, this method is used in dentistry, ophthalmology, otorhinolaryngology, and dermatology. According to related literature, the most important drugs studied or administered by iontophoresis are: Local anesthetics, opioids, steroids, non-steroidal anti-inflammatory drugs, antibacterial drugs, antifungal drugs, antiviral drugs, anticancer drugs, fluorides, and vitamins. The present review covers current available data regarding the selected medicines used in iontophoresis. Furthermore, indications and conditions of iontophoresis application are reviewed.
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Lorenzo-Martín E, Gallego-Muñoz P, Ibares-Frías L, Marcos S, Pérez-Merino P, Fernández I, Kochevar IE, Martínez-García MC. Rose Bengal and Green Light Versus Riboflavin–UVA Cross-Linking: Corneal Wound Repair Response. ACTA ACUST UNITED AC 2018; 59:4821-4830. [DOI: 10.1167/iovs.18-24881] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Elvira Lorenzo-Martín
- Departamento de Biología Celular, Histología y Farmacología, GIR de Técnicas Ópticas para el Diagnóstico, Universidad de Valladolid, Valladolid, Spain
| | - Patricia Gallego-Muñoz
- Departamento de Biología Celular, Histología y Farmacología, GIR de Técnicas Ópticas para el Diagnóstico, Universidad de Valladolid, Valladolid, Spain
| | - Lucía Ibares-Frías
- Departamento de Biología Celular, Histología y Farmacología, GIR de Técnicas Ópticas para el Diagnóstico, Universidad de Valladolid, Valladolid, Spain
- Departamento de Oftalmología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Susana Marcos
- Instituto de Óptica, Consejo Superior de Investigaciones Científicas, Madrid, Spain
| | - Pablo Pérez-Merino
- Instituto de Óptica, Consejo Superior de Investigaciones Científicas, Madrid, Spain
| | - Itziar Fernández
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Instituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, Valladolid, Spain
| | - Irene E. Kochevar
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - M. Carmen Martínez-García
- Departamento de Biología Celular, Histología y Farmacología, GIR de Técnicas Ópticas para el Diagnóstico, Universidad de Valladolid, Valladolid, Spain
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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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Atia R, Jouve L, Sandali O, Laroche L, Borderie V, Bouheraoua N. Early Epithelial Remodeling After Standard and Iontophoresis-Assisted Corneal Cross-linking as Evaluated by Spectral-Domain Optical Coherence Tomography. J Refract Surg 2018; 34:551-558. [DOI: 10.3928/1081597x-20180702-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/18/2018] [Indexed: 11/20/2022]
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Epi-Off versus Epi-On Corneal Collagen Cross-Linking in Keratoconus Patients: A Comparative Study through 2-Year Follow-Up. J Ophthalmol 2018; 2018:4947983. [PMID: 30151277 PMCID: PMC6087595 DOI: 10.1155/2018/4947983] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 04/29/2018] [Indexed: 11/26/2022] Open
Abstract
Aim To evaluate two different techniques of cross-linking: standard epithelium-off (CXL epi-off) versus transepithelial (CXL epi-on) cross-linking in patient with progressive keratoconus. Methods Forty eyes from 32 patients with progressive keratoconus were prospectively enrolled from June 2014 to June 2015 in this nonblinded, randomized comparative study. Twenty eyes were treated by CXL epi-off and 20 by CLX epi-on, randomly assigned, and followed for 2 years. All patients underwent a complete ophthalmologic testing that included uncorrected and best corrected visual acuity, central and peripheral corneal thickness, corneal astigmatism, simulated maximum, minimum, and average keratometry, corneal confocal microscopy, Schirmer I and break-up time (BUT) tests, and the Ocular Surface Disease Index. Intra- and postoperative complications were recorded. The solution used for CXL epi-off comprised riboflavin 0.1% and dextran 20.0% (Ricrolin), whereas the solution for CXL epi-on (Ricrolin TE) comprised riboflavin 0.1%, dextran 15.0%, trometamol (Tris), and ethylenediaminetetraacetic acid. Ultraviolet-A treatment was performed with a UV-X system at 3 mW/cm2. Results In both groups, a significant improvement in visual function (Group 1: baseline 0.36 ± 0.16 logMAR, two-year follow-up 0.22 ± 0.17 logMAR, p=0.01; Group 2: baseline 0.32 ± 0.18 logMAR, 2-year follow-up 0.27 ± 0.19 logMAR, p=0.01) was recorded. Keratometry remained unchanged in both groups. The mean corneal thickness showed a significant reduction (mean difference of corneal thickness: −55 micron and −71 micron, resp.). One-month after treatment, OSDI© reached 13.56 ± 2.15 in Group 1 (p=0.03) and 11.26 ± 2.12 in Group 2 (p=0.04). At confocal microscopy, abnormal corneal nerve alterations were found in both groups. Fibrotic reaction (43.75%) and activated keratocyte (62.6%) were more commonly recorded in Group 1 than in Group 2 (25.0% and 18.75%), with p=0.668 and 0.356, respectively. Conclusion Our findings demonstrate that both procedures are able to slow keratoconus progression. Both treatment modalities are equivalent in terms of results and related complications. CXL epi-on technique is preferable to CXL epi-off since it preserves the corneal thickness and improves visual acuity, also reducing the postoperative ocular discomfort during the study period.
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Jia HZ, Peng XJ. Efficacy of iontophoresis-assisted epithelium-on corneal cross-linking for keratoconus. Int J Ophthalmol 2018; 11:687-694. [PMID: 29675392 DOI: 10.18240/ijo.2018.04.25] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 02/07/2018] [Indexed: 12/16/2022] Open
Abstract
Corneal cross-linking (CXL) is a noninvasive therapeutic procedure for keratoconus that is aimed at improving corneal biomechanical properties by induction of covalent cross-links between stromal proteins. It is accomplished by ultraviolet A (UVA) radiation of the cornea, which is first saturated with photosensitizing riboflavin. It has been shown that standard epithelium-off CXL (S-CXL) is efficacious, and it has been recommended as the standard of care procedure for keratoconus. However, epithelial removal leads to pain, transient vision loss, and a higher risk of corneal infection. To avoid these disadvantages, transepithelial CXL was developed. Recently, iontophoresis has been adopted to increase riboflavin penetration through the epithelium. Several clinical observations have demonstrated the safety and efficacy of iontophoresis-assisted epithelium-on CXL (I-CXL) for keratoconus. This review aimed to provide a comprehensive summary of the published studies regarding I-CXL and a comparison between I-CXL and S-CXL. All articles used in this review were mainly retrieved from the PubMed database. Original articles and reviews were selected if they were related to the I-CXL technique or related to the comparison between I-CXL and S-CXL.
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Affiliation(s)
- Hong-Zhen Jia
- Department of Ophthalmology, Chinese PLA Navy General Hospital, Beijing 100048, China
| | - Xiu-Jun Peng
- Department of Ophthalmology, Chinese PLA Navy General Hospital, Beijing 100048, China
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Subasinghe SK, Ogbuehi KC, Dias GJ. Current perspectives on corneal collagen crosslinking (CXL). Graefes Arch Clin Exp Ophthalmol 2018; 256:1363-1384. [PMID: 29623463 DOI: 10.1007/s00417-018-3966-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 02/20/2018] [Accepted: 03/23/2018] [Indexed: 12/13/2022] Open
Abstract
Corneal collagen crosslinking has revolutionized the treatment of keratoconus and post-refractive corneal ectasia in the past decade. Corneal crosslinking with riboflavin and ultraviolet A is proposed to halt the progression of keratectasia. In the original "Conventional Dresden Protocol" (C-CXL), the epithelium is removed prior to the crosslinking process to facilitate better absorption of riboflavin into the corneal stroma. Studies analyzing its short- and long-term outcomes revealed that although there are inconsistencies as to the effectiveness of this technique, the advantages prevail over the disadvantages. Therefore, corneal crosslinking (CXL) is widely used in current practice to treat keratoconus. In an attempt to improve the visual and topographical outcomes of C-CXL and to minimize time-related discomfort and endothelial-related side effects, various modifications such as accelerated crosslinking and transepithelial crosslinking methods have been introduced. The comparison of outcomes of these modified techniques with C-CXL has also returned contradictory results. Hence, it is difficult to clearly identify an optimal procedure that can overcome issues associated with the CXL. This review provides an up-to-date analysis on clinical and laboratory findings of these popular crosslinking protocols used in the treatment of keratoconus. It is evident from this review that in general, these modified techniques have succeeded in minimizing the immediate complications of the C-CXL technique. However, there were contradictory viewpoints regarding their effectiveness when compared with the conventional technique. Therefore, these modified techniques need to be further investigated to arrive at an optimal treatment option for keratoconus.
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Affiliation(s)
- Sandeepani K Subasinghe
- Department of Anatomy, University of Otago, P.O. Box 913, 270 Great King Street, Dunedin, 9054, New Zealand.
| | - Kelechi C Ogbuehi
- Ophthalmology Section, Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - George J Dias
- Department of Anatomy, University of Otago, P.O. Box 913, 270 Great King Street, Dunedin, 9054, New Zealand
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Zhang X, Zhao J, Li M, Tian M, Shen Y, Zhou X. Conventional and transepithelial corneal cross-linking for patients with keratoconus. PLoS One 2018; 13:e0195105. [PMID: 29621306 PMCID: PMC5886478 DOI: 10.1371/journal.pone.0195105] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 03/17/2018] [Indexed: 11/19/2022] Open
Abstract
Previous studies investigating the effectiveness of conventional corneal collagen cross-linking (CXL) and transepithelial CXL in keratoconus treatment have reported conflicting outcomes. Therefore, we conducted a meta-analysis to compare the effectiveness of these treatments. We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials for prospective randomized controlled trials (RCTs) with no restrictions. We included visual acuity (corrected distance visual acuity, uncorrected distance visual acuity) and corneal keratometry (K) as primary outcome parameters, and spherical equivalent, central corneal thickness (CCT), and endothelial cell density, as secondary parameters. We finally included seven reports (including six RCTs involving 305 participants and 344 eyes). Our analysis revealed significant postoperative differences in average K and CCT values between conventional and transepithelial CXL-treated patients [K: weighted mean difference (WMD) = 0.79, 95% confidence interval (CI) = 0.04-1.53, p = 0.04; CCT: WMD = 4.53, 95% CI = 0.42-8.64, p = 0.03]. In contrast, we did not find any significant differences in visual acuity, flattest K value, steepest K value, cylinder K value, apex K value, spherical equivalent, or endothelial cell density between groups. In conclusion, transepithelial CXL has a more protective influence on corneal thickness than conventional CXL, and results in lesser postoperative corneal flattening. Further investigation of the clinical outcomes of transepithelial CXL is required.
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Affiliation(s)
- Xiaoyu Zhang
- Eye and ENT Hospital of Fudan University, Myopia Key Laboratory of the Health Ministry, Shanghai, China
| | - Jing Zhao
- Eye and ENT Hospital of Fudan University, Myopia Key Laboratory of the Health Ministry, Shanghai, China
| | - Meiyan Li
- Eye and ENT Hospital of Fudan University, Myopia Key Laboratory of the Health Ministry, Shanghai, China
| | - Mi Tian
- Eye and ENT Hospital of Fudan University, Myopia Key Laboratory of the Health Ministry, Shanghai, China
| | - Yang Shen
- Eye and ENT Hospital of Fudan University, Myopia Key Laboratory of the Health Ministry, Shanghai, China
| | - Xingtao Zhou
- Eye and ENT Hospital of Fudan University, Myopia Key Laboratory of the Health Ministry, Shanghai, China
- * E-mail:
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Lombardo M, Villari V, Micali N, Roy P, Sousa SH, Lombardo G. Assessment of trans-scleral iontophoresis delivery of lutein to the human retina. JOURNAL OF BIOPHOTONICS 2018; 11. [PMID: 28700128 DOI: 10.1002/jbio.201700095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/12/2017] [Accepted: 06/13/2017] [Indexed: 05/08/2023]
Abstract
The efficacy of novel scleral iontophoresis device for in situ delivery of lutein to the human retina was assessed by Resonance Raman spectroscopy (RRS) technique. Eight human donor eye globes were used for experiments, 6 of which underwent trans-scleral iontophoresis delivery of lutein and the other 2 were used as controls. The scleral iontophoresis applicator was filled with liposome-enriched 0.1% lutein solution and the generator's current was set at 2.5 mA and delivered for 4 min. A custom RRS setup was used for detecting lutein in the inner sclera, choroid, retinal periphery and macula of treated samples and controls. Forty minutes after iontophoresis, the inner sclera, choroid and retinal periphery were greatly enriched with lutein (P < .05); no lutein was found in the same ocular regions of non-treated samples. In the same period, the average concentration of lutein in the macula (4.8 ± 1.7 ng/mm2 ) of treated samples was 1.3 times greater than controls (3.7 ± 1.0 ng/mm2 ; P = .4). Scleral iontophoresis was shown to be effective in delivering lutein to the human retina. Future studies will aim at assessing if this therapeutic strategy is valuable to enrich the macular pigment in human subjects.
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Affiliation(s)
| | | | - Norberto Micali
- CNR-IPCF, Istituto per i Processi Chimico-Fisici, Messina, Italy
| | | | - Sara H Sousa
- Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
| | - Giuseppe Lombardo
- Vision Engineering Italy srl, Rome, Italy
- CNR-IPCF, Istituto per i Processi Chimico-Fisici, Messina, Italy
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Li W, Wang B. Efficacy and safety of transepithelial corneal collagen crosslinking surgery versus standard corneal collagen crosslinking surgery for keratoconus: a meta-analysis of randomized controlled trials. BMC Ophthalmol 2017; 17:262. [PMID: 29282020 PMCID: PMC5745766 DOI: 10.1186/s12886-017-0657-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 12/11/2017] [Indexed: 01/08/2023] Open
Abstract
Background The aim of this study was to evaluate the efficacy and safety of transepithelial corneal collagen crosslinking (transepithelial CXL) versus standard corneal collagen crosslinking (epithelium-off CXL) on keratoconus. Methods Eligible studies were identified by systematically searching PubMed, the Cochrane Library and Embase. Topographic parameters, corrected distant visual acuity (CDVA), uncorrected distant visual acuity (UDVA), and corneal thickness (CT) were assessed by the pooled weighted mean differences (WMDs) of the change from baseline to the end of follow up. Quality was assessed according to Cochrane handbook. And we used Review Manager to analysis the included trials. Results Three trials involving 244 eyes were evaluated, with 111 eyes in the standard CXL group and 133 eyes in the transepithelial CXL group. The pooled results showed that there were significant differences between the two groups in maximum keratometry (mean difference = 1.05D, 95% CI 0.19 to 1.92, P = 0.02)),and the standard CXL is more effective in decreasing the maximum keratometry at least 12 months after operation; the transepithelial CXL group gained more improvement in CDVA (mean difference = −0.07, 95% CI -0.12 to −0.02, P = 0.007);there were no significant differences in uncorrected distant visual acuity (UDVA) between the two groups (mean difference = −0.03, 95% CI -0.20 to 0.15, P = 0.75). A similar change was found in corneal thickness (mean difference = 4.35, 95% CI -0.43 to 9.13, P = 0.07)). Conclusions The standard CXL is more effective in decreasing the maximum keratometry than the transepithelial CXL; the transepithelial CXL provided favorable visual outcomes; they both exhibit similar safety.
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Affiliation(s)
- Wenwei Li
- Department of Ophthalmology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, China
| | - Bin Wang
- Department of Ophthalmology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, China.
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