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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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Raiskup F, Herber R, Lenk J, Pillunat LE, Spoerl E. Crosslinking with UV-A and riboflavin in progressive keratoconus: From laboratory to clinical practice - Developments over 25 years. Prog Retin Eye Res 2024; 102:101276. [PMID: 38830532 DOI: 10.1016/j.preteyeres.2024.101276] [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: 03/31/2023] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/05/2024]
Abstract
Changes in the biomechanical and biochemical properties of the human cornea play an important role in the pathogenesis of ectatic diseases. A number of conditions in primarily acquired (keratoconus or pellucid marginal degeneration) or secondarily induced (iatrogenic keratectasia after refractive laser surgeries) ectatic disorders lead to decreased biomechanical stability. Corneal collagen cross-linking (CXL) represents a technique to slow or even halt the progression of ectatic pathologies. In this procedure, riboflavin is applied in combination with ultraviolet A radiation. This interaction induces the production of reactive oxygen species, which leads to the formation of additional covalent bonds between collagen molecules and subsequent biomechanical corneal strengthening. This procedure is so far the only method that partially interferes etiopathogenetically in the treatment of ectatic diseases that slows or stops the process of corneal destabilization, otherwise leading to the need for corneal transplantation. Besides, CXL process increases markedly resistance of collagenous matrix against digesting enzymes supporting its use in the treatment of corneal ulcers. Since the discovery of this therapeutic procedure and the first laboratory experiments, which confirmed the validity of this method, and the first clinical studies that proved the effectiveness and safety of the technique, it has been spread and adopted worldwide, even with further modifications. Making use of the Bunsen-Roscoe photochemical law it was possible to shorten the duration of this procedure in accelerated CXL and thus improve the clinical workflow and patient compliance while maintaining the efficacy and safety of the procedure. The indication spectrum of CXL can be further expanded by combining it with other vision-enhancing procedures such as individualized topographically-guided excimer ablation. Complementing both techniques will allow a patient with a biomechanically stable cornea to regularize it and improve visual acuity without the need for tissue transplantation, leading to a long-term improvement in quality of life.
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Affiliation(s)
- Frederik Raiskup
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Robert Herber
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Janine Lenk
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Lutz E Pillunat
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Eberhard Spoerl
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Masarwa D, Blockstein K, Sela T, Munzer G, Kaiserman I. Tel-Aviv Protocol for Postrefractive Surgery Corneal Ectasia: A Case Series. Cornea 2024; 43:578-584. [PMID: 37983313 DOI: 10.1097/ico.0000000000003428] [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: 04/23/2023] [Accepted: 10/15/2023] [Indexed: 11/22/2023]
Abstract
PURPOSE The aim of this study was to describe the safety and efficacy of the Tel-Aviv Protocol (epithelial photorefractive keratectomy and corneal cross-linking) as a treatment for postrefractive surgery corneal ectasia. METHODS This study includes 8 eyes from 7 patients, each diagnosed with postrefractive surgery ectasia years after refractive surgery and treated with the Tel-Aviv Protocol. The procedure included transepithelial PRK using the EX500 excimer laser, a 50-μm laser ablation of the epithelium and anterior stroma, delivered on the visual axis with cyclotorsion correction, treating up to 50% of refractive astigmatism. After the epithelial photorefractive keratectomy, all patients underwent corneal cross-linking. RESULTS The mean keratometry (K) and maximal K both decreased [from 43.37 ± 2.23 to 41.84 ± 2.01 ( P = 0.03) and from 44.95 ± 3.08 to 42.78 ± 2.19 ( P = 0.03), respectively]. Astigmatism was significantly reduced (from 3.53 ± 2.36 to 0.88 ± 0.89 diopter; P = 0.02). Uncorrected visual acuity improved significantly in all patients from a mean of 0.56 ± 0.32 to 0.15 ± 0.14 logMAR ( P = 0.01). Best-corrected visual acuity improved from 0.22 ± 0.24 to 0.06 ± 0.06 logMAR ( P = 0.07; 1-tail P = 0.04). All patients maintained visual acuity during the follow-up period, up to 25 months, mean = 329 days. The Tel-Aviv Protocol was found to be safe [mean safety index: 1.63 ± 1.03 (range: 1.00-4)] and effective [mean efficacy index: 1.29 ± 0.66 (range: 0.71-2.1)]. CONCLUSIONS The Tel-Aviv Protocol, developed initially for keratoconus treatment, is a safe and promising procedure to stop postrefractive surgery ectasia progression while significantly improving vision, thereby avoiding keratoplasty.
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Affiliation(s)
- Dua Masarwa
- Department of Ophthalmology, Barzilai Medical Center, Ashkelon, Israel
| | - Keren Blockstein
- Department of Ophthalmology, Barzilai Medical Center, Ashkelon, Israel
| | - Tzahi Sela
- Care-Vision Laser Center, Tel Aviv, Israel; and
| | - Gur Munzer
- Care-Vision Laser Center, Tel Aviv, Israel; and
| | - Igor Kaiserman
- Department of Ophthalmology, Barzilai Medical Center, Ashkelon, Israel
- Care-Vision Laser Center, Tel Aviv, Israel; and
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel
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Amaral DC, Menezes AHG, Vilaça Lima LC, Faneli AC, Neto PFS, Canedo ALC, Mora-Paez DJ, Guedes JAF, Louzada RN, Fontes BM. Corneal Collagen Crosslinking for Ectasia After Refractive Surgery: A Systematic Review and Meta-Analysis. Clin Ophthalmol 2024; 18:865-879. [PMID: 38525385 PMCID: PMC10960511 DOI: 10.2147/opth.s451232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/26/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Corneal ectasia leads to progressive irregular corneal curvature and reduced visual acuity. Objective To assess the safety and effectiveness of corneal collagen cross-linking (CXL) for managing corneal ectasia resulting from refractive laser surgery (RSL). Methods A systematic review and meta-analysis were realized according to PRISMA guidelines. We searched PubMed, EMBASE, Cochrane, and Web of Science databases for studies on CXL in patients with ectasia after RLS. The outcomes of interest included visual acuity, refractive outcomes, topographic parameters (Kmax, index surface variance (ISV), index of Vertical Asymmetry (IVA), keratoconus index (KI), central keratoconus index (CKI), index of height asymmetry (IHA), index of height decentration (IHD) and Rmin (minimum sagittal curvature)), central corneal thickness, endothelial cell count, and possible adverse events. Statistical analysis was performed using the R software (version 4.2.3, R Foundation for Statistical Computing, Vienna, Austria). Results 15 studies encompassing 421 patients (512 eyes) were included. The mean age was 32.03 ± 4.4 years. The pooled results showed a stable uncorrected visual acuity post-CXL, with a significant improvement in corrected distance visual acuity (SMD = 0.09; 95% CI: -0.07 to 0.26). The spherical equivalent decreased significantly (SMD = -0.09; 95% CI: -0.35, -0.02). The topographic parameter Kmax decreased significantly (SMD = 0.15; 95% CI:0.01 to 0.28); however, the other parameters, ISV, IVA, KI, CKI, IHA, IHD, and Rmin, did not change significantly. Central corneal thickness decreased significantly (SMD = 0.24; 95% CI:0.07 to 0.41), and the endothelial cell count remained stable The complications were rare. Conclusion CXL is a safe and effective technique for managing corneal ectasia after RLS.
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Affiliation(s)
- Dillan Cunha Amaral
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Kandel H, Chen JY, Sahebjada S, Chong EW, Wiffen S, Watson SL. Cross-Linking Improves the Quality of Life of People With Keratoconus: A Cross-Sectional and Longitudinal Study From the Save Sight Keratoconus Registry. Cornea 2023; 42:1377-1383. [PMID: 36729643 DOI: 10.1097/ico.0000000000003185] [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: 07/13/2022] [Accepted: 09/20/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE The purpose of this study was to comprehensively evaluate the patient-reported quality-of-life (QoL) outcomes after corneal cross-linking for keratoconus. METHODS This Save Sight Keratoconus Registry study used cross-sectional and longitudinal designs. For the cross-sectional study, 532 patients with keratoconus (mean age 30.9 ± 11.9 years; 31.6% female) completed the Keratoconus Outcomes Research Questionnaire (KORQ) and 343 patients with keratoconus (mean age 28.3 ± 10.7 years; 32.7% female) completed the Impact of Vision Impairment (IVI) questionnaires. Similarly, for the longitudinal study, 39 patients (mean age 24.2 ± 8.4 years; 23.1% female) completed the KORQ and 16 patients (mean age 27.9 ± 17.1 years; 50.0% female) completed the IVI questionnaire before and after 6 months of cross-linking. The QoL data were analyzed using the Andrich Rating Scale Model of Rasch analysis. RESULTS For both cross-sectional and longitudinal studies, the KORQ and IVI scales demonstrated satisfactory psychometric properties [ordered and well-spaced categories, variance explained by the measure 52%-73%, person separation index 2.4-3.9, and fit statistics <1.3 (most cases)]. The patients who had not undergone corneal cross-linking had worse mean activity limitation than those with cross-linking ( P = 0.008). However, the differences in symptoms and emotional scores between the groups were not statistically significant (both P > 0.05). The longitudinal study showed that cross-linking was associated with improved activity limitation, symptoms, and emotional scores. CONCLUSIONS The KORQ and IVI are psychometrically robust tools to evaluate the QoL outcomes of corneal cross-linking. Cross-linking is associated with improved activity limitation, symptoms, and emotional status.
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Affiliation(s)
- Himal Kandel
- Faculty of Medicine and Health, Save Sight Institute, The University of Sydney, Sydney, Australia
- Sydney Eye Hospital, Sydney, Australia
| | - Jern Yee Chen
- Flinders Medical Centre, Flinders University, Adelaide, Australia
| | - Srujana Sahebjada
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Centre for Eye Research Australia, Melbourne, Australia
- Department of Surgery, Ophthalmology, The University of Melbourne, Melbourne, Australia
| | - Elaine W Chong
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia
- Centre for Eye Research Australia, Melbourne, Australia
- Department of Ophthalmology, Royal Melbourne Hospital, Melbourne, Australia; and
| | | | - Stephanie L Watson
- Faculty of Medicine and Health, Save Sight Institute, The University of Sydney, Sydney, Australia
- Sydney Eye Hospital, Sydney, Australia
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Greenstein SA, Yu AS, Gelles JD, Huang S, Hersh PS. Long-Term Outcomes After Corneal Cross-linking for Progressive Keratoconus and Corneal Ectasia: A 10-Year Follow-Up of the Pivotal Study. Eye Contact Lens 2023; 49:411-416. [PMID: 37565471 DOI: 10.1097/icl.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVES To report on the topographic and visual outcomes 10 years after corneal cross-linking in patients with progressive keratoconus and corneal ectasia after refractive surgery. METHODS Cross-sectional cohort study of an original, prospective, randomized, clinical trial. Patients treated in a single center cornea and refractive surgery practice as part of the U.S. pivotal trials, which led to the Food and Drug Administration approval of corneal cross-linking, were recruited for a 10-year follow-up examination. LogMar lines (LL) of uncorrected visual acuity (UCVA) and best spectacle--corrected visual acuity (BSCVA), maximum keratometry, and thinnest pachymetry were evaluated. In addition, the Belin ABCD progression display was used to determine progression (95% confidence interval) of the anterior curvature, posterior curvature, and corneal thickness of each individual eye included. RESULTS Nineteen eyes of 13 patients treated with standard cross-linking returned for a 10-year follow-up examination. Mean maximum keratometry changed from 58.2±12.0 diopters (D) to 58.3±10.1 D, thinnest pachymetry changed from 440.6±51.6 µm to 442.3±54.4 μm, UCVA changed from 0.79±0.42 LL to 0.86±0.46 LL, and BSCVA changed from 0.38±0.26 LL to 0.33±0.34 LL, 10 years after cross-linking. Individually, 68.5% of the entire cohort, 81.8% of keratoconus eyes, and 50% of eyes with corneal ectasia remained topographically stable 10 years after standard cross-linking. CONCLUSIONS In the entire cohort, visual acuity and topography remained stable 10 years after cross-linking. Over the long-term, eyes with keratoconus seem to be more stable than those with corneal ectasia.
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Affiliation(s)
- Steven A Greenstein
- Cornea and Laser Eye Institute (S.A.G., A.S.Y., J.D.G., S.H., P.S.H.); CLEI Center for Keratoconus, Teaneck, NJ; and Department of Ophthalmology (S.A.G., J.D.G., P.S.H.), Rutgers New Jersey Medical School, Newark, NJ
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Greenstein SA, Yu AS, Wawrzusin P, Ando A, Chung D, Garvey N, Su B, Hersh PS, Gelles JD. Correlation of Manifest Refraction and Simulated Keratometry to Tomography Characteristics in Patients With Keratoconus. Eye Contact Lens 2023; 49:428-432. [PMID: 37638876 DOI: 10.1097/icl.0000000000001024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVES To report on baseline refractive and keratometric values and their correlation with tomographic characteristics of eyes with keratoconus (KC). METHODS Retrospective chart review of patients treated in a single-center cornea and refractive surgery practice. Baseline topographic measurements were reviewed for 1,012 keratoconic eyes of 586 patients between 2008 and 2018. The manifest refraction, thinnest pachymetry (P thin ), corneal astigmatism (K astig ), and the maximum (K max ), steep (K steep ), flat (K flat ), and mean (K mean ) keratometry were analyzed. The location of K max (x, y) was used to determine central (<1 mm), paracentral (1-3 mm), pericentral (3-5 mm), or peripheral (>5 mm) cone locations. RESULTS In the entire cohort, the mean manifest sphere was -2.2±4.4 diopters (D) and the cylinder was -3.2±2.3 D. In total, 48.6% of patients had against the rule (ATR) manifest astigmatism (M astig ). The average K astig was 3.8±2.7 D, and unlike the manifest axis, 50.2% of patients had with the rule (WTR) K astig . Patients with a K max less than 50 D had an M astig of -1.9±1.6 D, 45.9% of which was ATR M astig . With respect to baseline tomography measurements, K max , K steep , K flat , and K mean were 58.0±9.4, 50.6±6.5, 46.8±5.9, and 48.6±6.1 D, respectively. There was a weak correlation between K max and simulated keratometry (K steep , K flat , and K mean ) for patients with a K max less than 60 D. CONCLUSIONS Simulated keratometry is poorly correlated with KC severity until the disease is more severe. M astig ≥2 D and ATR M astig were correlated with KC at all levels of severity. M astig ≥2 D and ATR M astig may serve as a simple, inexpensive, and widely available indicator for topographic analysis to identify possible KC and suggest further workup; however, further prospective studies are needed to confirm its utility.
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Affiliation(s)
- Steven A Greenstein
- Cornea and Laser Eye Institute (S.A.G., A.S.Y., A.A., D.C., N.G., B.S., P.S.H., J.D.G.) Teaneck, NJ; and Department of Ophthalmology (S.A.G., P.W., P.S.H., J.D.G.), Rutgers New Jersey Medical School, Newark, NJ
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Moscovici BK, Rodrigues PF, Dantas MPS, Okimoto JT, Naves OS, Taguchi FMDC, Malta JBNS, Campos M. Ten-year follow-up of corneal cross-linking and refractive surface ablation in patients with asymmetric corneal topography. Indian J Ophthalmol 2023; 71:3210-3218. [PMID: 37602610 PMCID: PMC10565913 DOI: 10.4103/ijo.ijo_2557_22] [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: 10/03/2022] [Revised: 04/11/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023] Open
Abstract
Purpose Compare the safety and efficacy of wavefront-guided photorefractive keratotomy (PRK) 6 months after cross-linking (CXL) to wavefront-guided PRK alone for refractive correction in patients with bilateral asymmetric corneal topography. Methods Prospective randomized clinical trial with 16 patients (32 eyes). CXL with subsequent PRK after 6 months in one eye, and PRK alone was performed in contralateral eyes. The follow-up was 10 years. We analyzed visual outcomes, Scheimpflug topography, and corneal haze evaluation. Results Eyes in the PRK group showed better results than in the CXL + PRK group. Mean postoperative CDVA was 0.044 logmar (SD, 0.073) in the PRK group and 0.1 logmar (SD, 0.21) in the CXL + PRK group, the mean sphere was + 0.21 (SD, 0.6) D in the PRK group and 0.87 (SD, 2.3) D in the CXL + PRK group, and mean SE was -0.35 (SD, 0.65) D in the PRK group and 0.62 (SD, 2.32) D in the CXL + PRK group. In one patient, a steepening of 2.5 D and a thinning of 17 μm occurred in PRK alone group. Two patients in the CXL + PRK group presented corneal haze. The overall complication rate was 18,75% (haze and ectasia). Conclusion Non-simultaneous CXL and PRK procedures yielded good refractive results, but worse than those obtained with PRK alone. Although one patient in the PRK group developed corneal ectasia, the CXL + PRK group had a higher loss of vision lines, indicating less safety.
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Affiliation(s)
- Bernardo Kaplan Moscovici
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo, Brazil
| | - Pablo Felipe Rodrigues
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo, Brazil
| | - Marcos Paulo Suehiro Dantas
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo, Brazil
| | - Juliana Taemy Okimoto
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo, Brazil
| | - Obidulho Sakassegawa Naves
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo, Brazil
| | - Felipe Marques de Carvalho Taguchi
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo, Brazil
| | - João Baptista Nigro Santiago Malta
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo, Brazil
| | - Mauro Campos
- Department of Ophthalmology and Visual Sciences, Paulista School of Medicine/Federal University of São Paulo (EPM/UNIFESP), São Paulo, Brazil
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Greenstein SA, Yu AS, Gelles JD, Eshraghi H, Hersh PS. Corneal tissue addition keratoplasty: new intrastromal inlay procedure for keratoconus using femtosecond laser-shaped preserved corneal tissue. J Cataract Refract Surg 2023; 49:740-746. [PMID: 36943309 DOI: 10.1097/j.jcrs.0000000000001187] [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: 02/01/2023] [Accepted: 03/15/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE To report results of Corneal Tissue Addition Keratoplasty (CTAK) for keratoconus (KC) and ectasia after laser in situ keratomileusis. SETTING Cornea and refractive surgery practice. DESIGN Single center, prospective, open label clinical trial. METHODS 21 eyes of 18 patients underwent CTAK. A tissue inlay of preserved corneal tissue was cut to customized specifications with a femtosecond laser and placed in a laser-created channel in the host cornea. Postoperative uncorrected and corrected distance visual acuity (UDVA, CDVA), manifest refraction spherical equivalent (MRSE), topographic mean keratometry (Kmean), maximum keratometry (Kmax), and the point of maximum flattening (Kmaxflat) were measured. RESULTS Average UDVA improved from 1.21 ± 0.35 logMAR lines (LL) (20/327) to 0.61 ± 0.25 LL (20/82) ( P < .001). Average CDVA improved from 0.62 ± 0.33 LL (20/82) to 0.34 ± 0.21 LL (20/43) ( P = .002), and average MRSE improved from -6.25 ± 5.45 diopters (D) to -1.61 ± 3.33 D ( P = .002). Individually, 20 eyes (95.2%) gained more than 2 lines of UDVA, with 10 eyes (47.6%) gaining more than 6 lines, and no eyes worsening. 12 eyes (57.1%) gained at least 2 lines of CDVA, with 1 eye worsening by more than 2 lines. At 6 months, average Kmean flattened by -8.44 D ( P = .002), Kmax flattened by -6.91 D ( P = .096), and mean Kmaxflat was -16.03 D. CONCLUSIONS CTAK is a promising procedure to improve visual acuity and topography in patients with KC and ectasia.
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Affiliation(s)
- Steven A Greenstein
- From the Cornea and Laser Eye Institute, CLEI Center for Keratoconus, Teaneck, New Jersey (Greenstein, Yu, Gelles, Hersh); Department of Ophthalmology, Rutgers New Jersey Medical School, Newark, New Jersey (Greenstein, Gelles, Eshraghi, Hersh)
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Wagner FM, Sekundo W. Iatrogenic Keratectasia after Refractive Surgery - Causes, Prophylaxis, Therapy. Klin Monbl Augenheilkd 2023; 240:783-794. [PMID: 37348513 DOI: 10.1055/a-2073-8478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Iatrogenic keratectasia is induced thinning and protrusion of the cornea after laser refractive surgery. Known risk factors include an excessively thin postoperative residual stromal bed, a thicker flap, or preoperatively undetected evidence of preexisting subclinical keratoconus. The rate of post-refractive ectasia in eyes without identifiable preoperative risk factors is 20 per 100 000 eyes for photorefractive keratectomy, 90 per 100 000 eyes for laser in situ keratomileusis, and 11 per 100 000 eyes for small incision lenticule extraction. Traditional screening tools for preoperative risk include the ectasia risk score system and percentage of tissue alteration. More recent methods include corneal elastography and epithelial mapping, in addition to Artificial Intelligence methods for data analysis. Therapy includes contact lenses, cross-linking, implantation of intracorneal ring segments, penetrating or lamellar keratoplasty, and, in early studies, implantation of corneal lenticules.
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Affiliation(s)
- Felix Mathias Wagner
- Universitätsaugenklinik Mainz, Mainz, Deutschland
- Universitätsaugenklinik Marburg, Marburg, Deutschland
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Margines JB, Rabinowitz YS, Li X, Gaster RN. Results of Corneal Collagen Cross-Linking in Patients with Corneal Ectasia after Laser Refractive Surgery - A Prospective Study. Photodiagnosis Photodyn Ther 2023; 42:103521. [PMID: 36931367 DOI: 10.1016/j.pdpdt.2023.103521] [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: 12/06/2022] [Revised: 02/24/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023]
Abstract
PURPOSE To evaluate the safety and efficacy of epithelium-off (epi-off) corneal cross-linking (CXL) in patients with post-LASIK corneal ectasia (PLE) SETTING: Private clinical practice DESIGN: Prospective clinical trial METHODS: 82 eyes of adult patients post-LASIK, ages 21-67, with a topography pattern consistent with corneal ectasia, corrected distance visual acuity (CDVA) worse than 20/20, and minimum corneal pachymetry > 400 µm underwent epi-off CXL. Exclusion criteria were patients with corneas that were thinner than 400 μm or demonstrated central corneal scarring, history of herpetic eye disease, pregnancy or nursing. Follow up examinations of spherical equivalent, uncorrected distance visual acuity (UDVA), CDVA, steep keratometry (KSteep) and minimum pachymetry occurred on different but highly overlapping subsets of the operated eyes yearly until 5 years post-CXL. RESULTS Over the 5 years of follow up, spherical equivalent did not significantly change while UCVA and CDVA stabilized or improved to a non-significant degree. KSteep and minimum pachymetry continued to be decreased to a statistically significant degree (p < 0.05 at 5 years). CONCLUSIONS CXL in PLE patients is safe and efficacious: it halts progression of PLE and may improve visual function. KSteep and minimum pachymetry decrease post-CXL. Patients with PLE should be encouraged to stop progression of the disease by undergoing epi-off CXL once progression is established.
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Affiliation(s)
| | | | - Xiaohui Li
- Institute for Translational Genomics and Population Sciences, The Lundquist Institute for Biomedical Innovation, and Department of Pediatrics at Harbor-UCLA Medical Center, Torrance, CA, USA
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Stein R, Ong Tone S, Lebovic G, Singal N, Hatch W. Subjective and objective evaluation of corneal haze after accelerated corneal crosslinking for corneal ectasias. Acta Ophthalmol 2023. [PMID: 36707973 DOI: 10.1111/aos.15639] [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: 04/20/2022] [Revised: 12/12/2022] [Accepted: 01/08/2023] [Indexed: 01/29/2023]
Abstract
PURPOSE To evaluate the relationship between subjective (slit lamp examination [SLE]) and objective (densitometry) measurements of corneal haze after accelerated corneal crosslinking (aCXL), assess the relationship between densitometry and corrected distance visual acuity (CDVA), and determine the effect of baseline characteristics on densitometry after aCXL in eyes with progressive keratoconus and other ectasias. SETTING Kensington Eye Institute and Bochner Eye Institute, Toronto, Canada. DESIGN Retrospective analysis of a prospective interventional cohort study. METHODS Scheimpflug-derived corneal densitometry, CDVA, maximum keratometry (Kmax ), and central corneal thickness were measured preoperatively and up to 1 year after aCXL, and post-operative haze was estimated with SLE (n = 483 eyes). A random effect model was used to examine the relationship between post-operative subjective haze with SLE and densitometry. Linear mixed models were used to examine the relationship between densitometry, pre-operative baseline characteristics, and CDVA. RESULTS There was a significant association between subjective haze with SLE and densitometry (p < 0.001). There was a significant relationship between CDVA and densitometry: for every 10 GSUs of increased densitometry in the 0-2 mm zone, CDVA worsened by approximately half a Snellen line (p < 0.001). Age and pre-operative Kmax were significant predictors of densitometry. For every 10 years of age, densitometry increased by 0.68 GSUs (95% CI [0.27 to 1.07], p < 0.001). For every 10 D of increased preoperative Kmax , densitometry increased by 0.69 GSUs (95% CI [0.41 to 0.98], p < 0.001). CONCLUSIONS Subjective haze after aCXL estimated with SLE, is significantly associated with densitometry. Increased densitometry after aCXL is associated with a reduction in CDVA.
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Affiliation(s)
- Rebecca Stein
- Kensington Eye Institute, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Stephan Ong Tone
- Kensington Eye Institute, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Kensington Crosslinking Working Group, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Neera Singal
- Kensington Eye Institute, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada.,Kensington Crosslinking Working Group, Toronto, Ontario, Canada
| | - Wendy Hatch
- Kensington Eye Institute, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
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Ferdi AC, Kandel H, Nguyen V, Tan J, Arnalich-Montiel F, Abbondanza M, Watson SL. Five-year corneal cross-linking outcomes: A Save Sight Keratoconus Registry Study. Clin Exp Ophthalmol 2023; 51:9-18. [PMID: 36240047 PMCID: PMC10091974 DOI: 10.1111/ceo.14177] [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: 03/24/2022] [Revised: 09/18/2022] [Accepted: 10/07/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND We aimed to determine the long-term outcomes of epithelium-off cross-linking (CXL) in keratoconus patients. METHODS An observational registry study from 41 centres across 5 countries was carried out. Primary outcomes included the mean change in visual acuity (VA), Kmax, K2, and thinnest corneal thickness (TCT) at 1-5 years. Secondary outcomes included the percentage of eyes with worsening, stable and improving outcomes. RESULTS There were 976 eyes of 794 patients with 1-year of complete follow-up, 501 eyes with 2-years, 355 with 3-years, 235 with 4-years and 162 with 5-years. There was a significant improvement in mean VA from baseline by 3.7 logMAR letters (p < 0.001) in year 1, and 6.9 (p < 0.001) in year 5. Mean Kmax decreased by 1.2 dioptres (D; p < 0.01) in year 1. During subsequent years the Kmax flattening appeared sustained but this was not statistically significant. K2 flattened significantly from baseline in year 1 and then remained stable. At 1 year, 4.1% patients were poor responders to CXL in terms of VA, losing ≥15 letters. The proportion of the poor responders remained unchanged: 4.9% at 5-years. The proportion of poor responders in terms of Kmax remained similar: 5.9% steepening by ≥2D at 1-year and 7.5% at 5-years. The proportion of K2 poor responders remained stable with 4.7% steepening by ≥2D at 1-year and 5.8% at 5-years. CONCLUSIONS Cross-linking is effective at stabilising keratoconus up to 5 years in most patients. However, a small proportion of eyes failed to stabilise and had reduced vision.
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Affiliation(s)
- Alex C Ferdi
- Specialty of Clinical Ophthalmology and Eye Health, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Himal Kandel
- Specialty of Clinical Ophthalmology and Eye Health, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Vuong Nguyen
- Specialty of Clinical Ophthalmology and Eye Health, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Jeremy Tan
- Specialty of Clinical Ophthalmology and Eye Health, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | | | | | - Stephanie L Watson
- Specialty of Clinical Ophthalmology and Eye Health, Sydney Medical School, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
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Nieuwsma A, Vander Zee BL, Berdahl JP, Ibach M, Ferguson TJ, Terveen D. Evaluating the safety and efficacy of epi-off corneal cross-linking in patients with thin corneas due to keratectasia. Ther Adv Ophthalmol 2023; 15:25158414231197064. [PMID: 37720204 PMCID: PMC10504847 DOI: 10.1177/25158414231197064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/07/2023] [Indexed: 09/19/2023] Open
Abstract
Background Corneal cross-linking (CXL) is a safe and effective procedure for slowing keratectasia progression in eyes with a corneal thickness of at least 400 µm. Limited research has evaluated the safety and efficacy of epi-off CXL in corneas thinner than 400 µm. Objective To evaluate the safety and efficacy of CXL to slow keratectasia progression in eyes with <400 µm preoperative corneal thickness. Design Retrospective chart review. Methods This retrospective chart review included 37 eyes who underwent epi-off, iso-osmolar riboflavin corneal CXL with a preoperative thinnest point of the cornea <400 µm and had at least 6-12 months of follow-up. Preoperative and postoperative uncorrected visual acuity, best-corrected visual acuity (BCVA), thinnest point of the cornea, flat keratometry, steep keratometry, maximum keratometry (Kmax), need for penetrating keratoplasty, and cases of endothelial failure were recorded. Data were collected at baseline and months 3, 6, 9, and 12 post-CXL. Results Following cross-linking, 18 eyes (47%) had improved BCVA, 13 (35%) had an unchanged BCVA, and 6 eyes (16%) had a worse BCVA (p = 0.05). The mean postoperative BCVA was 20/81 (0.61 LogMAR) compared to 20/121 (0.78 LogMAR) preoperatively (p = 0.06). Kmax decreased an average of 1.1 D at 3-month (p = 0.53) and 3.4 D at the furthest follow-up (p = 0.10). At the farthest follow-up, 22.7% of eyes had >1 D of Kmax steepening. No patients required keratoplasty and there were no cases of endothelial failure in the follow-up period. Conclusion This research supports the safety and efficacy of epi-off, iso-osmolar CXL in eyes with <400 μm baseline corneal thickness with no patients requiring penetrating or endothelial keratoplasty, a trend toward improvement in BCVA, and Kmax flattening. In the future, prospective studies would be helpful to confirm these findings.
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Affiliation(s)
- Abigail Nieuwsma
- University of Texas Health, San Antonio, TX, USA
- University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Brandon L. Vander Zee
- University of South Dakota Sanford School of Medicine, 3140 Limekiln Avenue, Madison, WI, 53719, USA
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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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Cronin B, Ghosh A, Chang CY. Oxygen-supplemented transepithelial-accelerated corneal crosslinking with pulsed irradiation for progressive keratoconus: 1 year outcomes. J Cataract Refract Surg 2022; 48:1175-1182. [PMID: 35383648 DOI: 10.1097/j.jcrs.0000000000000952] [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: 10/13/2021] [Accepted: 03/29/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the effects of combining oxygen supplementation with enhanced UV-A light and increased riboflavin permeability in improving the efficacy of epithelium-on crosslinking (epi-on CXL). SETTING Private eye clinic in Brisbane, Queensland, Australia. DESIGN Retrospective single-center nonrandomized uncontrolled longitudinal cohort case series. METHODS Transepithelial CXL was performed on keratoconic eyes. Applications of an oxygen goggle and pulsed UV-A irradiation (1 second on, 1 second off) were used to enhance oxygen kinetics during epi-on CXL. Additional procedural modifications included the use of benzalkonium chloride and high UV-A irradiance level (30 mW/cm 2 ) to improve the stromal bioavailability of riboflavin and UV-A. The main efficacy outcomes were the changes in mean corrected distance visual acuity (CDVA) and safety over 12 months. Additional refractive and keratometry (K) outcomes were also observed. RESULTS 53 eyes (38 patients) were included in this study. 12 months postoperatively, mean CDVA improved from a mean of 0.18 ± 0.2 at baseline to 0.07 ± 0.1 logMAR ( P < .0001). No statistically significant change was observed in maximum K (Kmax) and mean K, which were respectively 51.7 ± 5.8 diopters (D) and 46.4 ± 3.85 D at baseline and 51.2 ± 5.7 D ( P = .152) and 46.0 ± 3.84 D ( P = .06) 12 months postoperatively. Only 3 eyes experienced an increase of more than 2 D in Kmax; however, none of these eyes experienced a CDVA loss. There were no reported infections, corneal scarring, or other severe adverse effects. CONCLUSIONS Performing supplemental oxygen epi-on CXL with accelerated, pulsed UV-A irradiation in conjunction with riboflavin permeability enhancers resulted in improved CDVA ( P < .0001) and stable keratometry up to 12 months postoperatively with a good safety profile.
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Affiliation(s)
- Brendan Cronin
- From the Queensland Eye Institute, Brisbane, Queensland, Australia (Cronin, Ghosh); Glaukos Corp., Medical Affairs, Burlington, Massachusetts (Chang); Wills Eye Hospital, Cornea Service, Philadelphia, Pennsylvania (Chang)
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Wallerstein A, Gauvin M, Rocha G, Sison R, Korban S, Cohen M. Three-Year Outcomes of Under-flap Stromal Bed CXL for Early Post-LASIK Ectasia. J Refract Surg 2022; 38:511-519. [PMID: 35946998 DOI: 10.3928/1081597x-20220713-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To investigate the 36-month clinical outcomes of under-flap stromal bed CXL (ufCXL) and report on its ability to stabilize post-laser in situ keratomileusis (LASIK) ectasia. METHODS This case series included 20 eyes with diagnosed early post-LASIK ectasia treated with ufCXL. Inclusion criteria were early, mild post-LASIK ectasia, defined as new-onset postoperative manifest refraction cylinder of 1.50 diopters (D) or less, with new topographic inferior steepening consistent with ectasia, uncorrected distance visual acuity of 20/40 or better, and corrected distance visual acuity of 20/25 or better. The existing LASIK flap was lifted, 0.25% isotonic riboflavin was applied directly to the stromal bed, the flap was repositioned, and 18 mW/cm2 ultraviolet light was applied for 5 minutes to the corneal flap surface. Post-ufCXL ophthalmic data were compared to pre-ufCXL baseline measurements. RESULTS Visual outcomes were maintained pre-ufCXL to 36 months post-ufCXL, with preserved safety index (P = .6545), efficacy index (P = .4980), spherical equivalent accuracy (P = .1536), defocus equivalent accuracy (P = .1032), central corneal thickness (P = .5196), and corneal irregularity indices at 3 mm (P = .8548) and 5 mm (P = .3399). Refractive astigmatism significantly decreased from 0.83 to 0.55 D pre-ufCXL to post-ufCXL (P = .0439), as did maximum keratometry from 42.40 to 42.00 D pre-ufCXL to post-ufCXL (P = .0420). The ufCXL demarcation line depth was 336 ± 21 µm post-ufCXL, with normal endothelial cell density (2,574 ± 203 cells/mm2). Only 1 of 20 eyes showed evidence of progression of 1.00 D in maximum keratometry. CONCLUSIONS The ufCXL procedure shows promise in stabilizing early post-LASIK ectasia. Visual function, refractive astigmatism, maximum keratometry, and corneal irregularity indices were statistically maintained at 36 months postoperatively. [J Refract Surg. 2022;38(8):511-519.].
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Effects of Corneal Stromal Lens Collagen Cross-Linking Regraft on Corneal Biomechanics. J Ophthalmol 2022; 2022:8372156. [PMID: 35721228 PMCID: PMC9200565 DOI: 10.1155/2022/8372156] [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: 02/16/2022] [Revised: 04/08/2022] [Accepted: 05/27/2022] [Indexed: 11/18/2022] Open
Abstract
Background Corneal collagen cross-linking (CXL) therapy, a method that uses a combination of riboflavin and ultraviolet-A light (UVA), can promote the formation of covalent cross-linking of amino acid residues of corneal collagen and enhance the hardness of the cornea. In this study, we explored the effects of corneal stromal lens collagen cross-linking regraft on corneal biomechanics. Methods A total of 15 New Zealand white rabbits were divided into 3 groups: normal control group (group A), SMILE + uncross-linked lens implantation group (Group B), and SMILE + cross-linking lens implantation group (group C). The design parameters of SMILE surgery were as follows: the corneal cap was 120 um thick, the lens diameter was 6.5 mm, and the diopter was -6.0D. Riboflavin and ultraviolet-A (UVA) were used as corneal stromal lens CXL, which was implanted into the allogeneic rabbit corneal stromal bag 24 hours after the operation. Postoperative corneal thickness (CCT), refraction, AS-OCT, and corneal biomechanics were performed before and then at 1 and 3 months after the operation. Results All corneas appeared transparent and smooth 3 months after surgery. The corneal thicknesses of both group B and group C were lower than those before the operation. The corrected refraction of group B and group C after lens implantation was also lower than the expected corrected power; there was no significant difference between the two groups (P > 0.05). AS-OCT results showed an uneven surface and thickness of the corneal stromal lens in two eyes of group B. Moreover, corneal elastic deformation increased with intraocular pressure in each group; displacement from large to small was group B > group C and > group A. The creep from large to small was group B > group C > group A. The fiberboard layers of groups B and C were disordered, and there were a few autophagosomes in the fibroblasts of group B by transmission electron microscopy (TEM). Conclusions Allograft graft of corneal stromal lens collagen cross-linked can significantly increase the biomechanical properties of the cornea.
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Nasef MH, El Emam SY, Haleem TI, Shalaby WS, Allam WA. Visual and Topographic Outcomes of Corneal Collagen Cross Linking for Post LASIK Ectasia. Clin Ophthalmol 2022; 16:2025-2032. [PMID: 35757019 PMCID: PMC9231688 DOI: 10.2147/opth.s370033] [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: 04/12/2022] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the topographic and visual outcomes of corneal cross-linking (CXL) for post-LASIK ectasia. Methods A retrospective case series of patients who had progressive post-LASIK ectasia, with at least 2 years of follow-up. They had epithelium-off CXL. Topographical and visual changes were recorded. Results The study included 21 eyes of 11 patients. At month 24, the final logMAR corrected distance visual acuity (CDVA) and spherical equivalent (SE) were stable compared to baseline (0.16, and −2.0 diopter (D), respectively). The final Kmean and Kmax were 42.5 and 47.4 D, respectively. Stability or improvement in CDVA, SE, and Kmax was seen in 17 eyes (81%). Significant corneal thinning was seen (438 vs 457 microns, p = 0.003). Thinning by 2% or more was seen in 12 eyes (57.1%). Failure of CXL was seen in 4 eyes (19%). No other ocular complications were seen. Conclusion CXL for post LASIK ectasia is a safe and effective modality. Despite corneal thinning, there was stability or improvement in topographic parameters and CDVA over the 2-year follow-up period.
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Affiliation(s)
- Mohamed H Nasef
- Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, Gharbia, Egypt
- Correspondence: Mohamed H Nasef, Tanta University Ophthalmology Hospital, Tanta University Medical Campus, Al-Geish St, Tanta, Gharbia, 31527, Egypt, Tel +20 10 02826555, Email
| | - Sharif Y El Emam
- Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, Gharbia, Egypt
| | - Tamer I Haleem
- Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, Gharbia, Egypt
| | - Wesam S Shalaby
- Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, Gharbia, Egypt
| | - Waleed A Allam
- Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, Gharbia, Egypt
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Chanbour W, El Zein L, Younes MA, Issa M, Warhekar P, Chelala E, Jarade E. Corneal Cross-Linking for Keratoconus and Post-LASIK Ectasia and Failure Rate: A 3 Years Follow-Up Study. Cureus 2021; 13:e19552. [PMID: 34917434 PMCID: PMC8669145 DOI: 10.7759/cureus.19552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/13/2021] [Indexed: 11/05/2022] Open
Abstract
Purpose To report the response of keratoconus (KC) and post-LASIK ectasia (referred to as "ectasia") to the corneal crosslinking (CXL) and to compare the rate of progression between KC and ectasia at three years. Methods A retrospective cohort study of patients undergoing CXL for either KC or ectasia. Fifty-four eyes (31 patients) with ectasia and 111 eyes (67 patients) with KC were included in the study. Corrected distance visual acuities (CDVA), refraction, keratometry (K), and pachymetry were followed up for three years. Simultaneous photorefractive keratectomy (PRK) and CXL were performed on 20 KC and 20 ectasia eyes. Intrastromal Corneal Ring Segments (ICRS) were performed on 51 KC and six ectasia eyes. Results In KC, CDVA, spherical equivalence, sphere, cylinder, and mean K improved at three years post-CXL (p-value<0.05), but these values improved without reaching a statistical significance in ectasia(p-values <0.05). 12 of 54 eyes with ectasia (22.2%) and 4 of 111 eyes (3.6%) with KC had progression post CXL(p-value:0.0001). Ectasia patients diagnosed with progression were older at presentation (36.1 years) than non-progressive ectasia patients (31 years) (p-value 0.02) and also older than KC patients. Sub-analysis excluding PRK and ICRS cases showed that there was an improvement in mean sphere (from -5.23±4.2D to-4.46±3.89D) (p-value 0.03) cylinder (from 2.54 ± 1.68D to 1.97 ± 1.51D) (p-value 0.03) mean keratometry (from 46.81 ± 3.78D to 46.01 ± 3.25D) (p-value 0.006) in KC patients 3 years post CXL (40 patients). Compared to baseline, all the mean refractive and topographic variables deteriorated at three years post CXL in ectasia (28 patients) (p-value>0.05). Also, 2 of 40 patients with KC (5%) vs. 7 of 28 patients with ectasia (25%) had progression three years post-CXL, and the difference between both groups remained statistically significant(p-value 0.027). Conclusion Eyes with post-LASIK ectasia seem to be less responsive to CXL than KC.
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Affiliation(s)
- Wassef Chanbour
- Ophthalmology, Beth Israel Deaconess Medical Center (BIDMC), Boston, USA
| | - Lulwa El Zein
- Pediatric Ophthalmology, Bascom Palmer Eye Institute, Miami, USA
| | - Mohamad Ali Younes
- Internal Medicine, Faculty of Medical Sciences - Lebanese University, Hadath, LBN
| | - Mohamad Issa
- Ophthalmology, Hospital Foundation Adolphe De Rothschild, Paris, FRA
| | | | | | - Elias Jarade
- Ophthalmology, Beirut Eye & ENT Specialist Hospital, Beirut, LBN
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Kandel H, Nguyen V, Ferdi AC, Gupta A, Abbondanza M, Sullivan L, Apel A, Watson SL. Comparative Efficacy and Safety of Standard Versus Accelerated Corneal Crosslinking for Keratoconus: 1-Year Outcomes From the Save Sight Keratoconus Registry Study. Cornea 2021; 40:1581-1589. [PMID: 33935236 DOI: 10.1097/ico.0000000000002747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/04/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to compare the efficacy and safety of standard [Ultraviolet (UV) light power: 3 mW/cm2, duration: 30 minutes] versus accelerated (UV power: 9 mW/cm2, duration: 10 minutes) corneal crosslinking (CXL) for stabilizing keratoconus. METHODS A total of 684 eyes (555 patients; mean age ± SD, 25.0 ± 7.9 years; women, 30.6%) from 24 international sites with epithelium-off CXL for keratoconus had follow-up data at 1-year and met the inclusion criteria. Two hundred sixty-six eyes (228 patients) had undergone standard CXL, and 418 eyes (327 patients) had undergone accelerated CXL. The outcome measures included changes in visual acuity, keratometry, minimum corneal thickness, and frequency of adverse events. The outcomes were compared using mixed-effects regression models adjusted for age, sex, visual acuity, keratometry, pachymetry, doctor, practice, and eye laterality. RESULTS The adjusted mean changes (95% confidence interval) in outcomes were similar in standard and accelerated CXL in visual acuity [6.5 (2.0, 11.1) versus 5.5 (0.4, 10.6) logMAR letters, respectively], Kmax [-0.9 (-1.4, -0.3) D versus -1.2 (-1.9, -0.4) D, respectively], K2 [-0.4 (-0.9, 0.2) D versus -0.4 (-1.1, 0.3), D respectively], or minimum corneal thickness [-13.3 (-20.3, -6.3) μm versus -16.6 (-24.5, -8.6) μm, respectively] (all P > 0.05). The frequency of adverse events at the 12-month visit was also similar between the CXL groups (standard, 8.3% vs. accelerated, 5.5%; P = 0.21). CONCLUSIONS This real-world observational study found that both standard and accelerated CXL were similarly safe and effective in stabilizing keratoconus at 1-year postsurgery in the real-world setting. The findings support the adoption of accelerated CXL for time and convenience.
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Affiliation(s)
- Himal Kandel
- The University of Sydney, Faculty of Medicine and Health, Save Sight Institute, Sydney, NSW, Australia
| | - Vuong Nguyen
- The University of Sydney, Faculty of Medicine and Health, Save Sight Institute, Sydney, NSW, Australia
| | - Alex C Ferdi
- The University of Sydney, Faculty of Medicine and Health, Save Sight Institute, Sydney, NSW, Australia
| | - Aanchal Gupta
- Adelaide Eye & Laser Centre, Adelaide, SA, Australia
- South Australian Institute of Ophthalmology, Adelaide, SA, Australia
| | | | | | - Andrew Apel
- The Eye Health Centre, Brisbane, QLD, Australia
| | - Stephanie L Watson
- The University of Sydney, Faculty of Medicine and Health, Save Sight Institute, Sydney, NSW, Australia
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Screening of Keratoconus Using Autokeratometer and Keratometer Keratoconus Index. Diagnostics (Basel) 2021; 11:diagnostics11112120. [PMID: 34829466 PMCID: PMC8619968 DOI: 10.3390/diagnostics11112120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022] Open
Abstract
The keratometer keratoconus index (KKI) is a diagnostic index for the risk of keratoconus calculated from autokeratometer test values. We partially modified the KKI equation and assessed it without limiting the target age and severity of keratoconus. This retrospective study included 179 eyes of 99 patients with keratoconus and 468 eyes from 235 normal controls. In the modified KKI, oblique astigmatism or against-the-rule astigmatism was defined as ≥1D astigmatism. KKI diagnostic power was analyzed in subgroups of <50 and ≥50-year-old patients, and at different keratoconus stages. Although the sensitivity of modified KKI was comparable with that of original KKI (92.7% vs. 95.5%), modified KKI specificity was significantly higher (79.7% vs. 68.6%) (p = 0.0001). Using the modified KKI, sensitivity reached 100% (4/4) and specificity, 63.5% (33/52), in ≥50-year-old patients, while overall sensitivity in keratoconus ≥stage 2 was 100% (30/30). In conclusion, the modified KKI proved to be effective in keratoconus screening at all stages. However, it should be noted that false-positive frequency is higher in ≥50-year-old patients.
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Adverse events after riboflavin/UV-A corneal cross-linking: a literature review. Int Ophthalmol 2021; 42:337-348. [PMID: 34448966 DOI: 10.1007/s10792-021-02019-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Riboflavin/UV-A corneal cross-linking (CXL) for treating keratoconus and iatrogenic corneal ectasia has been well-established as first treatment option to stabilize corneal tissue biomechanical instability. Although the plethora of clinical studies has been published into the field, there is no systematic review assessing the type and frequency of adverse events after CXL. METHODS A systemic literature review on clinical safety and adverse events after CXL in patients with keratoconus and corneal ectasia was performed using PubMed. A literature search was performed for relevant peer-reviewed publications. The main outcome measures extracted from the articles were adverse events, endothelial cell density, corrected distance visual acuity and maximum simulated keratometry. RESULTS The most frequent adverse events after CXL were corneal haze and corneal edema, which were mild and transient. The severe adverse events were infrequent (cumulative incidence: < 1.3%) after CXL. The clinical benefits of CXL highly outweighed the risks for the treatment of keratoconus and corneal ectasia. CONCLUSIONS The severe adverse events with permanent sequelae are infrequent after CXL and all are associated with corneal de-epithelialization, such as infectious keratitis and corneal scarring.
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Brillouin microscopic depth-dependent analysis of corneal crosslinking performed over or under the LASIK flap. J Cataract Refract Surg 2021; 46:1543-1547. [PMID: 33149067 DOI: 10.1097/j.jcrs.0000000000000294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the impact of corneal crosslinking (CXL) performed over the laser in situ keratomileusis (LASIK) flap using the Standard CXL (S-CXL) protocol or under the flap after flap lift (flap-CXL) on regional corneal stiffness using Brillouin microscopy. SETTING University of Southern California Keck School of Medicine, Los Angeles, California, and Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA. DESIGN Laboratory ex vivo experiment. METHODS After epithelium debridement, LASIK flaps were created on intact fresh porcine eyes with a mechanical microkeratome. Then, S-CXL (riboflavin applied to the corneal surface followed by 3 mW/cm ultraviolet exposure with the flap in place for 30 minutes) or flap-CXL (riboflavin applied to the stromal bed after reflecting the flap followed by the same ultraviolet A exposure with the flap replaced) was performed. Depth profile of stiffness variation and averaged elastic modulus of anterior, middle, and posterior stroma were determined by analyzing Brillouin maps. Each eye served as its own control. RESULTS The study was performed on 24 fresh porcine eyes. S-CXL had maximal stiffening impact in the anterior most corneal stroma within the LASIK flap (8.40 ± 0.04 GHz), whereas flap-CXL had lower maximal stiffening impact (8.22 ± 0.03 GHz) (P < .001) that occurred 249 ± 34 μm under the corneal surface. S-CXL increased longitudinal modulus by 6.69% (anterior), 0.48% (middle), and -0.91% (posterior) as compared with flap-CXL, which increased longitudinal modulus by 3.43% (anterior, P < .001), 1.23% (middle, P < .1), and -0.78% (posterior, P = .68). CONCLUSIONS The S-CXL technique generated significantly greater stiffening effect in the anterior cornea than a modified protocol with riboflavin administration under the flap (flap-CXL). Minimal stiffening occurred in the middle or posterior cornea with either protocol.
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25
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Comparison of pulsed and continuous accelerated corneal crosslinking for keratoconus: 1-year results at a single center. J Cataract Refract Surg 2021; 47:641-648. [PMID: 33196569 DOI: 10.1097/j.jcrs.0000000000000488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 10/11/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the clinical outcomes between pulsed and continuous accelerated crosslinking (CXL) for keratoconus. SETTING Hospital. DESIGN Retrospective comparison study. METHODS Korean patients who were treated for keratoconus between September 2015 and January 2018 at Seoul St. Mary's Hospital were included. Eyes were subjected to pulsed accelerated crosslinking (30 mW/cm2 for 8 minutes, 1 second on/1 second off) or continuous accelerated crosslinking (30 mW/cm2 for 4 minutes; delivering 7.2 J/cm2). Outcomes were evaluated after 1 year. RESULTS At 1 year, the 2 groups did not exhibit changes in their corrected and uncorrected distance visual acuity values. The pulsed group (25 eyes in 25 patients) exhibited significantly improved values for sphere (P = .009) and spherical equivalent (P = .033), although no statistically significant difference was observed in the continuous group (20 eyes in 20 patients). All keratometry (k)values (SimKf, SimKs, SimKmean, and Kmax) improved in both groups (all P < .05), although the pulsed group had significantly greater changes in the SimKmean value (P = .036) and the Kmax value (P = .03). Both groups had significantly decreased central and thinnest corneal thicknesses (all P < .001), although the pulsed group had a substantially lower thinnest corneal thickness (P = .017). Corneal densitometry measured using the Pentacam device increased in both groups (all P < .001), with a higher densitometry value in the pulsed group (P = .013). Furthermore, the depth of the demarcation line was deeper in the pulsed group (P = .015). CONCLUSIONS Pulsed accelerated crosslinking might provide better postcrosslinking effects than continuous accelerated crosslinking.
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Beckman KA. Epithelium-on Corneal Collagen Cross-Linking with Hypotonic Riboflavin Solution in Progressive Keratoconus. Clin Ophthalmol 2021; 15:2921-2932. [PMID: 34262252 PMCID: PMC8273905 DOI: 10.2147/opth.s318317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/09/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Epithelium-off cross-linking (epi-off CXL) has long been established as the gold standard treatment for progressive keratoconus. Several protocols for epithelium-on (epi-on) CXL have been proposed to help reduce post-operative pain and facilitate visual recovery, but there is no epi-on treatment approach that is currently approved in the United States. The hydrophilic and macromolecular characteristics of conventional epi-off riboflavin formulations may create clinical challenges for absorption through an intact epithelium. This study investigates the clinical efficacy of a dextran-free hypotonic riboflavin ophthalmic solution (Photrexa, Glaukos, Burlington, MA, USA), approved for epi-off CXL, in a novel epi-on CXL protocol. Methods Twenty-five eyes of 17 patients were treated in this prospective, single-arm study using a hypotonic riboflavin formulation without dextran and low irradiance UVA (3mW/cm2) for epi-on CXL. Visual acuity, as well as refractive and keratometry outcomes, were observed over 12 months. Results At 12 months, Kmax was stable with no clinically or statistically significant change from a mean pre-op of 55.4D to 55.9D (p=0.13). Uncorrected and best corrected logMAR visual acuity significantly improved from 0.77 to 0.62 and from 0.17 to 0.12, respectively. There were no significant adverse safety events. Conclusion Patients who underwent epi-on CXL with dextran-free hypotonic riboflavin demonstrated improvements in uncorrected and best corrected visual acuity with stable keratometry at 12 months post-operatively. The efficacy is consistent with other epi-on studies to date but remains lower than standard epi-off CXL. New technologies, including supplemental oxygen and transepithelial riboflavin ophthalmic solutions, are currently under clinical evaluation and may offer a path forward for epi-on CXL in the USA.
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Affiliation(s)
- Kenneth A Beckman
- Comprehensive EyeCare of Central Ohio, Westerville, OH, USA.,The Ohio State University, Columbus, OH, USA
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Vasilikos I, Teixeira GQ, Seitz A, Nothelfer J, Haas J, Wilke HJ, Mizaikoff B, Beck J, Hubbe U, Neidlinger-Wilke C. Can UVA-light-activated riboflavin-induced collagen crosslinking be transferred from ophthalmology to spine surgery? A feasibility study on bovine intervertebral disc. PLoS One 2021; 16:e0252672. [PMID: 34081754 PMCID: PMC8174733 DOI: 10.1371/journal.pone.0252672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/19/2021] [Indexed: 11/19/2022] Open
Abstract
Background Collagen cross-links contribute to the mechanical resilience of the intervertebral disc (IVD). UVA-light-activated riboflavin-induced collagen crosslinking (UVA-CXL) is a well-established and effective ophthalmological intervention that increases the mechanical rigidity of the collagen-rich corneal matrix in Keratoconus. This study explores the feasibility, safety and efficacy of translating this intervention in reinforcing the IVD. Methods Annulus fibrosus (AF) cells were isolated from bovine IVDs and treated with different combinations of riboflavin (RF) concentrations (0.05–8 mM) and UVA light intensities (0.3–4 mW/cm2). Metabolic activity (resazurin assay), cell viability (TUNEL assay), and gene expression of apoptosis regulators C-FOS and PT5 were assessed immediately and 24 hours after treatment. Biomechanical effects of UVA-CXL on IVDs were measured by indentation analysis of changes in the instantaneous modulus and by peel-force delamination strength analysis of the AF prior and after treatment. Results Different intensities of UVA did not impair the metabolic activity of AF cells. However, RF affected metabolic activity (p < 0.001). PT53 expression was similar in all RF conditions tested while C-FOS expression decreased 24 hours after treatment. Twenty-four hours after treatment, no apoptotic cells were observed in any condition tested. Biomechanical characterizations showed a significant increase in the annular peel strength of the UVA-CXL group, when compared to controls of UVA and RF alone (p < 0.05). UVA-CXL treated IVDs showed up to 152% higher (p < 0.001) instantaneous modulus values compared to the untreated control. Conclusion This is the first study on UVA-CXL treatment of IVD. It induced significantly increased delamination strength and instantaneous modulus indentation values in intact IVD samples in a structure–function relationship. RF concentrations and UVA intensities utilized in ophthalmological clinical protocols were well tolerated by the AF cells. Our findings suggest that UVA-CXL may be a promising tool to reinforce the IVD matrix.
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Affiliation(s)
- Ioannis Vasilikos
- Department of Neurosurgery, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
- Laboratory of Experimental Neurosurgery (LENS), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- * E-mail:
| | - Graciosa Q. Teixeira
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center, University of Ulm, Ulm, Germany
| | - Andreas Seitz
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center, University of Ulm, Ulm, Germany
| | - Julia Nothelfer
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center, University of Ulm, Ulm, Germany
| | - Julian Haas
- Institute of Analytical and Bioanalytical Chemistry, University of Ulm, Ulm, Germany
| | - Hans-Joachim Wilke
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center, University of Ulm, Ulm, Germany
| | - Boris Mizaikoff
- Institute of Analytical and Bioanalytical Chemistry, University of Ulm, Ulm, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
- Laboratory of Experimental Neurosurgery (LENS), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
- Laboratory of Experimental Neurosurgery (LENS), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Cornelia Neidlinger-Wilke
- Institute of Orthopaedic Research and Biomechanics, Trauma Research Center, University of Ulm, Ulm, Germany
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The Interday Repeatability of Parameters for the Assessment of Progressive Disease in Subjects With Less Advanced Keratoconus. Am J Ophthalmol 2021; 225:38-46. [PMID: 33422466 DOI: 10.1016/j.ajo.2020.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate the interday repeatability in the measurement of parameters used for the detection of progression of keratoconus by prediction limits (PL) for single measurements, and the repeatability coefficient (RC) for the mean of replicate measurements. DESIGN Prospective reliability analysis for cases and control eyes. METHODS Twenty-five eyes in 25 subjects with KC and 25 eyes in 25 healthy controls were included. Four consecutive measurements were made, 3 days apart, with a Pentacam HR tomographic instrument (denoted the Pentacam) and a Nidek ARK 560-A auto-keratometer (denoted the keratometer). Main outcome measures were the intra- and interday RC of parameters used in the detection of progression of keratoconus. RESULTS The most repeatable parameter obtained with the Pentacam was the curvature power of the central flat meridian (K1, 0.44 D [RC], -0.55 to 0.60 diopter [D] [PL]), followed by the central steep meridian (K2, 0.72 D [RC], -0.90 to 0.94 D [PL]). The interday repeatability of K1 and K2 was similar when using the keratometer (K1, 0.32 D [RC], -0.66 to 0.57 D [PL], K2, 0.93 D [RC], -1.36 to 1.08 D [PL]). The interday repeatability of the curvature power of the steepest point (Kmax, 0.84 D [RC], -0.90 to 1.11 D [PL]) would benefit from being stratified: RC = 0.44 D and PL = -0.49 to 0.67 D for Kmax < 49.0 D, and RC = 1.08 D and PL = -1.19 to 1.42 D for Kmax ≥ 49.0 D. CONCLUSIONS The interday repeatability of measurements, single or replicate, in subjects with keratoconus should be considered when diagnosing progressive disease. K1 exhibited the best intraday repeatability. Kmax benefits from being stratified according to disease severity.
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Mazzotta C, Raiskup F, Hafezi F, Torres-Netto EA, Armia Balamoun A, Giannaccare G, Bagaglia SA. Long term results of accelerated 9 mW corneal crosslinking for early progressive keratoconus: the Siena Eye-Cross Study 2. EYE AND VISION 2021; 8:16. [PMID: 33931101 PMCID: PMC8088009 DOI: 10.1186/s40662-021-00240-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 04/09/2021] [Indexed: 11/18/2022]
Abstract
Purpose To assess clinical results of the 9 mW/5.4 J/cm2 accelerated crosslinking (ACXL) in the treatment of progressive keratoconus (KC) over a span of 5 years. Methods The prospective open non-randomized interventional study (Siena Eye-Cross Study 2) included 156 eyes of 112 patients with early progressive KC undergoing the Epi-Off 9 mW/5.4 J/cm2 ACXL at the Siena Crosslinking Centre, Italy. The mean age was 18.05 ± 5.6 years. The 20-min treatments were performed using the New KXL I (Avedro, Waltham, USA), 10 min of 0.1% HPMC Riboflavin soaking (VibeX Rapid, Avedro, Waltham, USA) and 10 min of continuous-light UV-A irradiation. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), Kmax, coma, minimum corneal thickness (MCT), surface asymmetry index (SAI), endothelial cell count (ECC) were measured, and corneal OCT performed. Results UDVA and CDVA improved significantly at the 3rd (P = 0.028), Δ + 0.17 Snellen lines and 6th postoperative month, respectively (P < 0.001), Δ + 0.23 Snellen lines. Kmax improved at the 6th postoperative month (P = 0.03), Δ − 1.49 diopters from the baseline value. Also, coma aberration value improved significantly (P = 0.004). A mild temporary haze was recorded in 14.77% of patients without affecting visual acuity and without persistent complications. Corneal OCT revealed a mean demarcation line depth at 332.6 ± 33.6 μm. Conclusion The 5-year results of Epi-Off 9 mW/5.4 J/cm2 ACXL demonstrated statistically significant improvements in UCVA and CDVA, corneal curvature and corneal higher-order aberrations which confers a long-term stability for progressive ectasia. Based on the results of the Siena Eye-Cross Study 2, the 9 mW/5.4 J/cm2 ACXL is a candidate to be the natural evolution of Epi-Off CXL treatment for the management of early progressive corneal ectasia, and thus optimize clinic workflow.
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Affiliation(s)
- Cosimo Mazzotta
- Departmental Ophthalmology Unit, USL Toscana Sud-Est, Campostaggia, Siena, Italy. .,Siena Crosslinking Center, 53035, Monteriggioni, Siena, Italy.
| | - Frederik Raiskup
- Department of Ophthalmology, C.G. Carus University Hospital, Dresden, Germany
| | - Farhad Hafezi
- ELZA Institute, Dietikon, Switzerland.,Medical Faculty, University of Geneva, Geneva, Switzerland.,Roski Eye Institute, University of Southern California, Los Angeles, CA, USA.,Department of Ophthalmology, University of Wenzhou, Wenzhou, China
| | - Emilio A Torres-Netto
- ELZA Institute, Dietikon, Switzerland.,Medical Faculty, University of Geneva, Geneva, Switzerland.,Department of Ophthalmology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ashraf Armia Balamoun
- Ashraf Armia Eye Clinic and Al Watany Eye Hospital, Watany Research and Development Centre, Cairo, Egypt
| | - Giuseppe Giannaccare
- Department of Ophthalmology, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Simone Alex Bagaglia
- Departmental Ophthalmology Unit, USL Toscana Sud-Est, Campostaggia, Siena, Italy
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30
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Greenstein SA, Hersh PS. Corneal Crosslinking for Progressive Keratoconus and Corneal Ectasia: Summary of US Multicenter and Subgroup Clinical Trials. Transl Vis Sci Technol 2021; 10:13. [PMID: 34967830 PMCID: PMC8740531 DOI: 10.1167/tvst.10.5.13] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose The multicenter studies reviewed were designed to evaluate the safety and efficacy of corneal collagen crosslinking (CXL) for the treatment of progressive keratoconus and corneal ectasia after laser refractive surgery. The results of these studies led to approval by the United States Food and Drug Agency for both conditions in 2016. This paper reviews these studies, as well as single-center substudies investigating other aspects of crosslinking outcomes. Methods As part of prospective, randomized, controlled clinical trials, the treatment group received standard CXL, and the sham control group received only riboflavin ophthalmic solution. The primary efficacy criterion was maximum keratometry (Kmax) 1 year after CXL. Secondary outcomes were corrected distance visual acuity (CDVA) and uncorrected distance visual acuity (UDVA). Safety and adverse events were analyzed. In single-center substudies, corneal topography, ocular aberrations, corneal haze measurements, corneal thickness, corneal biomechanics, subjective visual function, and outcomes predictors were also investigated. This paper presents a general review of the design and outcomes of crosslinking in these studies. Results In the crosslinking treatment group, Kmax flattened by 1.6 diopters (D) and 0.7 D in eyes with keratoconus and ectasia, respectively. In both studies, there was continued progression in the control group. The CDVA improved by an average of 5.7 logMAR letters (LL) in the keratoconus treatment group and by 5.0 LL in the ectasia group. In both studies, corneal haze was the most frequently reported crosslinking-related adverse finding. This was most prominent at 1 month and generally returned to baseline between 3 and 12 months. In general, corneal topography, ocular aberrations, and subjective visual function improved after crosslinking. Conclusions In the US multicenter trials, CXL was shown to be safe and effective in stabilizing Kmax, CDVA, and UDVA in eyes with progressive keratoconus or corneal ectasia. Translational Relevance Corneal crosslinking was originally developed in the laboratory at the University of Dresden in the late 1990s. The combination of ultraviolet-A light and riboflavin was found to be the most effective of a number of different modalities tested to increase the biomechanical strength of the cornea. The clinical study design for the US multicenter clinical trials of crosslinking demonstrated the safety and effectiveness of this technique for treatment of progressive keratoconus and corneal ectasia, bringing this important advancement to patients in the United States.
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Affiliation(s)
- Steven A Greenstein
- CLEI Center for Keratoconus, Cornea and Laser Eye Institute-Hersh Vision Group, Teaneck, NJ, USA.,Department of Ophthalmology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Peter S Hersh
- CLEI Center for Keratoconus, Cornea and Laser Eye Institute-Hersh Vision Group, Teaneck, NJ, USA.,Department of Ophthalmology, Rutgers New Jersey Medical School, Newark, NJ, USA
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31
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Blackburn BJ, Rollins AM, Dupps WJ. Biomechanics of Ophthalmic Crosslinking. Transl Vis Sci Technol 2021; 10:8. [PMID: 34328498 PMCID: PMC8327749 DOI: 10.1167/tvst.10.5.8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/19/2021] [Indexed: 12/12/2022] Open
Abstract
Crosslinking involves the formation of bonds between polymer chains, such as proteins. In biological tissues, these bonds tend to stiffen the tissue, making it more resistant to mechanical degradation and deformation. In ophthalmology, the crosslinking phenomenon is being increasingly harnessed and explored as a treatment strategy for treating corneal ectasias, keratitis, degenerative myopia, and glaucoma. This review surveys the multitude of exogenous crosslinking strategies reported in the literature, both "light" (involving light energy) and "dark" (involving non-photic chemical processes), and explores their mechanisms, cytotoxicity, and stage of translational development. The spectrum of ophthalmic applications described in the literature is then discussed, with particular attention to proposed therapeutic mechanisms in the cornea and sclera. The mechanical effects of crosslinking are then discussed in the context of their proposed site and scale of action. Biomechanical characterization of the crosslinking effect is needed to more thoroughly address knowledge gaps in this area, and a review of reported methods for biomechanical characterization is presented with an attempt to assess the sensitivity of each method to crosslinking-mediated changes using data from the experimental and clinical literature. Biomechanical measurement methods differ in spatial resolution, mechanical sensitivity, suitability for detecting crosslinking subtypes, and translational readiness and are central to the effort to understand the mechanistic link between crosslinking methods and clinical outcomes of candidate therapies. Data on differences in the biomechanical effect of different crosslinking protocols and their correspondence to clinical outcomes are reviewed, and strategies for leveraging measurement advances predicting clinical outcomes of crosslinking procedures are discussed. Advancing the understanding of ophthalmic crosslinking, its biomechanical underpinnings, and its applications supports the development of next-generation crosslinking procedures that optimize therapeutic effect while reducing complications.
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Affiliation(s)
- Brecken J. Blackburn
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Andrew M. Rollins
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - William J. Dupps
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Ophthalmology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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32
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Lang SJ, Maier P, Reinhard T. Crosslinking und Keratokonus. AUGENHEILKUNDE UP2DATE 2021. [DOI: 10.1055/a-1205-7737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungEin Keratokonus führt zu einer progressiven Vorwölbung und Verdünnung der
Hornhaut. Um dies aufzuhalten, kann ein Crosslinking durchgeführt werden. Dabei
ist eine Behandlung nach dem „Dresdener Protokoll“ eine effektive und sichere
Behandlungsmöglichkeit, aber auch zahlreiche neue Anwendungsprotokolle
(akzeleriertes Crosslinking, transepitheliales Crosslinking) und sogar weitere
Indikationen (refraktive Eingriffe, infektiöse Keratitis) wurden in den letzten
Jahren veröffentlicht.
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Lang SJ, Maier P, Reinhard T. [Crosslinking and Keratoconus]. Klin Monbl Augenheilkd 2021; 238:733-747. [PMID: 33873207 DOI: 10.1055/a-1472-0411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Keratoconus leads to a progressive protrusion and thinning of the cornea. In order to stop this, corneal crosslinking can be performed if the progression of the disease is proven. Crosslinking according to the "Dresden protocol" includes abrasion of the corneal epithelium, application of riboflavin eye drops and irradiation with UV-A light of an intensity of 3 mW/cm² for 30 minutes. The efficacy has been shown in several prospective randomized studies. One of the more recent developments is accelerated crosslinking, which allows a shorter irradiation time. On the other hand, the possibility of transepithelial crosslinking was presented, which does not require an abrasion of the cornea. This should reduce the occurrence of postoperative pain. The range of indications has also been expanded. Corneal crosslinking is used for post-LASIK keratectasia as well. It is also being considered for use in infectious keratitis. Topographically controlled crosslinking can likewise be used to try to positively influence the refractive power of the cornea. The risks of crosslinking include the occurrence of pain, haze or scarring, endothelial cell damage and, rarely, the occurrence of keratitis.
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Alternative Indications for Corneal Crosslinking. J Cataract Refract Surg 2021; 47:1360-1366. [PMID: 33929804 DOI: 10.1097/j.jcrs.0000000000000663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Corneal crosslinking (CXL) is the current mainstay treatment for progressive keratoconus. In the past 15 years, a variety of other indications have been tested. A systematic review was conducted to examine these alternative indications for CXL. In total, of 143 papers on crosslinking as a treatment for infectious keratitis, bullous keratopathy, pellucid marginal degeneration, post- laser in situ keratomileusis (LASIK) ectasia, and as a way to improve vision either on its own or in combination with other interventions were included. Post-LASIK ectasia is a definite indication for crosslinking. Surprisingly, only limited research has been performed on pellucid marginal degeneration, with no randomized trials available to date. Other interesting applications are the combined use of refractive lasers and crosslinking for suspicious or ectatic corneas and crosslinking as a standalone intervention for minor refractive errors. CXL might offer a solution for refractory bacterial keratitis. In bullous keratopathy, it seems to offer only a transient benefit.
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Ferdi A, Nguyen V, Kandel H, Tan JCK, Arnalich-Montiel F, Abbondanza M, Watson S. Predictors of progression in untreated keratoconus: a Save Sight Keratoconus Registry study. Br J Ophthalmol 2021; 106:1206-1211. [PMID: 33785509 DOI: 10.1136/bjophthalmol-2020-317547] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/08/2021] [Accepted: 03/12/2021] [Indexed: 11/04/2022]
Abstract
AIMS We set out to identify risk factors for progression in untreated keratoconus patients from 34 centres across Australia, New Zealand, Spain and Italy. METHODS Patients were divided into 'progressors' and 'stable' patients for each clinical parameter: visual acuity (VA), steepest keratometry (maximum keratometry (Max-K)) and thinnest corneal thickness (TCT). Primary outcomes were the proportion of eyes with sustained progression in VA, Max-K or TCT within 3 years. Secondary outcomes included predictors of progression. RESULTS There were 3994 untreated eyes from 2283 patients. The proportion of eyes with VA, Max-K and TCT progression at 1 year were 3.2%, 6.6% and 3.1% respectively. Factors associated with VA loss were higher baseline VA (HR 1.15 per logMAR line increase in VA; p<0.001) and steeper baseline Max-K (HR 1.07 per 1D increase; p<0.001). Younger baseline age was associated with Max-K steepening (HR 0.96 per year older; p=0.001). Thicker baseline TCT, steeper baseline Max-K and younger baseline age were associated with TCT thinning: (HR 1.08 per 10 µm increase in TCT; p<0.001), (HR 1.03 per 1D increase; p=0.02) and (HR 0.98 per year younger; p=0.01), respectively. CONCLUSIONS Steeper Max-K and younger age were the most clinically useful baseline predictors of progression as they were associated with worsening of two clinical parameters. Every 1D steeper Max-K was associated with a 7% and 3% greater risk of worsening VA and thinning TCT, respectively. Each 1 year younger was associated with a 4% and 2% greater risk of steepening Max-K and thinning TCT, respectively.
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Affiliation(s)
- Alex Ferdi
- The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Vuong Nguyen
- The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Himal Kandel
- The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
| | - Jeremy C K Tan
- Ophthalmology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | | | | | - Stephanie Watson
- The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
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Femtosecond laser-assisted stromal keratophakia for keratoconus: A systemic review and meta-analysis. Int Ophthalmol 2021; 41:1965-1979. [PMID: 33609200 DOI: 10.1007/s10792-021-01745-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Femtosecond lasers have revived the possibility of stromal keratophakia or tissue additive keratoplasty, a technique originally introduced by Prof. Jose Ignacio Barraquer in the 1960s. The surgical technique offers a unique solution to treat keratoconus. In the current study, we reviewed and performed a meta-analysis of the clinical outcomes of the femtosecond laser-assisted stromal keratophakia in the treatment of keratoconus. METHODS This is a systematic review and meta-analysis of the estimated outcome difference between pre- and post-lenticule implantations. RESULTS A total of related 10 studies were found in the literature. No studies reported adverse events, such as persistent haze or graft rejection, at last patients' visits. We further narrowed down the article selection in accordance to our inclusion criteria to report the composite outcomes (9 studies) and meta-analysis (4 studies). In the composite analysis, we demonstrated that lenticule implantation in keratoconus and post-LASIK ectasia patients appeared to expand the stromal volume of the thin corneas, flattened the cones, and significantly improved uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA) and spherical equivalent (SE). The meta-analysis showed that the random estimated UCVA, BCVA, SE and mean keratometry (Km) differences following the lenticule implantation was -0.214 (95% CI: -0.367 to 0.060; p = 0.006), -0.169 (-0.246 to 0.091; p < 0.001), -2.294 D (-3.750 to -0.839 D; p = 0.002), and 2.909 D (0.805 to 5.012 D; p = 0.007), respectively. CONCLUSIONS Femtosecond laser-assisted stromal keratophakia is a feasible technique to correct the refractive aberrations, expand corneal volume and regularize corneal curvature in patients with keratoconus. However, there is a need to standardize the technique (e.g., whether to crosslink or not or to use convex or concave lenticules) and to formulate a mathematical model that accounts for the long-term epithelial thickness changes and stromal remodeling to determine the shape or profile of the lenticules, in order to improve the efficacy of the keratophakia further.
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Comparison of accelerated CXL alone, accelerated CXL-ICRS, and accelerated CXL-TG-PRK in progressive keratoconus and other corneal ectasias. J Cataract Refract Surg 2021; 46:276-286. [PMID: 32126042 DOI: 10.1097/j.jcrs.0000000000000049] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare accelerated corneal crosslinking (CXL) alone, CXL with simultaneous intrastromal corneal ring segments (CXL-ICRS), and CXL with simultaneous topography-guided photorefractive keratectomy (CXL-TG-PRK) in progressive keratoconus, pellucid marginal degeneration (PMD), or laser in situ keratomileusis (LASIK)-induced ectasia. SETTING The Kensington Eye Institute and Bochner Eye Institute, Toronto, Canada. DESIGN Prospective nonrandomized interventional study. METHODS Visual and topographical outcomes using a comparative analysis adjusting for preoperative maximum keratometry (Kmax) were evaluated 1 year postoperatively. RESULTS Four hundred fifty-two eyes from 375 patients with progressive keratoconus, PMD, or LASIK-induced ectasia that underwent accelerated (9 mW/cm, 10 minutes) CXL alone (n = 204), CXL-ICRS (n = 126), or CXL-TG-PRK (n = 122) were included. Change in logarithm of the minimum angle of resolution uncorrected distance visual acuity was significant with CXL-ICRS (-0.31; 95% CI, -0.38 to -0.24) and CXL-TG-PRK (-0.16; 95% CI, -0.24 to -0.09), but not with CXL alone. No significant differences in change were found between the 3 groups. Change in corrected distance visual acuity (CDVA) was significant in all 3 groups: -0.12 (95% CI, -0.15 to -0.10) with CXL alone, -0.23 (95% CI, -0.27 to -0.20) with CXL-ICRS, and -0.17 (95% CI, -0.21 to -0.13) with CXL-TG-PRK. Improvement in CDVA was greater with CXL-ICRS than with CXL alone (-0.08 ± 0.02; P < .0001) and CXL-TG-PRK (-0.05 ± 0.02; P = .005). Change in Kmax was significant with CXL-ICRS [-3.21 diopters (D); 95% CI, -3.98 to -2.45] and CXL-TG-PRK (-3.69 D; 95% CI, -4.49 to -2.90), but not with CXL alone (-0.05 D; 95% CI, -0.66 to 0.55). CONCLUSIONS CXL alone might be best for keratoconic patients who meet the inclusion criteria. CXL-ICRS might be more effective for eyes with more irregular astigmatism and worse CDVA and CXL-TG-PRK for eyes requiring improvements in irregular astigmatism but still have good CDVA.
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Hayes S, Morgan SR, Meek KM. Keratoconus: cross-linking the window of the eye. THERAPEUTIC ADVANCES IN RARE DISEASE 2021; 2:26330040211003573. [PMID: 37181107 PMCID: PMC10032441 DOI: 10.1177/26330040211003573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/25/2021] [Indexed: 05/16/2023]
Abstract
Keratoconus is a condition in which the cornea progressively thins and weakens, leading to severe, irregular astigmatism and a significant reduction in quality of life. Although the precise cause of keratoconus is still not known, biochemical and structural studies indicate that overactive enzymes within the cornea break down the constituent proteins (collagen and proteoglycans) and cause the tissue to weaken. As the disease develops, collagen fibres slip past each other and are redistributed across the cornea, causing it to change shape. In recent years, it was discovered that the photochemical induction of cross-links within the corneal extracellular matrix, through the use of riboflavin and ultraviolet (UVA) light, could increase the strength and enzymatic resistance of the tissue and thereby halt keratoconus progression. Worldwide acceptance and use of riboflavin/UVA corneal cross-linking therapy for halting keratoconus progression has increased rapidly, in accordance with the growing body of evidence supporting its long-term effectiveness. This review focusses on the inception of riboflavin/UVA corneal cross-linking therapy for keratoconus, its clinical effectiveness and the latest scientific advances aimed at reducing patient treatment time, improving patient comfort and increasing patient eligibility for treatment. Plain language summary Review of current treatments using cross-linking to halt the progress of keratoconus Keratoconus is a disease in which the curved cornea, the transparent window at the front of the eye, weakens, bulges forward into a cone-shape and becomes thinner. This change of curvature means that light is not focussed onto the retina correctly and vision is progressively impaired. Traditionally, the effects of early keratoconus were alleviated by using glasses, specialist contact lenses, rings inserted into the cornea and in severe cases, by performing a corneal transplant. However, it was discovered that by inducing chemical bonds called cross-links within the cornea, the tissue could be strengthened and further thinning and shape changes prevented. The standard cross-linking procedure takes over an hour to perform and involves the removal of the cells at the front of the cornea, followed by the application of Vitamin B2 eye drops and low energy ultraviolet light (UVA) to create new cross-links within the tissue. Clinical trials have shown this standard procedure to be safe and effective at halting keratoconus progression. However, there are many treatment modifications currently under investigation that aim to reduce patient treatment time and increase comfort, such as accelerated cross-linking procedures and protocols that do not require removal of the surface cells. This review describes the different techniques being developed to carry out corneal cross-linking efficiently and painlessly, to halt keratoconus progression and avoid the need for expensive surgery.
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Affiliation(s)
- Sally Hayes
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ. UK
| | - Siân R Morgan
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
| | - Keith M Meek
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK
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Ramirez DA, Kam Y, Wilson CW, Ling JJ. Updates in the Management of Corneal Ectasia. Int Ophthalmol Clin 2021; 61:29-43. [PMID: 33337792 DOI: 10.1097/iio.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chonsui M, Touboul D. [Management of a case of post-LASIK ectasia]. J Fr Ophtalmol 2020; 44:e153-e155. [PMID: 33390254 DOI: 10.1016/j.jfo.2020.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 12/01/2022]
Affiliation(s)
- M Chonsui
- Centre de référence national du kératocône, CRNK, centre François-Xavier Michelet, groupe hospitalier Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France.
| | - D Touboul
- Centre de référence national du kératocône, CRNK, centre François-Xavier Michelet, groupe hospitalier Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
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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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Visual and Topographic Improvement with Epithelium-On, Oxygen-Supplemented, Customized Corneal Cross-Linking for Progressive Keratoconus. J Clin Med 2020; 9:jcm9103222. [PMID: 33049990 PMCID: PMC7600308 DOI: 10.3390/jcm9103222] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/11/2020] [Accepted: 09/22/2020] [Indexed: 02/02/2023] Open
Abstract
Customized cross-linking has been proposed as an alternative to conventional cross-linking in patients with progressive keratoconus, targeting greater flattening of the cone region and improved visual function. Epithelium-on cross-linking aims to reduce complications associated with epithelial removal, while the addition of oxygen aims to maintain treatment effect. Our study evaluates the combination of these novel treatment strategies to achieve a minimally invasive treatment targeting maximal functional outcomes. This prospective study included 42 eyes undergoing epithelium-on, accelerated, oxygen-supplemented, customized corneal cross-linking for progressive keratoconus. Outcome measures, including refraction, visual acuity, and corneal tomography were obtained at baseline and at 1, 3, and 6 months, and 1 year postoperatively. Logarithm of the minimum angle of resolution (logMAR) uncorrected visual acuity was significantly improved, from 0.87 ± 0.53 preoperatively, to 0.78 ± 0.56 1 year postoperatively (Wilcoxon rank sum test, p = 0.016). LogMAR best spectacle-corrected visual acuity was also significantly improved, from 0.19 ± 0.36 preoperatively, to 0.11 ± 0.33 postoperatively (p = 0.004). Manifest refractive cylinder was significantly decreased, from 4.50 ± 2.96 D preoperatively, to 3.27 ± 2.61 D postoperatively (p = 0.004). The baseline maximum keratometry (Kmax) was 53.04 ± 7.91 D, significantly flattening to 52.25 ± 7.31 D by 1 month, and remaining relatively stable at 1 year postoperatively (52.31 ± 7.50 D) (p < 0.001). No significant adverse events occurred in any eye. Epithelium-on, accelerated, oxygen-supplemented, customized corneal cross-linking is a promising new treatment approach, with reduced maximum keratometry, reduced astigmatism, and improved visual acuity at 1 year, with a favorable safety and patient comfort profile.
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Ansah DO, Wang J, Lu K, Jabbour S, Bower KS, Soiberman US. Post-FDA Approval Results of Epithelium-Off, Full-Fluence, Dresden Protocol Corneal Collagen Crosslinking in the USA. Ophthalmol Ther 2020; 9:1023-1040. [PMID: 33029700 PMCID: PMC7708565 DOI: 10.1007/s40123-020-00306-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/16/2020] [Indexed: 12/11/2022] Open
Abstract
Introduction The purpose of this non-comparative, prospective, observational study was to evaluate the post-US Food and Drug Administration approval outcomes of epithelium-off, full-fluence, Dresden protocol corneal collagen crosslinking (CXL) for the treatment of progressive keratoconus (KCN) and post-refractive corneal ectasia at a US academic tertiary medical center. Methods This study involved 125 eyes of 97 patients with KCN and 13 eyes of 12 patients with post-refractive ectasia which underwent CXL between November 2016 and September 2019. Best spectacle-corrected visual acuity (BSCVA) and corneal topographic parameters were measured preoperatively, at postoperative month 1 (POM-1), and between postoperative months 3 and 24 (POM 3–24). Results Best spectacle-corrected visual acuity, flat keratometry, steep keratometry, and mean corneal power worsened at POM-1 (p < 0.01) with a return to preoperative values at POM 3–24. Maximum keratometry (Kmax) steepened at POM-1 and then improved beyond preoperative levels at POM 3–24 (p < 0.01 and p = 0.03, respectively). Pachymetry at the apex and pupil decreased at POM-1 and POM 3–24 (p = 0.03). Pachymetry at the thinnest point decreased at POM-1 and trended toward reduction at POM 3–24 (p < 0.001 and p = 0.06, respectively). Visual and tomographic outcomes were similar between pediatric and adult populations, and between KCN and post-refractive ectasia patients. Conclusions Real-world results of CXL in the USA are similar to those reported in prior studies, demonstrating an initial worsening of BSCVA, pachymetry, and keratometry followed by corneal flattening and preservation of visual acuity. Improvements in Kmax and stability in visual acuity were observed over 24 months in children and adults with progressive KCN or post-refractive ectasia.
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Affiliation(s)
- Derick O Ansah
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jiangxia Wang
- Department of Biostatistics, Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kevin Lu
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samir Jabbour
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kraig S Bower
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uri S Soiberman
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Kobashi H, Torii H, Toda I, Kondo S, Itoi M, Tsubota K. Clinical outcomes of KeraVio using violet light: emitting glasses and riboflavin drops for corneal ectasia: a pilot study. Br J Ophthalmol 2020; 105:1376-1382. [PMID: 32892163 PMCID: PMC8479745 DOI: 10.1136/bjophthalmol-2020-316974] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIMS We developed a novel technology consisting of violet light (VL)-emitting glasses and defined the combination of VL irradiation and riboflavin treatment as KeraVio. Our goal was to evaluate the clinical results of KeraVio in patients with progressive corneal ectasia. METHODS Eyes were exposed to VL (375 nm, irradiance 310 μW/cm2)-emitting glasses for 3 hours daily for 6 months, and a riboflavin solution was administered onto the corneal epithelium six times during each 3-hour VL irradiation. The primary end point was a change in the maximum keratometry (Kmax) value over 6 months compared with that over the 1 year before baseline. RESULTS The efficacy of KeraVio was evaluated in 20 eyes with severe progression, and its safety was evaluated in all 40 eyes. The mean changes in Kmax over the 1 year before baseline and during the 6-month observation period were 6.03±3.41 dioptres (D) and -0.81±3.34 D, respectively (p=0.002). At 6 months, the Kmax value decreased by more than 2 D in 4 eyes (20%), remained within 2 D in 13 eyes (65%), and increased by 2 D or more in 3 eyes (15%). The corneal stromal demarcation line was identified in 16 eyes (80%), and its depth was 206.3±54.9 μm at 1 month. No significant decrease in endothelial cell density, lenticular opacity or transient corneal haze was noted. CONCLUSION Based on our 6-month results, daily treatment of progressive corneal ectasia with KeraVio can halt disease progression without any safety concerns. CLINICAL TRIAL REGISTRATION NUMBER jRCTs032180217.
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Affiliation(s)
- Hidenaga Kobashi
- Department of Ophthalmology, Keio University, School of Medicine, Shinjuku, Tokyo, Japan .,Department of Ophthalmology, Minami Aoyama Eye Clinic Tokyo, Minato-ku, Tokyo, Japan
| | - Hidemasa Torii
- Department of Ophthalmology, Keio University, School of Medicine, Shinjuku, Tokyo, Japan.,Department of Ophthalmology, Minami Aoyama Eye Clinic Tokyo, Minato-ku, Tokyo, Japan
| | - Ikuko Toda
- Department of Ophthalmology, Keio University, School of Medicine, Shinjuku, Tokyo, Japan.,Department of Ophthalmology, Minami Aoyama Eye Clinic Tokyo, Minato-ku, Tokyo, Japan
| | - Shinichiro Kondo
- Department of Ophthalmology, Keio University, School of Medicine, Shinjuku, Tokyo, Japan.,Tsubota Laboratory Inc., Tokyo, Japan
| | | | - Kazuo Tsubota
- Department of Ophthalmology, Keio University, School of Medicine, Shinjuku, Tokyo, Japan.,Tsubota Laboratory Inc., Tokyo, Japan
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Padmanabhan P, Belin MW, Padmanaban V, Sudhir RR. Extreme corneal flattening following collagen crosslinking for progressive keratoconus. Eur J Ophthalmol 2020; 31:1546-1552. [PMID: 32744058 DOI: 10.1177/1120672120947664] [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] [Indexed: 11/16/2022]
Abstract
PURPOSE To study the clinical, tomographic and densitometric features of eyes that showed >5 D of corneal flattening following collagen crosslinking (CXL) for progressive keratoconus and to identify preoperative predictive factors for such a response. METHODS This was a retrospective case control study of 548 eyes with progressive keratoconus which had undergone epithelium-off CXL (Dresden protocol) with a follow-up of 1 to 10 years. Eyes that showed ⩾5 D corneal flattening in maximum keratometry (Kmax) following CXL (group A) were compared with one eye of the remaining patients in the same cohort (group B). Changes in refraction and visual acuity, Kmax and thinnest pachymetry were compared between both groups. Univariate and multivariate regression analysis identified preoperative risk factors for unusual corneal flattening. RESULTS Forty three eyes in group A were compared with 502 eyes in group B. At the time of maximum flattening, group A showed more flattening (-7.6 ± 3.2 D) and thinning (-53.7 ± 45.2 µ) than group B (-1.69 ± 2.9 D and -26.6 ± 36.7 µ, respectively). Multivariate analysis based on parameters suggested by a univariate regression analysis identified pre-op Kmax to be the most significant predictor of intense corneal flattening. A subgroup analysis of K-matched eyes revealed that the duration of time following CXL was a significant risk factor for extreme corneal flattening following CXL. CONCLUSION An intense corneal flattening >5 D in Kmax was documented in 7.85% of a cohort of keratoconus patients who underwent CXL. High preoperative Kmax and the duration of time following CXL were significant predictors of this response which was accompanied by significant corneal thinning.
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Affiliation(s)
- Prema Padmanabhan
- Medical Research Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Michael W Belin
- Department of Ophthalmology and Vision Science, University of Arizona, Tucson, AZ, USA
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Corneal higher-order aberrations after crosslinking and intrastromal corneal ring segments for keratoconus. J Cataract Refract Surg 2020; 46:979-985. [DOI: 10.1097/j.jcrs.0000000000000209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Keratoconus Screening Using Values Derived From Auto-Keratometer Measurements: A Multicenter Study. Am J Ophthalmol 2020; 215:127-134. [PMID: 32114181 DOI: 10.1016/j.ajo.2020.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/04/2020] [Accepted: 02/20/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE Screening of early-stage keratoconus using auto-keratometer parameters. DESIGN Evaluation of a screening approach. METHODS At 5 major centers in Japan, we enrolled 123 eyes of 123 patients with Amsler-Krumeich classification stage 1 (<50 years of age [average 26.36 ± 8.68 years]; 84/39 male/female) and 205 eyes of 205 healthy subjects (average age 26.20 ± 7.34 years, 139/66 male/female). Participants were divided 2:1 into a prediction group and an application group. In the prediction group, multivariate logistic regression analysis was performed with keratoconus diagnosis as the dependent variable, and auto-keratometer parameters including average K, steep K, flat K, astigmatism, and astigmatic axis (no, with-the-rule, against-the-rule, and oblique) as independent variables. The diagnostic probability determined by regression analysis was defined as the keratometer keratoconus index. The cutoff value was determined from the receiver operating characteristic curve. This prediction equation was evaluated in the application group. Our primary outcome measure was the accuracy of the prediction equation for discriminating keratoconus from normal eyes. RESULTS The selected explanatory variables were steep K (partial regression coefficient [β] 1.284, odds ratio [OR] 3.610), flat K (β -0.618, OR 0.539), and with-the-rule astigmatism (β -3.163, OR 0.042). The area under the receiver operating characteristic curve of keratometer keratoconus index was 0.90, which was significantly better than individual parameters (P < .001). The sensitivity and specificity values in the application group were 85.0% and 86.7%, respectively. CONCLUSIONS Although the sensitivity/specificity was not high, the new prediction equation using auto-keratometer-derived parameters enabled better discrimination of early-stage keratoconus than the isolated parameters.
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Li H, Liu T, Mu B, Zhao X, Xue C, Shen M, Jhanji V, Wang Y. Biomechanical effect of ultraviolet-A-riboflavin cross-linking on simulated human corneal stroma model and its correlation with changes in corneal stromal microstructure. Exp Eye Res 2020; 197:108109. [PMID: 32565111 DOI: 10.1016/j.exer.2020.108109] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/11/2020] [Accepted: 06/02/2020] [Indexed: 12/28/2022]
Abstract
In this study, we established an experimental human corneal stroma model of simulated cornea tissue composed of thin anterior cornea strips layers obtained from small incision lenticular extraction (SMILE) surgery. We investigated the biomechanical effect of ultraviolet-A- riboflavin cross-linking at different depths of corneal stroma model and correlated it with stromal microstructural changes examined by transmission electron microscopy (TEM). Corneal strips were harvested from fresh human corneal lenticules obtained after SMILE surgery. Experimental models (n = 34) were established by superimposing the corneal lenticule strips until their thickness reached close to 500 μm. Corneal cross-linking (CXL) was performed subsequently using standard or accelerated protocol. Elasticity and viscosity were quantified using stress-strain extensometer. TEM was used to visualize the collagen fiber diameter and interfibrillar spacing. The relative change in Young's modulus (rel. ΔE) decreased nonlinearly with increasing stromal depth both in the standard and accelerated groups. Compared to the sham controls, the rel. ΔE in standard and accelerated CXL groups increased significantly in the anterior 400 μm and 275 μm depth, respectively. Also, the relative change in stress (rel. ΔS) was significantly lower after standard and accelerated CXL compared to sham controls. Depth analysis showed similar results for the elastic effect. TEM images showed a small, non-significant increase in fibril diameter. The interfibrillar spacing decreased significantly after standard and accelerated CXL in the anterior-mid stromal region. We noted that the increase of corneal stiffness correlated with decrease in interfibrillar spacing after CXL. The stiffening effect was depth dependent. The effect of accelerated CXL was less in the deep corneal stromal regions compared to standard CXL.
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Affiliation(s)
- Hongxun Li
- Clinical College of Ophthalmology, Tianjin Medical University, Tianjin, China; Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Institute, Tianjin Eye Hospital Tianjin, China
| | - Taiwei Liu
- Department of Mechanics, School of Mechanical Engineering, Tianjin University, Tianjin, China
| | - Bokun Mu
- Clinical College of Ophthalmology, Tianjin Medical University, Tianjin, China; Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Institute, Tianjin Eye Hospital Tianjin, China
| | - Xinheng Zhao
- Clinical College of Ophthalmology, Tianjin Medical University, Tianjin, China; Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Institute, Tianjin Eye Hospital Tianjin, China
| | - Chao Xue
- Clinical College of Ophthalmology, Tianjin Medical University, Tianjin, China
| | - Min Shen
- Department of Mechanics, School of Mechanical Engineering, Tianjin University, Tianjin, China
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yan Wang
- Clinical College of Ophthalmology, Tianjin Medical University, Tianjin, China; Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Institute, Tianjin Eye Hospital Tianjin, China.
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Intracorneal ring segments followed by toric pseudoaccomodating IOL for treatment of patients with corneal ectasia and cataract. Am J Ophthalmol Case Rep 2020; 18:100693. [PMID: 32368687 PMCID: PMC7184316 DOI: 10.1016/j.ajoc.2020.100693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/21/2018] [Accepted: 04/02/2020] [Indexed: 12/05/2022] Open
Abstract
Purpose Surgical management of keratoconus aims to improve corneal curvature, prevent progression of corneal ectasia, and manage refractive error. In older individuals with concurrent cataracts, management can be challenging due to topographic irregularity and difficult-to-interpret IOL calculations. We describe a sequential combination of two surgical techniques—intrastromal corneal ring segments (e.g. intacs) insertion and toric pseudoaccomodating lens implantation—to successfully manage concurrent keratoconus and cataracts. Observations In this case series, we present three eyes with corneal ectasia in two cataractous patients successfully managed by (1) Intacs placement to normalize corneal contour/asymmetry and enable more regular keratometry measurements, followed by (2) correction of astigmatism and presbyopia by placement of toric pseudoaccommodating IOL (Trulign) after cataract extraction. Conclusions and Importance This is the first description, to the authors’ knowledge, of the use of intraocorneal ring segments + toric pseudoaccommodating intraocular lenses for the management of concurrent keratoconus, cataract, and presbyopia.
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The Independent Effect of Various Cross-Linking Treatment Modalities on Treatment Effectiveness in Keratoconus. Cornea 2020; 39:63-70. [PMID: 31577628 DOI: 10.1097/ico.0000000000002168] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To investigate the 1-year outcomes of using various corneal cross-linking (CXL) techniques for treating keratoconus. METHODS Setting: This is a prospective longitudinal cohort study performed at a tertiary academic medical center. PATIENT POPULATION Six hundred seventy eyes of 461 patients with progressive keratoconus who underwent CXL were followed up for 1 year. INTERVENTION Eight combinations of CXL modalities were assessed, including 2 different CXL techniques (transepithelial or epithelium-off), 7 riboflavin formulations, and 2 ultraviolet-A protocols (conventional 3 mW/cm or accelerated 9 mW/cm). Patients treated using the Dresden protocol were used as the reference group. MAIN OUTCOME MEASURES Primary outcomes were maximum keratometry and mean keratometry 1 year after treatment. Multivariable linear regression was used which provides β coefficients (β). Secondary outcomes were uncorrected and corrected distance visual acuity, manifest refractive spherical equivalent, and corneal thickness 1 year after treatment. RESULTS Four treatment modalities differed significantly from the reference group regarding both maximum keratometry and mean keratometry: the transepithelial CXL (TE-CXL) group (β = 1.422; P = 0.001), 1 riboflavin formulation (Meran β = 1.210; P = 0.02), and both the 9 mW/cm protocols (Vibex Rapid β = 1.751; P < 0.001 and Collagex β = 1.170, P < 0.001). Overall, the visual outcome, manifest refractive spherical equivalent, and corneal thickness were similar among the treatment modalities. Infections were rare (1.6% of cases); however, re-treatment was required for 33.3% of cases that underwent TE-CXL. CONCLUSIONS TE-CXL, the use of Meran riboflavin, and applying the accelerated irradiation protocol appeared to be associated with reduced efficacy regarding controlling keratoconus progression. One-third of cases treated using TE-CXL required re-treatment.
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