Can Riboflavin Penetrate Stroma Without Disrupting Integrity of Corneal Epithelium in Rabbits? Iontophoresis and Ultraperformance Liquid Chromatography With Electrospray Ionization Tandem Mass Spectrometry

Efficacy of iontophoresis-assisted epithelium-on corneal cross-linking for keratoconus

Corneal cross-linking (CXL) is a noninvasive therapeutic procedure for keratoconus that is aimed at improving corneal biomechanical properties by induction of covalent cross-links between stromal proteins. It is accomplished by ultraviolet A (UVA) radiation of the cornea, which is first saturated with photosensitizing riboflavin. It has been shown that standard epithelium-off CXL (S-CXL) is efficacious, and it has been recommended as the standard of care procedure for keratoconus. However, epithelial removal leads to pain, transient vision loss, and a higher risk of corneal infection. To avoid these disadvantages, transepithelial CXL was developed. Recently, iontophoresis has been adopted to increase riboflavin penetration through the epithelium. Several clinical observations have demonstrated the safety and efficacy of iontophoresis-assisted epithelium-on CXL (I-CXL) for keratoconus. This review aimed to provide a comprehensive summary of the published studies regarding I-CXL and a comparison between I-CXL and S-CXL. All articles used in this review were mainly retrieved from the PubMed database. Original articles and reviews were selected if they were related to the I-CXL technique or related to the comparison between I-CXL and S-CXL.

Conventional Corneal Collagen Cross-Linking Versus Transepithelial Diluted Alcohol and Iontophoresis-Assisted Corneal Cross-Linking in Progressive Keratoconus

PURPOSE

To compare clinical outcomes of conventional corneal cross-linking (C-CXL) and diluted alcohol and iontophoresis-assisted corneal cross-linking (DAI-CXL) for the treatment of progressive keratoconus (KC).

METHODS

Ninety-three eyes of 80 patients with KC were treated by C-CXL (n = 47) or DAI-CXL (n = 46). Visual acuity, keratometry, KC indexes, pachymetry, and aberrations were recorded before treatment and 1, 3, 6, and 12 months after treatment. The demarcation line was assessed 1 month after treatment.

RESULTS

A significant improvement in visual acuity was observed at month 3 and month 6 after DAI-CXL and C-CXL, respectively. A significant decrease in maximum keratometry was observed in both groups at month 6. The front symmetry index significantly improved in both groups after 6 months, whereas the Baiocchi Calossi Versaci index significantly improved only after DAI-CXL at month 12 (P = 0.01). Average keratometry and other KC indexes were stable during 12 months of follow-up. Central corneal thickness decreased by 28.6 and 40.2 μm after DAI-CXL and C-CXL at month 1, respectively (P < 0.01), and it reached baseline at the 12th month (P = 0.14) only in the DAI-CXL group. Higher-order aberrations, coma, and spherical aberration significantly worsened at month 1 (P < 0.01) only after C-CXL; however, they improved significantly at month 12 compared with baseline (P < 0.05) in both groups. The demarcation line was visible in all cases at month 1 at a mean depth of 302 ± 56 μm and 311 ± 57 μm after DAI-CXL and C-CXL, respectively (P = 0.7).

CONCLUSIONS

The DAI-CXL protocol seems as effective as the C-CXL protocol in halting KC progression after 1 year of follow-up.

Dual-Phase Iontophoresis for the Delivery of Antisense Oligonucleotides

In support of ongoing research in the study of corneal and skin wound healing, we sought to improve on previously published results by using iontophoresis to deliver RNA interference-based oligonucleotides. By using a electromechanics-based approach, we were able to devise a two-phase solution that separated the buffering solution from the antisense oligonucleotide (ASO) solution. The separation was obtained by making the drug solution a higher density than the buffer, leading it to sink directly onto the tissue surface. This change immediately decreased the distance that the ASO would have to travel before delivery. The changes enabled delivery into ex vivo skin and corneas in 10 or fewer minutes and into in vivo corneas in 5 min. In vivo studies demonstrated short-term bioavailability of at least 24 h, a lack of chemical or thermal injury, a lack of interference in the healing of a corneal injury, and an antisense effect till at least day 7, but not day 14. The only side-effect observed was postdelivery edema that was not present when the vehicle alone was iontophoresed. This suggests that electro-osmotic flow from the delivery chamber was not the mechanism, but that the delivered solute likely increased the tissue's osmolarity. These results support the continued development and utilization of this ASO delivery approach in research-grade oligonucleotides to probe molecular biological pathways and in support of testing therapeutic ASOs in the skin and cornea.

Standard corneal collagen crosslinking versus transepithelial iontophoresis-assisted corneal crosslinking, 24 months follow-up: randomized control trial

Purpose

To compare the results of standard corneal crosslinking (CXL) and transepithelial iontophoresis‐assisted CXL after 24 months follow‐up.

Material and methods

Corneal crosslinking (CXL) was performed in a series of 149 eyes of 119 patients with keratoconus I–II of Amsler classification. Depending on the CXL method, patients were divided into two groups: (1) 73 eyes with standard CXL and (2) 76 eyes with transepithelial iontophoresis‐assisted CXL. Depending on the group, epithelium removal or administration of riboflavin solution by iontophoresis for 10 min was performed, after which standard surface UVA irradiation (370 nm, 3 mW/cm²) was performed at a 5‐cm distance for 30 min.

Results

A statistically significant difference in corrected distance visual acuity (CDVA) was observed between the two groups, with a better outcome in the second group after 6 months (p = 0.037); however, no significant difference was found 24 months after treatment (p = 0.829). Stabilization and regression of keratometry values were achieved in both groups, but standard CXL was more effective. The average demarcation line depth in the standard CXL group was 292 ± 14 μm after 14 days and 172 ± 16 μm in the transepithelial iontophoresis‐assisted CXL group. No demarcation line was detected after 1 month and 3 months in 45% and 100% of the eyes in the second group respectively.

Conclusion

Transepithelial iontophoresis‐assisted collagen crosslinking showed to be less effective than standard CXL after 24 months of follow‐up, possibly due to a more superficial formation of corneal collagen crosslinks, however the stopping of disease progression was achieved 24 months after procedure.

Evaluation of Antifungal Efficacy of 0.1% and 0.25% Riboflavin with UVA: A Comparative In Vitro Study

PURPOSE

Antifungal efficacy of photochemical cross-linking (PACK-CXL) with 0.1% and 0.25% riboflavin was evaluated with a comparative in vitro study.

METHODS

Candida albicans and Aspergillus fumigatus ATCC reference strains, Candida parapsilosis, Aspergillus fumigatus, Fusarium solani, Scedosporium apiospermum, and Alternaria alternata strains isolated from keratitis cases were chosen as targeted microorganisms. Unique "black plate method" was developed in polystyrene microplates. Riboflavin suspensions in 0.1% and 0.25% were separately added into inoculated wells. Non-inoculated wells were filled by black colored dye in order to protect treated wells from reflection of UV treatment. After ultraviolet A (UVA) treatment, each well was evaluated by microbiological culture in order to count viable fungal colonies. Fungal killing rate was calculated by comparing fungal counts (CFU/mL) before and after UVA application of riboflavin-added wells.

RESULTS

Four different fungal inoculum concentrations of targeted microorganisms, including 10⁴, 10³, 10², and 10¹ CFU/mL, were assayed. PACK-CXL with 0.25% riboflavin was found to be highly effective on fungal cells even in 10⁴ CFU/mL of concentration.

CONCLUSIONS

PACK-CXL appears as a promising treatment option for difficult-to-treat cases of fungal keratitis and 0.25% riboflavin concentration increases fungicidal effect of the procedure dramatically.