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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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Akhtar S, Smedowski A, Khan AA, Debasi H, Mofty H, Samivel R, Almubrad T. Glycosaminoglycans and collagen fibril distribution at various depths of the corneal stroma of normal and CXL treated rats. Exp Eye Res 2024; 239:109780. [PMID: 38176513 DOI: 10.1016/j.exer.2024.109780] [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: 10/13/2023] [Revised: 11/21/2023] [Accepted: 01/01/2024] [Indexed: 01/06/2024]
Abstract
Corneal collagen cross-linking (CXL) is widely used to treat keratoconus and ecstatic corneal disorders. The present studies were carried out to investigate the distribution of glycosaminoglycans (GAGs) and collagen fibril (CF) at different depths of the normal and CXL treated corneal stroma of four week old rats 7 days after standard CXL application. Ten Wistar rats' corneas were used for the study. The epithelium of the cornea from the left eye of each rat was removed and treated with standard CXL application using riboflavin and Ultraviolet-A (UVA) (3 mW/cm2 for 30 min). The cornea from the right eye was used as the control cornea. The cornea was removed from the eye and processed for transmission electron microscopy. A bottom mounted Quemesa camera was used to capture digital images and these images were analysed using iTEM software. In the control cornea, the GAGs area size was not significantly different in the anterior, middle, and posterior stroma. In the CXL treated rats the GAGs area size gradually increased from the anterior to the posterior stroma whereas the spacing between the GAGs gradually decreased. There were very large GAGs present in the posterior stroma of the CXL treated rats. When comparing the control and CXL cornea, the GAGs area in the CXL cornea was significantly higher and inter-GAGs-spacing was smaller than in the control cornea. In the control cornea, the collagen fibrils diameter was higher in the anterior stroma and lowest in the posterior stroma. In the CXL treated cornea, the CF diameter and the interfibrillar spacing gradually decreased from the anterior to the posterior stroma. On comparison between the control and the CXL treated cornea, the interfibrillar spacing was significantly smaller in the CXL treated cornea than the control cornea in the anterior, middle, and posterior stroma but there was no difference in the diameter. The CXL treatment significantly increased the GAGs area and decreased the inter-GAGs-spacing, and inter-CF-spacing. This could be due to the gradual decline in the availability of riboflavin, UVA, and oxygen in the middle and posterior stroma. Further studies are required to investigate the role of keratan sulphate and chondroitin sulphate by using monoclonal antibodies with immunogold technique.
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Affiliation(s)
- Saeed Akhtar
- College of Applied Medical Sciences, Inaya Medical College, Riyadh, Saudi Arabia; Cornea Research Chair, Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.
| | - Adrian Smedowski
- Department of Ophthalmology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland; Department of Ophthalmology, Professor K. Gibinski University Clinical Center, Medical University of Silesia, Katowice, Poland; GlaucoTech Co, Katowice, Poland
| | - Adnan Ali Khan
- Cornea Research Chair, Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Hind Debasi
- Cornea Research Chair, Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Hanan Mofty
- Cornea Research Chair, Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia; Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Ramachandran Samivel
- Cornea Research Chair, Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Turki Almubrad
- Cornea Research Chair, Department of Optometry, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
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Prinz J, Kuerten D, Schellhase H, Koutsonas A, Djalali-Talab Y, Walter P, Fuest M. Clinical, Anatomical, and Densitometric Changes following Dresden vs. Accelerated Corneal Cross-Linking in Progressive Keratoconus. Klin Monbl Augenheilkd 2024; 241:209-220. [PMID: 38232738 DOI: 10.1055/a-2206-1420] [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: 01/19/2024]
Abstract
BACKGROUND To compare clinical, anatomical, and densitometric changes following Dresden (DCXL) vs. accelerated (ACXL) corneal UVA cross-linking (CXL; Avedro KXL, Geuder, Heidelberg, Germany) in progressive keratoconus (KC). METHODS AND MATERIAL In this retrospective study, we analyzed 20 patients following DCXL (3 mW/cm², 30 min, 5.4 J/cm²) and 44 patients following ACXL (9 mW/cm², 10 min, 5.4 J/cm²) between January 2016 and February 2020. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), central corneal thickness (CCT), steepest keratometry (Kmax), keratoconus index (KI), thinnest pachymetry (Pthin), and corneal densitometry (CD) were measured before and 3, 6, 12, and 24 months after CXL. RESULTS During the follow-up period, no changes in UCVA, BSCVA, Kmax, KI, or Pthin occurred. CCT significantly decreased 3 months after DCXL (p = 0.032) and ACXL (p = 0.006). At the 12- and 24-month follow-up, CCT remained decreased in the DCXL (p = 0.035, 0.036, respectively) but not in the ACXL group. At the 12-month follow-up, the reduction in CCT was significantly greater in DCXL compared to ACXL (p = 0.012). At the 3-, 6-, 12-, and 24-month follow-ups, we found a significant increase in the anterior stroma CD following DCXL (p = 0.019, 0.026, 0.049, 0.047, respectively) but not ACXL. The CD changes were localized in the central concentric zones (0.0 to 6.0 mm). No intra- or postoperative complications occurred. CONCLUSION ACXL and DCXL effectively halted KC progression. ACXL proved to be a safe time-saving alternative to conventional DCXL. DCXL led to a reduction in CCT and an increment in the CD of the central anterior stroma during 24 months of follow-up.
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Affiliation(s)
- Julia Prinz
- Clinic of Ophthalmology, University Hospital Aachen, Aachen, Germany
| | - David Kuerten
- Clinic of Ophthalmology, University Hospital Aachen, Aachen, Germany
| | - Hannah Schellhase
- Clinic of Ophthalmology, University Hospital Aachen, Aachen, Germany
| | - Antonis Koutsonas
- Clinic of Ophthalmology, University Hospital Aachen, Aachen, Germany
| | | | - Peter Walter
- Clinic of Ophthalmology, University Hospital Aachen, Aachen, Germany
| | - Matthias Fuest
- Clinic of Ophthalmology, University Hospital Aachen, Aachen, Germany
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Herber R, Francis M, Spoerl E, Pillunat LE, Raiskup F, Roy AS. Evaluation of Biomechanical Changes After Accelerated Cross-Linking in Progressive Keratoconus: A Prospective Follow-Up Study. Cornea 2023; 42:1365-1376. [PMID: 36727878 DOI: 10.1097/ico.0000000000003219] [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: 07/07/2022] [Accepted: 11/15/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE The aim of this study was to analyze the biomechanical effect of accelerated corneal cross-linking (9*10) in progressive keratoconus (KC) in comparison to untreated fellow eyes using Scheimpflug-based tonometry (Corvis ST, CVS). METHODS Forty-three eyes of 43 patients with KC showed progressive KC and were treated using accelerated corneal cross-linking. Twenty-five untreated fellow eyes were used as the control group. All eyes were examined biomechanically (CVS) and tomographically (Pentacam) at baseline, after 1-month, 6-month, and 12-month follow-up. Statistical analysis was performed using a linear mixed model. A logistic regression was performed to attribute the effects of changes in each parameter to treatment status (treated or untreated). RESULTS Maximum keratometry values decreased statistically significantly at 12 months by -1.1 D (95 confidence interval: -2.0 to -0.1, P = 0.025) compared with baseline. Thinnest corneal thickness decreased significantly after 1 month ( P < 0.001) and recovered to baseline after 12 months ( P = 0.752). In the corneal cross-linking (CXL) group, biomechanical changes were observed by an increased bIOP, a shorter A2 time, and a lower integrated radius after 1 month (all P < 0.05). No biomechanical and tomographical changes were observed in the control group (all P > 0.05). Logistic regression pointed out that treated eyes can be separated from untreated eyes by differences in bIOP, corneal thickness, A1 velocity, integrated radius, and Kc mean at 1, 6, and 12 months. CONCLUSIONS The alterations in biomechanical parameters indicated a corneal stiffening effect after CXL treatment, which was mostly detectable 1 month after treatment, although corneal thickness was reduced. The logistic regression model showed an adequate separation between CXL-treated and untreated eyes.
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Affiliation(s)
- Robert Herber
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Germany; and
| | - Mathew Francis
- Imaging, Biomechanics and Mathematical Modeling Solutions Lab, Narayana Nethralaya Foundation, Bangalore, India
| | - Eberhard Spoerl
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Germany; and
| | - Lutz E Pillunat
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Germany; and
| | - Frederik Raiskup
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Germany; and
| | - Abhijit Sinha Roy
- Imaging, Biomechanics and Mathematical Modeling Solutions Lab, Narayana Nethralaya Foundation, Bangalore, India
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Vidas Pauk S, Jandroković S, Lešin Gaćina D, Tomić M, Bulum T, Pupić Bakrač A, Kuzman T, Knežević J, Kalauz M. Short-Term Effect of Conventional Versus Accelerated Corneal Cross-Linking Protocol on Corneal Geography and Stability. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1043. [PMID: 37374247 DOI: 10.3390/medicina59061043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/20/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023]
Abstract
Purpose: To determine the 6-month effect of conventional (CXL30) and accelerated cross-linking with a UVA intensity of 9 mW/cm2 (CXL10) on corneal stability and to investigate whether there was a difference in ABCD grading system parameters regarding the two different procedures. Methods: Twenty-eight eyes of 28 patients with a documented keratoconus (KN) progression were included. Patients were selected to undergo either epi off CXL30 or CXL10. At the baseline and the follow-up visits after one (V1), three (V2), and six months (V3), the patients underwent complete ophthalmic examination and corneal tomography. Results: In the CXL30 group, all the parameters from the ABCD grading system significantly changed from baseline to V3; parameter A decreased (p = 0.048), B and C increased (p = 0.010, p < 0.001), and D decreased (p < 0.001). In the CXL10 group, there were no changes in parameters A (p = 0.247) and B (p = 0.933), though parameter C increased (p = 0.001) and D decreased (p < 0.001). After an initial decline after one month, visual acuity (VA) recovered on V2 and V3 (p < 0.001), and median maximal keratometry (Kmax) decreased in both groups (p = 0.001, p = 0.035). In the CXL30 group, there were significant changes in other parameters; average pachymetric progression index (p < 0.001), Ambrósio relational thickness maximum (ARTmax) (p = 0.008), front and back mean keratometry (p < 0.001), pachymetry apex (PA) (p < 0.001), and front elevation (p = 0.042). However, in the CXL10 group, there were significant changes only in ARTmax (p = 0.019) and PA (p < 0.001). Conclusion: Both epi-off CXL protocols showed similar short-term efficacy in improving VA and Kmax, halting the progression of KN, and both similarly changed tomographic parameters. However, the conventional protocol modified the cornea more significantly.
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Affiliation(s)
- Sania Vidas Pauk
- Department of Ophthalmology, Zagreb University Hospital Center, 10000 Zagreb, Croatia
| | - Sonja Jandroković
- Department of Ophthalmology, Zagreb University Hospital Center, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 2, 10000 Zagreb, Croatia
| | - Dina Lešin Gaćina
- Department of Ophthalmology, Zagreb University Hospital Center, 10000 Zagreb, Croatia
| | - Martina Tomić
- Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000 Zagreb, Croatia
| | - Tomislav Bulum
- School of Medicine, University of Zagreb, Šalata 2, 10000 Zagreb, Croatia
- Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000 Zagreb, Croatia
| | - Ana Pupić Bakrač
- Department of Ophthalmology, Zagreb University Hospital Center, 10000 Zagreb, Croatia
| | - Tomislav Kuzman
- Department of Ophthalmology, Zagreb University Hospital Center, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 2, 10000 Zagreb, Croatia
| | - Josip Knežević
- Department of Ophthalmology, Zagreb University Hospital Center, 10000 Zagreb, Croatia
| | - Miro Kalauz
- Department of Ophthalmology, Zagreb University Hospital Center, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 2, 10000 Zagreb, Croatia
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Ashena Z, Doherty S, Gokul A, McGhee CNH, Ziaei M, Nanavaty MA. Flattening of Central, Paracentral, and Peripheral Cones After Non-accelerated and Accelerated Epithelium-off CXL in Keratoconus: A Multicenter Study. J Refract Surg 2022; 38:310-316. [PMID: 35536708 DOI: 10.3928/1081597x-20220404-02] [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 assess the flattening of central, paracentral, and peripheral cones following non-accelerated (non-A-CXL) and accelerated (A-CXL) epithelium-off corneal cross-linking with 10 times higher intensity. METHODS In this multicenter study of 200 eyes (100 in each group), following 10 minutes of soak time with riboflavin 0.1%, continuous CXL was performed for 30 minutes (intensity: 3 mW/cm2, fluence: 5.4 J/cm2) in the non-A-CXL group and 3 minutes (intensity: 30 mW/cm2, fluence: 5.4 J/cm2) in the A-CXL group. Anterior and posterior cone flattening were compared at 12 months. Multiple regression analysis was performed to establish correlation of age, sex, cone location, and preoperative maximum keratometry (Kmax) values with postoperative flattening at 12 months. RESULTS In the non-A-CXL and A-CXL groups, central cones were the steepest, followed by paracentral and peripheral cones. Both groups showed significant flattening in central (1.54 ± 1.94 and 1.09 ± 1.79 diopters [D]) and paracentral (0.62 ± 1.59 and 0.55 ± 0.98 D) cones only. In the non-A-CXL group, there was a positive correlation between postoperative flattening and preoperative Kmax values, whereas paracentral and peripheral cone locations were negatively related. In the A-CXL group, only paracentral location was negatively correlated to postoperative flattening and showed posterior cone steepening at 12 months. CONCLUSIONS Although central cones were the steepest in both groups, there was no difference in postoperative flattening between the groups for all cone locations. In the non-A-CXL group, postoperative flattening was proportional to preoperative Kmax values in central cones and was less with paracentral and peripheral locations. With A-CXL, postoperative flattening was less only with paracentral location. In the A-CXL group, significant posterior cone steepening was noticed only in paracentral cones. [J Refract Surg. 2022;38(5):310-316.].
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Gerberich BG, Wood-Yang AJ, Radmand A, Nichols LM, Hejri A, Echeverri ES, Gersch HG, Prausnitz MR. Computational modeling of corneal and scleral collagen photocrosslinking. J Control Release 2022; 347:314-329. [PMID: 35513208 DOI: 10.1016/j.jconrel.2022.04.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 04/21/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022]
Abstract
Scleral photocrosslinking is increasingly investigated for treatment of myopia and glaucoma. In this study a computational model was developed to predict crosslinking efficiency of visible/near infrared photosensitizers in the sclera. Photocrosslinking was validated against riboflavin corneal crosslinking experimental studies and subsequently modeled for the sensitizer, methylene blue, administered by retrobulbar injection to the posterior sclera and irradiated with a transpupillary light beam. Optimal ranges were determined for treatment parameters including light intensity, methylene blue concentration, injection volume, and inspired oxygen concentration. Additionally, sensitivity of crosslinking to various parameters was quantified. The most sensitive parameters (in order of greatest to least sensitive) were tissue parameters (including scleral thickness and choroidal melanin concentration), treatment parameters (including treatment duration and inspired oxygen concentration), and sensitizer parameters (including triplet quantum yield).
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Affiliation(s)
- Brandon G Gerberich
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Amy J Wood-Yang
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Afsane Radmand
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Lauren M Nichols
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Amir Hejri
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Elisa Schrader Echeverri
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Hannah G Gersch
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Mark R Prausnitz
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia; School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia.
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Effect of Ultraviolet-A and Riboflavin treatment on the architecture of the center and periphery of normal rat cornea: 7 days post treatment. Exp Eye Res 2022; 219:109064. [PMID: 35385757 DOI: 10.1016/j.exer.2022.109064] [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: 12/10/2021] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/22/2022]
Abstract
Corneal collagen cross-linking (CXL) is a treatment that is widely applied to halt the progression of ectatic diseases such as keratoconus by creating biomechanical strength in the cornea. Most of the studies assessed the effect of the CXL on the cornea without any differentiation of its effect between periphery and the center of the untreated control cornea especially after the 7 days of CXL application. We investigate the ultrastructural changes in the architecture of the center and periphery of rat corneas, 7 days after standard CXL application. Five Wistar rats (10 corneas) were used in the present study. The left eye corneas (5 mm area) were de-epithelialized and irradiated with standard CXL application using riboflavin and Ultraviolet-A (UVA) (3 mW/cm2 for 30 min). The right eye corneas were used as a control. The sclera-cornea button was removed and processed for electron microscopy. Digital images were captured with a bottom mounted Quemesa camera and analyzed using the iTEM software. The ultrastructure of epithelium, hemi-desmosomes, Bowman's layer and stroma were organized in both untreated control and CXL rat cornea in both untreated control and CXL rat cornea. Within the same CXL cornea, both the collagen fibril (CF) diameter and interfibrillar spacing at the center were significantly smaller compared to the peripheral diameter and spacing of the cornea. When comparing the untreated control and CXL cornea, the central interfibrillar spacing of the CXL cornea was significantly smaller than the central spacing the untreated control cornea. In the CXL cornea the peripheral spacing was significantly higher compared to the peripheral interfibrillar spacing of the untreated control cornea. Within the CXL cornea, the proteoglycans (PGs) area and density of the periphery was significantly higher compared to the area and density of the center of the cornea. It suggests that CXL was more effective at the periphery of the cornea. This could be due to the higher amount of leucine rich PG lumican and higher diffusion of oxygen and riboflavin at the periphery cornea.
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Herber R, Graehlert X, Raiskup F, Veselá M, Pillunat LE, Spoerl E. Statistical Evaluation of Correlated Measurement Data in Longitudinal Setting Based on Bilateral Corneal Cross-Linking. Curr Eye Res 2022; 47:995-1002. [PMID: 35354347 DOI: 10.1080/02713683.2022.2052105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE In ophthalmology, data from both eyes of a person are frequently included in the statistical evaluation. This violates the requirement of data independence for classical statistical tests (e.g. t-Test or analysis of variance (ANOVA)) because it is correlated data. Linear mixed models (LMM) were used as a possibility to include the data of both eyes in the statistical evaluation. METHODS The LMM is available for a variety of statistical software such as SPSS or R. The application was applied to a retrospective longitudinal analysis of an accelerated corneal cross-linking (ACXL (9*10)) treatment in progressive keratoconus (KC) with a follow-up period of 36 months. Forty eyes of 20 patients were included, whereas sequential bilateral CXL treatment was performed within 12 months. LMM and ANOVA for repeated measurements were used for statistical evaluation of topographical and tomographical data measured by Pentacam (Oculus, Wetzlar, Germany). RESULTS Both eyes were classified into a worse and better eye concerning corneal topography. Visual acuity, keratometric values and minimal corneal thickness were statistically significant between them at baseline (p < 0.05). A significant correlation between worse and better eye was shown (p < 0.05). Therefore, analyzing the data at each follow-up visit using ANOVA partially led to an overestimation of the statistical effect that could be avoided by using LMM. After 36 months, ACXL has significantly improved BCVA and flattened the cornea. CONCLUSION The evaluation of data of both eyes without considering their correlation using classical statistical tests leads to an overestimation of the statistical effect, which can be avoided by using the LMM.
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Affiliation(s)
- Robert Herber
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Xina Graehlert
- Coordination Center for Clinical Studies - KKS Dresden, Faculty of Medicine Carl Gustav Carus, TU Dresden, Germany
| | - Frederik Raiskup
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Martina Veselá
- Department of Ophthalmology, Faculty of Medicine Hradec Králové, Charles University, Prague, Czech Republic
| | - Lutz E Pillunat
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Germany
| | - Eberhard Spoerl
- Department of Ophthalmology, University Hospital Carl Gustav Carus, TU Dresden, Germany
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Nicula CA, Rednik AM, Nicula AP, Bulboaca AE, Nicula D, Horvath KU. Comparative Results Between "Epi-Off" Accelerated and "Epi-Off" Standard Corneal Collagen Crosslinking-UVA in Progressive Keratoconus - 7 Years of Follow-Up. Ther Clin Risk Manag 2021; 17:975-988. [PMID: 34522101 PMCID: PMC8434931 DOI: 10.2147/tcrm.s321410] [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: 05/24/2021] [Accepted: 08/14/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of the present study was to assess the long-term efficiency and safety of the “epi-off” accelerated CXL (9 mW/cm2 for 10 minutes) in comparison to the standard “epi-off” CXL (3 mW/cm2 for 30 minutes) in terms of topographical and keratometric parameters, refractive data and visual outcomes at 7 years of follow-up, in progressive keratoconus. Material and Method A retrospective and comparative study was performed. A total of 183 eyes from 183 patients with documented progressive keratoconus were included in the study. The patients were divided in two groups: 93 eyes from 93 patients underwent “epi-off” standard cross-linking technique (3 mW/cm2 for 30 minutes) (S-CXL group) and 90 eyes from 90 patients underwent accelerated “epi-off” corneal CXL technique (9 mW/cm2 for 10 minutes) (A-CXL group). Results Improvements in uncorrected distance visual acuity (UDVA) were statistically significant compared to baseline values in both groups at each time-point visit (p=0.0421 at 1 year, p=0.0411 at 7 years for A-CXL and p=0.0375 at 1 year, p=0.0389 at 7 years for S-CXL). At 7 years there was a statistically significant increase in CDVA (p=0.039 in the A-CXL group and p=0.0343 in the S-CXL group at 7 years). Statistically significant reduction was noticed in Ksteep (p=0.0411 in A-CXL group and p=0.0224 in S-CXL group), Kflat (p=0.0198 in A-CXL group and p=0.008 in S-CXL group), K mean (p=0.0106 in A-CXL group and p=0.0193 in S-CXL group) and Kmax (p=0.0413 in A-CXL group and p=0.054 in S-CXL group) at 7 years, compared to baseline values, in both groups, but without any statistically difference between the two procedures, at all time-point visits (p>0.05). Conclusion The long-term outcomes of “epi-off” accelerated corneal collagen crosslinking-UVA (9 mW/cm2 for 10 minutes) are similar to standard “epi-off” corneal collagen crosslinking procedure in the treatment of progressive keratoconus.
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Affiliation(s)
- Cristina Ariadna Nicula
- Department of Ophthalmology, Medicine and Pharmacy University "Iuliu Hațieganu", Cluj-Napoca, Romania.,Oculens Clinic, Cluj-Napoca, Romania
| | - Anca Maria Rednik
- Eye County Hospital, Department of Ophthalmology, Cluj-Napoca, Romania
| | | | - Adriana Elena Bulboaca
- Department of Pathophysiology, Medicine and Pharmacy University "Iuliu Hațieganu", Cluj Napoca, Romania
| | | | - Karin Ursula Horvath
- Department of Ophthalmology, Medicine and Pharmacy Science and Technology University "George Emil Palade", Târgu Mureș, Romania
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Matlov Kormas R, Abu Tailakh M, Chorny A, Jacob S, Knyazer B. Accelerated CXL Versus Accelerated Contact Lens-Assisted CXL for Progressive Keratoconus in Adults. J Refract Surg 2021; 37:623-630. [PMID: 34506244 DOI: 10.3928/1081597x-20210609-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare the clinical and tomographic properties of adult patients with keratoconus treated with accelerated corneal cross-linking (A-CXL) versus accelerated contact lens-assisted corneal cross-linking (A-CACXL). METHODS Patients who underwent A-CXL and A-CACXL due to progressive keratoconus were enrolled from January 2015 to January 2018 in this retrospective case-control study. The treatment group (minimum corneal thickness of less than 400 µm after epithelium removal; 30 patients, 30 eyes) was treated with A-CACXL; the control group (minimum corneal thickness of 400 µm or greater, 32 patients, 32 eyes) was treated with A-CXL. Assessments occurred before treatment and 12 months postoperatively. Demographic, clinical, and tomographic data were obtained from outpatient clinic reports. RESULTS Significant improvement in visual acuity was evident at 12-month follow-up for the control group in uncorrected distance visual acuity (0.62 ± 0.42 vs 0.43 ± 0.31 logMAR, P = .01) and the treatment group in corrected distance visual acuity (0.51 ± 0.30 vs 0.40 ± 0.49 logMAR, P = .03). Progression of keratoconus was halted at similar rates for both groups (76.7% treatment, 84.4% control, P = .21). Mean minimum corneal thickness showed minor but significant thinning at the 12-month follow-up visit compared to baseline (control group = 463 ± 31 vs 450 ± 35 µm, P > .01; treatment group = 398 ± 32 vs 388 ± 41 µm, P = .02). CONCLUSIONS A-CACXL halted keratoconus progression in 76.7% of eyes and achieved regression in 33.3% of eyes, with rates comparable to A-CXL. Visual outcomes improved for both groups, with similar keratometry changes. A-CACXL is an effective and safe option for patients with keratoconus and thin corneas, with results similar to A-CXL treatment in patients with a minimum corneal thickness of 400 µm or greater. [J Refract Surg. 2021;37(9):623-630.].
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Fischinger I, Seiler TG, Wendelstein J, Tetz K, Fuchs B, Bolz M. Biomechanical Response After Corneal Cross-linking With Riboflavin Dissolved in Dextran Solution Versus Hydroxypropyl Methylcellulose. J Refract Surg 2021; 37:631-635. [PMID: 34506235 DOI: 10.3928/1081597x-20210610-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate corneal stiffening in porcine eyes induced by corneal cross-linking (CXL) using riboflavin dissolved in either aqueous dextran or hydroxypropyl methylcellulose (HPMC) solution. METHODS Fifty-one porcine corneas were divided into three groups of 17 each. After deepithelialization, the first (Dresden) group was treated for 30 minutes with 0.1% riboflavin (riboflavin-5-monophosphate in 0.9% NaCl) dissolved in hypertonic 20% dextran and the second (HPMC) group for 30 minutes with isotonic solution containing 0.1% riboflavin and 1.1% HPMC. Thereafter, corneas of both groups were irradiated using 5.4 J/cm2 (irradiance of 9 mW/cm2 for 10 minutes; 10*9). After CXL, all corneas were kept in an isotonic 16% dextran bath for 2 hours to obtain an equal hydration state. The third group served as the control group. Stress-strain measurements were performed on 5-mm-wide strips. Corneal thickness was monitored throughout the entire course of the experiments. RESULTS The required stress for a 10% strain was increased by 83% in the Dresden group and 35% in the HPMC group compared to the control group. Resultant Young's modulus (at 10% strain) was 2.53 ± 0.73, 1.87 ± 0.50, and 1.47 ± 0.44 Pa for the Dresden, HPMC, and control groups, respectively. The differences between the Dresden and HPMC groups (P = .006), the Dresden and control groups (P < .001), and the HPMC and control groups (P = .014) were statistically significant. Pachymetry measurements showed a significantly increased corneal thickness after application of HPMC compared with the Dresden group (P = .002) and control group (P = .041). CONCLUSIONS The biomechanical stiffening of the cornea by CXL can be achieved using dextran- and HPMC-based riboflavin solutions in porcine corneas with an application time of 30 minutes. Dextran-based riboflavin solutions seem to induce a slightly stronger biomechanical response in this setting. HPMC solutions induce less thinning than dextran solutions. [J Refract Surg. 2021;37(9):631-635.].
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D'Oria F, Palazón A, Alio JL. Corneal collagen cross-linking epithelium-on vs. epithelium-off: a systematic review and meta-analysis. EYE AND VISION (LONDON, ENGLAND) 2021; 8:34. [PMID: 34565473 PMCID: PMC8465763 DOI: 10.1186/s40662-021-00256-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 08/08/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The purpose of the study was to determine the advantages and disadvantages of epi-on corneal cross-linking (CXL) techniques compared with standard epi-off CXL. METHODS We searched MEDLINE and EMBASE for randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) and we evaluated the selected papers according to the Cochrane risk of bias tool. We considered, as primary outcomes, average Kmax flattening, changes in uncorrected and corrected distance visual acuity (UDVA and CDVA); as secondary outcomes, we considered changes in pachymetry values and endothelial cell density (ECD). We also investigated adverse events related to the treatments and treatment failure. Meta-analysis was conducted with a fixed or random-effects model using weighted mean difference (MD) with 95% confidence interval (CI) as the effect size. RESULTS A total of 15 studies were included and among these 15 trials, 9 were RCTs and 6 were NRSIs, but only 4 studies showed no high risk of bias and were included in this meta-analysis. Our analysis revealed significant postoperative differences in CDVA (MD = 0.07; 95% CI 0.04 to 0.10; P < 0.001), and no significative differences in UDVA, Kmax, central corneal thickness (CCT) and ECD (P > 0.05). Epi-on CXL protocol was found to be significantly less prompt to have risks of delay in epithelial healing (P = 0.035) and persistent stromal haze (P = 0.026). CONCLUSION Epi-on CXL is as effective as epi-off CXL. Except for a higher significant improvement in CDVA with current epi-on protocols, our meta-analysis demonstrates that epi-on and epi-off CXL have comparable effects on visual, topographic, pachymetric, and endothelial parameters. Epi-on CXL has clinical advantages in terms of comfort and avoidance of complications as it reduces the risk of developing delay in epithelial healing and persistent stromal haze.
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Affiliation(s)
- Francesco D'Oria
- Vissum Innovation, c/ Cabañal, 1, 03016, Alicante, Spain
- Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
- Section of Ophthalmology, Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari, Bari, Italy
| | - Antonio Palazón
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
| | - Jorge L Alio
- Vissum Innovation, c/ Cabañal, 1, 03016, Alicante, Spain.
- Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain.
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Wang J, Wang L, Li Z, Wang YM, Zhu K, Mu G. Corneal Biomechanical Evaluation After Conventional Corneal Crosslinking With Oxygen Enrichment. Eye Contact Lens 2021; 46:306-309. [PMID: 31425353 DOI: 10.1097/icl.0000000000000645] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess corneal biomechanical changes after conventional corneal crosslinking (CXL), with and without oxygen enrichment. METHODS Sixty fresh porcine corneas were randomly divided into group 1 (control), group 2 (conventional CXL), and group 3 (conventional CXL in a high-oxygen environment during ultraviolet A [UVA] irradiation). After crosslinking, a 5-mm wide corneal strip was extracted using a double-bladed knife from 12 to 6'o clock. The Young's modulus of each strip was determined by stress-strain measurements. A comparison between the three groups was performed with a one-way analysis of variance. RESULTS At 4% strain, the Young's modulus of the corneas in groups 1, 2, and 3 were: 0.68±0.20 megapascal (MPa), 1.01±0.23 MPa, and 1.12±0.24 MPa, respectively. The Young's modulus values for groups 2 and 3 showed no statistical significance (P>0.05), However, both groups 2 and 3 were significantly higher than group 1 (P<0.05). At 6% strain, the Young's modulus of the corneas in groups 1, 2, and 3 were: 0.97±0.21, 1.35±0.25, and 1.64±0.44 MPa, respectively, and at 8% strain, the Young's modulus was: 1.29±0.26, 1.72±0.45, 2.20±0.74 MPa, respectively. At 6% and 8% strain, the Young's modulus for the corneas in group 3 was significantly higher than those in both group 1 and group 2 (P<0.05). CONCLUSIONS Increasing oxygen concentration during UVA irradiation may improve the efficacy of conventional CXL.
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Affiliation(s)
- Jia Wang
- Department of Ophthalmology (J.W., L.W., Z.L., K.Z., G.M.), Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China; Aier Eye Hospital Group (J.W.), Liaocheng Aier Eye Hospital, Liaocheng, Shandong, China; Department of Ophthalmology (L.W.), Binzhou Medical University Hospital, Binzhou, Shandong, China; and Department of Ophthalmology and Visual Sciences (Y.M.W.), The Chinese University of Hong Kong, Hong Kong, China
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Sot M, Gan G, François J, Chaussard D, Da Costa M, Luc MS, Goetz C, Dinot V, Lhuillier L, Perone JM. Risk factors for keratoconus progression after treatment by accelerated cross-linking (A-CXL): A prospective 24-month study. J Fr Ophtalmol 2021; 44:863-872. [PMID: 34059330 DOI: 10.1016/j.jfo.2020.08.040] [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: 04/20/2020] [Revised: 08/15/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Identification of potential predictive factors for keratoconus progression after treatment by accelerated Cross-linking (A-CXL) SECONDARY OBJECTIVES: Evaluation of clinical and topographic outcomes for two years following accelerated cross-linking treatment for progressive keratoconus including: best spectacle corrected visual acuity (BSCVA), thinnest pachymetry, maximum keratometry (Kmax), cylinder. STUDY Prospective, interventional, monocentric study. SITE: Metz-Thionville Regional Medical Center, Lorraine University, Mercy Hospital, Metz, France. PATIENTS AND METHODS We included 82 eyes of 60 patients between March 2014 and June 2016 who underwent accelerated corneal cross-linking (A-CXL) with epithelial debridement for progressive keratoconus, with a minimum follow-up of 2 years. A complete clinical evaluation and corneal topography were performed before cross-linking, and subsequently at 6, 12 and 24 months post-procedure. The following parameters were monitored during follow-up: best spectacle corrected visual acuity (BSCVA), minimal pachymetry, maximum keratometry (Kmax), mean anterior and posterior curvatures, maximum posterior curvature, presence of optical aberrations, subdivided into spherical aberration, coma, astigmatism, higher order optical aberrations and residual optical aberrations. After a 2-year follow-up, two groups, defined as "responders" and "non-responders" to treatment, were separated for analysis, and their initial characteristics were compared. RESULTS Data for 82 eyes of 60 patients with progressive keratoconus with a mean age of 24±7 years were studied. Fourteen eyes (17.1%) showed signs of progression after treatment by A-CXL (non-responders), and 68 eyes (82.9%) showed stabilization of the disease (responders). Characteristics of non-responding eyes after A-CXL included a younger mean age (20±5 vs. 25±7 years) (P=0.04) and a lower initial mean BCVA for non-responders of 0.44±0.16 logMAR vs. 0.29±0.19 logMAR (P=0.03). Non-responders also had a higher mean maximal posterior curvature (AKB) of -10.84±1.72D vs. -9.46± 1.12D (P=0.03). They also showed more higher order optical aberrations (3.84±1.72D vs. 2.4±1.02D; P=0.01), including coma (3.85±1.81D vs. 2.1±1.01D; P=0.03) and more residual aberrations than responders (1.05±0.44D vs. 0.45±0.6D; P=0.005). No significant differences were found between responders and non-responders for the other parameters in our study. CONCLUSION Eyes with progressive keratoconus who did not respond to A-CXL treatment were the most aggressive cases in the youngest patients, with highest maximum corneal curvatures and most pronounced optical aberrations. These patients should be informed in advance of the high risk of non-response to A-CXL treatment, and of the potential need for additional treatment in the future.
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Affiliation(s)
- M Sot
- Ophthalmology Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - G Gan
- Ophthalmology Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - J François
- Ophthalmology Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - D Chaussard
- Ophthalmology Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - M Da Costa
- Ophthalmology Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - M S Luc
- Ophthalmology Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - C Goetz
- Clinical Research Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - V Dinot
- Clinical Research Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - L Lhuillier
- Ophthalmology Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
| | - J M Perone
- Ophthalmology Department, Regional Hospital Center of Metz-Thionville, Mercy Hospital, 1, allee du Chateau CS 45001, 57085 Metz Cedex 03, France.
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Accelerated Versus Standard Corneal Cross-Linking for Progressive Keratoconus: A Meta-Analysis of Randomized Controlled Trials. Cornea 2020; 39:172-180. [PMID: 31369463 DOI: 10.1097/ico.0000000000002092] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the clinical results of accelerated corneal collagen cross-linking (ACXL) to standard corneal collagen cross-linking (SCXL) in progressive keratoconus by summarizing randomized controlled trials using a meta-analysis. METHODS Trials meeting the selection criteria were quality appraised, and data were extracted by 2 independent authors. A comprehensive search was performed using the Cochrane methodology to evaluate the clinical outcomes of ACXL and SCXL for treating progressive keratoconus. Estimates were evaluated by weighted mean difference (WMD) and 95% confidence interval (CI) for absolute changes of the outcomes during 12-month observation periods. Postoperative demarcation line depth was also compared. RESULTS We identified 6 randomized controlled trials that met the eligibility criteria for this meta-analysis. SCXL resulted in a significantly better outcome in postoperative changes in best spectacle-corrected visual acuity (WMD = -0.02; 95% CI, -0.03 to -0.01; P < 0.0001); however, the small differences may not be clinically significant. ACXL provided a significantly better improvement of cylindrical refraction after the 1-year follow-up (WMD = 0.15; 95% CI, 0.05-0.26; P = 0.005). Demarcation line depth at 1 month after SCXL was deeper than that after ACXL (WMD = -102.25; 95% CI, -157.16 to -47.35; P = 0.0003). No differences in the changes in maximum keratometry, central corneal thickness, uncorrected visual acuity, spherical equivalent refraction, corneal biomechanical properties, and corneal endothelial cell density were found among both groups. CONCLUSIONS An ACXL shows a comparable efficacy and safety profile at the 1-year follow-up, but it has less impact on improving best spectacle-corrected visual acuity when compared with the Dresden protocol. Overall, both methods similarly stop the disease progression.
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Beloshevski B, Shashar S, Mimouni M, Novack V, Malyugin BE, Boiko M, Knyazer B. Comparison between three protocols of corneal collagen crosslinking in adults with progressive keratoconus: Standard versus accelerated CXL for keratoconus. Eur J Ophthalmol 2020; 31:2200-2205. [PMID: 33183087 DOI: 10.1177/1120672120972632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The study aimed to compare eye outcomes between the standard and accelerated corneal cross-linking (CXL) protocols over a 1-year follow-up, and assess whether the accelerated protocols are non-inferior to the standard. METHODS A retrospective cohort study including patients older than 18 years diagnosed with progressive keratoconus who underwent a CXL procedure. The primary outcome was defined as an increase of more than 1.5 diopter (D) in Kmax. The analysis included intra- and inter-group comparisons assessing differences in eye characteristics before and 12 months after the procedure. Furthermore, we assessed whether the accelerated procedures were non-inferior to the standard regarding Kmax change after 12 months. RESULTS Eighty-four patients included in the study of which 23, 37 and 23 underwent the standard CXL (group I), 10-min. (group II) and the 3-min. (group III) accelerated procedures, respectively. Intra-group comparison before and after 12 months of mean Ksteep and anterior corneal astigmatism showed significant improvement only for group I (-0.3D decrease for both). Inter-group comparison showed better results after 12 months for group I (-0.9 ± 1.2) compared to group III (0.1 ± 0.8) in Ksteep, Kmean (-0.5+1. vs 0.1+0.7, respectively) and anterior astigmatism (-0.5 + 0.9 vs 0.3+1.1, respectively). We could not declare that the accelerated CXLs are non-inferior to the standard (p-value = 0.11 and 0.15). CONCLUSION The standard CXL showed better results for keratometry and astigmatism in comparison with the accelerated. Therefore, the wide use of the accelerated CXL should be considered and reviewed for longer follow-up time and larger sample size in focus on the visual acuity parameters.
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Affiliation(s)
- Boris Beloshevski
- Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Beloshevski and Shashar contributed equally to this paper
| | - Sagi Shashar
- Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Research Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer-Sheva, Israel.,Beloshevski and Shashar contributed equally to this paper
| | - Michael Mimouni
- Department of Ophthalmology, Rambam Health Care Campus, Haifa, Israel.,Bruce and Ruth Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Victor Novack
- Research Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer-Sheva, Israel
| | - Boris E Malyugin
- Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,S. Fyodorov Eye Microsurgery Institution, Moscow, Russia
| | - Matthew Boiko
- Division of Anesthesiology and Critical Care, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Boris Knyazer
- Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Moramarco A, Mastrofilippo V, Romano MG, Iannetta D, Braglia L, Fontana L. Efficacy and Safety of Accelerated Corneal Cross-linking for Progressive Keratoconus: A 5-Year Follow-up Study. J Refract Surg 2020; 36:724-730. [DOI: 10.3928/1081597x-20200819-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 08/13/2020] [Indexed: 11/20/2022]
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Comparative Results of "Epi-Off" Conventional versus "Epi-Off" Accelerated Cross-Linking Procedure at 5-year Follow-Up. J Ophthalmol 2020; 2020:4745101. [PMID: 32774904 PMCID: PMC7396097 DOI: 10.1155/2020/4745101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/22/2020] [Indexed: 01/08/2023] Open
Abstract
Purpose The aim of our study was to compare the long-term efficacy and safety of “epi-off” conventional and “epi-off” accelerated corneal cross-linking (CXL) in patients with progressive keratoconus. Methods “Epithelial-off” (“Epi-off”) CXL using the conventional technique (3 mW/cm2, 30 minutes) was performed in 93 eyes of 93 patients (S-CXL group) and “epi-off” accelerated method (9 mW/cm2, 10 minutes) in 76 eyes of 76 patients with progressive KCN (A-CXL group). Cases with different stages of keratoconus and topographic evidence of progression were included. Main outcomes comprised refraction, keratometry measurements, uncorrected (UCVA) and best-corrected visual acuity (BCVA), and topographical indices. Micromorphological analysis was assessed by anterior segment ocular coherence tomography (AS-OCT). The follow-up period was 5 years. Results In both groups, Kflat presented similar results: decrease at 1 year (p=0.465), at 2 years (p=0.672), at 3 years (p=0.198), at 4 years (p=0.32), and at 5 years (p=0.864). In both groups, Ksteep presented a similar decrease at 1 year (p=0.709), at 2 years (p=0.455), at 3 years (p=0.43), at 4 years (p=0.57), and at 5 years (p=0.494), with no statistically significant difference. Decrease in Kavg was similar in both groups at all analyzed time points (p=0.18 at 1 year, p=0.093 at 2 years, p=0.57 at 3 years, p=0.154 at 4 years, and p=0.247 at 5 years). Kmax had a similar decrease in both groups at 1 year (p=0.06), at 2 years (p=0.09), at 3 years (p=0.126), at 4 years (p=0.113), and at 5 years (p=0.114). There was no statistically significant difference between the cylinder decrease in both groups (p=0.349 at 1 year, p=0.6782 at 2 years, p=0.299 at 3 years, p=0.0943 at 4 years, and p=0.144 at 5 years). The BCVA values were statistically significantly higher than the preoperative values in both groups at all time points (p < 0.05). Topographical indices such as thinnest corneal point (TP), corneal volume (CV), index vertical asymmetry (IVA), index of vertical asymmetry (ISV), index of height asymmetry (IHA), index of height decentration (IHD), Belin/Ambrosio Enhanced Ectasia Display (BAD_D), and Ambrosio retinal thickness (ART Max) were significantly statistically decreased compared with baseline at all time points, in both groups. Conclusion “Epi-off” accelerated and conventional CXL have the same efficacy in terms of improvement in visual and topographic outcomes.
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Hatch W, El-Defrawy S, Ong Tone S, Stein R, Slomovic AR, Rootman DS, Rabinovitch T, Kranemann C, Chew HF, Chan CC, Bujak MC, Cohen A, Lebovic G, Jin Y, Singal N. Accelerated Corneal Cross-Linking: Efficacy, Risk of Progression, and Characteristics Affecting Outcomes. A Large, Single-Center Prospective Study. Am J Ophthalmol 2020; 213:76-87. [PMID: 31945333 DOI: 10.1016/j.ajo.2020.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE We examined the efficacy and preoperative characteristics that affect outcomes of accelerated (9 mW/cm2 for 10 minutes) corneal cross-linking (CXL). DESIGN Prospective single-center observational cohort study. METHODS We enrolled 612 eyes of 391 subjects with progressive keratoconus (n = 589), pellucid marginal degeneration (n = 11), and laser in situ keratomileusis-induced ectasia (n = 12). We evaluated best spectacle-corrected visual acuity (BSCVA), topography, refraction, endothelial cell density, corneal thickness, haze, intraocular pressure, and visual function before and 12 months after the CXL procedure. We tabulated the proportion of those with progression of maximum keratometry (Kmax). We included participant's race, age, sex, and the presence of preoperative apical scarring and environmental allergies in a multivariable linear regression model to determine the effect of these characteristics on outcomes. RESULTS At 1 year there was no significant change in mean Kmax (n = 569). Progression of Kmax was higher in subgroups with a baseline Kmax >58 diopters (n = 191) and those 14-18 years of age (n = 53). Preoperative BSCVA, Kmax, refraction, corneal cylinder, coma, central corneal thickness, and vision function were statistically and clinically significant predictors of outcomes (P < .001). Preoperative apical scarring led to worsening haze (P = .0001), more astigmatism (P = .002), more central corneal thinning (P = .002), and was protective to the endothelium (P = .008). Race, age, and sex affected some outcomes. CONCLUSION Mean Kmax was stable at 1 year after accelerated CXL. Younger patients and those with a higher preoperative Kmax need to be monitored closely for progression. Preoperative BSCVA, topography, refraction, CCT, and apical scarring were significant predictors of outcomes.
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Akkaya S, Ulusoy DM, Duru Z, Demirtaş AA. Long-term Outcomes of Accelerated Corneal Cross-linking in the Treatment of Keratoconus: Comparison of Hypotonic Riboflavin Solution With Standard Riboflavin Solution. J Refract Surg 2020; 36:110-117. [DOI: 10.3928/1081597x-20191218-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/17/2019] [Indexed: 11/20/2022]
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Khairy HA, Elsawy MF, Said-Ahmed K, Zaki MA, Mandour SS. Accelerated versus standard corneal cross linking in the treatment of ectasia post refractive surgery and penetrating keratoplasty: a medium term randomized trial. Int J Ophthalmol 2019; 12:1714-1719. [PMID: 31741859 DOI: 10.18240/ijo.2019.11.08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/04/2019] [Indexed: 11/23/2022] Open
Abstract
AIM To compare the clinical outcomes of the standard corneal cross linking (CXL) and the accelerated CXL in patients with progressive corneal ectasia post refractive surgery and penetrating keratoplasty. METHODS Totally 120 eyes of 83 patients scheduled to receive either standard CXL (3 mW/cm2 for a period of 30min) or accelerated CXL (18 mW/cm2 for a period of 5min). The main outcomes for comparison were the change in: maximum-K reading (K-max), manifest refractive spherical equivalent (SE), central corneal thickness (CCT), and the best corrected distance visual acuity (CDVA). RESULTS One hundred and eleven eyes completed the study. The main outcome measurement was the K-max reading. Both group showed significant improvement in the value postoperatively at 6 and 12mo. The mean change in the standard group was 1.21±0.11 D and in the accelerated group was 0.90±0.05 D at the end of 12mo postoperatively, with no statistically significant difference between the 2 groups. Similarly, CDVA improved significantly from their preoperative value in the standard group by 2.98±0.11 letters, and in the accelerated group by 2.20±0.06 letters, with no statistically significant difference between the two groups. Both of the SE, and CCT showed no statistically significant difference at the end of follow up period in each group. CONCLUSION Both standard CXL and accelerated CXL are safe and effective treatment in halting ectasia after corneal refractive surgery. The accelerated CXL results are comparable to the standard CXL with short time exposure of the cornea to ultraviolet irradiation, leading to reduced operation time, reduced operative ocular discomfort, and corneal haze.
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Affiliation(s)
- Hany A Khairy
- Department of Ophthalmology, Menoufia University Hospitals, Menoufia 35211, Egypt
| | - Moataz F Elsawy
- Department of Ophthalmology, Menoufia University Hospitals, Menoufia 35211, Egypt
| | - Khaled Said-Ahmed
- Department of Ophthalmology, Menoufia University Hospitals, Menoufia 35211, Egypt
| | - Marwa A Zaki
- Department of Ophthalmology, Menoufia University Hospitals, Menoufia 35211, Egypt
| | - Sameh S Mandour
- Department of Ophthalmology, Menoufia University Hospitals, Menoufia 35211, Egypt
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Valera-Cornejo DA, Vega-Estrada A, Alio JL. Invasive Pharmacology Outcomes with Different Corneal Cross-Linking Protocols: A Review. J Ocul Pharmacol Ther 2019; 35:475-490. [DOI: 10.1089/jop.2018.0144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
| | - Alfredo Vega-Estrada
- Miguel Hernandez University, Alicante, Spain
- VIssum Ophthalmic Corporation, Alicante, Spain
| | - Jorge L. Alio
- Miguel Hernandez University, Alicante, Spain
- VIssum Ophthalmic Corporation, Alicante, Spain
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Stone DU, Craven ER, Ahmad SI, AlBeshri A, Owaidhah OA. Glaucoma Patch Graft Surgery Utilizing Corneas Augmented with Collagen Cross-linking. Middle East Afr J Ophthalmol 2019; 26:148-152. [PMID: 31619902 PMCID: PMC6788316 DOI: 10.4103/meajo.meajo_78_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 07/14/2019] [Accepted: 08/28/2019] [Indexed: 11/04/2022] Open
Abstract
PURPOSE Glaucoma drainage device surgery (GDDS) has gained popularity, with outcomes equivalent to trabeculectomy. Erosion of the tube through the overlying conjunctiva may occur in 5%-10% of eyes. Donor corneal tissue has been used as a patch graft for GDDS. MATERIALS AND METHODS This was a prospective proof of concept study in 10 patients undergoing GDDS. From patients undergoing endothelial keratoplasty, the donor tissue (approximately 300 μ in thickness) was placed epithelial side down in a well and was allowed to soak in riboflavin solution (VibeX, Avedro, Waltham, MA, USA) for 15 min. This anterior corneal lenticule received 8 mW/cm2 ultraviolet (UV) irradiation applied for 15 min (total energy of 7.2 J/cm2). Each lenticule was then bisected and utilized for the two study participants. The tissue was sutured over the tube during the GDDS and then was covered with recipient conjunctiva as per the usual technique. Representative graft tissues were fixed and examined to determine the depth of cross-linking effect. The patients were followed for 1 year. RESULTS Histology revealed no apparent demarcation line in the cross-linked grafts; this supported a full-thickness cross-linking treatment effect. There were no intra- or postoperative complications attributed to the graft tissue. No patient developed erosion or exposure of the tube during the 1-year follow-up. CONCLUSIONS UV-riboflavin cross-linking of the corneal tissue patch graft material appears to be a safe modification when used in GDDS and warrants ongoing study. This method of patch graft can replace other costy methods used with GDD.
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Affiliation(s)
- Donald U Stone
- Department of Research, ReWilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Earl Randy Craven
- Department of Research, ReWilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Sameer I Ahmad
- Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.,Glaucoma Consultants of Washington, Virginia, USA.,Department of Ophthalmology and Visual Sciences, University of Maryland, Baltimore, Maryland, USA
| | - Ali AlBeshri
- Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Ohoud A Owaidhah
- Department of Research, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
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Knyazer B, Kormas RM, Chorny A, Lifshitz T, Achiron A, Mimouni M. Corneal Cross-linking in Thin Corneas: 1-Year Results of Accelerated Contact Lens–Assisted Treatment of Keratoconus. J Refract Surg 2019; 35:642-648. [DOI: 10.3928/1081597x-20190903-01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 09/03/2019] [Indexed: 11/20/2022]
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Accelerated Versus Conventional Corneal Collagen Cross-Linking in the Treatment of Keratoconus: A Meta-analysis and Review of the Literature. Interdiscip Sci 2019; 11:282-286. [DOI: 10.1007/s12539-019-00336-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 05/13/2019] [Accepted: 05/20/2019] [Indexed: 11/27/2022]
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Shajari M, Kolb CM, Agha B, Steinwender G, Müller M, Herrmann E, Schmack I, Mayer WJ, Kohnen T. Comparison of standard and accelerated corneal cross-linking for the treatment of keratoconus: a meta-analysis. Acta Ophthalmol 2019; 97:e22-e35. [PMID: 29855152 DOI: 10.1111/aos.13814] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 04/13/2018] [Indexed: 01/02/2023]
Abstract
PURPOSE To compare results between standard and accelerated corneal collagen cross-linking (CXL) for the treatment of progressive keratoconus. METHODS We performed literature searches in PubMed, Cochrane Library, Web of Science, ISRCTN registry, ClinicalTrials.gov, and EMBASE for studies comparing conventional Dresden (C-CXL) and accelerated CXL (A-CXL). Outcomes were clinical results and changes in corneal properties. Weighted mean differences were used to evaluate the effects. RESULTS Here, 22 studies with 1158 eyes (C-CXL: 577 eyes; A-CXL: 581 eyes) were included. At the last follow-up, C-CXL was superior regarding minimum keratometry (p < 0.00001) and demarcation line depth (p < 0.00001), whereas A-CXL should be favoured when considering minimum corneal thickness (p = 0.0005). No differences in uncorrected and corrected distance visual acuity (p = 0.09 and 0.98), spherical equivalent (p = 0.11), spherical and cylindrical error (p = 0.29 and 0.32), maximal and average keratometry (p = 0.05 and 0.65), central corneal thickness (p = 0.15), corneal biomechanical properties (p ≥ 0.21 respectively), time of reepithelialization (p = 0.76), subbasal nerve density (p = 0.69), endothelial cell density (p = 0.30) and morphology (p ≥ 0.40 respectively) were found among both groups. CONCLUSION Consideration of less corneal thinning favours A-CXL, whereas the deeper demarcation line and greater changes in minimum keratometric values in C-CXL may indicate a higher treatment efficacy. Altogether, C-CXL, as well as A-CXL, provides successful results in the strengthening of corneal tissue.
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Affiliation(s)
- Mehdi Shajari
- Department of Ophthalmology; Goethe-University; Frankfurt Germany
| | - Carolin M. Kolb
- Department of Ophthalmology; Goethe-University; Frankfurt Germany
| | - Bishr Agha
- Department of Ophthalmology; Goethe-University; Frankfurt Germany
| | | | - Michael Müller
- Department of Ophthalmology; Goethe-University; Frankfurt Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modeling; Goethe-University; Frankfurt Germany
| | - Ingo Schmack
- Department of Ophthalmology; Goethe-University; Frankfurt Germany
| | - Wolfgang J. Mayer
- Department of Ophthalmology; Ludwig Maximilians University; Munich Germany
| | - Thomas Kohnen
- Department of Ophthalmology; Goethe-University; Frankfurt Germany
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Randomized Study of Collagen Cross-Linking With Conventional Versus Accelerated UVA Irradiation Using Riboflavin With Hydroxypropyl Methylcellulose: Two-Year Results. Cornea 2019; 38:203-209. [PMID: 30365412 DOI: 10.1097/ico.0000000000001791] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the clinical outcome 2 years after corneal collagen cross-linking (CXL) with conventional and accelerated ultraviolet A (UVA) irradiation using riboflavin with hydroxypropyl methylcellulose. METHODS Prospective randomized controlled study. Forty patients with keratoconus (40 eyes) were randomized to either CXL using conventional 3 mW/cm UVA irradiation for 30 minutes (CXL30 group) or accelerated 9 mW/cm UVA irradiation for 10 minutes (CXL10 group). In both groups, a solution of 0.1% riboflavin with 1.1% hydroxypropyl methylcellulose (methylcellulose-riboflavin) was used. Uncorrected distance visual acuity, corrected distance visual acuity (CDVA), and Scheimpflug tomography were performed at baseline and after 24 months. RESULTS Both groups had statistically significant improvement in CDVA and maximum keratometric reading compared with baseline; however, with no statistically significant difference in the change between the 2 groups. No significant changes in flattest, steepest and mean keratometry (K1, K2 and K mean) were found in either of the groups. There were no statistically significant changes in ECD in either group after 2 years or in the difference in the change between the 2 groups. A literature review showed comparative clinical outcome after accelerated CXL compared with conventional CXL; however, in several studies, there was a tendency for less pronounced corneal flattening after accelerated CXL. CONCLUSIONS Improvement in visual acuity and maximum keratometric reading 2 years after CXL was found after both conventional and accelerated UVA irradiation using methylcellulose-riboflavin. This suggests that when using riboflavin with methylcellulose, the less time-consuming accelerated protocol is a valuable and effective option in CXL treatment.
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Herber R, Kunert KS, Veliká V, Spoerl E, Pillunat LE, Raiskup F. Influence of the beam profile crosslinking setting on changes in corneal topography and tomography in progressive keratoconus: Preliminary results. J Cataract Refract Surg 2018; 44:718-724. [PMID: 29778454 DOI: 10.1016/j.jcrs.2018.03.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 03/06/2018] [Accepted: 03/23/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE To evaluate the effect of accelerated corneal crosslinking (CXL) with a "higher peripheral intensity" profile setting compared with a standard "top hat" profile setting performed using different CXL systems. SETTING Department of Ophthalmology, University Hospital Carl Gustav Carus, Dresden, Germany. DESIGN Retrospective case series. METHODS Eyes from patients with progressive keratoconus were included. Group 1 included eyes treated with the higher peripheral intensity profile. Group 2 included eyes treated with the top hat profile. Accelerated CXL was performed based on the modified Dresden protocol (9 mW/cm2, 10 minutes). Corneal-topography and tomography are characterized using the Pentacam Scheimpflug system. RESULTS The study comprised 45 eyes (25 eyes in Group 1, 20 eyes in Group 2) from 45 patients. The keratometry (K) at the apex (maximum K) decreased significantly from 54.95 diopters (D) ± 6.73 (SD) to 53.21 ± 6.05 D for Group 1 (P < .001) and from 57.29 ± 7.16 D to 56.48 ± 6.88 D for Group 2 (P = .01). In Group 1, flat K (K1) and steep K (K2) decreased significantly after treatment (P < .05). The thinnest corneal thickness decreased significantly by -17.5 ± 21.9 μm (P = .001) in Group 1. In Group 2, no significant flattening was observed in K1 and K2 (P > .05), and the thinnest corneal thickness showed a slight but not significant thinning (P = .097). CONCLUSIONS In Group 1 (the higher peripheral intensity group), the corneal topographic and tomographic parameters improved significantly after accelerated CXL. The higher peripheral intensity profile effect on keratoconic cornea flattening seemed to be more pronounced compared with the top hat profile.
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Affiliation(s)
- Robert Herber
- From the Department of Ophthalmology (Herber, Spoerl, Pillunat, Raiskup), University Hospital Carl Gustav Carus, Dresden, and the Ernst-Abbe-University of Applied Sciences (Kunert), Jena, Germany; Department of Ophthalmology (Veliká, Raiskup), University Hospital Hradec Králové, Charles University, Prague, Czech Republic.
| | - Kathleen S Kunert
- From the Department of Ophthalmology (Herber, Spoerl, Pillunat, Raiskup), University Hospital Carl Gustav Carus, Dresden, and the Ernst-Abbe-University of Applied Sciences (Kunert), Jena, Germany; Department of Ophthalmology (Veliká, Raiskup), University Hospital Hradec Králové, Charles University, Prague, Czech Republic
| | - Věra Veliká
- From the Department of Ophthalmology (Herber, Spoerl, Pillunat, Raiskup), University Hospital Carl Gustav Carus, Dresden, and the Ernst-Abbe-University of Applied Sciences (Kunert), Jena, Germany; Department of Ophthalmology (Veliká, Raiskup), University Hospital Hradec Králové, Charles University, Prague, Czech Republic
| | - Eberhard Spoerl
- From the Department of Ophthalmology (Herber, Spoerl, Pillunat, Raiskup), University Hospital Carl Gustav Carus, Dresden, and the Ernst-Abbe-University of Applied Sciences (Kunert), Jena, Germany; Department of Ophthalmology (Veliká, Raiskup), University Hospital Hradec Králové, Charles University, Prague, Czech Republic
| | - Lutz E Pillunat
- From the Department of Ophthalmology (Herber, Spoerl, Pillunat, Raiskup), University Hospital Carl Gustav Carus, Dresden, and the Ernst-Abbe-University of Applied Sciences (Kunert), Jena, Germany; Department of Ophthalmology (Veliká, Raiskup), University Hospital Hradec Králové, Charles University, Prague, Czech Republic
| | - Frederik Raiskup
- From the Department of Ophthalmology (Herber, Spoerl, Pillunat, Raiskup), University Hospital Carl Gustav Carus, Dresden, and the Ernst-Abbe-University of Applied Sciences (Kunert), Jena, Germany; Department of Ophthalmology (Veliká, Raiskup), University Hospital Hradec Králové, Charles University, Prague, Czech Republic
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Long-term database analysis of conventional and accelerated crosslinked keratoconic mid-European eyes. Graefes Arch Clin Exp Ophthalmol 2018. [PMID: 29525838 DOI: 10.1007/s00417-018-3955-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
PURPOSE To investigate the long-term efficacy of accelerated corneal collagen cross-linking (CXL) in a large mid-European cohort with progressive keratoconus. METHODS Four hundred thirteen eyes of 316 patients with progressive keratoconus were enrolled and treated with conventional (group A) or accelerated (group B) CXL. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), slit lamp, and Pentacam® examinations were performed before and 12, 24, and 36 months after surgery. Maximum and mean anterior keratometry (Kmax, Kmf), corneal topography indices, and corneal pachymetry (TCT) were examined within each group and between groups. Further subgroup analysis of mild and moderate keratoconic eyes was performed. RESULTS One hundred thirty-one eyes of 101 patients were treated in group A, 282 eyes of 215 patients in group B. (UDVA, CDVA) and Kmax improved within each group, but not statistically significantly between groups after 36 months (p = 0.081, p = 0.344, p = 0.113, respectively). Kmf remained stable in both groups. TCT decreased significantly in group A (p = 0.014), but remained stable in group B (p = 0.063). Subgroup analysis showed similar results with improvement in visual acuity and keratometry and decrease of TCT. Corneal topography indices showed no differences between the groups after 36 months, but developed differently in the subgroup analysis. No correlation was detected between the change of corneal topography indices and TCT with regard to preoperative Kmax. CONCLUSION In a large mid-European study population including subgroup analysis of mild and moderate keratoconus, accelerated CXL showed similar results to conventional CXL regarding keratometry, corneal topography indices, and CDVA, but further improvement of UDVA. Preoperative Kmax did not affect the postoperative course of corneal topography indices and TCT.
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Comparative study of long-term outcomes of accelerated and conventional collagen crosslinking for progressive keratoconus. Eye (Lond) 2017; 32:32-38. [PMID: 29219951 DOI: 10.1038/eye.2017.296] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 11/09/2017] [Indexed: 01/22/2023] Open
Abstract
PurposeTo compare the long-term outcomes of accelerated corneal collagen crosslinking (CXL) to conventional CXL for progressive keratoconus.Patients and methodsComparative clinical study of consecutive progressive keratoconic eyes that underwent either accelerated CXL (9 mW/cm2 ultraviolet A (UVA) light irradiance for 10 min) or conventional CXL (3 mW/cm2 UVA light irradiance for 30 min). Eyes with minimum 12 months' follow-up were included. Post-procedure changes in keratometry readings (Flat meridian: K1; steep meridian: K2), central corneal thickness (CCT), best spectacle-corrected visual acuity (BSCVA), and manifest refraction spherical equivalent (MRSE) were analysed.ResultsA total of 42 eyes were included. In all, 21 eyes had accelerated CXL (20.5±5.5 months' follow-up) and 21 eyes had conventional CXL group (20.2±5.6 months' follow-up). In the accelerated CXL group, a significant reduction in K2 (P=0.02), however no significant change in K1 (P=0.35) and CCT (P=0.62) was noted. In the conventional CXL group, a significant reduction was seen in K1 (P=0.01) and K2 (P=0.04), but not in CCT (P=0.95). Although both groups exhibited significant reductions in K2 readings, no noteworthy differences were noted between them (P=0.36). Improvements in BSCVA (accelerated CXL; P=0.22 and conventional CXL; P=0.20) and MRSE (accelerated CXL; P=0.97 and conventional CXL; P=0.54) were noted, however were not significant in either group.ConclusionAccelerated and conventional CXL appear to be effective procedures for stabilising progressive keratoconus in the long-term.
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Kortuem KU, Vounotrypidis E, Athanasiou A, Müller M, Babenko A, Kern C, Priglinger S, Mayer WJ. Differences in corneal clinical findings after standard and accelerated cross-linking in patients with progressive keratoconus. BMC Ophthalmol 2017; 17:222. [PMID: 29183298 PMCID: PMC5706400 DOI: 10.1186/s12886-017-0610-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 11/16/2017] [Indexed: 12/02/2022] Open
Abstract
Background The purpose of this study was to identify differences in clinical corneal findings after standard and accelerated epithelial off cross-linking (CXL) during a long-term follow-up. Methods Two hundred forty-one patients (184 male) were included in this monocentric, retrospective, non-randomized and unmasked study. One hundred forty-eight eyes were treated with the accelerated protocol and 138 with the standard protocol with epithelial off CXL, if diagnosed with keratoconus and a progression in Kmax of more than one dioptre during the preceding 6 months, plus a minimal pachymetry measurement of 400 μm in keratometry (Pentacam, Oculus GmbH, Wetzlar, Germany). Exclusion criteria were previous surgery, other corneal conditions or age above 50 years. Follow-up time was 36 months with clinical examination and keratometry at every visit. Outcome measures were the observed rate of corneal changes, differences between treatment groups and correlation with keratometry measurements. Results In patients with accelerated CXL, significantly more clear corneas were seen at three (p = 0.015) and six (p = 0.002) months after surgery than following the standard protocol. The rate of clear corneas dropped from 52.2% pre-operation (OP) to a minimum of 19.3% after 6 months in the standard protocol group compared with 50.7% clear corneas pre-OP and a minimum of 40.8% in the accelerated group. In the standard protocol group, more striae were found 3 months after intervention than in the accelerated group (p = 0.05). Conclusions In patients with accelerated CXL, fewer morphological corneal changes were observed than after conventional CXL. However, rarely, corneal changes persisted for a long time.
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Affiliation(s)
- Karsten U Kortuem
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Mathildenstr. 8, 80336, Munich, Germany.
| | - Efstathios Vounotrypidis
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Alexandros Athanasiou
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Michael Müller
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Alexander Babenko
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Christoph Kern
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Siegfried Priglinger
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Wolfgang J Mayer
- Department of Ophthalmology, Ludwig-Maximilians-University Munich, Mathildenstr. 8, 80336, Munich, Germany
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Liu Y, Liu Y, Zhang YN, Li AP, Zhang J, Liang QF, Jie Y, Pan ZQ. Systematic review and Meta-analysis comparing modified cross-linking and standard cross-linking for progressive keratoconus. Int J Ophthalmol 2017; 10:1419-1429. [PMID: 28944203 DOI: 10.18240/ijo.2017.09.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 06/26/2017] [Indexed: 11/23/2022] Open
Abstract
AIM To compare the effectiveness and safety between modified cross-linking (MC) and standard cross-linking (SC) in mild or moderate progressive keratoconus. METHODS Eligible studies were retrieved from four electronic databases, including CENTRAL, Clinical Trials gov, PupMed and OVID MEDLINE. We set post-surgical maximum K value (Kmax) as the primary outcome. In addition, uncorrected and corrected distant visual acuity (UDVA and UDVA), spherical equivalent (SE), endothelial cell density (ECD), central cornea thickness (CCT) and depth of demarcation line (DDL) were Meta-analyzed as secondary outcomes. Mean differences for these outcomes were pooled through either a random-effect model or fixed-effect model according to data heterogeneity. RESULTS Twenty-four comparative studies either on accelerated cross-linking (AC) compared with SC or on trans-epithelial cross-linking (TC) compared with SC were included and pooled for analysis. The results indicated that MC was significantly inferior to SC at delaying Kmax deterioration [AC vs SC 0.49 (95% CI: 0.04-0.94, I2=75%, P=0.03); TC vs SC 1.15 (95% CI: 0.54-1.75, I2=50%, P=0.0002)]. SE decreased significantly for SC when compared to AC [0.62 (95% CI: 0.38-0.86, I2=22%, P<0.00001)]. DDL of SC was more significantly deeper than that of TC [-133.49 (95% CI: -145.94 to -121.04, I2=33%, P<0.00001)]. Other outcomes demonstrated comparable results between MC and SC. CONCLUSION SC is more favorable at halting the progression of keratoconus, but visual acuity improvement showed comparable results between MCs and SC.
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Affiliation(s)
- Yang Liu
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Yi Liu
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Ying-Nan Zhang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Ai-Peng Li
- Department of Ophthalmology, First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Jing Zhang
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Qing-Feng Liang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Ying Jie
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
| | - Zhi-Qiang Pan
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology and Visual Sciences Key Laboratory, Beijing 100005, China
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Andreanos KD, Hashemi K, Petrelli M, Droutsas K, Georgalas I, Kymionis GD. Keratoconus Treatment Algorithm. Ophthalmol Ther 2017; 6:245-262. [PMID: 28755306 PMCID: PMC5693837 DOI: 10.1007/s40123-017-0099-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Indexed: 11/25/2022] Open
Abstract
Keratoconus management has significantly changed over the last two decades. The advent of new interventions such as cornea cross-linking, intrastromal corneal ring segments, and combined treatments provide corneal clinicians a variety of treatment options for the visual rehabilitation of keratoconus patients. This review summarizes current evidence for these treatments and highlights their place in keratoconus management while new promising emerging therapies are being investigated.
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Affiliation(s)
- Konstantinos D Andreanos
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece.
| | - Kate Hashemi
- Faculty of Biology and Medicine, Jules Gonin Eye Hospital, University of Lausanne, Lausanne, Switzerland
| | - Myrsini Petrelli
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Droutsas
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece
| | - Ilias Georgalas
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece
| | - George D Kymionis
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece
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Sterile corneal infiltrates after simultaneous photorefractive keratectomy and corneal crosslinking. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.jcro.2017.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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36
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Accelerated versus conventional corneal crosslinking for refractive instability: an update. Curr Opin Ophthalmol 2017; 28:343-347. [PMID: 28594649 DOI: 10.1097/icu.0000000000000375] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Corneal crosslinking (CXL) is a relatively new treatment modality offering refractive stability in patients with ectatic disorders. The procedure as initially described (Dresden protocol) is time consuming; accelerated protocols have been lately developed. The purpose of this review is to present the recent findings regarding the comparison of accelerated CXL with the conventional Dresden protocol. RECENT FINDINGS A variety of accelerated protocols are described in the literature. Safety and efficacy of the procedures with regard to stability seem to be equivalent in initial studies but indirect measures of efficacy, such as demarcation line depth and laboratory measurements, do not always confirm equivalence of accelerated protocols in comparison to conventional one. Modified accelerated protocols must be developed in order to overcome this. SUMMARY Accelerated CXL protocols seem to be a valid alternative to the conventional protocol; however, more comparative long term studies are needed to confirm the validity and to elucidate which accelerated protocol is ideal in each case.
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Biomechanical and Histopathologic Effects of Pulsed-Light Accelerated Epithelium-On/-Off Corneal Collagen Cross-Linking. Cornea 2017; 36:854-859. [DOI: 10.1097/ico.0000000000001219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ameen SS, Mehboob MA, Ali K. Efficacy and safety of transepithelial collagen cross linking for progressive keratoconus. Pak J Med Sci 2016; 32:1111-1115. [PMID: 27882004 PMCID: PMC5103116 DOI: 10.12669/pjms.325.10922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To evaluate the efficacy and safety of transepithelial (TE) collagen cross-linking (CXL) in patients with progressive keratoconus (KC). Methods: This Quasi Experimental Study was conducted at PNS Shifa Naval Hospital, Karachi from June 2015 to June 2016. Sixty eyes of 32 patients who underwent TE CXL for progressive KC from June 2015 to June 2016 were analysed to ascertain efficacy and safety of TE CXL procedure. Statistical analysis of the data was done using SPSS version 17.0. Results: Twenty eight (87.5%) patients underwent TE CXL bilaterally, while 4 (12.5%) underwent unilateral CXL. Mean change in astigmatism, Maximum simulated Keratometry value (Kmax), Spherical equivalent (SE) and Central Corneal Thickness (CCT) were -0.67±0.35D, 1.28±0.64D, -0.58±0.17D and 0.40±7.58µm respectively, from baseline. Mean gain in lines on Snellen’s visual acuity chart was 1.13±0.83 lines. Changes in astigmatism, Kmax and SE were statistically significant (p<0.001), while change in CCT was not statistically significant. The procedure had excellent safety profile, with no major complication till 6 months follow up period. Conclusion: TE CXL is a safe and effective procedure with statistically significant reduction in corneal astigmatism, Kmax and SE with reasonable gain in Snellen’s visual acuity.
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Affiliation(s)
- Sameer Shahid Ameen
- Prof. Sameer Shahid Ameen, MCPS, FCPS. Department of Ophthalmology, PNS Shifa Naval Hospital, Karachi, Pakistan
| | - Mohammad Asim Mehboob
- Dr. Mohammad Asim Mehboob, MBBS. Department of Ophthalmology, PNS Shifa Naval Hospital, Karachi, Pakistan
| | - Kashif Ali
- Dr. Kashif Ali, FCPS. Department of Ophthalmology, PNS Shifa Naval Hospital, Karachi, Pakistan
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Aldahlawi NH, Hayes S, O'Brart DPS, O'Brart ND, Meek KM. An investigation into corneal enzymatic resistance following epithelium-off and epithelium-on corneal cross-linking protocols. Exp Eye Res 2016; 153:141-151. [PMID: 27765574 PMCID: PMC5131611 DOI: 10.1016/j.exer.2016.10.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/10/2016] [Accepted: 10/14/2016] [Indexed: 11/28/2022]
Abstract
The aim of this study was to investigate corneal enzymatic resistance following epithelium off and on riboflavin/UVA cross-linking (CXL). One hundred and fourteen porcine eyes were divided into four non-irradiated control groups and seven CXL groups. The latter comprised; (i) epithelium-off, 0.1% iso-osmolar riboflavin, 9 mW UVA irradiation for 10 min, (ii) disrupted epithelium, 0.1% hypo-osmolar riboflavin, 9 mW UVA for 10 min, (iii) epithelium-on, 0.25% hypo-osmolar riboflavin with 0.01% benzylalkonium chloride (BACS), 9 mW UVA for 10 min, (iv) epithelium-on, 5 min iontophoresis at 0.1 mA for 5 min with 0.1% riboflavin solution, 9 mW UVA for 10 min or (v) 12.5 min, (vi) epithelium-on, prolonged iontophoresis protocol of 25 min with 1.0 mA for 5 min and 0.5 mA for 5 min with 0.25% riboflavin with 0.01% BACS, 9 mW UVA for 10 min or (vii) 12.5 min. Enzymatic resistance was assessed by daily measurement of a corneal button placed in pepsin solution and measurement of corneal button dry weight after 11 days of digestion. This study revealed that the enzymatic resistance was greater in CXL corneas than non-irradiated corneas (p < 0.0001). Epithelium-off CXL showed the greatest enzymatic resistance (p < 0.0001). The prolonged iontophoresis protocol was found to be superior to all other trans-epithelial protocols (p < 0.0001). A 25% increase in UVA radiance significantly increased corneal enzymatic resistance (p < 0.0001). In conclusion, although epithelium-on CXL appears to be inferior to epithelium-off CXL in terms of enzymatic resistance to pepsin digestion, the outcome of epithelium-on CXL may be significantly improved through the use of higher concentrations of riboflavin solution, a longer duration of iontophoresis and an increase in UVA radiance. Epi-off CXL is superior to epi-on CXL in terms of enzymatic resistance. Epi-on CXL effectiveness can be improved by using a prolonged iontophoresis protocol. Higher riboflavin concentrations and increased UVA radiance may also enhance epi-on CXL.
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Affiliation(s)
- Nada H Aldahlawi
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ, UK
| | - Sally Hayes
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ, UK
| | - David P S O'Brart
- Keratoconus Research Institute, Department of Ophthalmology, St Thomas Hospital, London, SE1 7EH, UK
| | - Naomi D O'Brart
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ, UK
| | - Keith M Meek
- Structural Biophysics Research Group, School of Optometry and Vision Sciences, Cardiff University, Maindy Road, Cardiff, CF24 4HQ, UK.
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