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Neuhann L, Vogel D, Hall J, Dreyhaupt J, Werner JU, Garip-Kuebler A, Enders C. Keratometry Changes Between Year One to Seven After Corneal Cross-Linking in Patients With Keratoconus. Cornea 2024; 43:1397-1402. [PMID: 38289746 DOI: 10.1097/ico.0000000000003478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/10/2023] [Indexed: 02/01/2024]
Abstract
PURPOSE We evaluated the timing at and extent to which midterm to long-term keratometric changes can occur in year 1 to 7 after corneal collagen cross-linking (CXL) in patients with keratoconus. METHODS We conducted a subgroup analysis of a retrospective cohort study of all consecutive patients who underwent CXL at our cornea center between 2007 and 2011. The inclusion criteria comprised CXL according to the Dresden protocol and a full set of keratometry parameters collected by Scheimpflug tomography preoperatively and at year 1, 3, 5, and 7 after CXL. In addition, best-corrected visual acuity was evaluated. RESULTS Sixty-three eyes of 47 patients were enrolled. Mean age was 25.46 years ±7.39 years (80.9% male patients). All relevant keratometric parameters showed significant improvement at year 1 after CXL (except for posterior astigmatism). According to mixed-effects model analysis, they all showed further significant change at different points in time between year 1, 3, 5, and 7 (except for K1). In addition, best-corrected visual acuity improved statistically significant between year 1, 3, 5, and 7. Suspected disease progression was noted in 22.2% of patients, mostly between year 1 and 3 after CXL. CONCLUSIONS After initial improvement 1 year after CXL, keratometric and functional parameters were stable until year 5 after CXL in most cases; further improvement can take place even after up to 7 years post-CXL. By contrast, in case of disease progression, changes seem to occur already between year 1 and 3 after CXL.
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Affiliation(s)
- Lukas Neuhann
- Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany
- MVZ Prof. Neuhann, Munich, Germany
| | | | | | - Jens Dreyhaupt
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany ; and
| | | | - Aylin Garip-Kuebler
- Department of Ophthalmology, Ludwig-Maximilians-University, Munich, Germany
- MVZ Prof. Neuhann, Munich, Germany
| | - Christian Enders
- MVZ Prof. Neuhann, Munich, Germany
- Department of Ophthalmology, Ulm University, Ulm, Germany
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Greenstein SA, Hersh PS. Update on corneal crosslinking for keratoconus and corneal ectasia. Curr Opin Ophthalmol 2024; 35:273-277. [PMID: 38700496 DOI: 10.1097/icu.0000000000001056] [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: 05/05/2024]
Abstract
PURPOSE OF REVIEW To review corneal crosslinking for keratoconus and corneal ectasia, and recent developments in the field. This study will review the mechanism of crosslinking, clinical approaches, current results, and potential future innovations. RECENT FINDINGS Corneal crosslinking for keratoconus was first approved by U.S. FDA in 2016. Recent studies have confirmed the general long-term efficacy of the procedure in decreasing progression of keratoconus and corneal ectasia. New types of crosslinking protocols, such as transepithelial treatments, are under investigation. In addition, adjunctive procedures have been developed to improve corneal contour and visual function in these patients. SUMMARY Crosslinking has been found to be well tolerated and effective with the goal of decreasing progression of ectatic corneal diseases, keratoconus and corneal ectasia after refractive surgery. Studies have shown its long-term efficacy. New techniques of crosslinking and adjunctive procedures may further improve treatments and results.
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Affiliation(s)
- Steven A Greenstein
- Cornea and Laser Eye Institute, CLEI Center for Keratoconus, Teaneck, and the Department of Ophthalmology, Rutgers - New Jersey Medical School, Newark, New Jersey, USA
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Cortina MS, Greiner MA, Kuo AN, Li JY, Miller DD, Shtein RM, Veldman PB, Yin J, Kim SJ, Shen JF. Safety and Efficacy of Epithelium-Off Corneal Collagen Cross-Linking for the Treatment of Corneal Ectasia: A Report by the American Academy of Ophthalmology. Ophthalmology 2024:S0161-6420(24)00282-3. [PMID: 38935041 DOI: 10.1016/j.ophtha.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/03/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE To review the evidence on the safety and effectiveness of epithelium-off corneal collagen cross-linking (CXL) for the treatment of progressive corneal ectasia. METHODS A literature search of the PubMed database was most recently conducted in March 2024 with no date restrictions and limited to studies published in English. The search identified 359 citations that were reviewed in abstract form, and 43 of these were reviewed in full text. High-quality randomized clinical trials comparing epithelium-off CXL with conservative treatment in patients who have keratoconus (KCN) and post-refractive surgery ectasia were included. The panel deemed 6 articles to be of sufficient relevance for inclusion, and these were assessed for quality by the panel methodologist; 5 were rated level I, and 1 was rated level II. There were no level III studies. RESULTS This analysis includes 6 prospective, randomized controlled trials that evaluated the use of epithelium-off CXL to treat progressive KCN (5 studies) and post-laser refractive surgery ectasia (1 study), with a mean postoperative follow-up of 2.4 years (range, 1-5 years). All studies showed a decreased progression rate in treated patients compared with controls. Improvement in the maximum keratometry (Kmax) value, corrected distance visual acuity (CDVA), and uncorrected distance visual acuity (UDVA) was observed in the treatment groups compared with control groups. A decrease in corneal thickness was observed in both groups but was greater in the CXL group. Complications were rare. CONCLUSIONS Epithelium-off CXL is effective in reducing the progression of KCN and post-laser refractive surgery ectasia in most treated patients with an acceptable safety profile. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Maria S Cortina
- Department of Ophthalmology and Visual Science, University of Illinois College of Medicine, Chicago, Illinois
| | - Mark A Greiner
- Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Anthony N Kuo
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer Y Li
- UC Davis Eye Center, University of California, Davis, California
| | - Darby D Miller
- Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida
| | - Roni M Shtein
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan
| | - Peter B Veldman
- Department of Ophthalmology & Visual Science, The University of Chicago, Chicago, Illinois
| | - Jia Yin
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Stephen J Kim
- Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Joanne F Shen
- Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
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Roszkowska AM, Scorcia V, Mencucci R, Giannaccare G, Lombardo G, Alunni Fegatelli D, Vestri A, Bifezzi L, Bernava GM, Serrao S, Lombardo M. Assessment of the Predictive Ability of Theranostics for Corneal Cross-linking in Treating Keratoconus: A Randomized Clinical Trial. Ophthalmology 2024:S0161-6420(24)00367-1. [PMID: 38908553 DOI: 10.1016/j.ophtha.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/29/2024] [Accepted: 06/13/2024] [Indexed: 06/24/2024] Open
Abstract
PURPOSE To validate the ability of theranostic imaging biomarkers in assessing corneal cross-linking (CXL) efficacy in flattening the maximum keratometry (Kmax) index. DESIGN Prospective, randomized, multicenter, masked clinical trial (ClinicalTrails.gov identifier, NCT05457647). PARTICIPANTS Fifty patients with progressive keratoconus. INTERVENTION Participants were stratified to undergo epithelium-off (25 eyes) and epithelium-on (25 eyes) CXL protocols using an ultraviolet A (UV-A) medical device with theranostic software. The device controlled UV-A light both for performing CXL and assessing the corneal riboflavin concentration (riboflavin score) and treatment effect (theranostic score). A 0.22% riboflavin formulation was applied onto the cornea for 15 minutes and 20 minutes in epithelium-off and epithelium-on protocols, respectively. All eyes underwent 9 minutes of UV-A irradiance at 10 mW/cm2. MAIN OUTCOME MEASURES The primary outcome measure was validation of the combined use of theranostic imaging biomarkers through measurement of their accuracy (proportion of correctly classified eyes) and precision (positive predictive value) to classify eyes correctly and predict a Kmax flattening at 1 year after CXL. Other outcome measures included change in Kmax, endothelial cell density, uncorrected and corrected distance visual acuity, manifest spherical equivalent refraction and central corneal thickness 1 year after CXL. RESULTS Accuracy and precision of the theranostic imaging biomarkers in predicting eyes that had >0.1 diopter (D) of Kmax flattening at 1 year were 91% and 95%, respectively. The Kmax value significantly flattened by a median of -1.3 D (IQR, -2.11 to -0.49 D; P < 0.001); both the uncorrected and corrected distance visual acuity improved by a median of -0.1 logarithm of the minimum angle of resolution (logMAR; IQR, -0.3 to 0.0 logMAR [P < 0.001] and -0.2 to 0.0 logMAR [P < 0.001], respectively). No significant changes in endothelial cell density (P = 0.33) or central corneal thickness (P = 0.07) were noted 1 year after surgery. CONCLUSIONS The study demonstrated the efficacy of integrating theranostics in a UV-A medical device for the precise and predictive treatment of keratoconus with epithelium-off and epithelium-on CXL protocols. Concentration of riboflavin and its UV-A light mediated photoactivation in the cornea are the primary factors determining CXL efficacy. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Anna Maria Roszkowska
- Ophthalmology Unit, Gaetano Martino Hospital, University of Messina, Messina, Italy; Department of Ophthalmology, Andrzej Frycz Modrzewski University, Krakow, Poland
| | - Vincenzo Scorcia
- Ophthalmology Unit, Renato Dulbecco Hospital, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Rita Mencucci
- Ophthalmology Unit, Careggi Hospital, University of Firenze, Firenze, Italy
| | - Giuseppe Giannaccare
- Eye Clinic, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | | | - Danilo Alunni Fegatelli
- Department of Public Health and Infectious Diseases, University of Roma "La Sapienza," Rome, Italy; Department of Life Sciences, Health and Health Professions, Link Campus University, Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Diseases, University of Roma "La Sapienza," Rome, Italy
| | - Luca Bifezzi
- Ophthalmology Unit, Renato Dulbecco Hospital, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Liu B, Shang X, Tan X, Luo S, Fang X, Xie Z, Xiao X, He H, Gong L, Wu H, Lin Z. Clinical and Morphological in Vivo Confocal Microscopy Findings following a Modified Biphasic Higher Fluence Transepithelial Corneal Crosslinking. Curr Eye Res 2024; 49:119-130. [PMID: 37882774 DOI: 10.1080/02713683.2023.2276680] [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: 08/03/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023]
Abstract
Purpose: To compare the refractive efficacy and morphological changes in the cornea following a novel biphasic higher fluence transepithelial corneal crosslinking (BI-TE-CXL) and transepithelial corneal crosslinking (TE-CXL) in adults keratoconus.Methods: Patients with progressive keratoconus who required corneal crosslinking were assigned to the BI-TE-CXL group (32 eyes, phase 1: 7.2 J/cm2 for 5 min and 20 s of pulsed-light exposure, KXL, Glaukos-Avedro; phase 2: 3.6 J/cm2 for 6 min and 40 s of continuous light exposure at the front curvature apex with a 6 mm diameter light spot, UVX-2000, IROC) or the TE-CXL group (32 eyes, uniform 7.2 J/cm2 for 5 min and 20 s of pulsed-light exposure, KXL, Glaukos-Avedro). Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), corneal fluorescein staining (CFS), corneal topography, anterior segment optical coherence tomography (AS-OCT), and in vivo corneal confocal microscopy (IVCM) were performed 3, 6, 12 and 24 months after surgery.Results: The CFS scores in the BI-TE-CXL group were significantly higher than those in the TE-CXL group on the first two days after surgery (p < 0.001). The Kmax (at 12 and 24 months) and CDVA (logMAR) were significantly lower in the BI-TE-CXL group than those in the TE-CXL group (p < 0.05). The corneal demarcation line under AS-OCT was visible in 81.3% of patients in the BI-TE-CXL group and 15.6% in the TE-CXL group. The depth of the demarcation line under IVCM was significantly deeper in the BI-TE-CXL group (248.3 ± 25.0 μm) than that of the TE-CXL group (136.5 ± 15.6 μm) in the central cornea (p < 0.001). The cross-linked collagen structures in the central cornea were still present after 12 months in the BI-TE-CXL group. No significant difference in sub-basal nerve density between the two groups (p > 0.05).Conclusions: Following BI-TE-CXL, CDVA was significantly improved, accompanied by deeper demarcation line depth and persistent crosslinked structures in the central corneal stroma.
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Affiliation(s)
- Bin Liu
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Xiamen, Fujian, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
| | - Xumin Shang
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
| | - Xiuxian Tan
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Xiamen, Fujian, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
| | - Shunrong Luo
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
| | - Xie Fang
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
| | - Zhiwen Xie
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
| | - Xianwen Xiao
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
| | - Huan He
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Research Center for Eye Diseases and Key Laboratory of Ophthalmology, Xiamen, Fujian, China
| | - Lan Gong
- Department of Ophthalmology, Eye, Ear, Nose, and, Throat Hospital of Fudan University, Shanghai, China
| | - Huping Wu
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Xiamen, Fujian, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
| | - Zhirong Lin
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
- Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Xiamen, Fujian, China
- Fujian Key Laboratory of Ocular Surface & Corneal Diseases (affiliated Xiamen Eye Center of, Xiamen University), Xiamen, Fujian, China
- Xiamen Municipal Key Laboratory of Ocular Surface & Corneal Diseases, Xiamen, Fujian, China
- Xiamen Research Center for Eye Diseases and Key Laboratory of Ophthalmology, Xiamen, Fujian, China
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Qin D, Han Y, Wang L, Yin H. Recent advances in medicinal compounds related to corneal crosslinking. Front Pharmacol 2023; 14:1232591. [PMID: 37841929 PMCID: PMC10570464 DOI: 10.3389/fphar.2023.1232591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/21/2023] [Indexed: 10/17/2023] Open
Abstract
Corneal crosslinking (CXL) is the recognized technique to strengthen corneal collagen fibers through photodynamic reaction, aiming to halt progressive and irregular changes in corneal shape. CXL has greatly changed the treatment for keratoconus (KCN) since it was introduced in the late 1990's. Numerous improvements of CXL have been made during its developing course of more than 20 years. CXL involves quite a lot of materials, including crosslinking agents, enhancers, and supplements. A general summary of existing common crosslinking agents, enhancers, and supplements helps give a more comprehensive picture of CXL. Either innovative use of existing materials or research and development of new materials will further improve the safety, effectiveness, stability, and general applicability of CXL, and finally benefit the patients.
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Affiliation(s)
- Danyi Qin
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Eye Institute and Affiliated Xiamen Eye Center, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Yi Han
- Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Eye Institute and Affiliated Xiamen Eye Center, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Lixiang Wang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongbo Yin
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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