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Retrospective Analysis of Sterile Corneal Infiltrates in Patients with Keratoconus after Cross-Linking Procedure. J Clin Med 2022; 11:jcm11030585. [PMID: 35160037 PMCID: PMC8836725 DOI: 10.3390/jcm11030585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background: This paper’s objective is to analyze patients with keratoconus who developed sterile infiltrate after corneal collagen cross-linking (CXL), and to evaluate possible risk factors for their occurrence. Methods: 543 medical histories of patients after cross-linking (Epi-off, Epi-on) procedure performed according to the Dresden protocol were analyzed retrospectively. Results: Sterile corneal infiltrates occurred in four men (0.7%) in the age range (16–28) years, the average age being 20.3. The average time from procedure to onset of symptoms was 3.5 days (2–5 days). Inflammatory infiltration resolved in all patients, leaving scars on corneal stroma in two patients. Corneal healing time ranged from 4–12 weeks. In vivo confocal microscopy (IVCM), round inflammatory cells, and Langerhans cells in the epithelium and Bowman’s layer were observed at the site of infiltration. The Optical coherence tomography (OCT) shows hyperreflective lesions of various sizes which decreased over time. The corneal topographic parameters and Best-corrected visual acuity (BCVA) improved after the CXL procedure in all of the described cases. Conclusions: Most likely, damage to the epithelium and the phototoxic effect of the procedure is of significant importance in the formation of sterile corneal infiltrates. Appropriate classification and selection of CXL procedures in combination with protective measures in people at risk may have an overwhelming impact on the incidence of this complication.
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Chan E, Snibson GR. Current status of corneal collagen cross‐linking for keratoconus: a review. Clin Exp Optom 2021; 96:155-64. [DOI: 10.1111/cxo.12020] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 09/24/2012] [Accepted: 10/03/2012] [Indexed: 11/29/2022] Open
Affiliation(s)
- Elsie Chan
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia,
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Sterile keratitis following standard corneal collagen crosslinking: A case series and literature review. J Fr Ophtalmol 2019; 42:603-611. [DOI: 10.1016/j.jfo.2018.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 10/25/2018] [Accepted: 11/09/2018] [Indexed: 11/22/2022]
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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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García de Oteyza G, Álvarez de Toledo J. Sterile infiltrates after cross-linking. ACTA ACUST UNITED AC 2017; 92:451-454. [PMID: 28552439 DOI: 10.1016/j.oftal.2017.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 01/02/2017] [Accepted: 01/10/2017] [Indexed: 11/18/2022]
Abstract
CASE REPORT A 20 year-old woman presented with an asymmetric bilateral keratoconus. Cross-linking of the right eye was performed due of its topographic and pachymetric conditions. Three days after the procedure, the patient presented with some corneal infiltrates that where classified as sterile. DISCUSSION Cross-linking is known for its efficacy and safety. Nevertheless, there can be complications. Sterile infiltrates have already been described, although their aetiology is still not clear.
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Affiliation(s)
- G García de Oteyza
- Servicio de Córnea y Segmento Anterior, Centro de Oftalmología Barraquer, Barcelona, España.
| | - J Álvarez de Toledo
- Servicio de Córnea y Segmento Anterior, Centro de Oftalmología Barraquer, Barcelona, España
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Esteve-Taboada JJ, Domínguez-Vicent A, Ferrer-Blasco T, Alfonso JF, Montés-Micó R. Posterior chamber phakic intraocular lenses to improve visual outcomes in keratoconus patients. J Cataract Refract Surg 2017; 43:115-130. [DOI: 10.1016/j.jcrs.2016.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/06/2016] [Accepted: 05/25/2016] [Indexed: 12/01/2022]
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Abstract
: Collagen cross-linking (CXL) is a procedure that primarily aims to increase corneal stiffness. Although used for a variety of conditions, it is most commonly applied to the treatment of keratoconus. Collagen cross-linking involves irradiation of the cornea with ultraviolet A (UVA) irradiation after it has been soaked with riboflavin (vitamin B), a photosensitizer. In conventional treatment, based on the Dresden protocol, a minimum corneal thickness threshold of 400 μm is recommended and UVA (370 nm) irradiation of 3 mW/cm irradiance is applied for 30 min, resulting in a cumulative dose of 5.4 J/cm. Evidence presented in this review shows that conventional CXL stabilizes the vision and corneal topographic parameters in the majority of treated patients, with only a small failure rate. It has a good safety profile with no endothelial cell loss and a small risk of corneal infiltration and infection. To reduce the treatment duration, accelerated protocols of similar efficacy have been sought. In accelerated protocols, UVA irradiation of higher irradiance, typically 9 mW/cm, is applied for a shorter time, typically 10 min. The evidence, limited to small studies with short follow-up, shows that they may also stabilize the vision and the ectasia, with no additional safety concerns highlighted. Randomized controlled studies are, however, required to confirm the encouraging results and noninferiority to conventional treatment.
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Xu K, Chan TCY, Vajpayee RB, Jhanji V. Corneal Collagen Cross-linking: A Review of Clinical Applications. Asia Pac J Ophthalmol (Phila) 2015; 4:300-6. [PMID: 26381468 DOI: 10.1097/apo.0000000000000145] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Corneal collagen cross-linking (CXL) has been shown to slow down or stop the progression of keratoconus. In addition, CXL has been applied in cases of corneal ectasia. Recent reports of the use of CXL in cases of infectious keratitis have generated further interest in this treatment modality. This review discusses the principle, clinical uses, and complications associated with CXL.
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Affiliation(s)
- Kunyong Xu
- From the *Department of Ophthalmology, Queen's University, Kingston, Canada; †Department of Ophthalmology, Hotel Dieu and Kingston General Hospitals, Kingston, Canada; ‡Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong; §Hong Kong Eye Hospital, Hong Kong; ¶Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia; ∥Vision Eye Institute, Royal Victorian Eye and Ear Hospital, North West Academic Centre University of Melbourne, Melbourne, Australia; and **Department of Ophthalmology, Prince of Wales Hospital, Hong Kong
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Javadi MA, Feizi S. Sterile Keratitis following Collagen Crosslinking. J Ophthalmic Vis Res 2015; 9:510-3. [PMID: 25709779 PMCID: PMC4329714 DOI: 10.4103/2008-322x.150832] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 12/26/2013] [Indexed: 11/18/2022] Open
Abstract
Purpose: To report a keratoconic eye that developed severe sterile keratitis and corneal scar after collagen crosslinking necessitating corneal transplantation. Case Report: A 26-year-old man with progressive keratoconus underwent collagen crosslinking and presented with severe keratitis 72 hours after the procedure. The initial impression was infectious corneal ulcer and a fortified antibiotic regimen was administered. However, the clinical course and confocal microscopy results prompted a diagnosis of sterile keratitis. The eye developed severe corneal scars leading to reduced visual acuity and necessitating corneal transplantation. Conclusion: Sterile keratitis may develop after collagen crosslinking resulting in profound visual loss leading to corneal transplantation.
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Affiliation(s)
- Mohammad-Ali Javadi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sepehr Feizi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Kamiya K, Shimizu K, Kobashi H, Igarashi A, Komatsu M, Nakamura A, Kojima T, Nakamura T. Three-year follow-up of posterior chamber toric phakic intraocular lens implantation for the correction of high myopic astigmatism in eyes with keratoconus. Br J Ophthalmol 2014; 99:177-83. [PMID: 25147365 DOI: 10.1136/bjophthalmol-2014-305612] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To assess the clinical outcomes following the use of toric implantable collamer lenses (toric ICL, STAAR Surgical) for the correction of high myopic astigmatism with keratoconus. METHODS This retrospective study evaluated 21 eyes of 11 patients with spherical equivalents of -9.70±2.33 D (mean±SD) and astigmatism of -3.21±1.56 D who underwent toric ICL implantation for keratoconus. Preoperatively, and at 1, 3 and 6 months and 1, 2 and 3 years postoperatively, we assessed the safety, efficacy, predictability, stability and adverse events of the surgery. RESULTS The logarithm of the minimum angle of resolution (logMAR) uncorrected distance visual acuity (UDVA) and the logMAR corrected distance visual acuity (CDVA) were -0.06±0.11 and -0.12±0.09, respectively, at 3 years postoperatively. At 3 years, 67% and 86% of the eyes were within ±0.5 and ±1.0 D, respectively, of the targeted correction. Manifest refraction changes of 0.04±0.33 D occurred from 1 month to 3 years postoperatively. No significant change in manifest refraction (analysis of variance, p=0.989) or keratometry (p=0.951), or vision-threatening complications occurred during the observation period. CONCLUSIONS Toric ICL implantation is beneficial according to measures of safety, efficacy, predictability and stability for the correction of refractive errors for keratoconus during a 3-year observation period. The disease did not progress even in the late-postoperative period, suggesting the viability of this procedure as a surgical option for the treatment of such eyes.
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Affiliation(s)
- Kazutaka Kamiya
- Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa, Japan
| | - Kimiya Shimizu
- Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa, Japan
| | - Hidenaga Kobashi
- Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa, Japan
| | - Akihito Igarashi
- Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa, Japan
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Craig JA, Mahon J, Yellowlees A, Barata T, Glanville J, Arber M, Mandava L, Powell J, Figueiredo F. Epithelium-Off Photochemical Corneal Collagen Cross-Linkage Using Riboflavin and Ultraviolet A for Keratoconus and Keratectasia: A Systematic Review and Meta-Analysis. Ocul Surf 2014; 12:202-14. [DOI: 10.1016/j.jtos.2014.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 05/01/2014] [Accepted: 05/02/2014] [Indexed: 01/23/2023]
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Seiler TG, Schmidinger G, Fischinger I, Koller T, Seiler T. [Complications of corneal cross-linking]. Ophthalmologe 2014; 110:639-44. [PMID: 23760422 DOI: 10.1007/s00347-012-2682-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND More than 10 years after the clinical introduction of corneal cross-linking (CXL) the indications and contraindications are still not yet defined. Fundamental for such a list is the incidence of complications. METHODS A PubMed search for complications of corneal crosslinking published up to March 2013 was carried out. RESULTS The published complication rates ranged from 1 % to 10 % depending on the stage of keratoconus. Early postoperative complications were transient stromal haze, sterile infiltrates, endothelium decompensation, delayed epithelial healing and infectious keratitis. Stromal opacity can be a delayed postoperative event. CONCLUSIONS Complications after corneal cross-linking treatment for keratoconus are rare but the management of these complications may need keratoplasty.
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Affiliation(s)
- T G Seiler
- Institut für Refraktive und Ophthalmo-Chirurgie, Stockerstr. 37, 8002, Zürich, Schweiz.
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Balasubramanian SA, Mohan S, Pye DC, Willcox MDP. Proteases, proteolysis and inflammatory molecules in the tears of people with keratoconus. Acta Ophthalmol 2012; 90:e303-9. [PMID: 22413749 DOI: 10.1111/j.1755-3768.2011.02369.x] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the expression of proteases, proteolytic activity and cytokines in the tear film of people with keratoconus. METHODS Basal tears from people with keratoconus, from individuals who had undergone corneal collagen cross-linking for the treatment of keratoconus, and from normal controls were collected using a capillary tube. Corneal curvature of each subject was mapped. The total protein in tears was estimated. Levels and activity of proteases in the tears were analysed using specific antibody arrays and activity assays. RESULTS The total tear protein level was significantly reduced in keratoconus (4.1 ± 0.9 mg/ml) compared with normals (6.7 ± 1.4 mg/ml) (p < 0.0001) or subjects who had undergone corneal collagen cross-linking (5.7 ± 2.3 mg/ml) (p < 0.005). Significantly (p < 0.05) increased tear expression of matrix metalloproteinases (MMP) -1, -3, -7, -13, interleukins (IL) -4, -5, -6, -8 and tumour necrosis factor (TNF) -α, -β were evident in keratoconus. Tear IL-6 was the only cytokine significantly (p < 0.05) increased in tears of keratoconus subjects compared with the collagen cross-linked group. No significant difference in tear proteases were observed between the normal and the cross-linked groups, although the expression of TNF-α was significantly (p < 0.05) increased in the cross-linked group compared with the controls. Elevated gelatinolytic (87.5 ± 33.6 versus 45.8 ± 24.6 FIU, p < 0.0001) and collagenolytic (6.1 ± 3.2 versus 3.6 ± 2.0 FIU, p < 0.05) activities were observed in tears from keratoconus compared with normal subjects. The activity of tear gelatinases (69.6 ± 22.2 FIU) and collagenases (5.7 ± 3.3 FIU) in the collagen cross-linked group was not significantly different compared with either keratoconus or normals. CONCLUSION Tears of people with keratoconus had 1.9 times higher levels of proteolytic activity and over expression of several MMPs and cytokines compared with tears from controls. Further investigations are required to study the possible implications of these changes and whether they can be used to monitor disease progression or determine the success of corneal collagen cross-linking.
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Evaluation of combined riboflavin and ultraviolet A as an alternative treatment for keratitis. Graefes Arch Clin Exp Ophthalmol 2012; 251:995-6. [PMID: 22331148 DOI: 10.1007/s00417-012-1950-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Accepted: 01/30/2012] [Indexed: 11/27/2022] Open
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Collagen cross-linking: current status and future directions. J Ophthalmol 2012; 2012:406850. [PMID: 22288005 PMCID: PMC3263643 DOI: 10.1155/2012/406850] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 11/02/2011] [Accepted: 11/20/2011] [Indexed: 11/17/2022] Open
Abstract
Collagen cross-linking (CXL) using UVA light and riboflavin (vitamin B2) was introduced as a clinical application to stabilize the cornea by inducing cross-links within and between collagen fibers. CXL has been investigated extensively and has been shown clinically to arrest the progression of keratoconic or post-LASIK ectasia. With its minimal cost, simplicity, and proven positive clinical outcome, CXL can be regarded as a useful approach to reduce the number of penetrating keratoplasties performed. Small case series have also indicated that CXL is beneficial in corneal edema by reducing stromal swelling behavior and in keratitis by inhibiting pathogen growth. Despite these encouraging results, CXL remains a relatively new method that is potentially associated with complications. Aspects such as side effects and recurrence rates have still to be elucidated. In light of the growing interest in CXL, our paper summarizes present knowledge about this promising approach. We have intentionally endeavored to include the more relevant studies from the recent literature to provide an overview of the current status of CXL.
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