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Wójcik-Niklewska B, Filipek E, Janik P. Corneal Cross-Linking for Pediatric Keratoconus. Diagnostics (Basel) 2024; 14:1950. [PMID: 39272734 PMCID: PMC11393866 DOI: 10.3390/diagnostics14171950] [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: 06/23/2024] [Revised: 08/11/2024] [Accepted: 08/29/2024] [Indexed: 09/15/2024] Open
Abstract
AIM The aim of this study was to evaluate corneal cross-linking (CXL) for keratoconus in pediatric patients. MATERIALS AND METHODS After keratometric qualification according to the Amsler-Krumeich system, corneal collagen cross-linking was performed using ultraviolet light and photosensitizing riboflavin drops in 111 eyes of 74 children with a mean age of 15 ± 1.67 years. None of the children studied wore contact lenses before the procedure. Visual acuity, intraocular pressure, keratometry, and pachymetry parameters were analyzed before and after corneal cross-linking. RESULTS Visual acuity was 0.64 ± 0.31 and 0.66 ± 0.29 before CXL and at the end of the follow-up, respectively; the difference was not statistically significant. The mean intraocular pressure before CXL was 14.48 ± 3.13 mmHg, while the mean value at the end of the follow-up was 14.23 ± 3.03 mmHg; no statistically significant difference was found. Pre- and post-CXL astigmatism was 3.98 ± 2.34 Dcyl and 3.63 ± 1.86 Dcyl, respectively; the difference was not statistically significant. The mean keratometry before CXL was 47.99 ± 3.96 D; the mean post-follow-up value was 47.74 ± 3.63 D. The mean corneal thickness (pachymetry) at the apex of the keratoconus-the thinnest zone of the cornea-before CXL was 492.16 ± 38.75 µm, while the mean value at the end of the follow-up was 479.99 ± 39.71 µm; the difference was statistically significant. CONCLUSIONS Corneal cross-linking is an effective method for preventing keratoconus progression in children. However, further and detailed ophthalmic follow-up of patients who underwent CXL before the age of 18 is highly advisable.
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Affiliation(s)
- Bogumiła Wójcik-Niklewska
- Department of Pediatric Ophthalmology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland
- Professor Kornel Gibiński University Hospital Center, Medical University of Silesia, 40-514 Katowice, Poland
| | - Erita Filipek
- Department of Pediatric Ophthalmology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland
- Professor Kornel Gibiński University Hospital Center, Medical University of Silesia, 40-514 Katowice, Poland
| | - Paweł Janik
- Institute of Biomedical Engineering, Faculty of Science and Technology, University of Silesia in Katowice, 39 Będzińska Street, 41-200 Sosnowiec, Poland
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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] [MESH Headings] [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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Cankaya C, Gungor N. Outcomes after corneal crosslinking treatment in paediatric patients with keratoconus. Int Ophthalmol 2024; 44:56. [PMID: 38342827 DOI: 10.1007/s10792-024-02996-z] [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: 07/16/2023] [Accepted: 10/19/2023] [Indexed: 02/13/2024]
Abstract
PURPOSE This study aims to determine the efficacy and safety of accelerated corneal crosslinking in children with keratoconus. METHODS The study enrolled 64 patients aged 16 years or younger, each contributing one eye for a total of 64 eyes for analysis. Participants underwent an accelerated form of corneal cross-linking with 15 min of ultraviolet A irradiation at a rate of 7 mW/cm2, resulting in a cumulative energy dose of 5.4 J/cm2. The primary outcome measures were best corrected visual acuity (BCVA) and corneal tomography at 6 and 12 months post-intervention. Parameters assessed included BCVA, spherical and cylindrical refraction, keratometry (K1 and K2), maximum keratometry (Kmax) and thinnest corneal thickness (TCT). These metrics were documented preoperatively and then again at 6 and 12 months postoperatively. In addition, any ocular or systemic conditions related to keratoconus were recorded for each participant. RESULTS The results showed an improvement in BCVA at 12 months after surgery. K1 showed a decrease at both post-operative follow-ups while K2 remained constant throughout the observation period. Kmax showed a notable decrease at the 12 month postoperative follow-up. Although the TCT showed an initial decrease, it reached a stable state after 12 months of crosslinking. Refractive values remained stable at all subsequent examinations. Notably, no complications such as corneal opacity, non-healing epithelial defects or corneal infections occurred during the follow-up period. The most common ocular comorbidity was allergic conjunctivitis (34.4%). CONCLUSION The findings suggest that accelerated corneal crosslinking treatment is effective in slowing or halting the progression of keratoconus. Furthermore, there were no persistent overt complications observed at 12 months after the procedure.
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Affiliation(s)
- Cem Cankaya
- Department of Ophthalmology, Inonu University School of Medicine, Malatya, Turkey.
| | - Nur Gungor
- Department of Ophthalmology, Inonu University School of Medicine, Malatya, Turkey
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Naranjo A, Manche EE. A comprehensive review on corneal crosslinking. Taiwan J Ophthalmol 2024; 14:44-49. [PMID: 38654993 PMCID: PMC11034691 DOI: 10.4103/tjo.tjo-d-23-00055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/01/2023] [Indexed: 04/26/2024] Open
Abstract
Corneal crosslinking (CXL) represents a paradigm shift in the management of corneal ectatic disorders. Before CXL was introduced, patients would need specialty contact lenses and possible corneal transplantation. CXL involves a biochemical reaction in which ultraviolet A light is used in conjunction with Riboflavin to form crosslinks in between corneal stromal collagen. This leads to strengthening and stabilizing of the collagen lamellae, resulting in mechanical stiffening of the cornea. Multiple protocols have been proposed including epithelium on versus off and varying light intensity and duration of treatment. All protocols appear to be safe and effective with few reported complications including infection, stromal haze, scarring, and endothelial toxicity. Overall, CXL has demonstrated to halt the progression of the disease clinically and in keratometry readings and improve the quality of life for patients. It is a minimally invasive, cost-effective procedure that can be performed in an outpatient setting with a fast recovery time and long-lasting results.
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Affiliation(s)
- Andrea Naranjo
- Department of Ophthalmology, The Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Edward E. Manche
- Department of Ophthalmology, The Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
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Dervişoğulları S, Pelit A. Accelerated Corneal Cross-linking in Pediatric Patients with Progressive Keratoconus: 12-Month Follow-up Results. Niger J Clin Pract 2024; 27:131-135. [PMID: 38317046 DOI: 10.4103/njcp.njcp_598_22] [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: 09/06/2022] [Accepted: 12/01/2023] [Indexed: 02/07/2024]
Abstract
PURPOSE To evaluate effectiveness and safety of accelerated corneal cross-linking (CXL) in the treatment of keratoconus in pediatric patients. SETTING Tertiary care hospital. DESIGN Retrospective observational study. METHODS In this study, case series of patients 18 years old or younger with progressive keratoconus who underwent accelerated CXL were observed. All consecutive patients underwent accelerated CXL with setting of 9 mW/cm2 for 10-minute Ultraviolet-A radiation, corresponding to a total dose of 5.4 J/cm2. Preoperative and 12-month postoperative data including uncorrected distance visual acuity (UDVA), best-corrected distance visual acuity (BDVA), keratometry (K) measurements, mean spherical, and cylindrical refraction were evaluated. RESULTS The group consisted of 28 eyes from 14 patients (10 males and 4 females). Mean age of the patients was 16.9 years (11-18 years). UDVA did not change significantly from 0.71 ± 0.54 to 0.65 ± 0.43 logMAR (P = 0.41). BDVA improved significantly from 0.30 ± 0.35 to 0.21 ± 0.34 (P = 0.006). The steep K-value decreased from 48.4 ± 4.3 to 48.0 ± 4.6 diopters, but there was no significant change in steep K-value (P = 0.35). There was no significant change in flat and mean K-value (P > 0.05). Mean spherical and cylindrical refraction were not significantly altered (P > 0.05). One patient with vernal keratoconjunctivitis showed sterile peripheral corneal infiltrates. Patient was treated with topical corticosteroids, antibiotics, and artificial tears. CONCLUSION The findings revealed that accelerated CXL is an effective and safe procedure that halts the progression of keratoconus in pediatric patients.
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Affiliation(s)
- S Dervişoğulları
- Department of Ophthalmology, Başkent University Medical School, Adana Clinic and Research Center, Adana, Turkey
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Wang X, Zhang B, Li Z, Li M, Wang J, Mu G. The Keratectasia Volume (KEV) in Corneal Topography to Evaluate the Effect of Corneal Collagen Cross-linking in Pediatric Keratoconus. J Digit Imaging 2023; 36:1752-1759. [PMID: 37059888 PMCID: PMC10406998 DOI: 10.1007/s10278-021-00515-5] [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: 08/17/2020] [Revised: 08/20/2021] [Accepted: 09/02/2021] [Indexed: 04/16/2023] Open
Abstract
The study aimed to evaluate the keratectasia volume (KEV) before and after corneal cross-linking (CXL) in pediatric patients. This study included 40 eyes of 25 pediatric patients (10-19 years) undergoing standard CXL. The support vector machine (SVM) algorithm was applied to transform mass pixels in corneal topography into a three-dimensioned model to calculate the KEV. The KEV, Kmax, K1, K2, Kave, keratectasia area (KEA), and thinnest corneal thickness (TCT) were determined before CXL and at 3, 6, and 12 months after surgery. The correlation between KEV and other parameters (Kmax, TCT, max decentration, eccentricity, and so on) was calculated. The KEV was 4.75 ± 0.74 preoperatively and 4.43 ± 1.22 postoperatively at last follow-up (p < 0.002). There was strong positive correlation between the KEV and Kmax (r = 0.806, p < 0.0005). The preoperat ive KEV was 4.32 ± 0.69 in mild to moderate keratoconus (Kmax < 58D) and 5.27 ± 0.37 in advanced keratoconus (Kmax > 58D) (p < 0.0005, t-test). Postoperative KEV and K readings remained stable at the early stage, and the KEV showed a more drastic decreasing trend than Kmax at sixth month. Statistical significance was found in the KEV between preoperative and 6 months after surgery (p < 0.0005), but not in Kmax and other parameters. In 83.3% (15 eyes out of 18 eyes) of the eyes, the preoperative KEV was greater than 4.6 in patients with significant flattening after CXL. Compared with K readings, the KEV can be regarded as a more sensitive index to evaluate the postoperative morphological changes after CXL in pediatric patients.
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Affiliation(s)
- Xiangjun Wang
- Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bo Zhang
- School of Mathematics, Shandong University, Jinan, China
| | - Zhiwei Li
- Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Mengyao Li
- Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jia Wang
- Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Liaocheng Aier Eye Hospital, Aier Eye Hospital Group, Liaocheng, China
| | - Guoying Mu
- Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Knutsson KA, Genovese PN, Paganoni G, Ambrosio O, Ferrari G, Zennato A, Caccia M, Cataldo M, Rama P. Safety and Efficacy of Corneal Cross-Linking in Patients Affected by Keratoconus: Long-Term Results. Med Sci (Basel) 2023; 11:43. [PMID: 37367742 DOI: 10.3390/medsci11020043] [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: 03/11/2023] [Revised: 04/18/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023] Open
Abstract
The present study evaluated the effectiveness and safety of corneal collagen cross-linking (CXL). A total of 886 eyes with progressive keratoconus were enrolled in a retrospective cohort study in a tertiary care university hospital. CXL was performed using a standard epithelium-off Dresden protocol. Visual outcomes, maximum keratometry (Kmax), demarcation line measurements, and complications were recorded. Visual outcomes and keratometric data were analyzed in a subgroup comprising 610 eyes. Uncorrected distance visual acuity (UDVA) improved from 0.49 ± 0.38 LogMAR to 0.47 ± 0.39 LogMAR (p = 0.03, n = 610) three years after the procedure, while corrected distance visual acuity (CDVA) improved from 0.15 ± 0.14 LogMAR to 0.14 ± 0.15 LogMAR (p = 0.007, n = 610). A significant reduction of Kmax from 56.28 ± 6.10 to 54.98 ± 6.19 (p < 0.001, n = 610) was observed three years after CXL. In five eyes (0.82%, 5/610) keratoconus progression continued after CXL. Three eyes were retreated successfully with documented refractive and topographic stability after five years. In the 35 eyes that completed 10 years of follow-up, mean visual acuity and topographic parameters remained stable. In conclusion, CXL is a safe and effective treatment for avoiding keratoconus progression. Long-term data are encouraging, supporting a high safety profile for this procedure.
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Affiliation(s)
- Karl Anders Knutsson
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Paola Noemi Genovese
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Giorgio Paganoni
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Oriella Ambrosio
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Giulio Ferrari
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Arianna Zennato
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Michela Caccia
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Madeleine Cataldo
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Paolo Rama
- Cornea and Ocular Surface Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
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Wajnsztajn D, Shmueli O, Tarnovsky Y, Frucht-Pery J, Solomon A. Outcome indicators for cross linking in pediatric keratoconus. Front Med (Lausanne) 2023; 10:1149641. [PMID: 37250642 PMCID: PMC10213677 DOI: 10.3389/fmed.2023.1149641] [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: 01/22/2023] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose To evaluate the predictive factors for successful corneal collagen cross-linking (CXL) in pediatric patients with Keratoconus (KC). Methods This retrospective study was conducted using a prospectively built database. Patients (18 years old or younger) underwent CXL for KC between 2007 and 2017, with a 1-year follow-up period or longer. The outcomes included changes in Kmax (delta [Δ] Kmax = Kmaxlast - Kmaxpre) and LogMAR visual acuity (ΔLogMAR = LogMARlast - LogMARpre).The effects of CXL type (accelerated or non-accelerated), demographics (age, sex, background of ocular allergy, ethnicity), preoperative LogMAR visual acuity, maximal corneal power (Kmax), pachymetry (CCTpre), refractive cylinder, and follow-up (FU) time on the outcomes were analyzed. Results One hundred thirty-one eyes of 110 children were included (mean age, 16 ± 2 years; range, 10-18 years). Kmax and LogMAR improved from baseline to last visit: from 53.81 D ± 6.39 D to 52.31 D ± 6.06 D (p < 0.001) and from 0.27 ± 0.23 LogMAR units to 0.23 ± 0.19 LogMAR units (p = 0.005), respectively. A negative ΔKmax (meaning corneal flattening) was associated with a long FU, low CCTpre, high Kmaxpre, high LogMARpre, and non-accelerated CXL on univariate analysis. High Kmaxpre and non-accelerated CXL were associated with negative ΔKmax in the multivariate analysis.A negative ΔLogMAR (meaning vision improvement) was associated with a high LogMARpre in univariate analysis. Conclusion CXL is an effective treatment option in pediatric patients with KC. Our results showed that the non-accelerated treatment was more effective than the accelerated treatment. Corneas with advanced disease had a greater effect on CXL.
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Preethi B, Kumar KK, Babu GS, Sridhar S, Srinivasa KH. Outcomes of accelerated collagen cross linking in progressive paediatric keratoconus. Indian J Ophthalmol 2023; 71:1889-1893. [PMID: 37203050 PMCID: PMC10391506 DOI: 10.4103/ijo.ijo_1469_22] [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: 05/20/2023] Open
Abstract
Purpose To determine the efficacy and safety of pediatric accelerated cross linking (CXL). Methods A prospective study on progressive keratoconus (KC) cases under ≤18 years of age. Sixty four eyes of thirty nine cases underwent epithelium-off accelerated CXL protocol. Visual acuity (VA), slit-lamp examination, refraction, pentacam reading of keratometry (K), corneal thickness, and thinnest location pachymetry were noted. Cases were followed up on days 1, 5, and at 1st, 3rd, 6th, and 12th-month post procedure. Results Statistically, significant improvement of the mean aided VA, K, and mean corneal astigmatism (p < 0.0001) was noted. Mean Kmax reading reduced from 55.5 ± 5.64 (47.4-70.4) diopter (D) preoperatively to 54.41 ± 5.51 (46-68.3) D at 12 months postaccelerated CXL. Two cases had progression. Complications encountered were sterile infiltrate and persistent haze. Conclusion Accelerated CXL is effective and efficacious in pediatric KC.
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Affiliation(s)
- B Preethi
- Department of Ophthalmology, Dr. Chandramma Dayananda Sagar Institute of Medical Education and Research Harohalli, Kanakapura, Karnataka, India
| | - K Kiran Kumar
- Department of Ophthalmology, Minto Ophthalmic Hospital, RIO, BMC&RI, Bengaluru, Karnataka, India
| | - G Suresh Babu
- Department of Ophthalmology, Minto Ophthalmic Hospital, RIO, BMC&RI, Bengaluru, Karnataka, India
| | - Sriya Sridhar
- Department of Community Medicine, BMC&RI, Bengaluru, Karnataka, India
| | - K H Srinivasa
- Department of Ophthalmology, Minto Ophthalmic Hospital, RIO, BMC&RI, Bengaluru, Karnataka, India
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Prasher P, Sharma A, Sharma R, Vig VK, Nirankari VS. Paediatric cornea crosslinking current strategies: A review. ADVANCES IN OPHTHALMOLOGY PRACTICE AND RESEARCH 2023; 3:55-62. [PMID: 37846374 PMCID: PMC10577868 DOI: 10.1016/j.aopr.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 10/18/2023]
Abstract
Background In the general population, 1 in 2000 people has keratoconus. Indians and other people from Southeast Asia have a higher incidence of keratoconus. Children with keratoconus typically present earlier in life and with a more severe disease. Rubbing the eyes has been identified as a risk factor. Children have a higher incidence and a faster rate of keratoconus progression. Visual rehabilitation in children with keratoconus is challenging. They have a low compliance with contact lens use. Many of these children require penetrating keratoplasty at an early age. Therefore, stopping the progression of keratoconus in children is of paramount importance. Main text Compared to treatment, keratoconus progression prophylaxis is not only preferable, but also easier. Corneal collagen cross-linking has been shown to be safe and effective in stopping its progression in children. The Dresden protocol, which involves central corneal deepithelization (7-9 mm), saturation of the stroma with riboflavin (0.25%), and 30 min UV-A exposure, has proven to be the most successful. Two significant disadvantages of the typical Dresden regimen are the prolonged operating time and the significant post-operative pain. Accelerated-CXL (9 mW/cm2 x 10 min) has been studied to reduce operative time and has been shown to be equally effective in some studies. Compared to accelerated CXL or traditional CXL, epi-off procedures, transepithelial treatment without the need for de-epithelialization and without postoperative discomfort, have been shown to be safer but less effective. Corneal crosslinking should only be performed after treating children with active vernal keratoconjunctivitis. Corneal opacity, chronic corneal edema, sterile infiltrates, and microbial keratitis have been reported after cross-linking of corneal collagen. Conclusions The "Dresden protocol", also known as the conventional corneal cross-linking approach, should be used to halt the progression of keratoconus in young patients. However, if the procedure needs to be completed more rapidly, accelerated corneal crosslinking may be considered. Transepithelial corneal cross-linking has been proven to be less effective at stabilizing keratoconus, although being more safer.
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Affiliation(s)
- Pawan Prasher
- Department of Ophthalmology, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Ashok Sharma
- Cornea Centre, SCO 2463 - 2464, Sector 22 C, 160022, Chandigarh, India
| | - Rajan Sharma
- Cornea Centre, SCO 2463 - 2464, Sector 22 C, 160022, Chandigarh, India
| | - Vipan K. Vig
- Amritsar Eye Hospital, GNDU Shopping Complex, Amritsar, Punjab, India
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Polido J, Araújo MEXDS, Wakamatsu TH, Alexander JG, Cabral T, Ambrósio R, Freitas D. Long-term Safety and Efficacy of Corneal Collagen Crosslinking in a Pediatric Group With Progressive Keratoconus: A 7-year Follow-up. Am J Ophthalmol 2023; 250:59-69. [PMID: 36682518 DOI: 10.1016/j.ajo.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
PURPOSE To assess effectiveness and safety of corneal crosslinking (CXL) to reduce keratoconus (KC) progression and improve visual acuity among children with progressive KC and to analyze the use of 20% dextran-based (Dextran) and 1% hydroxypropyl methylcellulose-based (HPMC) riboflavin. DESIGN Prospective, clinical cohort study METHODS: Standard CXL (SCXL) was performed in 74 eyes (58 patients, 45 males, mean age 13.0 ± 2.1 years): 53 eyes with HPMC and 21 with Dextran. Examinations were performed at baseline, 3 and 6 months, and 1, 2, 3, 4, 5, and 7 years of follow-up, including uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), a complete ophthalmologic examination, anterior segment ocular coherence tomography, Scheimpflug corneal tomography, and specular microscopy. RESULTS UDVA and CDVA improved at all periods with statistically significant differences in CDVA at 1, 2, and 3 years. Compared with baseline, maximum K (Max K) reduced throughout the 7-year follow-up. Mean thinnest pachymetry (Th Pachy) decreased significantly at 3 months and remained low; in the Dextran group, the Th Pachy mean value returned to baseline 6 months postoperatively. After CXL, 1.5 diopter progression in max K was 1.4% to 14.6% of eyes; worsening was found at 4 to 7 years postoperatively. CONCLUSION SCXL reduced KC progression in children up to 7 years of follow-up and revealed improvement and stability of UDVA and CDVA in 82% of eyes. For visual acuity and KC stability, no statistically significant difference was observed between Dextran-HPMC. The HPMC group showed persistent cornea thinning, raising concerns about its use in SCXL.
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Affiliation(s)
- Júlia Polido
- From the Department of Ophthalmology (J.P., M.E.X.A., T.H.K., J.G.A., T.C., R.A., D.F.), Federal University of São Paulo
| | - Maria Emília Xavier Dos Santos Araújo
- From the Department of Ophthalmology (J.P., M.E.X.A., T.H.K., J.G.A., T.C., R.A., D.F.), Federal University of São Paulo; Department of Ophthalmology (M.E.X.A), HSPE/IAMSPE, São Paulo
| | - Tais H Wakamatsu
- From the Department of Ophthalmology (J.P., M.E.X.A., T.H.K., J.G.A., T.C., R.A., D.F.), Federal University of São Paulo
| | - João G Alexander
- From the Department of Ophthalmology (J.P., M.E.X.A., T.H.K., J.G.A., T.C., R.A., D.F.), Federal University of São Paulo
| | - Thiago Cabral
- From the Department of Ophthalmology (J.P., M.E.X.A., T.H.K., J.G.A., T.C., R.A., D.F.), Federal University of São Paulo; Department of Ophthalmology EBSERH (T.C.), HUCAM/CCS-UFES, Federal University of Espírito Santo, Vitória.
| | - Renato Ambrósio
- From the Department of Ophthalmology (J.P., M.E.X.A., T.H.K., J.G.A., T.C., R.A., D.F.), Federal University of São Paulo; and the Department of Ophthalmology (R.A.), Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Denise Freitas
- From the Department of Ophthalmology (J.P., M.E.X.A., T.H.K., J.G.A., T.C., R.A., D.F.), Federal University of São Paulo
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Song M, Chen T, Moktar A, Chan E, Chong EW, Daniell M, Sahebjada S. Diagnosis and Management of Keratoconus-A Narrative Review of Clinicians' Perspectives. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121973. [PMID: 36553416 PMCID: PMC9777227 DOI: 10.3390/children9121973] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
This review discusses the current practices, attitudes, and trends in diagnosing and managing keratoconus (KC) in adults and children by optometrists and ophthalmologists in order to highlight the differences on a global scale. Two independent reviewers searched the electronic databases and grey literature for all potential articles published from 1 January 2000 to 1 June 2022 on management of KC. Keywords used in searches included "keratoconus", "diagnosis", "management", "treatment", "attitude", "practices", "opinion", "optometrist", "ophthalmologist", "consensus", and "protocol". A total of 19 articles was included in this review-12 from the database search and seven from the grey literature. Although a common stepwise approach of non-surgical management was noted, there were differences in the rates of prescribing rigid gas permeable lenses. Furthermore, while clinicians agreed on the need for early diagnosis, the timeline and type of referral varied significantly. A similar discordance was found in the milestones for surgical intervention and preferred surgical techniques. Practice patterns in keratoconus diagnosis and management vary throughout the world. Multiple recommendations and suggestions to minimise the differences have been provided in the literature, with the main themes being improvement in education, interdisciplinary patient care, and further research to reach consensus.
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Affiliation(s)
- Minji Song
- Centre for Eye Research Australia, Melbourne, VIC 3002, Australia
- Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Tanya Chen
- Centre for Eye Research Australia, Melbourne, VIC 3002, Australia
- Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Adam Moktar
- Centre for Eye Research Australia, Melbourne, VIC 3002, Australia
- Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Elsie Chan
- Centre for Eye Research Australia, Melbourne, VIC 3002, Australia
- Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, VIC 3010, Australia
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC 3002, Australia
| | - Elaine W Chong
- Centre for Eye Research Australia, Melbourne, VIC 3002, Australia
- Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, VIC 3010, Australia
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC 3002, Australia
| | - Mark Daniell
- Centre for Eye Research Australia, Melbourne, VIC 3002, Australia
- Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, VIC 3010, Australia
- Royal Victorian Eye and Ear Hospital, Melbourne, VIC 3002, Australia
| | - Srujana Sahebjada
- Centre for Eye Research Australia, Melbourne, VIC 3002, Australia
- Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, VIC 3010, Australia
- Correspondence:
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13
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Knutsson KA, Genovese PN, Paganoni G, Ambrosio O, Ferrari G, Zennato A, Cataldo M, Caccia M, Rama P. Evaluation of a Post-Operative Therapy Protocol after Epithelium-Off Corneal Cross-Linking in Patients Affected by Keratoconus. J Clin Med 2022; 11:jcm11237093. [PMID: 36498668 PMCID: PMC9738184 DOI: 10.3390/jcm11237093] [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: 11/07/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
A large retrospective study evaluated the safety of a post-operative therapy protocol after epithelium-off corneal collagen cross-linking (CXL). In total, 1703 eyes of the 1190 patients with progressive keratoconus were enrolled in a retrospective cohort study in a tertiary care university hospital. CXL was performed using a standardized technique (Dresden protocol: 0.1% riboflavin solution containing dextran 20% for 30 min during the soaking phase followed by 30-min ultraviolet A irradiation (3 mW/cm2)). Postoperatively, a bandage contact lens was applied, and therapy included a topical fluoroquinolone antibiotic until the epithelium healed, followed by topical fluorometholone treatment for three weeks. Post-operative complications were recorded and analyzed. No cases of infectious keratitis occurred, whereas peripheral sterile infiltrates were observed in 1.17% of cases. Trace haze was typically present but did not have an impact on visual acuity. In fifteen cases (0.88%), visually significant anterior stromal opacity developed. Mild signs of dry eye were observed in 22 eyes (1.29%). The present study demonstrates that a post-operative treatment protocol including fluoroquinolone antibiotics and a BCL in the first phase until complete epithelial healing, followed by a three-week period of topical steroid treatment is safe and not associated with the development of microbial keratitis.
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14
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Somohano K, Alzaga-Fernandez AG. Controversies in Corneal Collagen Crosslinking: A Review of Investigational Crosslinking Protocols and Its Off-label Application. Int Ophthalmol Clin 2022; 62:51-62. [PMID: 36170222 DOI: 10.1097/iio.0000000000000426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Tharini B, Sahebjada S, Borrone MA, Vaddavalli P, Ali H, Reddy JC. Keratoconus in pre-teen children: Demographics and clinical profile. Indian J Ophthalmol 2022; 70:3508-3513. [PMID: 36190036 PMCID: PMC9789837 DOI: 10.4103/ijo.ijo_2579_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose To study the demographics and clinical profile of keratoconus (KC) presenting in pre-teen children in India. Methods This was a retrospective case series conducted as a single-institutional study at a tertiary eye center in India. A total of 586 eyes from 294 KC patients (aged 12 years or less) without any active comorbid conditions of the eye were included in the study. Slit-lamp biomicroscopy was used to document the clinical signs of KC. Information on age; gender; reason for consultation; family history; history of allergy, atopy, and eye rubbing; manifest refraction; uncorrected and best-corrected distance visual acuity (UCVA and BCVA, respectively); clinical presentation; and contact lens usage were also analyzed, along with data on types of medical and surgical treatments for KC and their outcomes. Results The mean age of this pediatric KC patient cohort was 9.3 ± 1.8 years, and there was a male (70%) preponderance. Baseline mean UCVA, BCVA, steep keratometry, and flat keratometry were 0.86 ± 0.58 logMAR, 0.44 ± 0.38 logMAR, 54.82 ± 8.4 D, and 48.21 ± 9.5 D, respectively. Progression, necessitating collagen crosslinking (CXL), was noted in 12.7% eyes. Post-CXL, visual and topographic parameters remained stable without any complications till 6 months posttreatment. However, in eyes that did not undergo CXL, significant progression over time (P < 0.001) was observed. A keratoplasty was required in 2.3% eyes. Conclusion KC was present at an advanced stage in 25% of the pre-teens in our series, and therefore, it is an important diagnostic entity when a refractive error is diagnosed, even in very young children.
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Affiliation(s)
- Bhava Tharini
- Cornea Institute, LV Prasad Eye Institute, Telangana, India
| | - Srujana Sahebjada
- Centre for Eye Research Australia, Melbourne, Australia,Department of Surgery, Ophthalmology, The University of Melbourne, Melbourne, Australia
| | | | - Pravin Vaddavalli
- Cornea Institute, LV Prasad Eye Institute, Telangana, India,Correspondence to: Dr. Pravin Vaddavalli, Cornea Institute, LV Prasad Eye Institute, Telangana, India. E-mail:
| | - Hasnat Ali
- Cornea Institute, LV Prasad Eye Institute, Telangana, India
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16
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Achiron A, El-Hadad O, Leadbetter D, Hecht I, Hamiel U, Avadhanam V, Tole D, Darcy K. Progression of Pediatric Keratoconus After Corneal Cross-Linking: A Systematic Review and Pooled Analysis. Cornea 2022; 41:874-878. [PMID: 34294638 DOI: 10.1097/ico.0000000000002808] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/15/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Corneal collagen cross-linking (CXL) is an effective treatment to slow down keratoconus (KC) progression in adults. Several studies have also shown efficacious outcomes in pediatric populations, yet no systematic analysis has been performed and no accepted definition for progression is available in children after CXL. This study aimed to establish the most commonly used criteria for progression and to conduct a systematic review of the literature with pooled analysis to assess children's keratoconus progression after CXL. METHODS A systemic literature review combined with pooled analysis was performed on full-length studies of KC after CXL treatment in a pediatric population and the methods used to report progression were analyzed. RESULTS Thirty-seven studies (2078 eyes) were identified on the rates of KC progression after CXL. The most common method to report progression was increased Kmax, Kmean, or Ksteep by ≥1.0 diopter (78.3% of studies). Using these criteria, the mean pooled progression rate after epithelium-off CXL was 9.9% (95% confidence interval: 6.1% -14.6%, total pooled sample size: 1508 eyes) with high heterogeneity between studies [I 2 = 86.48% (95% confidence interval: 80.98 - 90.39), P < 0.0001]. CONCLUSIONS When considering KC progression after CXL in children, with an increase in Kmax, Kmean, or Ksteep ≥ 1.0 diopter, the progression risk was roughly 10%. We encourage clear quantitative reporting of KC progression in future studies evaluating CXL efficacy in pediatric populations.
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Affiliation(s)
- Asaf Achiron
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omar El-Hadad
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
- Faculty of Medicine, Alexandria University, Egypt
| | - Duncan Leadbetter
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Idan Hecht
- Department of Ophthalmology, Shamir Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Uri Hamiel
- Genetics Institute, Tel Aviv Sourasky Medical Center & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Venkata Avadhanam
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Derek Tole
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Kieren Darcy
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
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Polido J, Dos Xavier Santos Araújo ME, Alexander JG, Cabral T, Ambrósio R, Freitas D. Pediatric Crosslinking: Current Protocols and Approach. Ophthalmol Ther 2022; 11:983-999. [PMID: 35482230 PMCID: PMC9114245 DOI: 10.1007/s40123-022-00508-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/31/2022] [Indexed: 11/24/2022] Open
Abstract
Keratoconus (KC) is likely to be more aggressive in the pediatric population, with a higher risk of progression and visual loss. Several techniques have been proposed for corneal crosslinking (CXL) so far. The standard CXL (SCXL) technique, or the Dresden Protocol, originally developed by Wollensak et al., has been shown to be safe and effective in the pediatric KC group. With similar efficacy to the conventional method, the accelerated CXL (ACXL) protocols proposed a reduced UVA exposure time by increasing the intensity of UVA irradiation. Transepithelial CXL (TCXL), considered an "epithelium-on" method, emerged as a strategy to improve safety and reduce postoperative complications and discomfort. For thinner corneas, we can highlight the use of hypoosmolar riboflavin and new studies, such as contact lens-assisted CXL (CACXL), the epithelial-island CXL (EI-CXL), and the Sub400 protocol. In addition to the different protocols used, another factor that changes CXL results is the type of carrier used: dextran-based or hydroxypropyl methylcellulose-based (HPMC) riboflavin solutions. There are several ways to perform a CXL surgery, and it is still unclear which method is the safest and most effective in the pediatric group. This review of the literature in English, available in PubMed, provides an update on corneal CXL in the pediatric KC group, exploring the data on the techniques currently used and under investigation, including their advantages, efficacy, safety profiles, risks, and cost analyses.
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Affiliation(s)
- Júlia Polido
- Department of Ophthalmology, Federal University of São Paulo (UNIFESP), Rua Botucatu, 806, Vila Clementino, São Paulo, SP, CEP 04023-062, Brazil.
| | - Maria Emília Dos Xavier Santos Araújo
- Department of Ophthalmology, Federal University of São Paulo (UNIFESP), Rua Botucatu, 806, Vila Clementino, São Paulo, SP, CEP 04023-062, Brazil.,Department of Ophthalmology, HSPE/IAMSPE, São Paulo, SP, Brazil
| | - João G Alexander
- Department of Ophthalmology, Federal University of São Paulo (UNIFESP), Rua Botucatu, 806, Vila Clementino, São Paulo, SP, CEP 04023-062, Brazil
| | - Thiago Cabral
- Department of Ophthalmology, Federal University of São Paulo (UNIFESP), Rua Botucatu, 806, Vila Clementino, São Paulo, SP, CEP 04023-062, Brazil.,Department of Ophthalmology EBSERH, HUCAM/CCS-UFES, Federal University of Espírito Santo (UFES), Vitória, ES, Brazil
| | - Renato Ambrósio
- Department of Ophthalmology, Federal University of São Paulo (UNIFESP), Rua Botucatu, 806, Vila Clementino, São Paulo, SP, CEP 04023-062, Brazil.,Department of Ophthalmology, The Federal University of the State of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Denise Freitas
- Department of Ophthalmology, Federal University of São Paulo (UNIFESP), Rua Botucatu, 806, Vila Clementino, São Paulo, SP, CEP 04023-062, Brazil
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18
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Management Outcomes in Pediatric Keratoconus: Childhood Keratoconus Study. J Ophthalmol 2022; 2022:4021288. [PMID: 35178249 PMCID: PMC8843789 DOI: 10.1155/2022/4021288] [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: 09/24/2021] [Revised: 12/19/2021] [Accepted: 01/08/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction. The Global Delphi Panel of Keratoconus (KC) and Ectatic Diseases formulated management guidelines for KC in 2015. The aim of this study was to evaluate management outcomes in pediatric KC. Materials and Methods. Prospective, interventional study was conducted at a tertiary care hospital including KC patients aged <18 years. Based on disease severity and progression of disease, patients were prescribed either glasses or contact lenses (CLs) or underwent corneal collagen crosslinking (CXL), deep anterior lamellar keratoplasty (DALK), or penetrating keratoplasty (PK). Main Outcome Measures. Best corrected visual acuity (BCVA), manifest cylinder, maximum keratometry, thinnest corneal thickness, total higher order aberrations, and corneal hysteresis at baseline and 12 and 24 months. Results. 116 eyes of 62 patients with a mean age of 14.76 ± 2.77 years were included. 32.8% of the eyes (n = 38) achieved satisfactory BCVA with glasses/CLs only. Corneal collagen crosslinking (CXL) was performed in 43.1% of the eyes (n = 50) with progressive KC and halting of progression was noted in 83.3% (n = 35) of the eyes at 2 years. 7.7% of the eyes (n = 9) were managed for acute hydrops. DALK and PK were successfully performed in 9.5% (n = 11) and 6.9% (n = 8) of the eyes with BCVA of 0.14 ± 0.09 and 0.08 ± 0.12 at 2 years, respectively. Conclusions. Pediatric KC cases with progression show good visual and aberrometric outcomes and halting of progression after CXL. DALK and PK have good outcomes. The global consensus guidelines showed good clinical utility in pediatric patients. Presence of VKC did not have an impact on the outcomes of CXL in pediatric patients.
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20
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Mohan S, Banerjee M, Annavajjhala S. Characteristics of pediatric keratoconus and the role of corneal topography in early diagnosis: A prospective study. TNOA JOURNAL OF OPHTHALMIC SCIENCE AND RESEARCH 2022. [DOI: 10.4103/tjosr.tjosr_3_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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21
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Alipour F, Ansari S, Dadman N, Hafezi F. Accelerated Corneal Collagen Cross-Linking in Pediatric Keratoconus. J Curr Ophthalmol 2021; 33:285-290. [PMID: 34765816 PMCID: PMC8579799 DOI: 10.4103/joco.joco_163_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/28/2021] [Accepted: 03/05/2021] [Indexed: 01/22/2023] Open
Abstract
Purpose To evaluate the visual, refractive, and topographic outcomes of accelerated corneal collagen cross-linking (CXL) in the pediatric age group. Methods In this retrospective case series study, 89 eyes of 56 patients with progressive keratoconus (KCN) who were under or equal to 18 years old at the time of surgery were included. All patients underwent accelerated corneal CXL. A thorough baseline and follow-up ophthalmic examination including uncorrected distance visual acuity, best corrected visual acuity (BCVA), slit-lamp and fundus examination, and corneal tomography by Scheimpflg camera Pentacam (Oculus, Wetzlar, Germany) were performed. Results The mean age of patients was 16.2 ± 1.8 years. Mean follow-up was 16.46 ± 11.6 months (range, 6-40 months). The mean BCVA improved significantly from 0.26 ± 0.26 to 0.16 ± 0.19 (logMAR) after accelerated CXL (P < 0.001). The mean corneal astigmatism based on refraction decreased from 3.69 ± 2.12 to 3.15 ± 1.86 after the intervention (P = 0.016). The mean maximum keratometry (Kmax) reduced significantly from 53.23 ± 6.07 diopter (D) to 52.23 ± 6.33 D (P = 0.047). The mean flat keratometry (K1) reduced from 46.37 ± 3.69 to 45.95 ± 3.65 after the intervention (P = 0.119). Conclusion Our study shows that accelerated CXL increases visual acuity and stabilizes or improves keratometric indices in pediatric patients with progressive KCN without any serious complication for a mean follow-up time of 16 months.
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Affiliation(s)
- Fateme Alipour
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shabnam Ansari
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nima Dadman
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Hafezi
- Department of Ophthalmology, Geneva University Hospitals, Geneva, Switzerland.,ELZA Institute, Dietikon, Switzerland.,Department of Ophthalmology, University of Wenzhou, Wenzhou, China
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22
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Simantov I, Or L, Gazit I, Dubinsky-Pertzov B, Zadok D, Pras E, Hartstein M, Einan Lifshitz A. Seven years follow-up of corneal cross-linking (CXL) in pediatric patients: Evaluation of treated and untreated eye. Eur J Ophthalmol 2021; 32:1482-1490. [PMID: 34058903 DOI: 10.1177/11206721211020632] [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: 11/16/2022]
Abstract
BACKGROUND Retrospective cohort study evaluating long term keratoconus progression amongst cross-linking (CXL) treated pediatric patients in the treated and the fellow untreated eyes. METHODS Data on 60 eyes of 30 patients, 18 years old or younger, who underwent CXL in at least one eye was collected and analyzed. Follow-up measurements taken from the treated and untreated eye up to 7 years after CXL treatment, were compared to baseline measurements. Parameters included uncorrected distance visual acuity (UCDVA), best-corrected spectacle visual acuity (BCSVA), manifest refraction, pachymetry, corneal tomography, and topography. RESULTS Mean age of patients was 16 ± 2.1 years. For the treated eyes, during follow-up period mean UCDVA had improved (from 0.78 ± 0.22 at baseline to 0.58 ± 0.26 logMAR at 7 years; p = 0.13), as well as mean BCSVA (from 0.23 ± 0.107 at baseline to 0.172 ± 0.05 logMAR at 7 years; p = 0.37). The mean average keratometry showed a significant flattening (from 49.95 ± 4.04 to 47.94 ± 3.3 diopters (D); p < 0.001), However there was no change in the mean maximal keratometry. The mean minimal corneal thickness (MCT) showed a significant mild reduction of 26 µm (p = 0.006). Although statistically insignificant, the mean manifest cylinder was also reduced to 2D (p = 0.15). During the follow-up period, eight untreated eyes (26.6%) deteriorated and underwent CXL, while only one treated eye (3.33%) required an additional CXL. CONCLUSION CXL is a safe and efficient procedure in halting keratoconus progression in the pediatric population, the fellow eye needs to be carefully monitored but only a 25% of the patients will require CXL in that eye during a period of 7 years.
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Affiliation(s)
- Iliya Simantov
- Department of Ophthalmology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Or
- Department of Ophthalmology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Inbal Gazit
- Department of Ophthalmology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Biana Dubinsky-Pertzov
- Department of Ophthalmology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Zadok
- Department of Ophthalmology, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Eran Pras
- Department of Ophthalmology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Morris Hartstein
- Department of Ophthalmology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Einan Lifshitz
- Department of Ophthalmology, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cinar Y, Han CC, Sahin A, Syed ZA. Long term results of accelerated corneal collagen cross-linking in pediatric keratoconus. Eur J Ophthalmol 2021; 31:3494-3499. [PMID: 34015954 DOI: 10.1177/11206721211018362] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate the long term visual, refractive, and corneal tomographic outcomes of epithelium-off accelerated corneal collagen cross-linking (ACXL) in the management of pediatric keratoconus (KC). METHODS This retrospective study included patients under 18 years old with progressive KC who underwent ACXL between 2012 and 2019 at Dicle University Hospital. Complete ophthalmic examination was performed including uncorrected distance visual acuity (UDVA), best spectacle-corrected distance visual acuity (CDVA), manifest refraction, and corneal tomography. Evaluations were performed preoperatively and at 6 months intervals postoperatively. RESULTS Forty-nine eyes of 49 patients were included in the study. The mean age of patients at the time of ACXL was 14.2 ± 1.8 (range: 9.5-17.3) years. Mean follow up was 4.61 ± 1.90 (range: 2.0-8.1) years. The mean LogMAR UDVA improved from 0.94 ± 0.41 to 0.81 ± 0.43, 0.69 ± 0.41, and 0.67 ± 0.33 after 1, 3, and 5 years respectively (p = 0.001). The mean LogMAR CDVA improved from 0.58 ± 0.36 to 0.46 ± 0.31, 0.34 ± 0.23, and 0.39 ± 0.27 after 1, 3, and 5 years respectively (p = 0.015). The mean refractive cylinder improved significantly from 6.01 ± 2.07 diopters (D) to 5.46 ± 1.87, 5.38 ± 2.18, and 5.02 ± 2.31 D after 1, 3, and 5 years respectively (p = 0.005). As compared to preoperative values, steep keratometry and maximum keratometry were not significantly different (p = 0.805 and 0.448, respectively) following ACXL, while flat keratometry significantly improved after ACXL (p = 0.012). Although central corneal thicknesses decreased significantly (p = 0.029), the decrease in thinnest corneal thickness was not statistically significant (p = 0.205). CONCLUSION Epithelium-off ACXL seems to be effective for halting KC progression with long term clinical benefits in pediatric patients.
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Affiliation(s)
| | | | | | - Zeba A Syed
- Cornea Service, Wills Eye Hospital, Philadelphia, PA, USA
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24
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Gupta Y, Sharma N, Maharana PK, Saxena R, Sinha R, Agarwal T, Jhanji V, Titiyal JS. Pediatric Keratoconus: Topographic, Biomechanical and Aberrometric Characteristics. Am J Ophthalmol 2021; 225:69-75. [PMID: 33385369 DOI: 10.1016/j.ajo.2020.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE This study sought to evaluate the demographic profile, clinical features, topographic features, and biomechanical and aberrometric characteristics in pediatric keratoconus (KC). DESIGN Cross-sectional study. METHODS Pediatric KC cases <18 years of age were evaluated at a tertiary hospital. Main outcome measurements were demographic profile, clinical features, visual acuity, corneal topography, aberrometry, and biomechanical and confocal microscopy findings. RESULTS A total of 116 eyes of 62 consecutive patients were recruited with a mean ± age of 14.7 ± 2.77 years (range: 8-18 years); 46 of 62 (88%) were males; 57 of 62 cases (92%) had bilateral disease; 53 of 116 eyes (46%) had progressive KC; and 9 of 116 eyes (8%) had acute hydrops. Systemic associations were found in 6 of 62 patients (9.7%) and ocular associations in 77 of 116 eyes (66.3%); 68 of 116 eyes (58.6%) had associated vernal keratoconjunctivitis (VKC). Among eyes with VKC, 29 of 68 eyes (46%) were in stage IV KC, versus 25% of eyes with no VKC (P = .004). The mean ± SD refractive spherical equivalent was -4.72 ± 3.32 diopters (D), and refractive astigmatism was 3.69 ± 3.09 D. The mean values of maximum keratometry, thinnest pachymetry, and corneal higher-order aberrations were 60.89 ± 10.9 D, 396.05 ± 95.03 μm, and 1.18 ± 1.2 μm, respectively. Values of corneal hysteresis and corneal resistance factor correlated with the stage of KC (r = -0.26; P = .007). CONCLUSIONS Pediatric KC was commonly associated with VKC in this cohort. Eyes with VKC had more severe KC than those without VKC. Nearly half of the patients presented with progressive disease. Corneal biomechanical changes correlated well with stage of KC in this pediatric age group.
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Larkin DFP, Chowdhury K, Burr JM, Raynor M, Edwards M, Tuft SJ, Bunce C, Caverly E, Doré C. Effect of Corneal Cross-linking versus Standard Care on Keratoconus Progression in Young Patients: The KERALINK Randomized Controlled Trial. Ophthalmology 2021; 128:1516-1526. [PMID: 33892046 DOI: 10.1016/j.ophtha.2021.04.019] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/31/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To examine the efficacy and safety of corneal cross-linking (CXL) for stabilization of progressive keratoconus. DESIGN Observer-masked, randomized, controlled, parallel-group superiority trial. PARTICIPANTS Sixty participants 10 to 16 years of age with progressive keratoconus, one eye of each deemed the study eye. METHODS The study eye was randomized to either CXL plus standard care or standard care alone, with spectacle or contact lens correction as necessary for vision. MAIN OUTCOME MEASURES The primary outcome was steep keratometry (K2) in the study eye as a measure of the steepness of the cornea at 18 months. Secondary outcomes included keratoconus progression defined as a 1.5-diopter (D) increase in K2, visual acuity, keratoconus apex corneal thickness, and quality of life. RESULTS Of 60 participants, 30 were randomized to CXL and standard care groups. Of these, 30 patients in the CXL group and 28 patients in the standard care group were analyzed. Mean K2 in the study eye 18 months after randomization was 49.7 D (standard deviation [SD], 3.8 D) in the CXL group and 53.4 D (SD, 5.8 D) in the standard care group. The adjusted mean difference in K2 in the study eye was -3.0 D (95% confidence interval [CI], -4.9 to -1.1 D; P = 0.002), favoring CXL. Adjusted differences between groups in uncorrected and corrected vision favored eyes receiving CXL: -0.31 logarithm of the minimum angle of resolution (logMAR; 95% CI, -0.50 to -0.11 logMAR; P = 0.002) and -0.51 logMAR (95% CI, -1.37 to 0.35 logMAR; P = 0.002). Keratoconus progression in the study eye occurred in 2 patients (7%) randomized to CXL compared with 12 patients (43%) randomized to standard care. The unadjusted odds ratio suggests that on average, patients in the CXL arm had 90% (odds ratio, 0.1; 95% CI, 0.02-0.48; P = 0.004) lower odds of experiencing progression compared with those receiving standard care. CONCLUSIONS CXL arrests progression of keratoconus in the majority of young patients. CXL should be considered as a first-line treatment in progressive disease. If the arrest of keratoconus progression induced by CXL is sustained in longer follow-up, particular benefit may be derived from avoiding a later requirement for contact lens wear or corneal transplantation.
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Affiliation(s)
- Daniel F P Larkin
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, United Kingdom.
| | - Kashfia Chowdhury
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
| | - Jennifer M Burr
- School of Medicine, University of St. Andrews, St. Andrews, United Kingdom
| | - Mathew Raynor
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Matthew Edwards
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Stephen J Tuft
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, United Kingdom
| | - Catey Bunce
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, United Kingdom
| | - Emilia Caverly
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
| | - Caroline Doré
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
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Zeri F, Swann PG, Naroo S. Osteogenesis imperfecta and keratoconus in an Italian family. Clin Exp Optom 2021; 101:400-403. [DOI: 10.1111/cxo.12617] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/10/2017] [Accepted: 07/14/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Fabrizio Zeri
- Ophthalmic Research Group, School of Life and Health Sciences, Aston University, Birmingham, UK,
| | - Peter G Swann
- School of Optometry and Vision Science, Queensland University of Technology, Brisbane, Queensland, Australia,
- School of Optometry, Hong Kong Polytechnic University, Hong Kong,
| | - Shehzad Naroo
- Ophthalmic Research Group, School of Life and Health Sciences, Aston University, Birmingham, UK,
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27
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Downie LE, Lindsay RG. Contact lens management of keratoconus. Clin Exp Optom 2021; 98:299-311. [DOI: 10.1111/cxo.12300] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 03/30/2015] [Accepted: 04/04/2015] [Indexed: 11/29/2022] Open
Affiliation(s)
- Laura E Downie
- Department of Optometry and Vision Sciences, The University of Melbourne, Parkville, Victoria, Australia
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Yilmaz M, Arikan S, Türkön H. Plasma homocysteine levels in patients with keratoconus. Clin Exp Optom 2021; 103:804-807. [DOI: 10.1111/cxo.13044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/02/2019] [Accepted: 01/05/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Mehmet Yilmaz
- Ophthalmology Clinic, Hatay Antakya State Hospital, Antakya, Turkey,
| | - Sedat Arikan
- Department of Ophthalmology, Canakkale Onsekiz Mart University, Canakkale, Turkey,
| | - Hakan Türkön
- Department of Medical Biochemistry, Canakkale Onsekiz Mart University, Canakkale, Turkey,
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Marty AS, Jurkiewicz T, Febvay C, Mouchel R, Burillon C. [Safety and efficiency of epithelium-off accelerated corneal cross-linking for progressive keratoconus in pediatric patients]. J Fr Ophtalmol 2021; 44:828-834. [PMID: 33846032 DOI: 10.1016/j.jfo.2020.11.012] [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: 01/30/2019] [Revised: 04/11/2020] [Accepted: 11/10/2020] [Indexed: 10/21/2022]
Abstract
In adults, the management of keratoconus has evolved in recent years to achieve a well-codified treatment algorithm. The technique of cross-linking (CXL) has allowed us to stabilize the progression of keratoconus and has been largely developed. It is very effective, with few postoperative complications. Currently, there is no specific keratoconus management protocol for children. As we already know that keratoconus usually evolves more rapidly in children, we might consider whether a stabilizing treatment should be proposed as first-line therapy at the time of diagnosis. We carried out a retrospective study including patients less than 18 years of age with keratoconus who consulted the ophthalmology department at Edouard Herriot hospital in Lyon between 2013 and 2017. The main study parameter was whether or not CXL was performed. The other parameters were gender, age, ethnicity, eye rubbing, presence or absence of atopic disease, maximum keratometry (Kmax), minimal pachymetry, best corrected visual acuity (BCVA) and spherical equivalent. Forty-eight eyes of 34 patients were included. We found that two-thirds of the patients were Caucasian boys. Half of the patients had allergies, and over 60% of patients rubbed their eyes regularly. Only six percent of patients had a family history of keratoconus. The mean age of the patients was 14 (7-18) years at the time of diagnosis. Thirty-four eyes of 22 patients underwent CXL, for a total of 71% of our cohort. No postoperative complications occurred. After CXL, there was no significant difference in minimum pachymetry (455.6±37.25μm vs. 453.45±42.6μm after treatment (P=0.71)) or Kmax (50.23±7.17D vs. 50.99±7.01D after treatment (P=0.058)). There was a significant improvement in BCVA (from 0.30±0.3LogMar to 0.17±0.17LogMar after CXL (P=0.024)) and spherical equivalent (-1.91±2.1D to -2.54±1.89D after treatment (P=0.009)). The mean duration of follow-up was 32.2 months (12-59). CXL shows long-term disease stabilization in children with keratoconus. Nevertheless, this technique is indicated only for progressive keratoconus. Early diagnosis and management are essential in this population where the disease is rapidly changing. Treatment of atopy and performance of corneal topography when a child has irregular astigmatism should become automatic for early detection of this disease.
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Affiliation(s)
- A-S Marty
- Clinique ophtalmologique Thiers, 330, avenue Thiers, 33100 Bordeaux, France.
| | - T Jurkiewicz
- Centre Vendôme, 13, rue Tronchet, 69006 Lyon, France; Hospices civils de Lyon, hôpital Pierre-Wertheimer, 59, boulevard Pinel, 69500 Bron, France
| | - C Febvay
- Service d'ophtalmologie, centre hospitalier de Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon, France
| | - R Mouchel
- Service d'ophtalmologie, Pavillon C, hôpital Edouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France
| | - C Burillon
- Service d'ophtalmologie, Pavillon C, hôpital Edouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France; Faculté de médecine Lyon Sud, Charles-Mérieux, rue du Grand-Revoyet, 69006 Oullins, France
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Ağca A, Tülü B, Yaşa D, Kepez Yıldız B, Sucu ME, Genç S, Fazıl K, Yıldırım Y. Accelerated corneal crosslinking in children with keratoconus: 5-year results and comparison of 2 protocols. J Cataract Refract Surg 2021; 46:517-523. [PMID: 32271294 DOI: 10.1097/j.jcrs.0000000000000101] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate long-term clinical results of 2 different accelerated corneal crosslinking (CXL) protocols in pediatric patients with keratoconus. SETTING Beyoğlu Eye Training and Research Hospital, Istanbul, Turkey. DESIGN Retrospective case-control study. METHODS Patients who were younger than 18 years were included in the study. Group 1 received 4 minutes of illumination at 30 mW/cm, and Group 2 received 5 minutes of illumination at 18 mW/cm. Uncorrected and corrected distance visual acuities, manifest refraction, corneal topographic parameters, and corneal higher-order aberrations (HOAs) were evaluated at baseline and during 1-, 3-, and 5-year follow-up visits. RESULTS A total of 143 eyes from 86 patients were included in the study. There were 30 eyes in Group 1 and 113 eyes in Group 2. The mean follow-up time was 4.15 ± 0.99 years. Mean keratometry (K) and/or maximum K progressed ≥1.00 diopter (D) in 7 eyes (23.3%) in Group 1 and 19 eyes (16.8%) in Group 2 (P = .411). Mean K and/or maximum K decreased ≥2.00 D in 2 eyes (6.7%) in Group 1 and 24 eyes (21.2%) in Group 2 (P = .06). In Group 1, there were no statistically significant differences in topographic parameters during follow-up. In Group 2, there was a statistically significant reduction in total HOA and coma during the 5-year visit when compared with the preoperative visit (P = .005 and P = .045, respectively). CONCLUSIONS Accelerated CXL is beneficial in terms of halting the progression of keratoconus in pediatric patients throughout 5 years of follow-up examinations. An increased irradiance with a reduced application time reduces the topographic effects of CXL.
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Affiliation(s)
- Alper Ağca
- From the Beyoğlu Eye Research and Training Hospital, Istanbul, Turkey
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Shah R, Amador C, Tormanen K, Ghiam S, Saghizadeh M, Arumugaswami V, Kumar A, Kramerov AA, Ljubimov AV. Systemic diseases and the cornea. Exp Eye Res 2021; 204:108455. [PMID: 33485845 PMCID: PMC7946758 DOI: 10.1016/j.exer.2021.108455] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 01/08/2023]
Abstract
There is a number of systemic diseases affecting the cornea. These include endocrine disorders (diabetes, Graves' disease, Addison's disease, hyperparathyroidism), infections with viruses (SARS-CoV-2, herpes simplex, varicella zoster, HTLV-1, Epstein-Barr virus) and bacteria (tuberculosis, syphilis and Pseudomonas aeruginosa), autoimmune and inflammatory diseases (rheumatoid arthritis, Sjögren's syndrome, lupus erythematosus, gout, atopic and vernal keratoconjunctivitis, multiple sclerosis, granulomatosis with polyangiitis, sarcoidosis, Cogan's syndrome, immunobullous diseases), corneal deposit disorders (Wilson's disease, cystinosis, Fabry disease, Meretoja's syndrome, mucopolysaccharidosis, hyperlipoproteinemia), and genetic disorders (aniridia, Ehlers-Danlos syndromes, Marfan syndrome). Corneal manifestations often provide an insight to underlying systemic diseases and can act as the first indicator of an undiagnosed systemic condition. Routine eye exams can bring attention to potentially life-threatening illnesses. In this review, we provide a fairly detailed overview of the pathologic changes in the cornea described in various systemic diseases and also discuss underlying molecular mechanisms, as well as current and emerging treatments.
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Affiliation(s)
- Ruchi Shah
- Eye Program, Board of Governors Regenerative Medicine Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Cynthia Amador
- Eye Program, Board of Governors Regenerative Medicine Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kati Tormanen
- Center for Neurobiology and Vaccine Development, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sean Ghiam
- Sackler School of Medicine, New York State/American Program of Tel Aviv University, Tel Aviv, Israel
| | - Mehrnoosh Saghizadeh
- Eye Program, Board of Governors Regenerative Medicine Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Departments of Molecular and Medical Pharmacology, Medicine, and Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Vaithi Arumugaswami
- Departments of Molecular and Medical Pharmacology, Medicine, and Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Ashok Kumar
- Department of Ophthalmology, Visual and Anatomical Sciences, Wayne State University, Detroit, MI, USA
| | - Andrei A Kramerov
- Eye Program, Board of Governors Regenerative Medicine Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander V Ljubimov
- Eye Program, Board of Governors Regenerative Medicine Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Departments of Molecular and Medical Pharmacology, Medicine, and Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
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Results of Corneal Collagen Cross-Linking in Adolescents with Progressive Keratoconus - A Prospective Study. J Cataract Refract Surg 2021; 47:1333-1337. [PMID: 33769766 DOI: 10.1097/j.jcrs.0000000000000617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 02/10/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Evaluate the safety and efficacy of epi-off corneal cross-linking (CXL) in adolescents with progressive keratoconus (KC). SETTING Private clinical practice DESIGN:: Nonrandomized prospective clinical trial METHODS:: 230 adolescent patients aged 10-19 years old with progressive keratoconus (increasing maximum keratometry (Kmax) or astigmatism of ≥ 1 D associated with decreased corrected distance visual acuity (CDVA)) underwent CXL. Exclusion criteria were age at time of CXL < 10 years or > 19 years, corneas that were thinner than 400 μm or demonstrated central corneal scarring, history of herpetic eye disease, or pregnancy or nursing. Follow up examinations of uncorrected distance visual acuity (UDVA), CDVA, Kmax and minimum pachymetry occurred on 130 eyes at 1 year, 77 eyes at 2 years and 55 eyes at 3 years post-CXL. RESULTS UCVA significantly improved from preop to 1, 2 and 3 years post-CXL. CDVA significantly improved from preop to 1, 2 and 3 years post-CXL. Kmax significantly reduced (improved) from preop to 1 and 3 years post-CXL and reduced (improved) (p=0.22) from preop to two years post-CXL. Minimum pachymetry decreased significantly from preop to 1, 2 and 3 years post-CXL. CONCLUSIONS CXL in patients aged 10-19 years old is safe and efficacious, halts progression of KC and can improve UCVA, CDVA and Kmax. Minimum pachymetry decreases and stabilizes post-CXL. Ophthalmologists should encourage adolescent patients with KC to obtain prompt evaluation and possible CXL to halt progression of the disease.
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Rocha G, Vieira BV, Mendes BMS, Iguma CI, Silva TCS, de Sousa LB, Tzelikis PF. Visual outcomes in advanced keratoconus using different strategies: Scleral lens, intracorneal ring segment and lamellar keratoplasty. Eur J Ophthalmol 2021; 31:1563-1570. [PMID: 33583232 DOI: 10.1177/1120672121994731] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare VA outcomes in patients with advanced keratoconus wearing SCL or after ICRS or DALK. In addition, determine the percentage of complimentary treatments after ICRS and DALK, and which of these was fitting a SCL, and final visual acuity (f-VA) results. METHODS Retrospective case series analyzed 55 eyes with advanced keratoconus fitted with SCL, or after ICRS or a DALK between 2010 and 2018. The variables analyzed were sex, age, UDVA, CDVA, SEQ, K-readings, and f-VA after complimentary treatments. RESULTS Twenty-eight eyes underwent a DALK, 14 were fitted with a SCL, and other 13 underwent ICRS insertion. Patients after DALK and after ICRS showed statistically significant improvement in UDVA and CDVA after surgery, with no difference between these groups. Patients fitted with SCL showed statistically higher CDVA improvement when compared to ICRS. After DALK and ICRS, respectively, nine eyes (32.14%) and seven eyes (53.85%) were fitted with SCL. Comparison between f-VA with SCL in three groups showed that the best result was achieved in DALK + SCL, with statistically significant difference to only SCL. CONCLUSION We showed that the CDVA of eyes fitted with SCL without any surgical treatment was statistically better than CDVA of eyes after ICRS insertion. After DALK and ICRS insertion, many patients needed a complimentary treatment to improve CDVA. The most chosen treatment was fitting a SCL. After this, all eyes showed statistically significant improvement in f-VA, with statistically better results for DALK + SCL when compared to SCL fitted in advanced keratoconus without any surgical treatment.
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Affiliation(s)
- Guilherme Rocha
- Contact Lens Sector, Refractive Surgery and Cornea Sector, Hospital Oftalmológico de Brasília, Brasilia, Brazil
| | | | | | | | | | | | - Patrick Frensel Tzelikis
- Cornea Sector and Refractive Surgery Sector, Hospital Oftalmológico de Brasília, Brasilia, Brazil
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Turhan SA, Yargi B, Toker E. Efficacy of Conventional Versus Accelerated Corneal Cross-linking in Pediatric Keratoconus: Two-Year Outcomes. J Refract Surg 2021; 36:265-269. [PMID: 32267958 DOI: 10.3928/1081597x-20200302-01] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 03/02/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare the efficacy and safety of accelerated corneal cross-linking (CXL) with conventional CXL in pediatric patients with keratoconus. METHODS Consecutive patients with keratoconus received either accelerated CXL (9 mW/cm2 irradiance for 10 minutes) or conventional CXL (3 mW/cm2 irradiance) for 30 minutes. Visual acuities (uncorrected [UDVA] and corrected [CDVA] distance visual acuity, logMAR), spherical error, cylindrical error, spherical equivalent, and keratometric values were recorded. Follow-up measurements were compared with baseline values. RESULTS The study enrolled 48 eyes: 22 eyes had accelerated CXL (mean age: 16.0 ± 1.7 years) and 26 eyes had conventional CXL (mean age: 15.7 ± 1.6 years). Compared with preoperative values, all mean keratometric values significantly improved in the accelerated CXL group (flat [K1]: Δ = -0.64 D, P < .0001, steep [K2]: Δ = -0.63 D, P = .009 and Kmax: Δ = -0.55 D, P = .028), but no significant changes were observed in the mean UDVA and CDVA. In the conventional CXL group, all mean keratometric values and CDVA significantly improved (K1: Δ = -0.65 D, P = .017, K2: Δ = -0.87 D, P = .006, Kmax: Δ = -1.47 D, P = .011). No significant changes were observed in refractive error in either CXL group. There were no significant differences in the keratometric readings, visual acuities, or refractive error between the two groups at the 2-year follow-up. CONCLUSIONS Both conventional and accelerated CXL protocols appear to be effective in stabilizing keratoconus progression in pediatric patients. Improved CDVA was also observed in the conventional CXL group. Accelerated CXL, with its advantage of shorter treatment duration, may be an alternative in pediatric patients. [J Refract Surg. 2020;36(4):265-269.].
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Anitha V, Vanathi M, Raghavan A, Rajaraman R, Ravindran M, Tandon R. Pediatric keratoconus - Current perspectives and clinical challenges. Indian J Ophthalmol 2021; 69:214-225. [PMID: 33463562 PMCID: PMC7933850 DOI: 10.4103/ijo.ijo_1263_20] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/18/2020] [Accepted: 07/16/2020] [Indexed: 01/09/2023] Open
Abstract
Keratoconus is an ectatic corneal disease characterized by progressive stromal thinning, irregular astigmatism, and defective vision. It can be unilateral or bilateral with asymmetric presentation. It starts at puberty and either progresses rapidly to an advanced stage of the disease or stops in case of delayed onset and slow progression. Pediatric keratoconus is more aggressive than in adults and the management protocols differ because of various rationales such as accelerated progression, advanced stage of disease at the time of diagnosis and co-morbidities. It poses a burden to the society as it affects the quality of life, social, and educational development in children. Hence early diagnosis, recognition of progression, and timely intervention with collagen crosslinking is imperative to arrest the worsening. Association with systemic syndromes and ocular comorbidities can be of concern in pediatric keratoconus. Severe ocular allergy when associated hastens progress and complicates timely intervention of crosslinking treatment and compliance to contact lens wear. Keratoplasty in pediatric keratoconus has good outcomes but can encounter frequent suture-related concerns. This article discusses the epidemiology, etiopathogenesis, clinical challenges, and current perspectives of management of pediatric keratoconus.
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Affiliation(s)
- Venugopal Anitha
- Cornea Consultant, Aravind Eye Hospital & Postgraduate Institute, Tirunelveli, Tamil Nadu, India
| | - Murugesan Vanathi
- Prof of Ophthalmology, Cornea, Cataract & Refractive Services, Dr R P Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Anita Raghavan
- Cornea Consultant, Aravind Eye Hospital & Postgraduate Institute, Coimbatore, Tamil Nadu, India
| | - Revathi Rajaraman
- Cornea Consultant, Aravind Eye Hospital & Postgraduate Institute, Coimbatore, Tamil Nadu, India
| | - Meenakshi Ravindran
- Cornea Consultant, Aravind Eye Hospital & Postgraduate Institute, Tirunelveli, Tamil Nadu, India
| | - Radhika Tandon
- Prof of Ophthalmology, Cornea, Cataract & Refractive Services, Dr R P Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
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Khoo P, Cabrera-Aguas M, Watson SL. Microbial Keratitis After Corneal Collagen Cross-Linking for Corneal Ectasia. Asia Pac J Ophthalmol (Phila) 2021; 10:355-359. [PMID: 33534235 DOI: 10.1097/apo.0000000000000379] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The aim of this study was to report the clinical profile and microbiological of patients with microbial keratitis post accelerated corneal collagen cross-linking (CXL). METHODS A retrospective case series of all patients diagnosed with microbial keratitis post-CXL who attended the Sydney Eye Hospital, Australia from January 1, 2012 to December 31, 2019 were included. Patients were identified from hospital coding and pathology data. Data were extracted from patients' medical records. RESULTS Eleven eyes from 10 patients with a mean age of 29 ± 11 years (range 16-48) were included. The median time of infection after CXL surgery was 4 days [interquartile range (IQR) 3-83]. Median initial and final Visual acuity at presentation were 1.3 logMAR (IQR 1-2.0) and 0.8 logMAR (IQR 0.6-1.2), respectively. The culture positivity rate was 92%, identifying 13 isolates, predominately made up of coagulase-negative Staphylococcus (n = 6, 50%) and Staphylococcus aureus (n = 3, 25%). The median epithelial healing time was 30 days (IQR 15-53). CONCLUSIONS Post-CXL microbial keratitis was predominately associated with gram-positive bacteria and in some cases delayed epithelialization. Microbial keratitis post-CXL may lead to moderate to poor patient outcomes.
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Affiliation(s)
- Pauline Khoo
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
| | - Maria Cabrera-Aguas
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
| | - Stephanie L Watson
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia
- Corneal Unit, Sydney Eye Hospital, Sydney, New South Wales, Australia
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Chan C. Corneal Cross-Linking for Keratoconus: Current Knowledge and Practice and Future Trends. Asia Pac J Ophthalmol (Phila) 2020; 9:557-564. [PMID: 33323709 DOI: 10.1097/apo.0000000000000335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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) with riboflavin is an accepted universal standard of care for our keratoconus patients with progressive disease. It has been a game changer in how we manage keratoconus. Early diagnosis and treatment is essential in paediatric patients as younger patients progress more rapidly and have poorer transplant outcomes. There is an ongoing debate around standard, accelerated, and transepithelial protocols of CXL, the role of CXL, and the combination of laser refractive surgery. Future developments will improve CXL safety and efficacy and the scope of utilization, but we must be careful not to leap too far ahead with clinical applications before publication of basic science research and good clinical results with standardized protocols.
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Affiliation(s)
- Colin Chan
- University of Canberra, Faculty of Health, ACT, Australia; University of Sydney, Faculty of Medicine, NSW, Australia
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Corneal collagen cross-linking in pediatric keratoconus with three protocols: a systematic review and meta-analysis. J AAPOS 2020; 24:331-336. [PMID: 33279597 DOI: 10.1016/j.jaapos.2020.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/31/2020] [Accepted: 08/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Keratoconus is a bilateral progressive noninflammatory degenerative disease of the cornea characterized by corneal thinning, irregular astigmatism, and subsequent visual impairment. It has an aggressive course in children. This systematic review evaluates the efficacy of available corneal collagen cross-linking (CXL) protocols for stabilizing the cornea in pediatric patients with keratoconus. METHODS We searched all peer-reviewed publications from 2000 to 2019 indexed in PubMed, Google Scholars, Web of Science, and Cochrane's Database for the terms keratoconus and cross-linking. The following data were extracted from eligible studies: study design, type of intervention, number of the eyes and mean age of patients for each study, duration of follow-up period, mean pre- and postoperative uncorrected and corrected visual acuity, keratometric and aberrometric indices, were analyzed with RevMan 5.3 software. Intra-and intergroup post hoc analyses of outcome variables were performed using t tests. RESULTS A total of 28 studies, including 1,300 eyes, were reviewed. In conventional and accelerated epithelium-off techniques, there was a significant improvement in uncorrected and corrected visual acuities. Similarly, the keratometric indices improved significantly after CXL. Uncorrected visual acuity did not alter after CXL using transepithelial method. CONCLUSIONS Both conventional and accelerated collagen CXL of the cornea are effective therapeutic options in management of keratoconus in children.
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Amer I, Elaskary A, Mostafa A, Hazem HA, Omar A, Abdou A. Long-Term Visual, Refractive and Topographic Outcomes of "Epi-off" Corneal Collagen Cross-Linking in Pediatric Keratoconus: Standard versus Accelerated Protocol. Clin Ophthalmol 2020; 14:3747-3754. [PMID: 33177802 PMCID: PMC7650037 DOI: 10.2147/opth.s275797] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/29/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To compare the visual, refractive and topographic outcomes of standard and accelerated corneal collagen cross-linking (CXL) in pediatric keratoconus patients. METHODS Prospective, comparative observational study on 68 eyes of 35 pediatric keratoconus patients (<18 years). Patients were classified into two groups, group (I) included 34 eyes and received standard "Epi-Off" CXL (3 mW/cm2, 30 min.) and group (II) included 34 eyes and received accelerated "Epi-Off" CXL (9 mW/cm2, 10 min.). Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE), simulated keratometry (Sim K-1, Sim K-2, K-max, K-mean), cylindrical (CYL), pachymetry and Q-value were evaluated preoperatively and for 3 years postoperatively. RESULTS Postoperative UDVA and CDVA did not significantly change in both groups after 3 years. Postoperative SE was increased significantly in accelerated CXL (p=0.012) with no significant change in the postoperative cylinder in both procedures. Standard CXL had greater "significant" effect in decreasing Sim K-1, K-max and K-mean. The mean reduction in postoperative corneal pachymetry (at thinnest location) was significant in standard CXL (18.4 μm) (p=0.001). No significant change was noticed in postoperative Q-value. CONCLUSION Standard and accelerated CXL protocols are efficient in pediatric keratoconus management with better outcomes in the standard procedure.
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Affiliation(s)
- Ibrahim Amer
- Ophthalmology Department, Faculty of Medicine, AL-Azhar University, Assiut, Egypt
| | - Abdelhakeem Elaskary
- Ophthalmology Department, Faculty of Medicine, AL-Azhar University, Assiut, Egypt
| | - Ali Mostafa
- Ophthalmology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hazem A Hazem
- Ophthalmology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Omar
- Ophthalmology Department, Faculty of Medicine, Assiut University, Assiut, Egypt.,University Hospitals Eye Institute and the Department of Ophthalmology and Visual Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ahmed Abdou
- Ophthalmology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
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Antunes-Foschini R, Faria-E-Sousa SJ. Three-year follow-up in advanced pediatric keratoconus: thin corneas may not have pachymetry properly assessed after crosslinking. Int J Ophthalmol 2020; 13:1561-1566. [PMID: 33078105 DOI: 10.18240/ijo.2020.10.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/18/2020] [Indexed: 11/23/2022] Open
Abstract
AIM To analyze the crosslinking (CXL) effects in pediatric keratoconus, and to identify the patients' corneal characteristics whose pachymetry could not be adequately evaluated by Scheimpflug method after procedure. METHODS Consecutive pediatric patients with progressive keratoconus underwent CXL were included. Best-corrected visual acuity (BCVA) and spheric equivalent (SE) were measured before and after CXL. After CXL, groups 1 and 2 were divided based on the posterior surface Pentacam quality specifications (QS): "OK" (Group 1) and "not OK" (Group 2). The mean (RmF and RmB) and minimum (RminF and RminB) radius of curvatures of the anterior and posterior corneal surfaces, and the thinnest pachymetry (Pmin) were measured preoperatively at 3, 6, 12, 24, and 36mo. Haze was annotated. RESULTS Twenty-six patients (14 men, mean age 14±1.8y) and median Kmax of 59.9 D initially and 61.4 D preoperatively were treated. BCVA was not different before and 24mo after CXL. Group 2 statistically differed to group 1 in that SE was more myopic before and with no difference 24mo after CXL; RmF and RmB were steeper and Pmin was thinner pre-surgically. Group 2, in which pachymetric changes could not be adequately evaluated after surgery, presented with significant RmF flattening, a shift to hyperopia, and more haze after CXL. CONCLUSION Patients whose pachymetry could not be adequately evaluated after CXL had steeper and thinner corneas before surgery. The predictive factors for impaired QS after CXL are RmF, RmB, and Pmin. In advanced keratoconus, alternative methods to analyze pachymetry and the posterior surface should be considered.
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Affiliation(s)
- Rosalia Antunes-Foschini
- Hospital das Clínicas, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| | - Sidney Júlio Faria-E-Sousa
- Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14049-900, Brazil
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Accelerated Epi-On Versus Standard Epi-Off Corneal Collagen Cross-Linking for Progressive Keratoconus in Pediatric Patients: Five Years of Follow-Up. Cornea 2020; 39:1493-1498. [DOI: 10.1097/ico.0000000000002463] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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Uçakhan ÖÖ, Celik Buyuktepe T, Yavuz Z, Asbell PA. Pediatric versus Adult Corneal Collagen Crosslinking: Long-term Visual, Refractive, Tomographic and Aberrometric Outcomes. Curr Eye Res 2020; 46:14-22. [PMID: 32538202 DOI: 10.1080/02713683.2020.1782940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To comparatively evaluate the long-term visual, refractive, topographic and aberrometric outcomes of conventional corneal collagen crosslinking (CXL) in the management of pediatric versus adult progressive keratoconus patients. MATERIALS AND METHODS Retrospective, cross-sectional review of consecutive progressive keratoconus cases of corneal standard CXL using a standardized protocol for treatment and examinations was performed. Best spectacle-corrected distance visual acuity (CDVA), manifest refraction, slit lamp biomicroscopy, corneal tomography, corneal aberrometry and endothelial cell counts were evaluated at baseline and yearly at all postoperative follow-up examinations after month-12. The outcomes were analyzed by dividing the patients into 2 age groups; pediatric (≤18 years) versus adult (>18 years). RESULTS Eighty-eight eyes (54 patients) in the pediatric and 104 eyes (68 patients) in the adult age groups completed 3 years follow-up. Compared to baseline, the mean CDVA, manifest refraction, keratometric readings, tomographic and aberrometric parameters improved statistically significantly in both groups at postoperative year-3 and year-4, without any statistically significant between-group differences. No change in the mean endothelial cell density (p > .05), or no sight threating complication was encountered in any patient eye in either group. In a subset of patients who were followed for 4 years (71 eyes in the pediatric and 70 eyes in the adult age groups), the outcome analyses were again similar between-groups. CONCLUSION Conventional corneal CXL effectively halts the progression of keratoconus in both pediatric and adult age groups in long-term follow-up with similar visual, refractive, tomographic and aberrometric efficacy in both groups.
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Affiliation(s)
- Ömür Ö Uçakhan
- Department of Ophthalmology, Ankara University Faculty of Medicine , Ankara, Turkey
| | - Tuna Celik Buyuktepe
- Department of Ophthalmology, Ankara University Faculty of Medicine , Ankara, Turkey
| | - Zeynep Yavuz
- Department of Biostatistics, Ankara University Faculty of Medicine , Ankara, Turkey
| | - Penny A Asbell
- Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center , Memphis, Tennessee, USA
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Iqbal M, Elmassry A, Saad H, AM Gad A, Ibrahim O, Hamed N, Saeed A, S. Khalil A, Tawfik M, Said A, Amer I, Nooreldin A, Said O, Reffat M, Anwar S, Badawi A. Standard cross-linking protocol versus accelerated and transepithelial cross-linking protocols for treatment of paediatric keratoconus: a 2-year comparative study. Acta Ophthalmol 2020; 98:e352-e362. [PMID: 31654497 PMCID: PMC7216930 DOI: 10.1111/aos.14275] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 09/18/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE To compare the efficacy, safety and stability of standard epithelium-off cross-linking (SCXL) versus accelerated epithelium-off cross-linking (ACXL) and transepithelial epithelium-on cross-linking (TCXL) in the treatment of progressive keratoconus (KC) in children. METHODS This prospective multicentre controlled trial included 271 eyes (136 children) with grade 1-3 progressive KC who were randomized to undergo SCXL (n = 91, as a control group), ACXL (n = 92) or TCXL (n = 88). Uncorrected and corrected distance visual acuity, subjective refraction, pachymetry, keratometry and corneal topography measurements were recorded preoperatively and 6, 12 and 24 months postoperatively. RESULTS At 1 year, there was no significant difference in uncorrected distance visual acuity, refractive sphere, cylinder, spherical equivalent or Kmax between the ACXL and SCXL groups; however, during year 2, ACXL regressed while SCXL continued to improve. After 2 years, there were significant differences in all visual, refractive and keratometric components between SCXL and both ACXL and TCXL (p < 0.0001) and between ACXL and TCXL (p < 0.0001). KC progressed in 5.4% of patients who had ACXL and 28.4% of those who had TCXL but in none of those who had SCXL. Vernal keratoconjunctivitis was documented in 43.3% of eyes that progressed postoperatively. CONCLUSION SCXL was more effective for paediatric KC and achieved greater stability than either ACXL or TCXL, and ACXL was superior to TCXL. SCXL also achieved marked improvement in both myopia and spherical equivalent; however, these refractive outcomes were unpredictable and uncontrollable. TCXL had a 28.4% failure rate within 2 years. SCXL is preferable for management of paediatric KC.
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Affiliation(s)
- Mohammed Iqbal
- Department of OphthalmologyFaculty of MedicineSohag UniversitySohagEgypt
| | - Ahmed Elmassry
- Department of OphthalmologyFaculty of MedicineAlexandria UniversityAlexandriaEgypt
| | - Hisham Saad
- Department of OphthalmologyFaculty of MedicineTanta UniversityTantaEgypt
| | - Ahmed AM Gad
- Department of OphthalmologyFaculty of MedicineZagazig UniversityZagazigEgypt
| | - Ola Ibrahim
- Department of OphthalmologyFaculty of MedicineAin Shams UniversityCairoEgypt
| | - Noha Hamed
- Department of OphthalmologyFaculty of MedicineAin Shams UniversityCairoEgypt
| | - Ahmed Saeed
- Department of OphthalmologyFaculty of MedicineBenha UniversityBenhaEgypt
| | - Ahmad S. Khalil
- Department of OphthalmologyFaculty of MedicineZagazig UniversityZagazigEgypt
| | - Mohamed Tawfik
- Department of OphthalmologyMemorial Institute of OphthalmologyGizaEgypt
| | - Amr Said
- Department of OphthalmologyFaculty of MedicineAlexandria UniversityAlexandriaEgypt
| | - Ibrahim Amer
- Department of OphthalmologyFaculty of MedicineAlazhar UniversityAssuitEgypt
| | - Asaad Nooreldin
- Department of OphthalmologyFaculty of MedicineAlazhar UniversityAssuitEgypt
| | - Omar Said
- Department of OphthalmologyFaculty of MedicineFayoum UniversityFayoumEgypt
| | - Mohamed Reffat
- Department of OphthalmologyMansoura Ophthalmic HospitalMansouraEgypt
| | - Seif Anwar
- Department of OphthalmologyMansoura Ophthalmic HospitalMansouraEgypt
| | - Amani Badawi
- Department of OphthalmologyFaculty of MedicineMansoura UniversityMansouraEgypt
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Nicula CA, Rednik AM, Bulboacă AE, Nicula D. Comparative Results Between "Epi-Off" Conventional and Accelerated Corneal Collagen Crosslinking for Progressive Keratoconus in Pediatric Patients. Ther Clin Risk Manag 2020; 15:1483-1490. [PMID: 31920322 PMCID: PMC6941695 DOI: 10.2147/tcrm.s224533] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/04/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose The aim of our study was to evaluate the efficacy and safety of epi-off conventional and accelerated corneal collagen cross-linking in the treatment of progressive keratoconus in pediatric patients up to 4 years after treatment. Patients and methods Conventional (standard) CXL epi-off technique was performed in 37 eyes (S-CXL group) and accelerated CXL in 27 eyes (A-CXL group). Refraction, keratometry, cylindrical equivalent, spherical equivalent, slit lamp examination, pachymetry, corneal tomography, anterior segment ocular coherence tomography and visual acuity were performed up to 4 years. Results In the S-CXL group: the flat K values decreased from 47.41±3.39 D to 45.36±3.62 D at 4 years (p=0.004); steep K decreased from 51.98±4.11 to 50.21±4.81 D at 4 years (p=0.0078); mean K decreased with 1.99 D at 4 years (p=0.009). In the A-CXL group: the flat K values decreased from 46.97±4.17 D to 44.97±4.24 D at 4 years (p=0.048); steep K decreased from 50.55±4.10 D to 48.75±4.17 D at 4 years (p=0.0287); mean K decreased from 48.79±3.86 D to 46.86±4.11 D at 4 years (p=0.0356). The preoperative mean UCVA in the S-CXL group was 0.8 ±0.23 logMar and improved during the follow-up reaching 0.65 ±0.24 logMar at 4 years (p=0.072). The baseline mean UCVA in A-CXL group was 0.77±0.25 logMar and increased during the follow-up to 0.63 ±0.25 logMar at 4 years (p=0.0039). A similar improvement of BCVA was observed during the follow-up. Conclusion Epi-off conventional and accelerated CXL are efficient procedures for progressive keratoconus in pediatric patients. Accelerated and conventional CXL were comparable at all time points and both represent viable options for the therapy of KC in these patients.
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Affiliation(s)
- Cristina Ariadna Nicula
- Department of Ophthalmology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Oculens Clinic, Cluj-Napoca, Romania
| | | | - Adriana Elena Bulboacă
- Department of Physiopathology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Sarac O, Kosekahya P, Caglayan M, Tanriverdi B, Taslipinar Uzel AG, Cagil N. Mechanical versus transepithelial phototherapeutic keratectomy epithelial removal followed by accelerated corneal crosslinking for pediatric keratoconus: Long-term results. J Cataract Refract Surg 2019; 44:827-835. [PMID: 30055691 DOI: 10.1016/j.jcrs.2018.04.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/24/2018] [Accepted: 04/23/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare the 36-month outcomes of mechanical or transepithelial phototherapeutic keratectomy (PTK) epithelial removal before accelerated corneal crosslinking (CXL) for pediatric keratoconus. SETTING Atatürk Training and Research Hospital, Ankara, Turkey. DESIGN Retrospective case series. METHODS Eyes that had accelerated CXL after mechanical (Group 1) or transepithelial PTK (Group 2) epithelial removal were evaluated preoperatively and 12, 24, and 36 months postoperatively. The uncorrected (UDVA) and corrected distance visual acuities, spherical equivalent (SE), manifest astigmatism, and corneal tomographic and aberrometric parameters were assessed. RESULTS The study included 40 eyes of 35 consecutive keratoconus patients younger than 18 years with a 36-month follow-up. Group 1 comprised 15 patients, and Group 2 comprised 20 patients. Both groups had a significant improvement in UDVA (P = .001 and P = .02, respectively) and a significant decrease in maximum keratometry (K) and thinnest corneal thickness (all P < .001) 36 months postoperatively. The improvements in maximum K, topographic astigmatism, and spherical aberration were greater in Group 2 than in Group 1 at 12 months (P = .03, P = .01, and P = .04, respectively). After 12 months, the outcomes in the 2 groups were more similar. CONCLUSIONS The initial visual and topographic outcomes of transepithelial PTK ablation were better than those of mechanical epithelium removal before accelerated CXL in pediatric patients with keratoconus. Over the long-term, the results were similar between the 2 groups.
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Affiliation(s)
- Ozge Sarac
- From the Departments of Ophthalmology, Yildirim Beyazit University, Ankara Atatürk Training and Research Hospital (Sarac, Tanriverdi, Cagil), Ulucanlar Eye Training and Research Hospital (Kosekahya), Ankara, Gazi Yasargil Training and Research Hospital (Caglayan), Diyarbakir, and Afyon Sandikli State Hospital (Uzel), Afyon, Turkey.
| | - Pinar Kosekahya
- From the Departments of Ophthalmology, Yildirim Beyazit University, Ankara Atatürk Training and Research Hospital (Sarac, Tanriverdi, Cagil), Ulucanlar Eye Training and Research Hospital (Kosekahya), Ankara, Gazi Yasargil Training and Research Hospital (Caglayan), Diyarbakir, and Afyon Sandikli State Hospital (Uzel), Afyon, Turkey
| | - Mehtap Caglayan
- From the Departments of Ophthalmology, Yildirim Beyazit University, Ankara Atatürk Training and Research Hospital (Sarac, Tanriverdi, Cagil), Ulucanlar Eye Training and Research Hospital (Kosekahya), Ankara, Gazi Yasargil Training and Research Hospital (Caglayan), Diyarbakir, and Afyon Sandikli State Hospital (Uzel), Afyon, Turkey
| | - Burak Tanriverdi
- From the Departments of Ophthalmology, Yildirim Beyazit University, Ankara Atatürk Training and Research Hospital (Sarac, Tanriverdi, Cagil), Ulucanlar Eye Training and Research Hospital (Kosekahya), Ankara, Gazi Yasargil Training and Research Hospital (Caglayan), Diyarbakir, and Afyon Sandikli State Hospital (Uzel), Afyon, Turkey
| | - Ayse Güzin Taslipinar Uzel
- From the Departments of Ophthalmology, Yildirim Beyazit University, Ankara Atatürk Training and Research Hospital (Sarac, Tanriverdi, Cagil), Ulucanlar Eye Training and Research Hospital (Kosekahya), Ankara, Gazi Yasargil Training and Research Hospital (Caglayan), Diyarbakir, and Afyon Sandikli State Hospital (Uzel), Afyon, Turkey
| | - Nurullah Cagil
- From the Departments of Ophthalmology, Yildirim Beyazit University, Ankara Atatürk Training and Research Hospital (Sarac, Tanriverdi, Cagil), Ulucanlar Eye Training and Research Hospital (Kosekahya), Ankara, Gazi Yasargil Training and Research Hospital (Caglayan), Diyarbakir, and Afyon Sandikli State Hospital (Uzel), Afyon, Turkey
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Alrobaian M, Elsayed M, Alotaibi AK, AlHarbi M, May W, Stone DU. Safety and Efficacy of Corneal Cross-linking in Pediatric Patients with Keratoconus and Vernal Keratoconjunctivitis. Middle East Afr J Ophthalmol 2019; 26:95-100. [PMID: 31543667 PMCID: PMC6737785 DOI: 10.4103/meajo.meajo_240_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE: The purpose of the study is to determine the safety and efficacy of corneal collagen cross-linking for keratoconus in pediatric patients with and without vernal keratoconjunctivitis (VKC). METHODS: This is a retrospective analysis of 89 eyes of 58 patients <18 years of age that underwent corneal collagen cross-linking for progressive keratoconus; inclusion criteria included a minimum of 2-year follow-up after cross-linking. The main outcomes measures included keratometry, pachymetry, vision, and complications following epithelial-off cross-linking with the Dresden protocol. RESULTS: VKC patients were more likely to be male; 81.6% of the non-VKC patients and 96.3% of VKC patients were male (P = 0.038). Comparing pretreatment to the 2-year follow-up, there was no statistically significant change in the mean steep or flat keratometry, corneal thickness, and uncorrected visual acuity or best spectacle-corrected visual acuity in either group. There were no statistically significant differences in the mean visual, keratometric, or adverse event outcomes between the two groups. The proportion exhibiting progression of ectasia at 2 years was 18.5% in the VKC group and 16.7% in the non-VKC group (P = 0.83). CONCLUSIONS: Cross-linking appears to be as safe and effective in pediatric patients with vernal keratoconjunctivits as in those without, with similar outcomes, adverse events, and progression of keratoconus after treatment. The proportion of patients exhibiting progression appears to be higher in pediatric patients than adults, and there is an association between male sex and diagnosis of VKC.
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Affiliation(s)
- Malek Alrobaian
- Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.,Division of Ophthalmology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | | | - Mosa AlHarbi
- Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - William May
- Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.,Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Donald U Stone
- Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.,Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
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Walkden A, Burkitt-Wright E, Au L. Brittle cornea syndrome: current perspectives. Clin Ophthalmol 2019; 13:1511-1516. [PMID: 31496642 PMCID: PMC6698176 DOI: 10.2147/opth.s185287] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022] Open
Abstract
Brittle cornea syndrome (BCS) is a rare autosomal recessive connective tissue disorder characterised by severe corneal thinning, with the major ocular risk being spontaneous ocular perforation due to progressive stromal thinning and ectasia. It is a complex condition with limited treatment options. The purpose of this review is to highlight the difficulties associated with the condition and examine the available published evidence with regards to management.
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Affiliation(s)
- Andrew Walkden
- Manchester Royal Eye Hospital, Manchester University Foundation Trust, Manchester, UK.,Medical Academic Health Sciences Centre, University of Manchester, UK
| | - Emma Burkitt-Wright
- Genetic Medicine, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK.,Genetic Medicine, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Leon Au
- Manchester Royal Eye Hospital, Manchester University Foundation Trust, Manchester, UK.,Medical Academic Health Sciences Centre, University of Manchester, UK
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