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Hacıağaoğlu S, Akkaya Turhan S, Toker E. A comparison of conventional and accelerated corneal crosslinking: corneal epithelial remodeling and in vivo confocal microscopy analysis. Int Ophthalmol 2024; 44:87. [PMID: 38363414 DOI: 10.1007/s10792-024-03020-0] [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: 04/01/2023] [Accepted: 01/09/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE To evaluate the effect of conventional and accelerated corneal crosslinking (CXL) on visual acuity, corneal topography, corneal epithelial thickness, and subbasal nerve morphology in progressive keratoconus patients. METHODS In this prospective and randomized study, twenty eyes of 20 patients were treated with conventional CXL (3 mW/cm2, 30 min, C-CXL) and 19 eyes of 19 patients were treated with accelerated CXL (9 mW/cm2, 10 min, A-CXL). The spherical equivalent, uncorrected visual acuity, best-corrected visual acuity, keratometric measurements, demarcation line measurement and epithelial thickness mapping analyses, and subbasal nerve morphology with in vivo confocal microscopy (IVCCM) were evaluated at baseline and at postoperative months 1, 3 and 6. RESULTS At postoperative 6 months, a significant improvement was observed in all keratometric values in both treatment groups (p < 0.05). All epithelial thickness indices, except central, temporal, and inferotemporal thickness, were reduced at 1 month postoperatively in both treatment groups. The epithelial map uniformity indices (standard deviation and difference between min-max thickness) were significantly lower than the baseline values at all time points after CXL in both treatment groups (p < 0.001). Compared with the preoperative values, there was a significant decrease in all IVCCM parameters at 1 month postoperatively (p < 0.05). At 6 months postoperatively, corneal nerve fiber density and corneal nerve branch density recovered to preoperative values in the A-CXL group, whereas corneal nerve regeneration was not complete in the C-CXL group. CONCLUSION Both conventional and accelerated CXL treatments appear to be effective in halting the progression of KC. Corneal epithelial irregularity slightly improves after CXL. The regeneration of subbasal nerves is faster after A-CXL treatment.
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Affiliation(s)
- Sezer Hacıağaoğlu
- Department of Ophthalmology, Bahçeşehir University, Sahrayıcedit Mah. Batman Sk. No:66, 34734 Kadıköy, Istanbul, Turkey.
| | - Semra Akkaya Turhan
- Department of Ophthalmology, Marmara University, Marmara Üniversitesi Pendik Eğitim ve Araştırma Hastanesi, Fevzi Çakmak Mah. Muhsin Yazıcıoğlu Cad. No:10 Pendik, Istanbul, Turkey
| | - Ebru Toker
- Department of Ophthalmology and Visual Sciences, West Virginia University, Morgantown, United States
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Shimizu T, Hayashi T, Ishida A, Kobayashi A, Yamaguchi T, Mizuki N, Yuda K, Yamagami S. Evaluation of corneal nerves and dendritic cells by in vivo confocal microscopy after Descemet's membrane keratoplasty for bullous keratopathy. Sci Rep 2022; 12:6936. [PMID: 35484297 PMCID: PMC9050645 DOI: 10.1038/s41598-022-10939-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/11/2022] [Indexed: 11/09/2022] Open
Abstract
This study evaluated changes in corneal nerves and the number of dendritic cells (DCs) in corneal basal epithelium following Descemet membrane endothelial keratoplasty (DMEK) surgery for bullous keratopathy (BK). Twenty-three eyes from 16 consecutive patients that underwent DMEK for BK were included. Eyes of age-matched patients that underwent pre-cataract surgery (12 eyes) were used as controls. In vivo confocal microscopy was performed pre- and postoperatively at 6, 12, and 24 months. Corneal nerve length, corneal nerve trunks, number of branches, and the number of DCs were determined. The total corneal nerve length of 1634.7 ± 1389.1 μm/mm2 before surgery was significantly increased in a time-dependent manner to 4485.8 ± 1403.7 μm/mm2, 6949.5 ± 1477.1 μm/mm2, and 9389.2 ± 2302.2 μm/mm2 at 6, 12, and 24 months after DMEK surgery, respectively. The DC density in BK cornea pre- and postoperatively at 6 months was significantly higher than in the controls, and decreased postoperatively at 12 and 24 months and was significantly lower than that at 6 months postoperatively. Thus, our results suggest that DMEK can repair and normalize the corneal environment.
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Affiliation(s)
- Toshiki Shimizu
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Ohyaguchikami-machi 30-1, Itabashi-ku, Tokyo, 173-8610, Japan.,Department of Ophthalmology, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan.,Kikuna Yuda Eye Clinic, Yokohama, Kanagawa, Japan
| | - Takahiko Hayashi
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Ohyaguchikami-machi 30-1, Itabashi-ku, Tokyo, 173-8610, Japan. .,Kikuna Yuda Eye Clinic, Yokohama, Kanagawa, Japan.
| | | | - Akira Kobayashi
- Department of Ophthalmology, Graduate School of Medical Science, Kanazawa University, Ichikawa, Japan
| | - Takefumi Yamaguchi
- Department of Ophthalmology, Tokyo Dental College Ichikawa General Hospital, Ichikawa-shi, Chiba, Japan
| | - Nobuhisa Mizuki
- Department of Ophthalmology, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Kenji Yuda
- Kikuna Yuda Eye Clinic, Yokohama, Kanagawa, Japan
| | - Satoru Yamagami
- Division of Ophthalmology, Department of Visual Sciences, Nihon University School of Medicine, Ohyaguchikami-machi 30-1, Itabashi-ku, Tokyo, 173-8610, Japan
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Teo AWJ, Mansoor H, Sim N, Lin MTY, Liu YC. In Vivo Confocal Microscopy Evaluation in Patients with Keratoconus. J Clin Med 2022; 11:393. [PMID: 35054085 PMCID: PMC8778820 DOI: 10.3390/jcm11020393] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 02/05/2023] Open
Abstract
Keratoconus is the most common primary corneal ectasia characterized by progressive focal thinning. Patients experience increased irregular astigmatism, decreased visual acuity and corneal sensitivity. Corneal collagen crosslinking (CXL), a minimally invasive procedure, is effective in halting disease progression. Historically, keratoconus research was confined to ex vivo settings. In vivo confocal microscopy (IVCM) has been used to examine the corneal microstructure clinically. In this review, we discuss keratoconus cellular changes evaluated by IVCM before and after CXL. Cellular changes before CXL include decreased keratocyte and nerve densities, disorganized subbasal nerves with thickening, increased nerve tortuosity and shortened nerve fibre length. Repopulation of keratocytes occurs up to 1 year post procedure. IVCM also correlates corneal nerve status to functional corneal sensitivity. Immediately after CXL, there is reduced nerve density and keratocyte absence due to mechanical removal of the epithelium and CXL effect. Nerve regeneration begins after 1 month, with nerve fibre densities recovering to pre-operative levels between 6 months to 1 year and remains stable up to 5 years. Nerves remain tortuous and nerve densities are reduced. Corneal sensitivity is reduced immediately postoperatively but recovers with nerve regeneration. Our article provides comprehensive review on the use of IVCM imaging in keratoconus patients.
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Affiliation(s)
- Alvin Wei Jun Teo
- Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore 168751, Singapore;
| | - Hassan Mansoor
- Al Shifa Trust Eye Hospital, Jhelum Road, Rawalpindi 46000, Pakistan;
| | - Nigel Sim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 168751, Singapore;
| | - Molly Tzu-Yu Lin
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore;
| | - Yu-Chi Liu
- Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore 168751, Singapore;
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore 169856, Singapore;
- Cornea and Refractive Surgery Group, Singapore Eye Research Institute, Singapore 169856, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore 169857, Singapore
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Bonzano C, Cutolo CA, Musetti D, Di Mola I, Pizzorno C, Scotto R, Traverso CE. Delayed Re-epithelialization After Epithelium-Off Crosslinking: Predictors and Impact on Keratoconus Progression. Front Med (Lausanne) 2021; 8:657993. [PMID: 34722556 PMCID: PMC8554242 DOI: 10.3389/fmed.2021.657993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 09/16/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: To investigate the demographic and corneal factors associated with the occurrence of delayed reepithelialization (DRE) after epithelium-off crosslinking (epi-off CXL). Design:Retrospective case series. Methods:A chart review was performed to identify patients treated with epi-off CXL. DRE was defined as a corneal epithelial defect detected by fluorescein staining that persisted for more than 10 days. Slit-lamp examination, anterior segment optical coherence tomography, corneal topography, and corneal in vivo confocal microscopy (IVCM) were always performed preoperatively and at each follow-up visit (1, 3, 6, 12 months). A generalized estimating equation was used to assess the baseline factors associated with DRE. Results:Data from 153 eyes were analyzed. The mean age of patients was 24.9 ± 8.5 years, and 47 (30.7%) were women. The average reepithelization time was 4.7 ± 1.8 days. Six eyes (3.9%) experienced DRE. In the multivariate model, both the age of the patient (OR = 1.30; p = 0.02) and the corneal steepest meridian (OR = 0.44, p = 0.047) were associated with DRE. Baseline nerve count was also associated with DRE (0.87, p = 0.03). Male gender was associated with a slower early nerve regrowth (1–6 months) (p = 0.048), but not with the occurrence of DRE (p = 0.27). Preoperative central corneal thickness was not related to DRE (p = 0.16). DRE was not associated with keratoconus progression after epi-off CXL (p = 0.520). Conclusions:The association between DRE and age may reflect the age-related decrease in the corneal healing response. Also, low baseline corneal nerve count is associated with DRE. Gender seems to affect reinnervation measured by IVCM but not the reepithelization time. DRE does not seem to affect the efficacy of epi-off CXL.
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Affiliation(s)
- Chiara Bonzano
- Eye Clinic, DiNOGMI, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Carlo Alberto Cutolo
- Eye Clinic, DiNOGMI, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Donatella Musetti
- Eye Clinic, DiNOGMI, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Ilaria Di Mola
- Eye Clinic, DiNOGMI, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Chiara Pizzorno
- Eye Clinic, DiNOGMI, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Riccardo Scotto
- Eye Clinic, DiNOGMI, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Carlo Enrico Traverso
- Eye Clinic, DiNOGMI, University of Genoa and IRCCS San Martino Polyclinic Hospital, Genoa, Italy
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Sheludchenko VM, Voronin GV, Osipyan GA, Djalili RA. [Methods of surgical treatment of keratectasia and analysis of postsurgical quality of vision]. Vestn Oftalmol 2020; 136:308-316. [PMID: 33063982 DOI: 10.17116/oftalma2020136052308] [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: 11/17/2022]
Abstract
Keratectasias are non-inflammatory dystrophic diseases of the cornea characterized by progressive bilateral thinning of the cornea that lead to deterioration in the quantitative and qualitative characteristics of vision reducing patient's quality of life. The changes can be asymmetrical and destructive. A number of surgeries have been proposed to reduce the negative effects of keratectasia including penetrating keratoplasty and its modifications, implantation of corneal ring segments, corneal cross-linking - alone and in combination with other methods, intrastromal keratoplasty. These methods can improve visual acuity to a certain degree and help slow the progression of keratectasia. This article studies various surgical methods used for treating keratectasia and analyses possible assessment of the quality of vision before and after the treatment.
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Affiliation(s)
| | - G V Voronin
- Research Institute of Eye Diseases, Moscow, Russia
| | - G A Osipyan
- Research Institute of Eye Diseases, Moscow, Russia
| | - R A Djalili
- Research Institute of Eye Diseases, Moscow, Russia
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Andreanos KD, Hashemi K, Petrelli M, Droutsas K, Georgalas I, Kymionis GD. Keratoconus Treatment Algorithm. Ophthalmol Ther 2017; 6:245-262. [PMID: 28755306 PMCID: PMC5693837 DOI: 10.1007/s40123-017-0099-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Indexed: 11/25/2022] Open
Abstract
Keratoconus management has significantly changed over the last two decades. The advent of new interventions such as cornea cross-linking, intrastromal corneal ring segments, and combined treatments provide corneal clinicians a variety of treatment options for the visual rehabilitation of keratoconus patients. This review summarizes current evidence for these treatments and highlights their place in keratoconus management while new promising emerging therapies are being investigated.
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Affiliation(s)
- Konstantinos D Andreanos
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece.
| | - Kate Hashemi
- Faculty of Biology and Medicine, Jules Gonin Eye Hospital, University of Lausanne, Lausanne, Switzerland
| | - Myrsini Petrelli
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Droutsas
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece
| | - Ilias Georgalas
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece
| | - George D Kymionis
- 1st Department of Ophthalmology, 'G. Gennimatas Hospital', National and Kapodistrian University of Athens, Athens, Greece
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Zhou HY, Cao Y, Wu J, Zhang WS. Role of corneal collagen fibrils in corneal disorders and related pathological conditions. Int J Ophthalmol 2017; 10:803-811. [PMID: 28546941 DOI: 10.18240/ijo.2017.05.24] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/23/2017] [Indexed: 01/24/2023] Open
Abstract
The cornea is a soft tissue located at the front of the eye with the principal function of transmitting and refracting light rays to precisely sense visual information. Corneal shape, refraction, and stromal stiffness are to a large part determined by corneal fibrils, the arrangements of which define the corneal cells and their functional behaviour. However, the modality and alignment of native corneal collagen lamellae are altered in various corneal pathological states such as infection, injury, keratoconus, corneal scar formation, and keratoprosthesis. Furthermore, corneal recuperation after corneal pathological change is dependent on the balance of corneal collagen degradation and contraction. A thorough understanding of the characteristics of corneal collagen is thus necessary to develop viable therapies using the outcome of strategies using engineered corneas. In this review, we discuss the composition and distribution of corneal collagens as well as their degradation and contraction, and address the current status of corneal tissue engineering and the progress of corneal cross-linking.
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Affiliation(s)
- Hong-Yan Zhou
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Yan Cao
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Jie Wu
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Wen-Song Zhang
- Department of Ophthalmology, the Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
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Outcome of Keratoconus Management: Review of the Past 20 Years' Contemporary Treatment Modalities. Eye Contact Lens 2017; 43:141-154. [DOI: 10.1097/icl.0000000000000270] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Refractive, Topographic, and Aberrometric Results at 2-Year Follow-Up for Accelerated Corneal Cross-Link for Progressive Keratoconus. J Ophthalmol 2017; 2017:5714372. [PMID: 28197339 PMCID: PMC5286471 DOI: 10.1155/2017/5714372] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 06/12/2016] [Accepted: 09/28/2016] [Indexed: 11/18/2022] Open
Abstract
Purpose. To report the visual, refractive, and corneal topography and wavefront aberration results of accelerated corneal cross-linking (CXL) during a 24-month follow-up. Methods. Forty-seven eyes underwent riboflavin-ultraviolet A-induced accelerated CXL treatment (30 mW/cm2 with a total dose of 7.2 joules/cm2). Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical and cylindrical values, keratometry (K) measurements (Ksteep, Kflat, Kavg, and Kapex), central corneal thickness, and anterior corneal aberrometric analyses including total wavefront error (WFE), total high order aberration (HOA), astigmatism, trefoil, coma, quadrafoil, secondary astigmatism, and spherical aberration were evaluated. Results. The mean UDVA and CDVA were significantly improved at 1 (p = 0.003 and p = 0.004, resp.) and 2 years after treatment (p = 0.001 and p = 0.001, resp.). The mean Ksteep, Kflat, Kaverage, and Kapex values were significantly lower than baseline at 12 months (p = 0.008, p = 0.024, p = 0.001, and p = 0.014, resp.) and 24 months (p = 0.014, p = 0.017, p = 0.001, and p = 0.012, resp.). Corneal thickness showed a significant decrease at 1 month. Total HOA and coma decreased significantly at the 12-month (p = 0.001 and p = 0.009, resp.) and 24-month visits (p = 0.001 and p = 0.007, resp.). Conclusion. Accelerated CXL (30 mW/cm2) was found to be effective in improving UDVA, CDVA, corneal topography readings, total HOA, and coma aberrations during the 24-month follow-up.
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Kurt T, Ozgurhan EB, Yildirim Y, Akcay BIS, Cosar MG, Bozkurt E, Taskapili M. Accelerated (18 mW/cm(2)) Corneal Cross-Linking for Progressive Keratoconus: 18-Month Results. J Ocul Pharmacol Ther 2016; 32:186-91. [PMID: 27027668 DOI: 10.1089/jop.2015.0127] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The aim of this study is to report the results of 18 months of follow-up after treatment with accelerated (18 mW/cm(2)) corneal cross-linking in patients with progressive keratoconus. METHODS Forty-two eyes of 42 patients with progressive keratoconus were included in this retrospective study. All patients underwent accelerated corneal cross-linking at an irradiance of 18 mW/cm(2) for 5 min (total surface dose 5.4 J/cm(2)). Visual acuity, topographic findings (Kflat, Ksteep, Kaverage, and apical keratometry), and central corneal thickness were evaluated during the 18-month follow-up period. RESULTS The mean ± standard deviation age of the 16 female and 26 male patients was 24.28 ± 6.32 years (range 14-36). Uncorrected distance visual acuity improved clinically significant from 0.52 ± 0.31 to 0.44 ± 0.25 logMAR (P = 0.031), and corrected distance visual acuity improved clinically significant from 0.34 ± 0.21 to 0.28 ± 0.19 logMAR (P = 0.018). At the last examination during the follow-up period, the flat keratometry (Kflat) decreased from a baseline of 45.65 ± 2.71 to 45.41 ± 2.72 diopters (D) (P = 0.001), the steep keratometry (Ksteep) decreased from 49.20 ± 3.54 to 48.96 ± 3.43 D (P = 0.023), and apical keratometry decreased from 56.62 ± 6.43 to 55.19 ± 5.69 D (P = 0.001), all of them were clinically significant at the 18-month visit. The preoperative values of central corneal thickness changed from 458.95 ± 38.79 to 461.85 ± 41.36 μm 18 months after the operation (P = 0.476). CONCLUSION The accelerated corneal cross-linking was found to be effective for the stabilization of progressive keratoconus during the 18 months of follow-up visits.
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Affiliation(s)
- Tugba Kurt
- 1 Department of Ophthalmology, Tekirdag State Hospital , Tekirdag, Turkey
| | - Engin Bilge Ozgurhan
- 2 Department of Ophthalmology, Beyoglu Eye Training and Research Hospital , Istanbul, Turkey
| | - Yusuf Yildirim
- 2 Department of Ophthalmology, Beyoglu Eye Training and Research Hospital , Istanbul, Turkey
| | | | - Mediha Gulen Cosar
- 4 Department of Ophthalmology, Malkara State Hospital , Tekirdag, Turkey
| | - Ercument Bozkurt
- 2 Department of Ophthalmology, Beyoglu Eye Training and Research Hospital , Istanbul, Turkey
| | - Muhittin Taskapili
- 2 Department of Ophthalmology, Beyoglu Eye Training and Research Hospital , Istanbul, Turkey
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Randleman JB, Khandelwal SS, Hafezi F. Corneal cross-linking. Surv Ophthalmol 2015; 60:509-23. [PMID: 25980780 DOI: 10.1016/j.survophthal.2015.04.002] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 12/26/2022]
Abstract
Since its inception in the late 1990s, corneal cross-linking has grown from an interesting concept to a primary treatment for corneal ectatic disease worldwide. Using a combination of ultraviolet-A light and a chromophore (vitamin B2, riboflavin), the cornea can be stiffened, usually with a single application, and progressive thinning diseases such as keratoconus arrested. Despite being in clinical use for many years, some of the underlying processes, such as the role of oxygen and the optimal treatment times, are still being worked out. More than a treatment technique, corneal cross-links represent a physiological principle of connective tissue, which may explain the enormous versatility of the method. We highlight the history of corneal cross-linking, the scientific underpinnings of current techniques, evolving clinical treatment parameters, and the use of cross-linking in combination with refractive surgery and for the treatment of infectious keratitis.
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Affiliation(s)
- J Bradley Randleman
- Department of Ophthalmology, Emory University, Atlanta, Georgia, USA; Emory Vision, Emory Eye Center, Atlanta, Georgia, USA.
| | | | - Farhad Hafezi
- ELZA Institute, Zurich, Switzerland; Laboratory for Ocular Cell Biology, University of Geneva, Geneva, Switzerland; Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
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