Epithelial and stromal remodeling after corneal collagen cross-linking evaluated by spectral-domain OCT

Diurnal changes of corneal epithelial and stromal thickness maps and visual quality in mild form of Fuchs' endothelial corneal dystrophy

PURPOSE

To investigate the functional and structural daily variations in eyes with a mild form of Fuchs' endothelial corneal dystrophy (FECD).

METHODS

This prospective study included 30 eyes with the mild form of FECD. Subjects underwent functional and structural testing at 8 AM, 2 PM, and 8 PM. Testing included measurement of uncorrected distance visual acuity (UDVA), best corrected twilight vision (TV), and contrast sensitivity function (CSF) testing (Vista Vision Far-Pola, DMD MedTech charts). Corneal epithelial and stromal parameters were evaluated with anterior segment optical coherence tomography (AngioVue, AvantiRTVue-XR; Optovue, CA, USA).

RESULTS

UDVA, TV, and CSF for spatial frequencies B, C, and F showed significant changes during the day, with the lowest values in the morning ( P < 0.0001 for UDVA, P = 0.0109 for TV, and P < 0.0001, P = 0.0126, and P = 0.0471 for the three spatial frequencies, respectively). There was no significant change in epithelial parameters between visits. Central corneal thickness showed significant decrease during the day ( P < 0.0001), as did the central stromal thickness on the 5- and 7-mm maps ( P = 0.0002 and P < 0.0001, respectively), stromal thickness in the superior section of the 5-mm map ( P = 0.0107), stromal thickness in the inferior section of the 7-mm map ( P = 0.0002), and minimal stromal thickness on both maps ( P < 0.0001).

CONCLUSION

A significant negative correlation was found between central stromal thickness and TV, implying that simultaneous evaluation of corneal layers and visual quality may be useful in assessing FECD.

Comparison of the repeatability and reproducibility of corneal thickness mapping using optical coherence tomography according to tear film break-up time

BACKGROUND

To compare the repeatability and reproducibility of corneal and corneal epithelial thickness mapping using anterior segment optical coherence tomography (AS-OCT) according to tear film break-up time (TBUT).

METHODS

The included eyes were divided into three subgroups according to TBUT (group 1: TBUT ≤ 5 s, group 2: 5 s < TBUT ≤ 10 s, and group 3: TBUT > 10 s). All eyes were imaged separately thrice by two operators to obtain the thickness maps (TMs) of the cornea and corneal epithelium based on spatial zones encompassing a 9-mm-diameter area. Each TM consisted of 25 areas. Intraoperator (repeatability) and interoperator (reproducibility) standard deviations (Sws), coefficients of variation (CoVs), and intraclass correlation coefficients (ICCs) among the tests were calculated and compared in all the areas.

RESULTS

Altogether, 132 eyes of 67 subjects were included (50, 47, and 35 eyes in groups 1, 2, and 3; respectively). The ICCs of corneal epithelial thickness and corneal thickness were > 0.75 in most of the areas. Pairwise comparisons showed that AS-OCT exhibited lower repeatability in group 1 than in groups 2 and 3 (P < 0.05). However groups 2 and 3 showed similar results. Sws and CoVs of corneal epithelial thickness exhibited no significant interoperator differences. While no significant differences were observed in corneal thickness in most of the areas.

CONCLUSIONS

TBUT significantly influences the repeatability of corneal and corneal epithelial thickness measurements. Poor tear film stability requires careful evaluation of corneal epithelial thickness.

Corneal Collagen Crosslinking for Ectasia After Refractive Surgery: A Systematic Review and Meta-Analysis

Introduction

Corneal ectasia leads to progressive irregular corneal curvature and reduced visual acuity.

Objective

To assess the safety and effectiveness of corneal collagen cross-linking (CXL) for managing corneal ectasia resulting from refractive laser surgery (RSL).

Methods

A systematic review and meta-analysis were realized according to PRISMA guidelines. We searched PubMed, EMBASE, Cochrane, and Web of Science databases for studies on CXL in patients with ectasia after RLS. The outcomes of interest included visual acuity, refractive outcomes, topographic parameters (Kmax, index surface variance (ISV), index of Vertical Asymmetry (IVA), keratoconus index (KI), central keratoconus index (CKI), index of height asymmetry (IHA), index of height decentration (IHD) and Rmin (minimum sagittal curvature)), central corneal thickness, endothelial cell count, and possible adverse events. Statistical analysis was performed using the R software (version 4.2.3, R Foundation for Statistical Computing, Vienna, Austria).

Results

15 studies encompassing 421 patients (512 eyes) were included. The mean age was 32.03 ± 4.4 years. The pooled results showed a stable uncorrected visual acuity post-CXL, with a significant improvement in corrected distance visual acuity (SMD = 0.09; 95% CI: -0.07 to 0.26). The spherical equivalent decreased significantly (SMD = -0.09; 95% CI: -0.35, -0.02). The topographic parameter Kmax decreased significantly (SMD = 0.15; 95% CI:0.01 to 0.28); however, the other parameters, ISV, IVA, KI, CKI, IHA, IHD, and Rmin, did not change significantly. Central corneal thickness decreased significantly (SMD = 0.24; 95% CI:0.07 to 0.41), and the endothelial cell count remained stable The complications were rare.

Conclusion

CXL is a safe and effective technique for managing corneal ectasia after RLS.

A comparison of conventional and accelerated corneal crosslinking: corneal epithelial remodeling and in vivo confocal microscopy analysis

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.

Corneal Epithelial Thickness Mapping: A Major Review

The corneal epithelium (CE) is the outermost layer of the cornea with constant turnover, relative stability, remarkable plasticity, and compensatory properties to mask alterations in the underlying stroma. The advent of quantitative imaging modalities capable of producing epithelial thickness mapping (ETM) has made it possible to characterize better the different patterns of epithelial remodeling. In this comprehensive synthesis, we reviewed all available data on ETM with different methods, including very high-frequency ultrasound (VHF-US) and spectral-domain optical coherence tomography (SD-OCT) in normal individuals, corneal or systemic diseases, and corneal surgical scenarios. We excluded OCT studies that manually measured the corneal epithelial thickness (CET) (e.g., by digital calipers) or the CE (e.g., by confocal scanning or handheld pachymeters). A comparison of different CET measuring technologies and devices capable of producing thickness maps is provided. Normative data on CET and the possible effects of gender, aging, diurnal changes, refraction, and intraocular pressure are discussed. We also reviewed ETM data in several corneal disorders, including keratoconus, corneal dystrophies, recurrent epithelial erosion, herpes keratitis, keratoplasty, bullous keratopathy, carcinoma in situ, pterygium, and limbal stem cell deficiency. The available data on the potential role of ETM in indicating refractive surgeries, planning the procedure, and assessing postoperative changes are reviewed. Alterations in ETM in systemic and ocular conditions such as eyelid abnormalities and dry eye disease and the effects of contact lenses, topical medications, and cataract surgery on the ETM profile are discussed.

Evaluation of the effect of artificial tears on corneal epithelial thickness changes after photorefractive keratectomy

PURPOSE

This study aimed to evaluate the corneal epithelial thickness changes after photorefractive keratectomy (PRK) and the impact of long-term artificial tear usage on epithelial thickness changes in these patients.

METHODS

This study was performed on 71 patients (142 eyes) without dry eye disease who received PRK for myopic refractive correction. The corneal epithelial thickness profile was obtained before, one, three, and six months after surgery using anterior segment optical coherence tomography. Patients were randomly divided into two groups: group A, who received preservative-free artificial tears post-surgery, and group B, who did not receive artificial tears.

RESULTS

The epithelial thickness decreased universally in the first month and then increased in the 3- and 6-month follow-ups. Group A had a significantly thicker epithelium in central, paracentral, and midperipheral zones compared with group B in the 3-month follow-up. In the 6-month follow-up, no significant differences were detected between groups. At the last follow-up, the central, paracentral, and midperipheral zone epithelial thicknesses in all patients were significantly higher than preoperative values, but peripheral zone thickness only increased to preoperative values.

CONCLUSIONS

Patients using artificial tears showed a faster thickening, especially in the central and paracentral zones, but there were no significant differences between the two groups in the final follow-up. Artificial tear usage may increase the rate of the epithelial remodeling process in post-PRK patients without significantly altering the final epithelial thickness profile. Further studies are warranted to evaluate the influence of different factors on epithelial remodeling.

New keratoconus staging system based on OCT

PURPOSE

To establish a numerical spectral-domain optical coherence tomography (SD-OCT)-based keratoconus (KC) staging system and compare it with existing KC staging systems.

SETTING

Eye Hospital of Wenzhou Medical University, Wenzhou, China.

DESIGNS

Retrospective case-control study.

METHODS

Scheimpflug tomography, air-puff tonometry, and SD-OCT were performed on 236 normal and 331 KC eyes. All SD-OCT-derived parameters of the corneal epithelium and stroma were evaluated based on their receiver operating characteristic (ROC) curves, area under the curve (AUC), sensitivity, and specificity to discriminate between normal and KC eyes. The best performing parameters were subsequently used to create an OCT-based staging system, which was compared with existing tomographic and biomechanical staging systems.

RESULTS

236 eyes from 236 normal patients and 331 eyes from 331 KC patients of different stages were included. The highest ranked AUC ROC SD-OCT parameters, derived from stroma and epithelium, were stroma overall minimum thickness (ST: AUC 0.836, sensitivity 90%, specificity 67%) and epithelium overall SD (EP: AUC 0.835, sensitivity 75%, specificity 78%). A numerical SD-OCT staging system called STEP including 2 parameters-"ST" and "EP"-with 5 stages was proposed.

CONCLUSIONS

The new SD-OCT-based KC staging system is the first to take the epithelium with its sublayer stroma information into account, showing a strong agreement to the existing staging systems. This system could be incorporated into daily practice, potentially leading to an overall improvement in KC treatment and follow-up management.

The Evolution of Diagnostics for Keratoconus: From Ophthalmometry to Biomechanics

PURPOSE

To enumerate the various diagnostic modalities used for keratoconus and their evolution over the past century.

METHODS

A comprehensive literature search including articles on diagnosis on keratoconus were searched on PUBMED and summarized in this review.

RESULTS

Initially diagnosed in later stages of the disease process through clinical signs and retinoscopy, the initial introduction of corneal topography devices like Placido disc, photokeratoscopy, keratometry and computer-assisted videokeratography helped in the earlier detection of keratoconus. The evolution of corneal tomography, initially with slit scanning devices and later with Scheimpflug imaging, has vastly improved the accuracy and detection of clinical and sub-clinical disease. Analyzing the alteration in corneal biomechanics further contributed to the earlier detection of keratoconus even before the tomographic changes became evident. Anterior segment optical coherence tomography has proven to be a helpful adjuvant in diagnosing keratoconus, especially with epithelial thickness mapping. Confocal microscopy has helped us understand the alterations at a cellular level in keratoconic corneas.

CONCLUSION

Thus, the collective contribution of the various investigative modalities have greatly enhanced earlier and accurate detection of keratoconus, thus reducing the disease morbidity.

Effect of corneal epithelial remodeling on visual outcomes of topography-guided femtosecond LASIK

PURPOSE

To assess the effect of epithelial remodeling on visual outcomes over a 9 mm diameter corneal surface after topography-guided laser in situ keratomileusis (LASIK) for myopia correction using spectral-domain anterior segment optical coherence tomography (AS-OCT).

SETTING

Outpatient clinical practice at the Stanford University Byers Eye Institute in Palo Alto, California.

DESIGN

Prospective nonrandomized observational study.

METHODS

Visual acuity, including uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), 5% and 25% contrast sensitivity CDVA, manifest refraction, and corneal epithelial thickness after topography-guided femtosecond LASIK were analyzed. Corneal epithelial thickness was mapped across 13 sections and 3 concentric zones using AS-OCT preoperatively and at 1 month, 3 months, 6 months, and 12 months postoperatively.

RESULTS

60 eyes of 30 patients with a mean age of 32.8 years (range 23 to 52 ± 7.03 years) undergoing myopic LASIK correction were assessed. In eyes with complete follow-up data (n = 30), mean preoperative UDVA was logMAR 1.48 ± 0.45 and logMAR -0.11 ± 0.08 at postoperative 12 months. Mean preoperative CDVA was logMAR -0.08 ± 0.11 and logMAR -0.13 ± 0.07 at 12 months. Linear mixed modeling demonstrated a significant correlation between improvement in UDVA and decreased superior and nasal corneal epithelial thickness and between improvement in CDVA and increased central epithelial thickness 12 months postoperatively.

CONCLUSIONS

Improvement in UDVA and CDVA at 12 months after topography-guided femtosecond LASIK was correlated with nonuniform epithelial remodeling, including epithelial thickening in the central zone and thinning in the superior and nasal sections as measured by AS-OCT.

Understanding Corneal Epithelial Thickness Mapping

Corneal epithelial thickness (CET) and the regional variations in response to changes in corneal architecture and biomechanics have recently drawn the interest of corneal surgeons. Corneal epithelium possesses the tremendous capability of remodeling and changing its thickness. This remodeling of corneal epithelium takes place in response to underlying stromal irregularities which can result from a variety of corneal disorders including corneal ectasia. Measurement of CET can reveal the underlying stromal abnormalities and supplement in early diagnosis of corneal disorders especially corneal ectasia which has been one of the leading challenges in planning corneal refractive surgery. A significant number of patients ends up in ectasia after refractive surgery and the most common cause of this complication is the presence of preoperative subclinical keratoconus. Furthermore, postoperative complications of corneal refractive surgery are partly masked by epithelial remodeling and make the diagnosis and management difficult and extremely challenging. This leads not only to unpredictable visual and refractive outcome but also the need of multiple interventions to treat these complications. Although corneal tomography is considered as gold standard in the detection and diagnosis of corneal ectasia, a small number of subclinical cases may still go undetected. In this review, we have highlighted the underlying mechanism of epithelial remodeling, the devices and imaging modalities used to measure CET, and application of epithelial mapping in the diagnosis and management of various corneal disorders.

Reliability of Corneal, Epithelial, and Stromal Thickness Mapping for a 9-mm Zone Using Spectral-Domain Optical Coherence Tomography

PURPOSE

To evaluate the reliability of spectral-domain optical coherence tomography (SD-OCT; RTVue XR; Optovue, Inc., Fremont, CA, USA) for thickness mapping of the entire cornea (CT), corneal epithelium (ET). and corneal stroma (ST) over a 9-mm zone in healthy eyes. We sought to develop reference values for different age groups and elucidate potential sex- and age-dependent characteristics of corneal sublayer pachymetry maps.

METHODS

Three consecutive SD-OCT scans were obtained in 166 healthy right eyes (mean age = 50 ± 20 years). The thickness maps contain 25 sectors over a 9-mm diameter zone. To test measurement reliability, intraclass correlation coefficients (ICC), coefficients of variation (CoV), and within-subject standard deviations (WSSD) were calculated.

RESULTS

CT, ET, and ST ICCs ranged from 0.961 to 0.998, 0.896 to 0.945, and 0.955 to 0.998, respectively. CoV values for CT, ET, and ST ranged between 0.3 and 1.5%, 1.6 and 4.2%, and 0.4 and 1.7%, respectively. WSSD ranged from 6 to 41, 4 to 8, and 7 to 46 µm, respectively. A negative correlation was found between age and ET (p < 0.05) but not between age and ST or CT. No gender-related differences in CT, ET, or ST were detected. CoV of CT, ET, and ST measurements showed a positive correlation with age in 28, 64, and 28% of the sectors, respectively.

CONCLUSION

SD-OCT is a rapid and noninvasive technique that provides excellent reliability for corneal sublayer thickness measurements over a 9-mm zone. The reliability of the ET measurement seems to be negatively affected by age. Peripheral CT and global ET thin with age.

The Influence of Tomographic Corneal Characteristics on Epithelial Thickness Profile

Purpose

To understand the influence of tomographic corneal characteristics on the epithelium of normal eyes.

Methods

We scanned a total of 98 eyes of 98 individuals using anterior segment tomography and a spectral-domain optical coherence tomography (OCT) epithelial mapping tool. Only eyes with no previous pathology were included, with a refractive range of +5 diopters (D) to -6 D, intraocular pressure of < 22 mmHg, and no evidence of dry eye (Schirmer’s test 2 value > 5 mm). Corneal curvature metrics were statistically correlated with regional epithelial thickness parameters.

Results

The anterior and posterior corneal surface flat and steep axis, the maximum and minimum curvature, corneal topographic astigmatism, astigmatism polar values, and corneal volume had no statistically significant correlation (p>0.05) with the epithelial thickness. Similarly, anterior corneal surface asphericity had no significant correlation. Posterior surface asphericity had a statistically significant moderate correlation with the epithelium in all areas. Similar results were seen in the multivariate analysis.

Conclusions

None of the front or back surface parameters had any influence on the corneal epithelium except for the posterior surface asphericity. This statistically significant yet clinically insignificant correlation may be enhanced in diseased populations like keratoconus and could indicate epithelial remodeling with early posterior corneal changes.

Post-FDA Approval Results of Epithelium-Off, Full-Fluence, Dresden Protocol Corneal Collagen Crosslinking in the USA

Introduction

The purpose of this non-comparative, prospective, observational study was to evaluate the post-US Food and Drug Administration approval outcomes of epithelium-off, full-fluence, Dresden protocol corneal collagen crosslinking (CXL) for the treatment of progressive keratoconus (KCN) and post-refractive corneal ectasia at a US academic tertiary medical center.

Methods

This study involved 125 eyes of 97 patients with KCN and 13 eyes of 12 patients with post-refractive ectasia which underwent CXL between November 2016 and September 2019. Best spectacle-corrected visual acuity (BSCVA) and corneal topographic parameters were measured preoperatively, at postoperative month 1 (POM-1), and between postoperative months 3 and 24 (POM 3–24).

Results

Best spectacle-corrected visual acuity, flat keratometry, steep keratometry, and mean corneal power worsened at POM-1 (p < 0.01) with a return to preoperative values at POM 3–24. Maximum keratometry (Kmax) steepened at POM-1 and then improved beyond preoperative levels at POM 3–24 (p < 0.01 and p = 0.03, respectively). Pachymetry at the apex and pupil decreased at POM-1 and POM 3–24 (p = 0.03). Pachymetry at the thinnest point decreased at POM-1 and trended toward reduction at POM 3–24 (p < 0.001 and p = 0.06, respectively). Visual and tomographic outcomes were similar between pediatric and adult populations, and between KCN and post-refractive ectasia patients.

Conclusions

Real-world results of CXL in the USA are similar to those reported in prior studies, demonstrating an initial worsening of BSCVA, pachymetry, and keratometry followed by corneal flattening and preservation of visual acuity. Improvements in Kmax and stability in visual acuity were observed over 24 months in children and adults with progressive KCN or post-refractive ectasia.

Longitudinal Epithelial Thickness Profile Changes 18 Months After Photorefractive Keratectomy

PURPOSE

Long-term evaluation of corneal epithelial thickness (ET) profile changes after photorefractive keratectomy (PRK) using Fourier-domain anterior segment optical coherence tomography.

METHODS

Three hundred twenty-six eyes of 163 patients were included in this prospective observational study. The corneal epithelial map was obtained across a 9-mm diameter area of the cornea before and up to 27 months after surgery. ET was assessed in 25 sectors and 4 annular zones (central 2 mm, paracentral 2-5 mm, midperipheral 5-7 mm, and peripheral 7-9 mm).

RESULTS

There was a significant reduction in mean ET in all zones 1 month after PRK. Subsequently, ET increased in all annular zones. The change in mean ET became stable in the midperipheral and peripheral zones at 3 to 6 months and in the central zone at 12 months, and it continued to increase in the paracentral zone even after 18 months after surgery. The ET was 3.40 μm and 4.05 μm in the central and paracentral zones at 6 months, respectively. Postoperative spherical equivalent changed significantly only from 1 to 3 months (P < 0.04). There was a significant correlation between postoperative spherical equivalent at month 1 and ET change in the paracentral and midperipheral zones (P < 0.027).

CONCLUSIONS

There is a significant reduction in ET 1 month after myopic PRK with a gradual thickening thereafter until it reaches stability at 12 months in the central zone. However, it continues to change even after 18 months in the paracentral zone. The greatest thickening is in the paracentral zone, followed by the central zone.

Repeatability of OCT Anterior Surface and Bowman's Layer Curvature and Aberrations in Normal and Keratoconic Eyes

PURPOSE

To study the repeatability of anterior surface and Bowman's layer curvature in normal and keratoconic eyes using optical coherence tomography (OCT).

METHODS

In this study, 96 normal and 96 keratoconic eyes underwent corneal imaging using Pentacam (Oculus Optikgeräte, Wetzlar, Germany) and OCT (Triton, Topcon Corporation, Tokyo, Japan). The elevation data from segmented air-epithelium (A-E) and epithelium-Bowman's layer (E-B) interfaces in OCT scans were used to quantify curvature and aberrations. The wavefront aberrations were evaluated with the ray tracing method and 6th order Zernike polynomials. The intraclass correlation coefficient (ICC), within-subject standard deviation (Sw), and coefficient of variation (CoV) were used to assess repeatability.

RESULTS

For curvatures, the Sw was less than 0.25 diopters (D) for the normal and keratoconic eyes. The Sw was highest for root mean square of lower order aberrations (0.14 µm) in keratoconic eyes. The CoV for curvatures was well below 0.5% for both groups. For some aberrations irrespective of groups, the CoV was greater because some individual aberrations (mean of three successive measurements) tended to be smaller in magnitude and even a small Sw resulted in a high CoV. For all variables, the ICC ranged between 0.80 and 0.99 for both the OCT and Pentacam measurements. Most variables were similar between the A-E and E-B interfaces (P > .05) for both groups. However, both differed significantly from all Pentacam variables (P < .05) in normal and keratoconic eyes.

CONCLUSIONS

The repeatability of OCT curvatures and aberrations compared well with the Pentacam indices for normal and keratoconic eyes. [J Refract Surg. 2020;36(4):247-252.].

Three-year follow-up of accelerated transepithelial corneal cross-linking for progressive paediatric keratoconus

Purpose

To investigate the long-term safety and efficacy of accelerated transepithelial cornealcross-linking (ATE-CXL) in children with progressive keratoconus.

Methods

Fifty-three eyes of 41 paediatric patients (34 boys, 7 girls; mean age 14.81±1.96 years) undergoing ATE-CXL were enrolled in the study. Corrected distance visual acuity (CDVA) and manifest refraction were assessed preoperatively and 36 months postoperatively. Corneal keratometry, corneal thickness and posterior elevation were measured using Pentacam preoperatively and 1, 6, 12 and 36 months postoperatively. Pachymetry and epithelial thicknesses were measured using optical coherence tomography preoperatively and 6, 12, and 36 months postoperatively.

Results

Thirty-six months postoperatively, CDVA improved from 0.32±0.28 to 0.26±0.25 in logarithm of the minimum angle resolution (p=0.025). Maximum keratometry was 58.73±9.70 D preoperatively and 59.20±10.24, 58.28±9.33, 57.88±9.99 and 58.98±10.79 D at 1, 6, 12 and 36 months postoperatively throughout the 36-month follow-up period (p>0.05). Similarly, corneal central thickness, which was 492.42±33.83 µm postoperatively, also remained stable during the 36-month follow-up (p>0.05). Both posterior central elevation and posterior highest elevation were stable at 12 months after ATE-CXL (p>0.05), but increased at 36 months postprocedure (p<0.05). Corneal pachymetry and epithelial thicknesses remained stable throughout the follow-up period (p>0.05).

Conclusions

ATE-CXL is a safe and effective treatment in paediatric progressive keratoconus patients, leading to stable keratometry and corneal thickness throughout the 36-month follow-up.

Effect of Corneal Cross-linking on Epithelial Hyperplasia and Myopia Regression After Transepithelial Photorefractive Keratectomy

PURPOSE

To investigate the effect of accelerated corneal cross-linking (CXL) on epithelial thickness change and refractive outcome after myopic transepithelial photorefractive keratectomy (TPRK).

METHODS

This study compared epithelial thickness changes in 49 patients undergoing TPRK-CXL with 49 patients undergoing TPRK who were matched for age and refractive error. Corneal epithelial thickness, obtained using spectral-domain optical coherence tomography preoperatively and 12 months postoperatively, was compared between the groups. Regression analysis was performed to investigate the association between changes in epithelial thickness and keratometric power. Factors affecting myopic regression (> 0.50 diopters] were evaluated using logistic regression analysis.

RESULTS

For TPRK, the mean epithelial thickness of the center (2-mm diameter), paracenter (2- to 5-mm diameter), and pericenter (5- to 6-mm diameter) increased by 6.5 ± 3.1, 7.0 ± 2.9, and 4.9 ± 2.9 µm, respectively; increases of 4.8 ± 3.0, 5.9 ± 2.8, and 4.8 ± 2.7 µm were observed following TPRK-CXL, indicating a significant difference in the center (P = .013). Epithelial thickness increased linearly to the magnitude of myopic correction and was negatively correlated with the optical zone diameter of ablation. Change in epithelial thickness showed a linear correlation with the change in keratometric power between 1 and 12 months postoperatively, indicating regression in eyes following TPRK. Corneal epithelial thickening was significantly associated with myopic regression and simultaneous CXL tended to reduce the risk of regression.

CONCLUSIONS

TPRK-CXL induces less epithelial hyperplasia than does TPRK, presumably owing to the effect of CXL, and the magnitude of epithelial thickening seemed to be associated with myopic regression. [J Refract Surg. 2019;35(6):354-361.].

Ultrahigh-resolution anterior segment optical coherence tomography for analysis of corneal microarchitecture during wound healing

PURPOSE

To employ ultrahigh-resolution (UHR) optical coherence tomography (OCT) for investigation of the early wound healing process in corneal epithelium.

METHODS

A custom-built UHR-OCT system assessed epithelial healing in human keratoconic cornea after epi-off crosslinking (CXL) procedure and a wound healing model in rabbits with iatrogenic corneal injury. 3D OCT data sets enhanced obtaining epithelial thickness maps and evaluation of reepithelization stage. Accompanying changes in deeper corneal microarchitecture were analysed.

RESULTS

The mean central corneal thickness in 40 eyes with keratoconus at baseline was 482.7 ± 38.2 μm, while mean central epithelial thickness (CET) was 43.8 ± 6.4 μm. At the final visit 20 ± 5 days post-CXL procedure, CET was 35.0 ± 5.8 μm, significantly thinner after reepithelization (p < 0.001). Surgical success was assessed at the final visit through the demarcation line (DL), identified at 43.7 ± 13.5% stromal depth. In rabbits, the mean CET in 20 eyes at baseline was 35.9 ± 2.6 μm. In rabbits that revealed complete wound closure (10/20 eyes) at the last study day at 72 hr, CET was significantly thinner compared to baseline (30.4 ± 2.8 μm versus 35.4 ± 2.9 μm, p = 0.005). An intra-stromal landmark indicating early keratocyte apoptosis was measured at 30.0 ± 5.1% stromal depth. Epithelial thickness maps showed the time-course of corneal healing.

CONCLUSION

Ultrahigh-resolution (UHR)-OCT provided precise assessment of epithelial wound and its healing by 3D-mapping. In addition, microarchitectural changes in the cornea in early phases of epithelial healing were revealed.

Optical coherence tomography imaging in keratoconus

Optical coherence tomography (OCT) is being increasingly used as a tool in the diagnosis and management of keratoconus. While elevation-based topography remains essential, there is an expanding role for cross-sectional OCT imaging in the diagnosis of the disease. Images and measurements of corneal thickness, and in particular, epithelial thickness, may be important in diagnosing early cases, and following procedures such as intrastromal corneal ring segments, corneal transplants and corneal collagen cross-linking.

Longitudinal and Regional Non-uniform Remodeling of Corneal Epithelium After Topography-Guided FS-LASIK

PURPOSE

To observe the epithelial remodeling over a 9-mm diameter cornea induced by topography-guided femtosecond laser-assisted in situ keratomileusis (FS-LASIK) for myopia correction using spectral-domain optical coherence tomography (SD-OCT).

METHODS

Forty-three eyes of 22 patients who underwent topography-guided FS-LASIK for myopic correction were included. The "Pachymetrywide" scan pattern was used to generate the epithelial thickness map using SD-OCT preoperatively and 1, 3, and 6 months postoperatively. Epithelial thickness was compared and analyzed by section and zone.

RESULTS

Compared to the preoperative values, the change in the average epithelial thickness in the central, paracentral, and mid-peripheral zones was 2.09, 4.53, and -0.87 µm at 1 month; 3.00, 4.61, and -0.97 µm at 3 months; and 3.28, 4.55, and -0.81 µm at 6 months postoperatively, respectively. From 1 to 3 months postoperatively, the central epithelial thickness changed significantly (P = .021), whereas the epithelial thickness in the paracentral (P = .973) and mid-peripheral (P = .996) zones stabilized. No significant epithelial thickness change was observed in the zones between 3 and 6 months postoperatively (all P > .05). The epithelial thickness in the paracentral inferotemporal section increased by 12.7% at 6 months after surgery. The central epithelial hyperplasia showed no correlation with the change in postoperative manifest refraction spherical equivalent (P = .313).

CONCLUSIONS

After topography-guided FS-LASIK, the 9-mm diameter epithelial thickness showed a longitudinal and regional non-uniform redistribution. Central epithelial remodeling stabilized more slowly. The greatest increase in epithelial thickness was observed in the paracentral inferotemporal section. This epithelial remodeling did not cause refractive regression. [J Refract Surg. 2019;35(2):88-95.].

Anterior segment optical coherence tomography and its clinical applications

Anterior segment optical coherence tomography (AS-OCT) has become one of the cornerstones of non-contact imaging modalities for assessing such structures as the cornea, anterior chamber angle, aqueous outflow pathway, sclera, and ocular surface structures. As such, it has a broad range of clinical applications, which have been independently reported in the literature. This paper aims to present a review of extant literature on the utility of AS-OCT and its efficacy in clinical applications, and to evaluate the quality of available evidence. The following databases were searched from inception to 24 June 2018: Medline via Ovid, Cochrane Central Register of Controlled Trials, PubMed, World Health Organization International Clinical Trials Registry Platform, EMBASE, and CINAHL. Bibliographies of identified papers were hand searched. Inclusion criteria: articles describing or assessing the use of OCT for visualising the AS. The authors excluded studies without an identified primary outcome variable. One author independently selected studies, extracted data, and assessed for risk of bias using PRISMA guidelines. This review included 82 studies, of which there were 11 cohort studies, 37 case series, 10 case studies, 21 comparative observational studies, and three non-systematic review articles. Primary outcome variables included anterior chamber angle, angle opening distance, angle recess area, trabecular iris angle, trabecula-iris space area, corneal thickness, tear meniscus height, tear meniscus area, tear meniscus volume, and the morphology of AS structures, including the ocular surface, blebs, flaps, and graft sites. This review attempts to encompass the breadth and depth of evidence for AS-OCT in the arena of diagnostics, therapeutics, and prognostics. At the same time, it brings to light the dearth of high-level evidence on this topic, suggesting the important role of randomised controlled trials and meta-analyses for the future validation of this technology.

Medium- to Long-Term Results of Corneal Cross-Linking for Keratoconus Using Phototherapeutic Keratectomy for Epithelial Removal and Partial Stromal Ablation

PURPOSE

To evaluate the medium- to long-term outcomes of corneal cross-linking in treatment of keratoconus using transepithelial phototherapeutic keratectomy (PTK-CXL) for epithelial removal and partial stromal ablation to stabilize the cornea, reduce corneal irregularity, and improve corrected vision.

METHODS

Retrospective analysis of 46 keratoconic eyes that underwent PTK-CXL. Corrected distance visual acuity (CDVA), manifest refraction, steep and flat simulated keratometry (Kmax and Kmin), corneal irregularity index (IRI), corneal higher order aberrations (HOAs), epithelial thickness profile, and corneal biomechanical characteristics were evaluated preoperatively and postoperatively.

RESULTS

At a mean follow-up time of 21.0 ± 7.6 months (range: 10 to 43 months) postoperatively, CDVA improved from 0.25 ± 0.24 to 0.18 ± 0.22 logMAR (P = .002). CDVA remained unchanged in 32.6% (15 eyes) and 56.5% (26 eyes) gained up to five Snellen lines of CDVA, whereas 6.5% (3 eyes) lost two or more lines of CDVA, respectively. Postoperatively, flattening of Kmax from 50.58 ± 5.26 to 48.96 ± 4.00 diopters (D) and Kmin from 45.80 ± 3.11 to 44.77 ± 2.63 D (P < .001), reduction of IRI from 49.7 ± 24.5 to 43.4 ± 21.4 µm (P = .002), decrease of root mean square HOAs (at 5-mm diameter) from 2.66 ± 1.31 to 2.37 ± 1.37 µm (P = .037), and slight thickening of corneal epithelium were registered, whereas most of the corneal biomechanical measurements did not show statistically significant change. Two eyes demonstrated slight topographic regression.

CONCLUSIONS

PTK-CXL seems to be effective in arresting the progression of keratoconus, improving CDVA, flattening the cornea, regularizing corneal surface, and reducing corneal HOAs. [J Refract Surg. 2017;33(7):488-495.].

Corneal Cross-Linking for Pediatric Keratcoconus Review

PURPOSE

To comprehensively review the available published literature for cross-linking in the pediatric population.

METHODS

Review of the literature published in English in PubMed.

RESULTS

Two hundred ten publications were considered. One hundred fifteen were considered relevant to this review.

CONCLUSIONS

Studies of cross-linking in pediatric patients are sparse, with relatively short follow-up times, and mostly on small groups of patients. Treatment with cross-linking halts progression of keratoconus in the pediatric population, and early treatment seems to be cost-effective compared with later penetrating keratoplasty. Long-term effects and regression rates remain unclear, and further studies are needed in this population.

Corneal Epithelial Remodeling After Standard Epithelium-off Corneal Cross-linking in Keratoconic Eyes

PURPOSE

To evaluate remodeling of the corneal epithelium after epithelium-off corneal cross-linking (CXL).

METHODS

In this prospective single-center study, 93 eyes of 93 patients with progressive keratoconus underwent standard CXL. The maximum keratometry was assessed before and after CXL with Scheimpflug imaging, and the epithelial thickness profile across the central 5 mm of the cornea was assessed with spectral-domain optical coherence tomography anterior segment imaging.

RESULTS

The mean patient age was 27 ± 11 years; 76 patients (81%) were male and 17 (19%) were female. Between baseline and 6 months after CXL, the mean corneal maximum keratometry flattened from 58.90 to 57.80 diopters (P < .0001). The mean minimum epithelial thickness increased slightly (from 41 ± 6 to 42 ± 7 μm, P = .12), whereas the mean maximum epithelial thickness decreased slightly (from 65 ± 6 to 64 ± 7 μm, P = .067), reducing the net difference between the minimum and maximum epithelial thickness (from 24 ± 9 to 22 ± 9 μm, P = .0023). The difference between the minimum and maximum epithelial thickness was strongly positively correlated with the maximum keratometry reading at baseline (R² = 0.38) and at 6 months after CXL (R² = 0.59).

CONCLUSIONS

Epithelium-off CXL resulted in modest regularization of the epithelial thickness profile across the central 5 mm of the cornea at 6 months. This could slightly mask flattening of the underlying stroma. [J Refract Surg. 2018;34(6):408-412.].

Noncontact Quantification of Topography of Anterior Corneal Surface and Bowman's Layer With High-Speed OCT

PURPOSE

To quantify keratometry and wavefront aberration of the anterior corneal surface and epithelium-Bowman's layer interface using anterior segment optical coherence tomography (OCT).

METHODS

Twenty-five normal eyes and 25 eyes with keratoconus were retrospectively analyzed. The anterior corneal edge and epithelium-Bowman's layer interface were segmented from 12 distortion-corrected OCT B-scans. Axial tangential curvatures and wavefront aberration were calculated by ray tracing and 6th order Zernike analyses. All eyes underwent simultaneous imaging with Pentacam (Oculus Optikgeräte GmbH, Wetzlar, Germany). The Pentacam elevation data were used for aberration analyses using the same ray-tracing method. The paired t test was used to compare the variables.

RESULTS

In normal eyes, mean steep axis and maximum keratometry of OCT of the anterior corneal surface and epithelium-Bowman's layer interface were significantly greater than the same of the Pentacam anterior corneal surface (P < .05). Mean root mean square of higher order aberrations of the OCT surfaces was greater than the same of the Pentacam surface by a factor of 4. In eyes with keratoconus, mean steep axis and maximum keratometry of the OCT epithelium-Bowman's layer interface was the greatest (P < .05). Mean root mean square of the higher order aberrations and vertical coma of the OCT epithelium-Bowman's layer interface was the greatest (P < .05). In general, the aberrations of the OCT epithelium-Bowman's layer interface were significantly greater than those of the Pentacam anterior corneal surface.

CONCLUSIONS

A noncontact method to quantify the topography and aberrations of corneal surfaces with OCT was presented. OCT measurements yielded greater curvature and aberrations than Pentacam in both normal and keratoconic eyes. [J Refract Surg. 2017;33(5):330-336.].

Epithelial Thickness Profile Change After Combined Topography-Guided Transepithelial Photorefractive Keratectomy and Corneal Cross-linking in Treatment of Keratoconus

PURPOSE

To evaluate corneal epithelial remodeling after topography-guided transepithelial photorefractive keratectomy (PRK) combined with corneal collagen cross-linking (CXL) in the treatment of keratoconus.

METHODS

Retrospective analysis of the epithelial thickness distribution changes in 53 keratoconic eyes of 44 patients. Manifest refraction, maximum (Kmax) and minimum (Kmin) keratometry obtained by Placido topography, corneal irregularity index (IRI) measured by Scheimpflug topography, and the epithelial thickness profile over the central 5-mm zone obtained by anterior-segment spectral domain optical coherence tomography (SD-OCT) were evaluated preoperatively and at 1 to 3, 3 to 6, and more than 6 months postoperatively.

RESULTS

Preoperatively, the epithelial thickness at the thinnest area (MinArea) was 48.8 ± 4.4 µm, correlating negatively with Kmax (r = -0.310, P < .05) and IRI (r = -0.362, P < .05). At more than 6 months postoperatively, epithelial thickening of 5.5 ± 5.1 µm occurred at the thinnest area (MinArea). There was no significant change in the epithelial thickness in other areas, resulting in a decrease of difference in epithelial thickness between MinArea and the rest of the paracentral areas of 5.5 ± 4.3 µm. Corrected distance visual acuity, refractive astigmatism, Kmax, Kmin, and IRI all improved after the treatment (P < .05).

CONCLUSIONS

A significant epithelial thickness profile change occurred after the treatment due to an increase in thickness at the preoperatively thinnest area. Because the thickness in other areas remained largely unchanged, the treatment resulted in a more even epithelial thickness distribution. This may be attributed to regularized postoperative corneal stromal shape. [J Refract Surg. 2016;32(9):626-634.].

Comparison of the Effect of Epithelial Removal by Transepithelial Phototherapeutic Keratectomy or Manual Debridement on Cross-linking Procedures for Progressive Keratoconus

PURPOSE

To compare the visual, refractive, keratometric, topographic, and pachymetric outcomes of corneal collagen cross-linking (CXL) for progressive keratoconus following epithelial removal by transepithelial phototherapeutic keratectomy (PTK) or manual debridement.

METHODS

In this analysis, 339 eyes (78% male, 22% female) that had undergone CXL following manual epithelial debridement (n = 180) or ablation via PTK (n = 159) were evaluated preoperatively and at 6, 12, and 24 months postoperatively for uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), maximum corneal keratometry, pachymetry, and spherical equivalent. The data were analyzed in a t test to evaluate the relative efficacy of each epithelial removal procedure.

RESULTS

Manual epithelial debridement and ablation via PTK produce equivalent changes for all variables at each time interval with the exception of maximum corneal keratometry at 6 months postoperatively, for which PTK exhibited a significantly improved (flatter) result. This difference was present but not statistically significant at 12 and 24 months postoperatively.

CONCLUSIONS

Prior to CXL, both manual epithelial debridement and ablation via PTK result in equivalent visual, refractive, and keratometric outcomes up to 24 months postoperatively. [J Refract Surg. 2016;32(10):699-704.].

Conventional and Iontophoresis Corneal Cross-Linking for Keratoconus: Efficacy and Assessment by Optical Coherence Tomography and Confocal Microscopy

PURPOSE

To compare the efficacy, safety, and microstructural corneal changes during 2 years after conventional corneal collagen cross-linking (C-CXL) and transepithelial corneal CXL by iontophoresis (I-CXL) for keratoconus.

METHODS

Eighty eyes of 80 patients with progressive keratoconus were treated by C-CXL (n = 40) or I-CXL (n = 40). Patients were investigated before surgery and 1, 3, 6, 12, and 24 months after treatment. We measured central corneal thickness and maximal simulated keratometry values (Kmax) and performed specular microscopy and in vivo confocal microscopy at each time point. The demarcation line was assessed 1 month after treatment.

RESULTS

Kmax remained stable after I-CXL during the entire study period (P = 0.56), whereas the average keratometry increased by 0.2 diopter (50.9 ± 5.6-51.1 ± 5.2). Kmax significantly decreased 1 (P = 0.02) to 2 years (P < 0.01) after C-CXL, with an average decrease of 1.1 diopters (49.9 ± 4.5-48.8 ± 4.2). The failure rate of I-CXL was 20% and that of C-CXL 7.5%. The demarcation line was superficially visible in 35% of cases after I-CXL compared with 95% of cases after C-CXL. Endothelial cell density and central corneal thickness remained stable during the entire study period. The change in Kmax 2 years after C-CXL and I-CXL and the preoperative Kmax were negatively correlated (r = 0.14, P = 0.013, and r = 0.17, P = 0.007, respectively).

CONCLUSIONS

I-CXL halted progression of keratoconus less efficiently than did C-CXL after 2 years of follow-up. Longer prospective studies are still needed to ensure I-CXL efficacy.

Applications of Anterior Segment Optical Coherence Tomography in Cornea and Ocular Surface Diseases

Optical coherence tomography (OCT) is a noncontact technology that produces high-resolution cross-sectional images of ocular tissues. Anterior segment OCT (AS-OCT) enables the precise visualization of anterior segment structure; thus, it can be used in various corneal and ocular surface disorders. In this review, the authors will discuss the application of AS-OCT for diagnosis and management of various corneal and ocular surface disorders. Use of AS-OCT for anterior segment surgery and postoperative management will also be discussed. In addition, application of the device for research using human data and animal models will be introduced.

Central Corneal Thickness After Cross-linking Using High-Definition Optical Coherence Tomography, Ultrasound, and Dual Scheimpflug Tomography: A Comparative Study Over One Year

PURPOSE

To assess central corneal thickness (CCT) and corneal haze in keratoconus eyes following corneal cross-linking (CXL).

DESIGN

Prospective noncomparative case series.

METHODS

Forty patients (44 eyes) with keratoconus that had serial evaluation for CCT, following CXL, using high-definition optical coherence tomography (HD-OCT), ultrasound pachymetry (USP), and dual Scheimpflug tomography. CCT was measured at baseline, then at 2 weeks and 1, 3, 6, and 12 months postoperatively.

RESULTS

The mean baseline CCT measurements were 470.02 μm, 469.79 μm, and 466.66 μm using the HD-OCT, the USP, and dual Scheimpflug tomography, respectively (P = .91). Following CXL, the mean CCT measurements by dual Scheimpflug, at all follow-up periods, were lower compared to mean baseline reading (P < .003). The mean CCT measurements by the HD-OCT and USP were similar to baseline readings except for the thicker readings at the 2-week follow-up visit. Overall, the mean CCT obtained by the USP was similar to that obtained by the HD-OCT throughout the 12-month period. However, the mean CCT measurements obtained by dual Scheimpflug tomography were statistically and clinically significantly lower than those obtained by both HD-OCT and USP at all follow-up visits.

CONCLUSIONS

USP and HD-OCT showed better agreement in CCT readings at all visits, and may better estimate the true CCT following CXL as compared to dual Scheimpflug tomography. The lower mean CCT post-CXL as measured by the latter seems to be correlated with the amount of haze that develops after cross-linking.

Epithelial Thinning in Limbal Stem Cell Deficiency

PURPOSE

To investigate the epithelial thickness in the cornea and limbus in limbal stem cell deficiency (LSCD) by using in vivo laser scanning confocal microscopy.

DESIGN

Cross-sectional comparative study.

METHODS

Confocal images of 48 eyes of 35 patients with LSCD collected by the Heidelberg Retina Tomograph III Rostock Corneal Module Confocal Microscope from 2010 to 2014 were analyzed. Volume Z-scans of the central cornea and the superior, nasal, inferior, and temporal limbus were included in the analysis. Eleven normal eyes served as control. Epithelial thickness in all locations was measured by 2 independent observers.

RESULTS

The mean epithelial layer thickness was 48.6 ± 2.3 μm in the central cornea and 63.7 ± 11.3 μm in the limbus in the control. Compared with the epithelial thickness in normal control, the epithelial thickness in LSCD patients was reduced by an average of 20.2% in the central cornea and 38.5% in the limbus (all P < .05). The mean corneal epithelial thickness in patients with LSCD reduced 7.6%, 20.8%, and 61.3% in the early, intermediate, and late stage, respectively, compared to the control. In the limbus, the overall epithelial thickness decreased 30.0%, 39.7%, and 62.8% in the early, intermediate, and late stage of LSCD, respectively (all P < .05). Epithelial thinning correlated with the severity of LSCD in both cornea and limbus. In eyes with sectoral LSCD, a similar degree of epithelial thinning was also detected in the clinically unaffected limbal regions.

CONCLUSIONS

Both corneal and limbal epithelia become progressively thinner in LSCD. Epithelial thickness could be used as a diagnostic measure of LSCD.

Comparison of Corneal Epithelial Thickness Measurement Between Fourier-Domain OCT and Very High-Frequency Digital Ultrasound

PURPOSE

To compare measurements of corneal epithelial thickness using optical coherence tomography (OCT) and very high-frequency digital ultrasound (VHFDU).

METHODS

Retrospective analysis of 189 virgin corneas and 175 post-laser refractive surgery (LRS) corneas that had corneal epithelial thickness measurement with RTVue Fourier-domain OCT (Optovue, Inc., Fremont, CA) (tear film included) and Artemis VHFDU (ArcScan Inc., Morrison, CO) (tear film excluded). Averages were calculated for the central 2-mm diameter zone and for two further concentric annuli of 1.5- and 0.5-mm width, each divided into eight sectors. Agreement was analyzed by mean difference (OCT - VHFDU), 95% limits of agreement (LoA) (1.96 standard deviation of the difference), and Bland-Altman analysis.

RESULTS

In virgin epithelium, mean central thickness was 53.4 ± 3.20 µm (range: 46 to 62 µm) with OCT and 54.1 ± 2.96 µm (range: 48 to 61 µm) with VHFDU; OCT measured thinnest in 70% with a mean difference of -0.71 µm (95% LoA of ± 3.94 µm, P < .001). In post-LRS epithelium, mean central thickness was 57.9 ± 6.08 µm (range: 42 to 77 µm) with OCT and 60.5 ± 6.47 µm (range: 42 to 79 µm) with VHFDU; OCT measured thinnest in 88%, with a mean difference of -2.48 µm (95% LoA of ± 5.33 µm, P < .001). A larger difference between methods was more common with thicker epithelium.

CONCLUSIONS

Corneal epithelial thickness measurements using OCT were found to be slightly thinner than for VHFDU. In contrast to VHFDU, OCT measurement includes the tear film, so the true difference is probably approximately 4 µm more than reported. The difference was greatest inferiorly and higher for post-LRS eyes and in thicker epithelium.

Corneal cross-linking

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.

Intraoperative Optical Coherence Tomography Using the RESCAN 700: Preliminary Results in Collagen Crosslinking

Purpose. To compare the penetration of riboflavin using a microscope-integrated real time spectral domain optical coherence tomography (ZEISS OPMI LUMERA 700 and ZEISS RESCAN 700) in keratoconus patients undergoing accelerated collagen crosslinking (ACXL) between epithelium on (epi-on) and epithelium off (epi-off). Methods. Intraoperative images were obtained during each of the procedures. Seven keratoconus patients underwent epi-on ACXL and four underwent epi-off ACXL. A software tool was developed using Microsoft.NET and Open Computer Vision (OpenCV) libraries for image analysis. Pre- and postprocedure images were analyzed for changes in the corneal hyperreflectance pattern as a measure of the depth of riboflavin penetration. Results. The mean corneal hyperreflectance in the epi-on group was 12.97 ± 1.49 gray scale units (GSU) before instillation of riboflavin and 14.46 ± 2.09 GSU after AXCL (P = 0.019) while in the epi-off group it was 11.43 ± 2.68 GSU and 16.98 ± 8.49 GSU, respectively (P = 0.002). The average depth of the band of hyperreflectance in the epi-on group was 149.39 ± 15.63 microns and in the epi-off group it was 191.04 ± 32.18 microns. Conclusion. This novel in vivo, real time imaging study demonstrates riboflavin penetration during epi-on and epi-off ACXL.

Stromal surface topography-guided custom ablation as a repair tool for corneal irregular astigmatism

PURPOSE

To illustrate the concept of using a stromal surface topography-guided procedure for therapeutic repair after a complication following primary laser refractive surgery.

METHODS

One case example of therapeutic retreatment for short nasal flap after primary LASIK performed in September 2000 is presented. The Artemis very high-frequency digital ultrasound arc-scanner (Arc-Scan, Inc., Morrison, CO) was used to obtain layered corneal thickness including epithelial thickness profile. Corneal front surface elevation was measured with the Orbscan II (Bausch & Lomb, Salt Lake City, UT). Stromal surface height was then calculated by subtracting epithelial thickness data from corneal front surface elevation data and used to calculate the ablation profile applied to the eye. The treatment was performed using the Ultralink system (ArcScan, Inc.), linking the ultrasound corneal thickness data with the Technolas 217c laser (Bausch & Lomb). Postoperative data were available at 30 days and 13 years.

RESULTS

One month after treatment, the epithelial thickness map demonstrated that the difference in thickness between the thinnest and thickest points located 2.5-mm nasally was reduced by 26 µm (from 56 to 30 µm). The axial difference map demonstrated an increase in corneal curvature of approximately 4 diopters where the cornea was the flattest nasally, thereby reducing the corneal asymmetry. The anterior elevation map also showed a reduced depression nasally. The patient reported significant improvement of her night vision.

CONCLUSIONS

This case example of stromal surface topography-guided treatment demonstrated a significant reduction in the irregularity of the stromal surface and an improvement in the topography, and the visual quality. Stromal surface topography-guided ablation might become the tool of the future for therapeutic repairs because it offers advantages over the current alternative of transepithelial phototherapeutic keratectomy.

Evaluation of corneal changes after conventional versus accelerated corneal cross-linking: a randomized controlled trial

PURPOSE

To evaluate the outcome of accelerated and conventional corneal cross-linking (CXL) procedures regarding their effect on morphological and optical properties of the cornea.

METHODS

One hundred fifty-three eyes of 153 patients were evaluated before and during a 15-month follow-up period after CXL (76 eyes in the conventional group and 77 eyes in the accelerated group). Measured variables include corrected distance visual acuity (CDVA), uncorrected distance visual acuity (UDVA), refraction, maximum keratometry, endothelial cell density, anterior and posterior stromal keratocyte density, and subbasal nerve density. All variables were compared between the two study groups.

RESULTS

Cylindrical and spherical components of refraction improved significantly during 15 months of follow-up. No difference was observed between the two study groups. UDVA and CDVA improved in the same manner, with no intergroup differences. Endothelial cell density did not change significantly during the follow-up period in either group. K-max increased slightly in the first month of the follow-up, but started to decrease at postoperative visits without any significant difference in the two groups. Anterior stromal keratocyte density and subbasal nerve density decreased significantly in both groups 1 month postoperatively. Both variables had a more significant decrease in the conventional group at all visits before the 1-year visit. At the final 15-month visit, there were no significant differences in any value between the two groups.

CONCLUSIONS

Accelerated and conventional CXL seem to have a comparable and acceptable effect on keratoconus in the short-term follow-up period.

Spectral-domain optical coherence tomography epithelial and flap thickness mapping in femtosecond laser-assisted in situ keratomileusis

PURPOSE

To evaluate the change of epithelial and flap thickness after femtosecond laser-assisted in situ keratomileusis (LASIK) using spectral-domain optical coherence tomography (SD OCT) in correlation with the spherical equivalent refraction treated and clinical outcomes.

DESIGN

Prospective, randomized, contralateral-eye study.

METHODS

Forty myopic eyes underwent LASIK using an excimer laser with refraction ranging from -1.00 to -7.25 diopters (mean -3.25±1.9). Flap creation was randomized between eyes, using the IntraLASE FS60 laser (IL) in 1 eye and WaveLight FS200 laser (FS) in the contralateral eye. SD OCT was used to evaluate the epithelial and flap thickness profiles and corneal power preoperatively and at 1 week and 1, 3, and 9 months postoperatively. Manifest and wavefront refractions were performed at each postoperative visit.

RESULTS

Statistically significant epithelial thickening was observed in both IL and FS groups as early as 1 month postoperatively (P=.033 and P=.042), but this stabilized between 3 (P=.042 and P=.035) and 9 months (P=.043 and P=.041). Femtosecond-LASIK flaps were thicker in the IL group in comparison to the FS group at 3 and 9 months postoperatively (P=.003 and P=.005, respectively). There was a statistically significant correlation between the magnitude of preoperative myopic refraction and the central epithelial thickness at 1, 3, and 9 months (Pearson correlation coefficients 0.485, 0.587 and 0.576) (P=.0021, P=.0010, and P=.0011), respectively. SD OCT corneal power maps showed steepening at 3 and 9 months along with mild myopic shift.

CONCLUSION

Progressive epithelial and flap thickening with increased corneal power were observed after femtosecond laser-assisted in situ keratomileusis for myopia with consequent stabilization between 3 to 9 months postoperatively. The magnitude of epithelial and flap thickness remodeling correlated to the preoperative myopic refractive error.