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Niazi S, Doroodgar F, Nazari SH, Rahimi Y, Del Barrio JLA, Gatzioufas Z, Findl O, Vinciguerra P, Vinciguerra R, Moshirfar M, Ambrósio R, Alio JL. Refractive surgical approaches to keratoconus: A systematic review and network meta-analysis. Surv Ophthalmol 2024:S0039-6257(24)00045-6. [PMID: 38710236 DOI: 10.1016/j.survophthal.2024.04.008] [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: 10/25/2023] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
Advancements in diagnostic methods and surgical techniques for keratoconus (KC) have increased non-invasive treatment options. Successful surgical planning for KC involves a combination of clinical science, empirical evidence, and surgical expertise. Assessment of disease progression is crucial, and halting the progression should be the focus if it is progressive. While surgeons used to rely on experience alone to decide the surgical method, comparing the network of primary factors, such as visual acuity, across studies can help them choose the most appropriate treatments for each patient and achieve optimal outcomes. Meticulous tabulation methods facilitate interpretation, highlighting the importance of selecting the correct surgical and rehabilitation approach based on each patient's condition and stage of the disease. We detail the outcomes of a comprehensive network meta-analysis comparing the effectiveness of various combined therapeutic refractive treatments for KC at identical stages of the disease, spanning four distinct follow-up intervals. Additionally, the comprehensive analysis suggests that for corneas with optimal best corrected visual acuity (BCVA) preoperatively (classified as regular), combining phakic intraocular lenses with intracorneal ring segments (ICRS) and corneal cross-linking (CXL) could offer the best therapeutic approach provided the disease stage does not exceed stage 3. For irregular corneas, although initial follow-ups show a significant difference in BCVA with surface ablation, longer-term follow-ups recommend combining surface ablation with ICRS and CXL, especially at higher stages.
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Affiliation(s)
- Sana Niazi
- Negah Aref Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Translational Ophthalmology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farideh Doroodgar
- Negah Aref Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Translational Ophthalmology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Saeed Hashemi Nazari
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yekta Rahimi
- Student Research Committee, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jorge L Alió Del Barrio
- Vissum Miranza, Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
| | | | - Oliver Findl
- Vienna Institute for Research in Ocular Surgery (VIROS), A Karl Landsteiner Institute, Hanusch Hospital, 1140, Vienna, Austria
| | - Paolo Vinciguerra
- Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | - Majid Moshirfar
- John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA
| | - Renato Ambrósio
- Instituto de Olhos Renato Ambrósio, Rio de Janeiro, Brazil; Rio de Janeiro Corneal Tomography and Biomechanics Study Group, Rio de Janeiro, Brazil; BrAIN: Brazilian Artificial Intelligence Networking in Medicine, Rio de Janeiro & Maceió, Brazil; Department of Ophthalmology, Federal University the state of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil; Department of Ophthalmology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jorge L Alio
- Vissum Miranza, Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
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Deshmukh R, Ong ZZ, Rampat R, Alió del Barrio JL, Barua A, Ang M, Mehta JS, Said DG, Dua HS, Ambrósio R, Ting DSJ. Management of keratoconus: an updated review. Front Med (Lausanne) 2023; 10:1212314. [PMID: 37409272 PMCID: PMC10318194 DOI: 10.3389/fmed.2023.1212314] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Keratoconus is the most common corneal ectatic disorder. It is characterized by progressive corneal thinning with resultant irregular astigmatism and myopia. Its prevalence has been estimated at 1:375 to 1:2,000 people globally, with a considerably higher rate in the younger populations. Over the past two decades, there was a paradigm shift in the management of keratoconus. The treatment has expanded significantly from conservative management (e.g., spectacles and contact lenses wear) and penetrating keratoplasty to many other therapeutic and refractive modalities, including corneal cross-linking (with various protocols/techniques), combined CXL-keratorefractive surgeries, intracorneal ring segments, anterior lamellar keratoplasty, and more recently, Bowman's layer transplantation, stromal keratophakia, and stromal regeneration. Several recent large genome-wide association studies (GWAS) have identified important genetic mutations relevant to keratoconus, facilitating the development of potential gene therapy targeting keratoconus and halting the disease progression. In addition, attempts have been made to leverage the power of artificial intelligence-assisted algorithms in enabling earlier detection and progression prediction in keratoconus. In this review, we provide a comprehensive overview of the current and emerging treatment of keratoconus and propose a treatment algorithm for systematically guiding the management of this common clinical entity.
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Affiliation(s)
- Rashmi Deshmukh
- Department of Cornea and Refractive Surgery, LV Prasad Eye Institute, Hyderabad, India
| | - Zun Zheng Ong
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
| | - Radhika Rampat
- Department of Ophthalmology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Jorge L. Alió del Barrio
- Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain
- Division of Ophthalmology, School of Medicine, Universidad Miguel Hernández, Alicante, Spain
| | - Ankur Barua
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
| | - Marcus Ang
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Jodhbir S. Mehta
- Singapore National Eye Centre, Singapore Eye Research Institute, Singapore, Singapore
| | - Dalia G. Said
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Harminder S. Dua
- Department of Ophthalmology, Queen’s Medical Centre, Nottingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Renato Ambrósio
- Department of Cornea and Refractive Surgery, Instituto de Olhos Renato Ambrósio, Rio de Janeiro, Brazil
- Department of Ophthalmology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
- Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Darren Shu Jeng Ting
- Birmingham and Midland Eye Centre, Birmingham, United Kingdom
- Academic Ophthalmology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, 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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Prevalence and risk factors for keratoconus in a university-based population in Turkey. J Cataract Refract Surg 2021; 47:1524-1529. [PMID: 33929805 DOI: 10.1097/j.jcrs.0000000000000669] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE This study aimed to determine the prevalence of keratoconus (KC) in the students and faculty members (aged ≥18 and ≤30 years) studying/working at the Medical and Health Sciences faculties of Eskişehir Osmangazi University. SETTING Eskişehir Osmangazi University. DESIGN Prevalence study. METHODS Subjects were randomly selected to undergo KC screening using a proportional stratified sampling method. Out of the 648 invited subjects, 585 (90.3%) responded to the invitation. The demographic data, medical/family history and habits of the subjects were collected using a standardized questionnaire. Subjects were classified as KC, ectasia susceptibility, and normal based on the corneal tomography. The chi-square and Kruskal-Wallis tests were used for the analysis of categorical variables and parametric values, respectively. Risk factors for KC were determined using logistic regression analysis. RESULTS The prevalence of KC was 2,393/100,000 (2.4%, 95% CI: 1.3%-4%), whereas that of ectasia susceptibility was 1,538/100,000 (1.5%, 95% CI: 0.7%-2.9%). Although the prevalence was much higher in male (4%, 95% CI: 1.7%-7.7%) than in female (1.6%, 95% CI: 1.1%-4.4%) the difference was not statistically significant (p=0.09). The majority (78.6%, n=11) of KC patients were unaware of their disease. Eye rubbing (OR:3.53, p=0.024) and consanguineous marriage (OR:12.87, p=0.032) were independent risk factors for KC. CONCLUSION This is the first population-based KC prevalence study in a randomized sample conducted in Turkey. The prevalence of KC in Turkey was much higher than in European countries but similar to neighboring countries in the Middle East. Eye rubbing and history of consanguineous marriage were significant risk factors.
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Jiménez-García M, Ní Dhubhghaill S, Koppen C, Varssano D, Rozema JJ. Baseline Findings in the Retrospective Digital Computer Analysis of Keratoconus Evolution (REDCAKE) Project. Cornea 2021; 40:156-167. [PMID: 32541189 DOI: 10.1097/ico.0000000000002389] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/31/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To present the baseline data for a large cohort of patients with keratoconus enrolled in the Retrospective Digital Computer Analysis of Keratoconus Evolution (REDCAKE) study. METHODS Eight centers contributed the Scheimpflug tomographical data for 906 patients with keratoconus, 743 measured with a Pentacam and 163 with a Galilei. The stage of keratoconus at baseline, the location of the reference points, minimum pachymetry (Pmin), and maximum keratometry (Kmax) were analyzed. The intereye asymmetry was evaluated for Kmax (anterior and posterior), Pmin, and keratoconus stage. Average maps and elevation profiles were calculated for each degree of keratoconus. RESULTS Keratoconus was more frequently diagnosed in men (73%) than in women (27%). At baseline, 500/1155 eyes (43%) presented with moderate to severe changes in the posterior surface, whereas moderate/severe changes were only found in 252 and 63 eyes when evaluating anterior surface and pachymetry, respectively. The location of Pmin was usually inferotemporal (94% OD and 94% OS), while the location of Kmax showed more variability and significantly higher distance from apex (P < 0.05). The keratoconus presentation was chiefly asymmetric for all the parameters studied. Clear differences between stages could be identified in the maps and elevation profiles. CONCLUSIONS The staging map set presented can be used as a graphical guidance to classify keratoconus stage. Keratoconus presented asymmetrically, and generally the posterior surface was more affected than the anterior surface or the thickness. Asymmetry is playing a role in KC detection. Although Pmin was almost invariably located inferotemporally, Kmax location showed higher variability and distance from the apex.
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Affiliation(s)
- Marta Jiménez-García
- Department of Ophthalmology, Antwerp University Hospital (UZA), Edegem, Belgium
- Department of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium ; and
| | - Sorcha Ní Dhubhghaill
- Department of Ophthalmology, Antwerp University Hospital (UZA), Edegem, Belgium
- Department of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium ; and
| | - Carina Koppen
- Department of Ophthalmology, Antwerp University Hospital (UZA), Edegem, Belgium
- Department of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium ; and
| | - David Varssano
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jos J Rozema
- Department of Ophthalmology, Antwerp University Hospital (UZA), Edegem, Belgium
- Department of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium ; and
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Abstract
Ectatic corneal disease (ECD) comprises a group of disorders characterized by progressive thinning and subsequent bulging of the corneal structure. Different phenotypes have been recognized, including keratoglobus, pellucid marginal degeneration (PMD), and keratoconus (KC). Keratoconus has been widely investigated throughout the years, but the advent of laser refractive surgery boosted an immediate need for more knowledge and research about ectatic diseases. This article discusses nomenclature of ectatic disease, etiology and pathogenesis, along with treatment options, with special focus ok KC and forme fruste keratoconus.
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Salomão M, Hoffling-Lima AL, Lopes B, Belin MW, Sena N, Dawson DG, Ambrósio R. Recent developments in keratoconus diagnosis. EXPERT REVIEW OF OPHTHALMOLOGY 2018. [DOI: 10.1080/17469899.2018.1555036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Marcella Salomão
- Instituto de Olhos Renato Ambrósio, Rio de Janeiro, Brazil
- Rio de Janeiro Corneal Tomography and Biomechanics Study Group, Rio de Janeiro, Brazil
- Instituto Benjamin Constant, Rio de Janeiro, Brazil
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | | | - Bernardo Lopes
- Instituto de Olhos Renato Ambrósio, Rio de Janeiro, Brazil
- Rio de Janeiro Corneal Tomography and Biomechanics Study Group, Rio de Janeiro, Brazil
- Instituto Benjamin Constant, Rio de Janeiro, Brazil
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
- Department of Biomaterial Mechanics, University of Liverpool, Liverpool, Tucson, UK
| | - Michael W. Belin
- Department of Ophthalmology and Visual Sciences, University of Arizona, USA
| | - Nelson Sena
- Rio de Janeiro Corneal Tomography and Biomechanics Study Group, Rio de Janeiro, Brazil
- Department of Ophthalmology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Daniel G. Dawson
- Department of Ophthalmology, University of Florida, Gainesville, FL, USA
| | - Renato Ambrósio
- Instituto de Olhos Renato Ambrósio, Rio de Janeiro, Brazil
- Rio de Janeiro Corneal Tomography and Biomechanics Study Group, Rio de Janeiro, Brazil
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
- Department of Ophthalmology, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
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