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2413
Methods
Twenty-four patients with corneal edema resulting from PBK of
more than 4 months duration and awaiting keratoplasty were
enrolled to undergo CXL followed by penetrating keratoplasty.
They were allocated randomly into 2 groups of 12 patients each
using computer-generated tables at the time of enrollment: 12
patients underwent penetrating keratoplasty 1 month after CXL
(group A), whereas the remaining 12 patients underwent penetrating keratoplasty 3 months after CXL (group B). All eligible
patients signed an informed consent form at the time of enrolment
in the study. The inclusion criteria for the study were between 30
and 70 years of age, endothelial decompensation lasting more than
4 months after cataract surgery, and CCT of more than 550 mm.
Patients with intraocular pressure of more than 22 mmHg, corneal
opacities, dry eye, or a history of photosensitivity were excluded
from the study.
The primary outcome of the study was the effect on CCT,
ocular discomfort, and histopathologic modications of corneal
stroma at 1 or 3 months after CXL. The research was approved by
the ethics committee of the institution and adhered to the tenets of
Declaration of Helsinki.
Before CXL treatment, patients were using hyperosmolar drops
(hyperosmotic sodium chloride 5% 4 times daily). All the participating patients underwent serial clinical examinations, including
visual acuity, grading of ocular discomfort, and pachymetry before
surgery and during subsequent visits after CXL at 1 week and 1
month. Only 12 patients in group B were followed up to 3 months
after CXL. At the time of keratoplasty, the corneal buttons were
processed appropriately and were submitted for detailed histopathologic analysis. All 24 samples were evaluated by a single
masked observer (R.K.S.).
The visual acuity of all patients was recorded at each visit using
Snellens chart and later was converted to the logarithm of the
minimum angle of resolution scale. The visual analog scale
(VAS)26 was used to quantify ocular discomfort, which included
excessive tearing, redness, and pain. The patients were asked to
mark on the line, from 1 to 10, the point that they believed
represented their perception of pain. The VAS score was
determined by measuring from the left hand end of the line to
the point marked by the patient. Zero stood for no pain, whereas
10 stood for unbearable pain. Corneal haze was categorized into
4 grades24 on slit-lamp examination: 1 corneal edema in the
posterior stroma; 2 microcystic epithelial edema plus corneal
edema in the posterior stroma; 3 epithelial erosions and bullae
formations; and 4 brosis of corneal surface.
Central corneal thickness was measured using ultrasound
pachymetry (Sonomed-PacScan plus; New York, NY) and
noncontact anterior segment optical coherence tomography (OCT;
RTvue-100 [Freemont, CA] with monochrome charge-coupled
device camera). Anterior segment OCT was found to record CCT
in severely edematous corneas where ultrasound pachymetry was
difcult. Central corneal thickness was measured before surgery in
all patients and at subsequent visits after CXL. Corneal CXL was
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Statistical Analysis
Standard follow-up visits were made at 1 week, 1 month, and
3 months for the purpose of statistical analysis. Parameters were
compared between the 2 groups and within each group at each
follow-up visit with the preoperative ndings. Data were analyzed
using the paired t test, the nonparametric ManneWhitney U test,
and the Wilcoxon signed-rank test wherever appropriate. A P value
less than 0.05 was considered signicant.
Results
The mean visual acuity of patients in group A improved from
1.94!0.2 before surgery to 1.76!0.44 at 1 week and 1.88!0.22 at
1 month after CXL (Table 1). This change was not found to be
statistically signicant (P 0.47). The mean visual acuity of the
12 patients in group B improved from 1.91!0.15 before surgery
to 1.64!0.34 at 1 week (P 0.02), 1.62!0.31 at 1 month (P
0.006), and 1.81!0.23 at 3 months (P 0.083) after CXL.
Corneal CXL improved vision signicantly 1 month after the
procedure; however, this improvement was not sustained at 3
months (Table 2).
The mean VAS scores of patients in group A showed a statistically signicant decrease from 4.25!1.138 before surgery to
1.67!0.651 and 1.83!0.835 at 1 week and 1 month, respectively,
after CXL (Table 1). In the 12 patients followed up to 3 months
after CXL in group B, the mean VAS scores decreased from
5.25!1.357 before surgery to 2.08!1.084, 2.17!1.03, and
2.67!1.231 at 1 week, 1 month, and 3 months, respectively. The
VAS score showed a worsening trend to 2.67!1.231 for
12 patients at 3 months, but it was still signicantly lower than
the preoperative value (Table 2).
Arora et al
&
Before Surgery
P Value
P Value
1.94!0.2
4.25!1.14
837.83!83.96
817.09!65.08
1.76!0.44
1.67!0.65
780.92!78.45
757.45!63.05
0.115
0.002
0.007
0.00
1.88!0.22
1.83!0.84
787.58!84.7
788.73!77.82
0.47
0.002
0.011
0.029
ASOCT anterior segment optical coherence tomography; CCT central corneal thickness; UP ultrasonic pachymeter; VAS visual analog scale.
Data are mean ! standard deviation unless otherwise indicated.
Discussion
Postsurgical corneal edema is one of the leading indications
for penetrating keratoplasty. Corneal transplantation alone
provides permanent visual recovery and relief of symptoms.
In developing countries with a shortage of donor corneas
and huge waiting lists of patients awaiting corneal transplantation, patients need to be provided with relief of
symptoms and, if possible, temporary improvement in
vision for the interim.
Corneal CXL is being advocated of late as a new tool in
the armamentarium for the temporary reduction in corneal
edema in patients with bullous keratopathy. It has been
found to improve corneal transparency, corneal thickness,
and ocular pain after surgery.21,22
Previous studies have reported signicant relief in
symptoms of ocular discomfort at up to 6 months, with
Before Surgery
P Value
P Value
P Value
1.91!0.15
5.25!1.357
855.08!96.202
809.08!88.703
1.64!0.34
2.08!1.084
767.00!132.568
734.20!83.50
0.020
0.002
0.077
0.025
1.62 !0.31
2.17!1.03
774.42!114.62
704.40!74.123
0.006
0.002
0.013
0.001
1.81!0.23
2.67!1.231
805.08!136.064
732.30!79.762
0.083
0.003
0.084
0.010
ASOCT anterior segment optical coherence tomography; CCT central corneal thickness; UP ultrasonic pachymeter; VAS visual analog scale.
Data are mean ! standard deviation unless otherwise indicated.
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Figure 1. Clinical photographs of a patient in group B: (A) before corneal collagen cross-linking (CXL), (B) 1 month after CXL, and (C) 3 months after CXL.
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Arora et al
&
References
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1
Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi,
India.
2
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Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Correspondence:
Gaurav Goyal, MS, 63, Savarkar Apartments, IP extension, Patparganj,
New Delhi 110092, India. E-mail: dr.gaurav.mamc@gmail.com.