Professional Documents
Culture Documents
for Keratoconus
ASHOK SHARMA, JENNIFER MARIE NOTTAGE, KANISH MIRCHIA, RAJAN SHARMA, KANWAR MOHAN,
AND VERINDER SINGH NIRANKARI
PURPOSE: To present a new complication of persistent
corneal edema after collagen cross-linking (CXL) in
keratoconus patients.
DESIGN: Retrospective case series of postoperative
corneal edema after CXL.
METHODS: STUDY POPULATION: All patients who underwent CXL treatment with subsequent corneal edema.
Patients with stromal haze were excluded. INTERVENTION:
The CXL treatments used the Dresden protocol with
corneal thickness of more than 400 m after epithelium
was removed. MAIN OUTCOME MEASURE: The resolution of
corneal edema after surgery.
RESULTS: Postoperative corneal edema was identified
in 10 (2.9%) of 350 patients who were followed up for
a mean of 14 4 months. The edema started on
postoperative day 1 (10/10) and increased for 3 weeks.
Additional findings included: deep vascularization (2
eyes; 20%), iris atrophy (6 eyes; 60%), pigment dispersion (5 eyes; 50%), persistent epithelial defect (3 eyes;
30%), and infectious keratitis (1 eye; 10%). Specular
microscopy was unsuccessful, but the fellow untreated
eyes had normal endothelial counts. Intraocular pressure
and lenticular evaluations were normal. Corneal edema
improved in 4 patients and resolved in 1 patient. In these
5 patients, the logarithm of the minimal angle of resolution best-corrected visual acuity was 0.5 0.18. Penetrating keratoplasty was offered to 5 patients when
improvement plateaued at 3 months, but only 2 patients
underwent penetrating keratoplasty.
CONCLUSIONS: CXL is a safe and effective procedure
with few known side effects. This case series reports the
possibility of corneal endothelial damage with visually
significant corneal edema after CXL treatment. Based on
the extent of endothelial damage, patients may require
penetrating keratoplasty. (Am J Ophthalmol 2012;
154:922926. 2012 by Elsevier Inc. All rights
reserved.)
922
2012 BY
inflammatory, progressive ectatic degeneration resulting in stromal thinning and distortion of the
cornea. Depending on the severity and progression of the
disease, it can be treated with spectacles, rigid gas permeable contact lenses, intracorneal ring segments, deep anterior lamellar keratoplasty, or penetrating keratoplasty.15
Recently, collagen cross-linking (CXL) with riboflavin
drops has been reported to be effective in increasing the
biomechanical strength and stability of the cornea.6 8
CXL, if preformed according to standard protocols, has
been found to be a safe procedure.9,10 Despite the high
safety profile reported, there are a few reports of adverse
events after CXL. Persistent corneal haze is one of the
more frequently reported complications of CXL.1113 In
addition, a few cases of infectious keratitis after CXL have
been reported.14,15 Furthermore, Gokhale recently reported a single case of CXL-induced corneal endothelial
cell damage resulting in corneal edema.16 We observed
several cases of persistent corneal edema after CXL for
treatment of progressive keratoconus and have evaluated
this case series of 10 patients.
METHODS
AFTER APPROVAL FROM THE CORNEA CENTRE INSTITU-
RIGHTS RESERVED.
0002-9394/$36.00
http://dx.doi.org/10.1016/j.ajo.2012.06.005
TABLE. Investigational Parameters for Patients in Whom Persistent Corneal Edema Developed after Collagen Cross-Linking
Treatment for Progressive Keratoconus
VA
Max K
CCT
Patient
No.
Age
(y)
Sex
Preoperative
Postoperative
Preoperative
Postoperative
Preoperative
3 Weeks
after
Surgery
1
2a
3a
4b
5
6b
7
8
9
10b
17
21
24
20
29
16
32
26
16
22
M
F
M
M
F
M
F
M
M
M
0.00
0.00
0.00
0.20
0.00
0.00
0.00
0.00
0.00
0.20
0.20
0.80
0.20
1.00
0.50
1.00
0.30
0.60
0.60
0.80
53.8
51.2
59.8
59.4
57.9
53.8
58.3
56.9
59.5
56.9
48.0
50.0
49.3
56.8
55.4
54.2
55.6
54.8
57.9
54.6
493
482
484
480
496
474
463
447
449
458
621
698
656
695
598
687
620
678
634
658
3 Months
after
Surgery
6 Months
after
Surgery
12 Months
after
Surgery
Follow-up
(mos)
596
693
645
685
587
659
582
674
626
632
586
682
594
663
585
633
571
628
597
609
565
664
585
657
572
585
569
590
575
584
22
12
18
8
10
15
16
14
16
12
CCT central or minimal corneal thickness; F female; M male; Max K maximum keratometry; mos months; VA visual acuity;
y year.
a
Patients who underwent penetrating keratoplasty after cross-linking.
b
Patients offered penetrating keratoplasty after cross-linking, but declined.
The CXL
treatment was preformed as an outpatient procedure following the Dresden protocol by an experienced ophthalmologist (K.Mi.).17 The treatment was performed under
sterile conditions in an operating theater. After obtaining
informed consent, the ocular surface was anesthetized with
topical proparacaine hydrochloride 0.5% solution. An
eyelid speculum was inserted, and the corneal epithelium
was removed using a hockey stick blade (Grieshaber;
Alcon, Schaffhausen, Switzerland). The epithelium was
debrided to expose 80% to 90% of the central cornea. The
corneal thickness was measured after the epithelium was
removed to confirm a thickness of more than 400 m in all
cases. Next, isotonic riboflavin 0.1% drops (Medio-Cross;
Medizinprodukte GmbH, Neudorf, Germany) were instilled every 2 minutes for 30 minutes, concurrent with
instillation of topical proparacaine. The corneas then were
exposed to ultraviolet A light (UV-X System; Peschke
Meditrade GmbH, Huenenberg, Switzerland) for 30 minutes. Administration of additional isotonic riboflavin drops
occurred every 3 minutes during the ultraviolet A exposure. The parameters of emitted ultraviolet light included:
wavelength, 370 nm; irradiance, 3 mW/cm2; and diameter,
7.5 mm. A calibrated ultraviolet meter was used to confirm
the irradiance (3.0 mW/cm2) before each treatment session; however, the corneal thickness was not remeasured
during the ultraviolet exposure. After completion of ultraviolet A exposure, the eyelid speculum was removed and a
drop of moxifloxacin hydrochloride ophthalmic solution
0.5% (Cipla Ltd, Roorkee, India) was instilled. An eye pad
VOL. 154, NO. 6
RESULTS
OF THE 520 CHARTS OF PATIENTS WITH PROGRESSIVE KERA-
toconus that were reviewed, 350 consecutive patients received CXL from a referring ophthalmologist. Of these,
postoperative corneal edema developed in 10 (10/350; 2.9%).
Three patients (3/350; 0.9%) were excluded: 1 because of
stromal haze, 1 because of infectious keratitis without corneal
edema, and 1 because of corneal melt. No intraoperative
complications were noted at the time of CXL treatment. The
average age was 22 5 years (range, 16 to 32 years). Patients
were followed up for mean of 14 4 months (range, 8 to 22
months). Before surgery, the median logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuAFTER
COLLAGEN CROSS-LINKING
923
FIGURE 1. Photograph showing corneal edema and iris atrophy in a keratoconus patient after collagen cross-linking
treatment.
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
DECEMBER
2012
ordinary intraocular fluid currents. This condition resembled intraoperative floppy iris syndrome. These 2 patients
were not taking an -1-adrenergic blocker, and their
pathology reports showed only stromal scarring and inflammation. Their posttreatment logMAR visual acuities were
0.2 and 0.8. For the 3 patients with significant edema who
declined PK, their posttreatment logMAR visual acuity
was 1 0.12.
DISCUSSION
CXL HAS BEEN REPORTED TO BE A SAFE AND EFFECTIVE
COLLAGEN CROSS-LINKING
925
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF
interest and none were reported. Involved in Design and conduct of study (A.S., J.M.N., K.Mi., R.S., K.Mo., V.S.N.); Collection, management, and
analysis of data (A.S.); and Preparation (A.S.) and review or approval (A.S., J.M.N., K.Mi., R.S., K.Mo., V.S.N.) of manuscript. This retrospective study
of patient data was approved by the Institutional Review Board from the Cornea Centre, Chandigarh.
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OPHTHALMOLOGY
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2012
Biosketch
Ashok Sharma is the Director of Cornea Centre in Chandigarh, India, where he has served on the faculty for 11 years.
He is also the founder and honorary secretary of Eye Bank Society, Chandigarh, India, and has over 80 peer-reviewed
publications. Dr Sharma also received the Achievement Award and the International Ophthalmologist Education Award
from the American Academy of Ophthalmology. His research interests include cornea and external diseases.
AFTER
COLLAGEN CROSS-LINKING
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