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Ghenciu LA, Faur AC, Bolintineanu SL, Salavat MC, Maghiari AL. Recent Advances in Diagnosis and Treatment Approaches in Fungal Keratitis: A Narrative Review. Microorganisms 2024; 12:161. [PMID: 38257986 PMCID: PMC10820712 DOI: 10.3390/microorganisms12010161] [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: 12/17/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Fungal keratitis represents a potentially sight-threatening infection associated with poor prognosis, as well as financial burden. Novel diagnostic methods include polymerase-chain-reaction (PCR)-based approaches, metagenomic deep sequences, in vivo confocal microscopy, and antifungal susceptibility testing. The ideal therapeutic approaches and outcomes have been widely discussed in recent times, with early therapy being of the utmost importance for the preservation of visual acuity, minimizing corneal damage and reducing the scar size. However, combination therapy can be more efficacious compared to monotherapy. Understanding the pathogenesis, early diagnosis, and prevention strategies can be of great importance. In this narrative, we discuss the recent progress that may aid our understanding of the diagnosis, treatment, and prevention of mycotic keratitis.
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Affiliation(s)
- Laura Andreea Ghenciu
- Department III Functional Sciences, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania;
- Department IX Surgery, Discipline of Ophtalmology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania;
| | - Alexandra Corina Faur
- Department of Anatomy and Embryology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania; (S.L.B.); (A.L.M.)
| | - Sorin Lucian Bolintineanu
- Department of Anatomy and Embryology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania; (S.L.B.); (A.L.M.)
| | - Madalina Casiana Salavat
- Department IX Surgery, Discipline of Ophtalmology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania;
| | - Anca Laura Maghiari
- Department of Anatomy and Embryology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania; (S.L.B.); (A.L.M.)
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Olshaker H, Achiron A, Chorny A, Hafezi F, Yahalomi T, Kratz A, Tsumi E, Lu NJ, Knyazer B. Accelerated high fluence photoactivated chromophore for infectious keratitis-corneal cross-linking (PACK-CXL) at the slit lamp: a pilot study. Front Pharmacol 2023; 14:1229095. [PMID: 37745064 PMCID: PMC10512457 DOI: 10.3389/fphar.2023.1229095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction: Photoactivated Chromophore for Infectious Keratitis-Corneal Cross-Linking (PACK-CXL) has garnered substantial interest among researchers and ophthalmologists due to its high promise as a potential treatment for infectious keratitis. The aim of this study is to evaluate the efficacy and safety of high fluence PACK-CXL, using 10.0 J/cm2 (30 mW/cm2, 5 min, and 33 s) at the slit lamp. Methods: This prospective interventional, nonrandomized cohort study included 20 eyes of 20 patients with bacterial, fungal, or mixed origin keratitis who underwent high fluence PACK-CXL treatment as an adjunct therapy to conventional antimicrobial therapy per American Academy of Ophthalmology treatment guidelines. The re-epithelization time was recorded, and corneal endothelial cell density was counted before and after treatment. Results: The average re-epithelization time was 8.2 ± 2.8 days (range 3-14 days). After PACK-CXL treatment, eight patients (40%) were directly discharged, while the remained patients stayed in the hospital for an average of 5.6 ± 3.5 days. No eyes required keratoplasty. Endothelial cell density counts before and after the PACK-CXL procedure were 2,562.1 ± 397.3, and 2,564.8 ± 404.5 cells/mm2, respectively (p = 0.96). Conclusion: although it was not a randomized control trial, we conclude that high fluence PACK-CXL as an adjuvant therapy is safe with no complications observed, and efficient as time to re-epithelization was less than 14 days for all patients and no patients underwent tectonic keratoplasties. Further research is needed to compare it to the current standard of care.
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Affiliation(s)
- Hagar Olshaker
- Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Achiron
- Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Chorny
- Department of Ophthalmology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Farhad Hafezi
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
- ELZA Institute, Dietikon, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Ophthalmology, University of Southern California Roski Eye Institute, University of Southern California, Los Angeles, Los Angeles, CA, United States
- School of Ophthalmology and Optometry, Wenzhou Medical University, Wenzhou, China
| | - Tal Yahalomi
- Department of Ophthalmology, Samson Assuta Ashdod, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Assaf Kratz
- Department of Ophthalmology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Erez Tsumi
- Department of Ophthalmology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Nan-Ji Lu
- ELZA Institute, Dietikon, Switzerland
| | - Boris Knyazer
- Department of Ophthalmology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel
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Al-Mahrouqi H, Cheung IMY, Angelo L, Yu TY, Gokul A, Ziaei M. Therapeutic non-ectasia applications of cornea cross-linking. Clin Exp Optom 2023; 106:580-590. [PMID: 36690333 DOI: 10.1080/08164622.2022.2159790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/28/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023] Open
Abstract
Corneal cross-linking is a photopolymerization technique traditionally used to strengthen corneal tissue. Corneal cross-linking utilizes riboflavin (vitamin B2) as a photosensitizer and ultraviolet-A light (UVA) to create strong covalent bonds within the corneal stroma, increasing tissue stiffness. Multiple studies have demonstrated corneal cross-linking's effectiveness in treating corneal ectasia, a progressive, degenerative, and non-inflammatory thinning disorder, as quantified by key tomographic, refractive, and visual parameters. Since its introduction two decades ago, corneal cross-linking has surpassed its original application in halting corneal ectatic disease and its application has expanded into several other areas. Corneal cross-linking also possesses antibacterial, antienzymolytic and antioedematous properties, and has since become a tool in treating microbial keratitis, correcting refractive error, preventing iatrogenic ectasia, stabilising bullous keratopathy and controlling post keratoplasty ametropia. This review provides an overview of the current evidence base for the therapeutic non-ectasia applications of cornea cross-linking and looks at future developments in the field.
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Affiliation(s)
| | | | - Lize Angelo
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | - Tzu-Ying Yu
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland District Health Board, Auckland, New Zealand
| | - Akilesh Gokul
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | - Mohammed Ziaei
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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Hafezi F, Torres-Netto EA, Hillen M. Expanding indications for corneal cross-linking. Curr Opin Ophthalmol 2023; 34:339-347. [PMID: 37097193 DOI: 10.1097/icu.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to summarize the recent developments in corneal cross-linking (CXL) and its indications, including corneal ectasias, refractive surgery and infectious keratitis. RECENT FINDINGS Advances in CXL technology, such as the use of higher-intensity LED ultraviolet (UV) light sources and a better understanding of the UV-riboflavin photochemical reaction, have enabled safer and more effective methods of cross-linking thin and ultra-thin corneas, and more effective accelerated transepithelial/'epi-on' CXL procedures that are beginning to supplant the Dresden protocol as the 'gold standard' CXL method. CXL is also being used in combination with laser surgery, not only to expand the patient base who can receive refractive surgery, but also to help rehabilitate vision in patients with ectasia. CXL, and CXL combined with photorefractive keratectomy (PRK), can result in corneal flattening of 1-2 D, and corneal regularization of 4-5 D, respectively. Finally, photoactivated chromophore for keratitis-corneal cross-linking (PACK-CXL) has been shown to be an effective therapy for infectious keratitis, both alone, and in combination with antimicrobial drugs. SUMMARY CXL has evolved from a single technique to treat a single corneal ectasia, keratoconus, to several techniques with several indications, spanning a spectrum of corneal ectasias, as well as visual rehabilitation, refractive procedures and infectious keratitis treatment.
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Affiliation(s)
- Farhad Hafezi
- ELZA Institute, Dietikon/Zurich
- Laboratory of Ocular Cell Biology, Center for Applied Biotechnology and Molecular Medicine, University of Zurich, Zurich
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- USC Roski Eye Institute, University of Southern California, Los Angeles, California, USA
- Department of Ophthalmology, Medical University of Wenzhou, Wenzhou, China
| | - Emilio A Torres-Netto
- ELZA Institute, Dietikon/Zurich
- Laboratory of Ocular Cell Biology, Center for Applied Biotechnology and Molecular Medicine, University of Zurich, Zurich
- Department of Ophthalmology, Paulista School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
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Chang YT, Lai CC, Lin DJ. Collagen Scaffolds Laden with Human Periodontal Ligament Fibroblasts Promote Periodontal Regeneration in SD Rat Model. Polymers (Basel) 2023; 15:2649. [PMID: 37376295 DOI: 10.3390/polym15122649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/28/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Periodontitis, a chronic inflammatory disease caused by microbial communities carrying pathogens, leads to the loss of tooth-supporting tissues and is a significant contributor to tooth loss. This study aims to develop a novel injectable cell-laden hydrogel consisted of collagen (COL), riboflavin, and a dental light-emitting diode (LED) photo-cross-linking process for periodontal regeneration. Utilizing α-SMA and ALP immunofluorescence markers, we confirmed the differentiation of human periodontal ligament fibroblasts (HPLFs) into myofibroblasts and preosteoblasts within collagen scaffolds in vitro. Twenty-four rats with three-wall artificial periodontal defects were divided into four groups, Blank, COL_LED, COL_HPLF, and COL_HPLF_LED, and histomorphometrically assessed after 6 weeks. Notably, the COL_HPLF_LED group showed less relative epithelial downgrowth (p < 0.01 for Blank, p < 0.05 for COL_LED and COL_HPLF), and the relative residual bone defect was significantly reduced in the COL_HPLF_LED group compared to the Blank and the COL_LED group (p < 0.05). The results indicated that LED photo-cross-linking collagen scaffolds possess sufficient strength to withstand the forces of surgical process and biting, providing support for HPLF cells embedded within them. The secretion of cells is suggested to promote the repair of adjacent tissues, including well-oriented periodontal ligament and alveolar bone regeneration. The approach developed in this study demonstrates clinical feasibility and holds promise for achieving both functional and structural regeneration of periodontal defects.
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Affiliation(s)
- Yi-Tao Chang
- Graduate Institute of Clinical Medical Science, School of Medicine, China Medical University, Taichung 404, Taiwan
- School of Dentistry, College of Dentistry, China Medical University, Taichung 404, Taiwan
| | - Chuan-Ching Lai
- Department of Post-Baccalaureate Veterinary Medicine, Asia University, Taichung 413, Taiwan
- Department of Physical Therapy, Asia University, Taichung 413, Taiwan
| | - Dan-Jae Lin
- School of Dentistry, College of Dentistry, China Medical University, Taichung 404, Taiwan
- Department of Biomedical Engineering, College of Biomedical Engineering, China Medical University, Taichung 404, Taiwan
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Said DG, Rallis KI, Al-Aqaba MA, Ting DSJ, Dua HS. Surgical management of infectious keratitis. Ocul Surf 2023; 28:401-412. [PMID: 34592475 DOI: 10.1016/j.jtos.2021.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/18/2021] [Indexed: 12/27/2022]
Abstract
The successful management of infectious keratitis is usually achieved with a combination of tools for accurate diagnosis and targeted timely antimicrobial therapy. An armamentarium of surgical interventions is available in the acute stage which can be resorted to in a step wise manner or in combination guided by the response to treatment. Simple surgical modalities can facilitate accurate diagnosis e.g. corneal biopsy and alcohol delamination. Surgery to promote epithelial healing can vary from tarsorrhaphy, amniotic membrane transplantation or conjunctival flaps depending on the extent of infection, visual prognosis, availability of tissue and surgeon's experience. Collagen crosslinking has been increasingly utilized with successful results to strengthen the cornea and reduce the infective load consequently the need for further elaborate surgical interventions. It has shown encouraging results specially in superficial bacterial and fungal keratitis but for deeper infections, viral and acanthamoeba keratitis, its use remains questionable. When globe integrity is compromised, corneal gluing is the most commonly used procedure to seal small perforations. In larger perforations/fulminant infections a tectonic/therapeutic graft is advisable. Partial thickness grafts are increasingly popular to treat superficial infection or internally tamponade perforations. Peripheral therapeutic grafts face challenges with potential requirement for a manually fashioned graft, and increased risk of rejection due to proximity to the limbal vessels. Late stage visual rehabilitation is likely to require further surgical interventions after complete resolution of infection and inflammation. A preliminary assessment of corneal sensation and integrity of the ocular surface are key for any successful surgical intervention to restore vision.
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Affiliation(s)
- Dalia G Said
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK; Research Institute of Ophthalmology, Cairo, Egypt.
| | | | | | - Darren S J Ting
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK
| | - Harminder S Dua
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK
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Tillmann A, DanielKampik D, Borrelli M, Seidl M, Menzel-Severing J, Seiler TG, Geerling G. Acute corneal melt and perforation – A possible complication after riboflavin/UV-A crosslinking (CXL) in keratoconus. Am J Ophthalmol Case Rep 2022; 28:101705. [PMID: 36187442 PMCID: PMC9519437 DOI: 10.1016/j.ajoc.2022.101705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To report two cases of acute corneal melting and perforation requiring emergency penetrating keratoplasty after corneal crosslinking (CXL) in advanced keratoconus. Observations Case 1 was a 34 and case 2 was a 16-year old male, both with progressive keratoconus, who underwent CXL (Dresden protocol). After riboflavin imbibition, patients had a minimal pachymetry of 337 μm and 347 μm, and therefore required stromal swelling by hypoosmolar riboflavin resulting in pachymetries of 470 μm and 422 μm, prior to the 30 minute UV-irradiation with 3mW/cm2. In case 1, on the 7th postoperative day a 4mm linear perforation occurred. Extensive post-hoc examinations revealed no infectious cause. In case 2, a corneal melting developed within 24 hours, from which Staphylococcus aureus was cultured. Conclusions and importance Acute corneal melting and perforation may occur after CXL. Dysfunctional collagen metabolism, atopia, thin preoperative pachymetry and the use of hypoosmolar substances may have initiated this complication in our cases.
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Affiliation(s)
- Anne Tillmann
- Department of Ophthalmology, University of Düsseldorf, Düsseldorf, Germany
- Corresponding author. University Hospital Duesseldorf, Department of Ophthalmology, Moorenstraße 5, D-40225, Duesseldorf, Germany.
| | | | - Maria Borrelli
- Department of Ophthalmology, University of Düsseldorf, Düsseldorf, Germany
| | - Maximilian Seidl
- Institute of Pathology, University of Düsseldorf, Düsseldorf, Germany
| | | | - Theo Günter Seiler
- Department of Ophthalmology, University of Düsseldorf, Düsseldorf, Germany
- Department of Ophthalmology, University of Bern, Bern, Switzerland
- Institute for Refractive and Ophthalmic Surgery (IROC), Zurich, Switzerland
| | - Gerd Geerling
- Department of Ophthalmology, University of Düsseldorf, Düsseldorf, Germany
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Barac IR, Artamonov AR, Baltă G, Dinu V, Mehedințu C, Bobircă A, Baltă F, Barac DA. Photoactivated Chromophore Corneal Collagen Cross-Linking for Infectious Keratitis (PACK-CXL)-A Comprehensive Review of Diagnostic and Prognostic Factors Involved in Therapeutic Indications and Contraindications. J Pers Med 2022; 12:1907. [PMID: 36422083 PMCID: PMC9698237 DOI: 10.3390/jpm12111907] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 09/07/2023] Open
Abstract
Infectious keratitis is a severe infection of the eye, which requires urgent care in order to prevent permanent complications. Typical cases are usually diagnosed clinically, whereas severe cases also require additional tools, such as direct microscopy, corneal cultures, molecular techniques, or ophthalmic imaging. The initial treatment is empirical, based on the suspected etiology, and is later adjusted as needed. It ranges from topical administration of active substances to oral drugs, or to complex surgeries in advanced situations. A novel alternative is represented by Photoactivated Chromophore Corneal Collagen Cross-Linking (PACK-CXL), which is widely known as a minimally invasive therapy for corneal degenerations. The purpose of this review is to identify the main diagnostic and prognostic factors which further outline the indications and contraindications of PACK-CXL in infectious keratitis. Given the predominantly positive outcomes in the medical literature, we ponder whether this is a promising treatment modality, which should be further evaluated in a systematic, evidence-based manner in order to develop a clear treatment protocol for successful future results, especially in carefully selected cases.
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Affiliation(s)
- Ileana Ramona Barac
- Department of Ophthalmology/ENT, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | | | - George Baltă
- Department of Ophthalmology/ENT, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | - Valentin Dinu
- Department of Ophthalmology/ENT, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | - Claudia Mehedințu
- Department of Obstetrics and Gynecology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
| | - Anca Bobircă
- Department of Rheumatology and Internal Medicine, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
| | - Florian Baltă
- Department of Ophthalmology/ENT, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | - Diana Andreea Barac
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
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Bagga B, Sharma S, Ahirwar LK, Sheba E, Vaddavalli PK, Mishra DK. Clinical outcomes of Rose Bengal mediated Photodynamic Antimicrobial Therapy on Fungal Keratitis with their microbiological and pathological correlation. Curr Eye Res 2022; 47:987-994. [PMID: 35385332 DOI: 10.1080/02713683.2022.2058019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To report the clinical outcome of Photodynamic Antimicrobial Therapy (PDAT) with Rose Bengal (RB) used as an early adjuvant therapy in patients with fungal keratitis and their microbiological and pathological correlation. METHODS Patients with microbiologically confirmed fungal keratitis underwent PDAT-RB along with topical natamycin 5% drops hourly and oral ketoconazole 200 mg twice a day. This was performed by applying rose bengal (0.1%) to the de-epithelialized cornea for 30 minutes, followed by irradiation with a 6 mW/cm2 custom-made green LED source for 15 minutes (5.4 J/cm2). The corresponding fungal isolates were tested in vitro using PDAT-RB and corneal buttons were evaluated for correlation. RESULTS Following informed consent, seven patients (male-5, female-2, mean age 47.7 years) with fungal keratitis were recruited. There were 3 cases each of Fusarium and Aspergillus flavus and 1 case of Acremonium sp. The average vertical and horizontal diameters of the corneal infiltrate were 4.12+/- 0.55 and 3.99+/- 1.19 mm, respectively. The average depth of corneal involvement was 283 +/- 75.27μ as measured by anterior segment OCT. Clinical resolution was achieved in the cases with Fusarium keratitis with an average time of 39 days. Three cases of A. flavus and a single patient with Acremonium keratitis worsened and needed therapeutic keratoplasty (TPK) for resolution. Post-TPK, the corneal tissues grew Aspergillus flavus in one out of three cases and Acremonium sp. in one case. In vitro PDAT-RB experiment was performed on the corresponding fungal isolates grown from the corneal scraping. PDAT-RB produced clear inhibition of Fusarium and Acremonium sp. with no effect on the growth of A. flavus. Histopathologically, 2 out of 4 (50%) corneal buttons showed fungal filaments. CONCLUSION While the in vitro and in vivo results of PDAT-RB matched for Fusarium species and Aspergillus flavus keratitis being favourable in the former and non-favourable in the latter, these results were discrepant in Acremonium sp.
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Affiliation(s)
- Bhupesh Bagga
- The Cornea Institute, LV Prasad Eye Institute, Hyderabad, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Hyderabad, India
| | | | - Esther Sheba
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Hyderabad, India
| | | | - Dilip K Mishra
- Ophthalmic Pathology Laboratory, LV Prasad Eye Institute, Hyderabad, India
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Bagga B, Vishwakarma P, Sharma S, Jospeh J, Mitra S, Mohamed A. Sensitivity and specificity of potassium hydroxide and calcofluor white stain to differentiate between fungal and Pythium filaments in corneal scrapings from patients of Pythium keratitis. Indian J Ophthalmol 2022; 70:542-545. [PMID: 35086234 PMCID: PMC9023980 DOI: 10.4103/ijo.ijo_1880_21] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose: To assess the sensitivity of potassium hydroxide and calcofluor white (KOH+CFW) mount in the diagnosis of Pythium keratitis and concordance among microbiologists. Methods: Three microbiologists evaluated the microscopic images of KOH + CFW mounts of confirmed cases of Pythium and fungal keratitis seen between January 2019 and February 2021. The filaments were compared using specific differentiating features. The sensitivity and specificity of KOH + CFW in diagnosing Pythium infection were evaluated along with concordance among the microbiologists. Results: Sixty consecutive cases with confirmed growth of fungus or Pythium insidiosum (n = 29) were evaluated. The sensitivity of KOH + CFW in the correct identification of Pythium filaments ranged from 79.3% to 96.5% among three microbiologists. There was good interobserver (k = 0.76–0.90) and intraobserver (k = 0.70–0.97) agreements among three microbiologists. The differentiating findings (P < 0.0001) suggestive of Pythium filaments were the absence of septae in 23 (79.3%) and collapsed walls in 22 (75.9%) cases. Conclusion: KOH + CFW has good sensitivity and specificity in the diagnosis of Pythium keratitis with good interobserver and intraobserver concordance.
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Affiliation(s)
| | | | - Savitri Sharma
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Joveeta Jospeh
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Sanchita Mitra
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Hyderabad, Telangana, India
| | - Ashik Mohamed
- Ophthalmic Biophysics, LV Prasad Eye Institute, Hyderabad, Telangana, India
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11
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Lu Y, Yin Y, Hu T, Du K, Fu Y, Xiang A, Fu Q, Wu X, Li Y, Wen D. Polymicrobial keratitis after accelerated corneal collagen cross-linking in keratoconus: Case reports and literature review. Eur J Ophthalmol 2021; 32:1375-1385. [PMID: 34821524 DOI: 10.1177/11206721211051922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To report two cases of polymicrobial keratitis following corneal collagen cross-linking for keratoconus and to review the literature. METHODS Retrospective case note and literature review. RESULTS The first case involved a 27-year-old male who presented with amebic corneal ulcers 3 days after the collagen cross-linking procedure. Some gram-negative (gram-ve) cocci were found upon staining, and cysts were observed by confocal microscopy at 7 days after surgery. Acanthamoeba infection mixed with gram-ve organisms was diagnosed. In the second case, a 14-year male developed Staphylococcus aureus corneal infection with anterior chamber empyema 3 days after the collagen cross-linking procedure for keratoconus. Occasional gram-positive (gram + ve) cocci and gram-ve bacilli were observed under a microscope. The mixed keratitis in the two patients resolved after systemic and topical antibiotic therapy, but the infection ultimately resulted in corneal scarring. Follow-up keratoplasty was needed to improve vision acuity in both patients. CONCLUSION Although ultraviolet irradiation and the reactive oxygen released by riboflavin during collagen cross-linking have bactericidal effects, a lack of a corneal epithelial barrier, bandage contact lens usage, perioperative hygiene, and an abnormal immune state are risk factors for infectious keratitis after collagen cross-linking. Perioperative management of collagen cross-linking is important to prevent infection.
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Affiliation(s)
- Ying Lu
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Yewei Yin
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Tu Hu
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Kaixuan Du
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Yanyan Fu
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Aiqun Xiang
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Qiuman Fu
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Xiaoying Wu
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Yuanjun Li
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
| | - Dan Wen
- 159374Eye Center of Xiangya Hospital, Central South University, Changsha, China.,Hunan Key Laboratory of Ophthalmology, Central South University, Changsha, China
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12
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Raj N, Vanathi M, Ahmed NH, Gupta N, Lomi N, Tandon R. Recent Perspectives in the Management of Fungal Keratitis. J Fungi (Basel) 2021; 7:jof7110907. [PMID: 34829196 PMCID: PMC8621027 DOI: 10.3390/jof7110907] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/28/2022] Open
Abstract
Mycotic keratitis is common in warm, humid regions with a varying profile of pathogenic fungi according to geographical origin, socioeconomic status, and climatic condition. Clinical diagnosis can be challenging in difficult cases and those refractory to treatment. Fungal hyphae on microscopic examination and culture isolation have been the gold standard in the laboratory diagnosis of fungal keratitis. A culture isolate of the aetiological fungus is essential to perform antifungal susceptibility testing. As the culture isolation of fungi is time-consuming, causing delays in the initiation of treatment, newer investigative modalities such as in vivo confocal microscopy and molecular diagnostic methods have recently gained popularity. Molecular diagnostic techniques now help to obtain a rapid diagnosis of fungal keratitis. Genomic approaches are based on detecting amplicons of ribosomal RNA genes, with internal transcribed spacers being increasingly adopted. Metagenomic deep sequencing allows for rapid and accurate diagnosis without the need to wait for the fungus to grow. This is also helpful in identifying new emerging strains of fungi causing mycotic keratitis. A custom-tear proteomic approach will probably play an important diagnostic role in future in the management of mycotic keratitis. Positive repeat cultures are being suggested as an important gauge indicative of a poor prognosis. Positive repeat fungal cultures help to modify a treatment regimen by increasing its frequency, providing the addition of another topical and oral antifungal agent along with close follow-up for perforation and identifying need for early therapeutic keratoplasty. The role of collagen crosslinking in the treatment of fungal keratitis is not convincingly established. Rapid detection by multiplex PCR and antifungal susceptibility testing of the pathogenic fungi, adopted into a routine management protocol of fungal keratitis, will help to improve treatment outcome. Early therapy is essential in minimizing damage to the corneal tissue, thereby providing a better outcome. The role of conventional therapy with polyenes, systemic and targeted therapy of antifungal agents, newer azoles and echinocandins in fungal keratitis has been widely studied in recent times. Combination therapy can be more efficacious in comparison to monotherapy. Given the diversity of fungal aetiology, the emergence of new corneal pathogenic fungi with varying drug susceptibilities, increasing the drug resistance to antifungal agents in some genera and species, it is perhaps time to adopt recent molecular methods for precise identification and incorporate antifungal susceptibility testing as a routine.
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Affiliation(s)
- Nimmy Raj
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Murugesan Vanathi
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
- Correspondence: ; Tel.: +91-11-26593010; Fax: +91-11-26588919
| | - Nishat Hussain Ahmed
- Ocular Microbiology Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India;
| | - Noopur Gupta
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Neiwete Lomi
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
| | - Radhika Tandon
- Cornea, Lens & Refractive Surgery Services—Dr R P Centre for Ophthalmic Sciences, All India Institute for Medical Sciences, New Delhi 110029, India; (N.R.); (N.G.); (N.L.); (R.T.)
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13
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Li M, Yu T, Gao X, Wu XY. Accelerated corneal collagen cross-linking in clinical management of infectious keratitis. J Int Med Res 2021; 48:300060520926411. [PMID: 32589855 PMCID: PMC7436827 DOI: 10.1177/0300060520926411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the clinical efficacy of corneal collagen cross-linking (CXL) in the treatment of infectious corneal diseases. Methods This study retrospectively analyzed the clinical efficacy of CXL in 65 eyes with infectious keratitis in Jinan Second People’s Hospital from December 2016 to June 2018. During 6 months of follow-up after CXL treatment, the results of confocal microscopy and anterior segment optical coherence tomography, as well as visual acuity and corneal biomechanical parameters, were recorded in detail. Results In general, the overall cure rate was 93.85%; no corneal endothelial dysfunction was encountered in any patients. After 6 months of follow-up, the visual acuity of cured patients was significantly enhanced, while corneal thickness was significantly reduced. Hyphae growth of patients with fungal keratitis was completely inhibited at 1 month postoperatively. Furthermore, corneal biomechanical parameters (i.e., central corneal thickness, deformation amplitude, and pachymetry intraocular pressure) were significantly improved after surgery, compared with baseline measurements. Conclusion Accelerated CXL may be an effective adjuvant treatment for infectious keratitis.
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Affiliation(s)
- Miao Li
- Department of Ophthalmology, Qilu Hospital of Shandong University, Jinan, P.R. China
- Department of Ophthalmology, Jinan Second People’s Hospital, Jinan, P.R. China
| | - Tao Yu
- Department of Ophthalmology, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, P.R. China
| | - Xin Gao
- Department of Ophthalmology, Jinan Second People’s Hospital, Jinan, P.R. China
| | - Xin-Yi Wu
- Department of Ophthalmology, Qilu Hospital of Shandong University, Jinan, P.R. China
- Xin-Yi Wu, Department of Ophthalmology, Qilu Hospital of Shandong University, No. 107 Wenhua xi lu, Jinan, Shandong 250011, P.R. China.
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14
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Bamdad S, Khalili MR, Khosravi A, Attarzade A, Movahedan H, Nejabat M. Corneal Cross-linking as an Adjunct for The Management of Refractory Fungal Keratitis. Middle East Afr J Ophthalmol 2021; 27:204-209. [PMID: 33814816 PMCID: PMC7993049 DOI: 10.4103/meajo.meajo_130_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 04/15/2020] [Accepted: 09/19/2020] [Indexed: 11/13/2022] Open
Abstract
PURPOSE: To evaluate the effectiveness of ultraviolet (UV)-A/Riboflavin corneal cross-linking (CXL) for the treatment of the refractory cases of fungal keratitis. METHODS: In this prospective interventional study, 9 patients with the diagnosis of fungal keratitis that were referred to our emergency eye center were included. These patients were resistant to conventional treatment and underwent therapeutic UV-A/Riboflavin CXL. Response to the treatment was considered as good if rapid epithelialization and rapid decrease in stromal infiltration was occurred after PACK-CXL, and poor when the emergency transplantation was necessary to eradicate the infection. RESULTS: Nine patients treated with CXL due to recalcitrant fungal keratitis. Culture of the corneal scrapings showed Aspergillus species in 4 patients, Candida albicans in 1 patient and Fusarium species in the remainder of them. CXL was performed from 1 to 20 days after the presentation of corneal ulcers (Mean: 9.12 ± 4.02; range: 5–20 days). Postoperatively, the mean time to epithelialization was 14.25 ± 2.38 days, and mean time to resolution of stromal infiltration was 22.5 ± 7.29 days, in responsive cases. Four out of 9 eyes showed good response, and five patients showed no response, and corneal transplantation was performed to eradicate the infection. There was no statistically significant difference in mean depth of infiltration and mean size of ulcer between responsive and unresponsive patients (P = 0.86 and 0.08, respectively). CONCLUSION: Although UV-A/Riboflavin CXL is not a definite treatment for all of the fungal keratitis, it seems promising in the management of some refractory cases.
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Affiliation(s)
- Shahram Bamdad
- Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad R Khalili
- Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Khosravi
- Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Adel Attarzade
- Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Movahedan
- Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmood Nejabat
- Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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15
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Gulias-Cañizo R, Benatti A, De Wit-Carter G, Hernández-Quintela E, Sánchez-Huerta V. Photoactivated Chromophore for Keratitis-Corneal Collagen Cross-Linking (PACK-CXL) Improves Outcomes of Treatment-Resistant Infectious Keratitis. Clin Ophthalmol 2020; 14:4451-4457. [PMID: 33376299 PMCID: PMC7762451 DOI: 10.2147/opth.s284306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/04/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the efficacy of photoactivated chromophore corneal collagen cross-linking (PACK)-CXL in the management of treatment-resistant infectious keratitis. Design Observational cohort study. Participants Forty-two eyes from 41 patients with treatment-resistant infectious keratitis. Methods Eyes underwent PACK-CXL treatment with the Dresden modified protocol in addition to standard antimicrobial therapy. The primary endpoint was the size of the corneal ulcer. Descriptive statistics, Wilcoxon rank test, McNemar test and Spearman correlation coefficient were used for statistical analysis, and p values lower than 0.05 were considered statistically significant. Results Success rate at third postoperative month was of 90.5%. Statistical analyses showed a significant effect of (PACK)‑CXL with standard antimicrobial therapy to reduce corneal ulcer size (p=0.031). Conclusion As adjuvant therapy to standard antimicrobial treatment, PACK-CXL improves the outcomes in patients with treatment-resistant corneal ulcers.
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Affiliation(s)
| | - Andres Benatti
- Cordoba Eye Clinic, Cornea and Refractive Surgery Department, Cordoba, Argentina
| | - Guillermo De Wit-Carter
- Asociación para Evitar la Ceguera en México, Hospital Dr. Luis Sanchez Bulnes, Cornea Department, Mexico City 04030, Mexico
| | - Everardo Hernández-Quintela
- Asociación para Evitar la Ceguera en México, Hospital Dr. Luis Sanchez Bulnes, Cornea Department, Mexico City 04030, Mexico
| | - Valeria Sánchez-Huerta
- Asociación para Evitar la Ceguera en México, Hospital Dr. Luis Sanchez Bulnes, Cornea Department, Mexico City 04030, Mexico
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16
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Davletshina NI, Samoylov AN. [Epidemiology and treatment of fungal keratitis]. Vestn Oftalmol 2020; 136:138-145. [PMID: 32779468 DOI: 10.17116/oftalma2020136041138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Infectious keratitis in most cases is caused by bacterial, viral or fungal agents, but their structure is changing. Some researchers have noted a substantial increase in fungal corneal lesions in recent decades, but important local etiological therapy remains unavailable in developing countries. While bacterial keratitis and ophthalmoherpes are controlled by widely available local etiotropic therapy, treatment of keratomycosis in the Russian Federation is carried out with off-label medicine. Lack of skills and availability of diagnostic methods and official etiotropic therapy creates unequal conditions for ophthalmology specialists in the fight against ophthalmomycosis. In part, this causes a reduced level of «myco-caution», which leads to long-term ineffective treatment using antibacterial drops, lasting suffering of patients, and results in the loss of the eye functionally and - in some cases - anatomically. Therefore, the study of fungal keratitis remains relevant. The article provides an overview of research data on current epidemiology in different regions of the world, analyzes available antifungal drugs and the prospects for development of affordable and effective treatment of fungal keratitis.
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Affiliation(s)
- N I Davletshina
- Kazan State Medical University, Kazan, Russia.,Republican Clinical Ophthalmological Hospital, Kazan, Russia
| | - A N Samoylov
- Kazan State Medical University, Kazan, Russia.,Republican Clinical Ophthalmological Hospital, Kazan, Russia
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17
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Jeyalatha Mani V, Parthasarathy D, Padmanabhan P, Narayanan N, Lakshmipathy M, Pachayappan SK, Jayavel P, Therese KL, Rao Madhavan HN, Jambulingam M. Therapeutic Effect of Corneal Crosslinking on Fungal Keratitis: Efficacy of Corneal Collagen Crosslinking as an Adjuvant Therapy for Fungal Keratitis in a Tertiary Eye Hospital in South India. Ocul Immunol Inflamm 2020; 29:1648-1655. [PMID: 32644867 DOI: 10.1080/09273948.2020.1770296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the efficacy of CXL in treating fungal keratitis as an adjuvant therapy. METHODS Detailed clinical examination microbiological investigation was performed. Twenty fungal keratitis patients were recruited and randomized into two groups: group 1 (n= 11, standard antifungal), group 2 (n=9, corneal collagen crosslinking with standard antifungal). Corneal scraping and tear samples collected were subjected to real-time PCR targeting ITS, TLR analysis and cytokine analysis. RESULTS The mean time for complete resolution of ulcer for group 2 was significantly shorter compared to group 1 and the final mean BCVA was better for group 2. Expression of IL-1β, IL-8, IFN-γ significantly decreased immediately post CXL in group 2 patients. Significant downregulation of TLR 6, TLR-3, TLR-4 was observed 3-days post CXL compared to group 1 patients. CONCLUSION Adjuvant effect of CXL was significant in treating fungal keratitis compared to standalone antifungal treatment.
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Affiliation(s)
- Vimalin Jeyalatha Mani
- L&T Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Durgadevi Parthasarathy
- L&T Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Prema Padmanabhan
- Department of Cornea and Refractive Surgery, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Niveditha Narayanan
- Department of Cornea and Refractive Surgery, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Meena Lakshmipathy
- Department of Cornea and Refractive Surgery, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | | | - Padmapriya Jayavel
- L&T Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | - Kulandhai Lily Therese
- L&T Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, India
| | | | - Malathi Jambulingam
- L&T Microbiology Research Centre, Vision Research Foundation, Sankara Nethralaya, Chennai, India
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18
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Awad EA, Abdelkader M, Abdelhameed AG, Gaafar WM, Mokbel TH. Collagen crosslinking with photoactivated riboflavin in advanced infectious keratitis with corneal melting: Electrophysiological Study. Int J Ophthalmol 2020; 13:574-579. [PMID: 32399407 DOI: 10.18240/ijo.2020.04.07] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 02/18/2020] [Indexed: 11/23/2022] Open
Abstract
AIM To assess the effect of photoactivated chromophore for keratitis crosslinking (PACK-CXL) in case of severe keratitis with melting on the electrophysiological function of the retina and the optic nerve. METHODS The study included 32 eyes of 32 patients with smear positive severe infectious keratitis with corneal melting. The patients were randomly divided into two groups. Group I (control group) included 16 eyes received systemic and topical antimicrobial drugs guarded by culture and sensitivity test. Group II underwent CXL and then continued their antimicrobial treatment. Full field electroretinogram (ERG) and flash visual evoked potential (VEP) were done for each patient in both groups basically and then 1wk, 1 and 3mo post-treatment to assess the changes in the electrophysiological function of the retina and optic nerve. RESULTS Healing of 10 eyes in group I in comparison to 14 eyes in group II was recorded. The mean duration of healing was 36.56±5.21d in group I vs 20.2±4.4d in group II (P<0.005). In group II, ERG showed an insignificant reduction of all parameters of ERG and VEP after CXL. The amplitude of scotopic rod response, oscillatory potential amplitude, flicker amplitude and photopic cone response were insignificantly decreased (P=0.4, 0.8, 0.1, and 0.3 respectively). There were insignificant prolongation of latencies of scotopic rod, oscillatory potential, flicker and photopic cone response (P=0.2, 0.7, 0.5 and 0.1). There was slight delay in latency of VEP without a significant reduction in amplitude. CONCLUSION CXL is an effective technique in treatment of severe infectious keratitis with melting as it halts the melting process with acceptable safety on the retinal and optic nerve function.
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Affiliation(s)
- Eman A Awad
- Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura PO.35516, Egypt
| | - Mona Abdelkader
- Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura PO.35516, Egypt
| | - Ameera G Abdelhameed
- Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura PO.35516, Egypt
| | - Walid M Gaafar
- Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura PO.35516, Egypt
| | - Tharwat H Mokbel
- Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura PO.35516, Egypt
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19
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Khan S, Naseem I. A comparative insight into the oxidative damage and cell death potential of photoilluminated aminophylline - riboflavin system in normal and cancer lung cells of swiss albino mice. Toxicol In Vitro 2019; 61:104651. [PMID: 31526835 DOI: 10.1016/j.tiv.2019.104651] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/06/2019] [Accepted: 09/11/2019] [Indexed: 02/03/2023]
Abstract
Photosensitisation of riboflavin (Rf) activates aminophylline (Am) resulting into the formation of a highly pro-oxidant Am-Rf system. We have previously shown its macromolecular damaging response in human peripheral lymphocytes, however, its potential inside a cancer cell is yet to be explored. Since, altered redox status of a cancer cell is a reliable therapeutic window in designing anticancer strategies, therefore, it's imperative to investigate whether the reactive oxygen species (ROS) generated by this system readily triggers apoptosis or it is countered by elevated antioxidant machinery of a cancer cell. Here, we have demonstrated DNA damaging and cytotoxic potential of this system in benzopyrene induced lung carcinoma cells. Using various biochemical assays significant macromolecular damage was observed along with mitochondrial membrane disruption as evaluated by rhodamine 6G membrane permeant. The 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay showed decreased cell viability, confirming cytotoxic action whereas fluorescence and electron microscopic evaluation confirmed apoptosis. ROS scavengers ameliorated the oxidative damage and inhibited cell death, thus confirming, pivotal role of ROS in causing cell death. It was evidently found out that the lung cancer cells were more sensitive towards the photodynamic action of this system, which can be attributed to the upregulated riboflavin metabolism in cancer cell. Hence, we propose a photodynamic mechanism to kill lung cancer cell that exhibits enhanced sensitivity towards cancer cells.
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Affiliation(s)
- Saniyya Khan
- Department of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University, Aligarh, UP 202002, India.
| | - Imrana Naseem
- Department of Biochemistry, Faculty of Life Sciences, Aligarh Muslim University, Aligarh, UP 202002, India.
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20
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Ting DSJ, Henein C, Said DG, Dua HS. Photoactivated chromophore for infectious keratitis - Corneal cross-linking (PACK-CXL): A systematic review and meta-analysis. Ocul Surf 2019; 17:624-634. [PMID: 31401338 DOI: 10.1016/j.jtos.2019.08.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/29/2019] [Accepted: 08/07/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To examine the efficacy of adjuvant photoactivated chromophore for infectious keratitis-corneal cross-linking (PACK-CXL) for the treatment of infectious keratitis (IK). METHODS Electronic databases, including MEDLINE, EMBASE and Cochrane Central, were searched for articles related to PACK-CXL. All clinical studies, including randomized controlled trials (RCTs), non-randomized controlled studies, case series and case reports, were included. A meta-analysis was further performed when there were sufficient similarities in the included RCTs. Primary outcome measure was time to complete corneal healing and secondary outcome measures included size of epithelial defect and infiltrate, corrected-distance-visual-acuity (CDVA), and adverse events. RESULTS Forty-six eligible studies (including four RCTs) with 435 patients were included. When compared to standard antimicrobial treatment (SAT) alone, adjuvant PACK-CXL resulted in shorter mean time to complete corneal healing (-7.44 days; 95% CI, -10.71 to -4.16) and quicker resolution of the infiltrate at 7 days (-5.49 mm2; 95% CI, -7.44 to -3.54) and at 14-30 days (-5.27 mm2; 95% CI, -9.12 to -1.41). There was no significant difference in the size of epithelial defect, CDVA and risk of adverse events. Evidence on the use of PACK-CXL in acanthamoeba and mixed IK was insufficient. CONCLUSIONS Our study demonstrates that adjuvant PACK-CXL expedites the healing of IK when compared to SAT alone (low-quality evidence). Further adequately powered, high-quality RCTs are required to fully ascertain the therapeutic effect of PACK-CXL.
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Affiliation(s)
- Darren Shu Jeng Ting
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen Medical Centre, Nottingham, UK.
| | - Christin Henein
- Newcastle University, Newcastle Upon Tyne, UK; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Dalia G Said
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen Medical Centre, Nottingham, UK
| | - Harminder S Dua
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen Medical Centre, Nottingham, UK
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Hellander Edman A, Ström L, Ekesten B. Corneal cross-linking (CXL)-A clinical study to evaluate CXL as a treatment in comparison with medical treatment for ulcerative keratitis in horses. Vet Ophthalmol 2019; 22:552-562. [PMID: 31012258 DOI: 10.1111/vop.12662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/17/2019] [Accepted: 02/20/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Compare CXL treatment with medical treatment alone in horses with stromal, ulcerative keratitis. ANIMALS STUDIED 24 horses (24 eyes) with stromal, ulcerative keratitis were included. PROCEDURE 12 horses were initially treated with CXL, and 12 horses were given conventional medical treatment. Topical medical treatment was added to horses in the CXL group if necessary. Parameters including cytology, microbial growth, time to fluorescein negativity, and time to inhibition of stromal melting were evaluated. RESULTS After the first day of treatments, a decrease in inflammatory signs and pain from the eye was observed in both groups. Stromal melting ceased within 24 hours regardless of treatment. CXL treatment alone was sufficient in 3 horses with noninfectious, superficial stromal ulcerations. Clinical signs of impaired wound healing were seen after 3-14 days in corneas with suspected or proven bacterial infection treated with CXL only, most likely because of insufficient elimination of bacteria deeper in the corneal stroma or because of re-infection from bacteria in the conjunctiva. The average decrease in stromal ulcer area per day after onset of treatment was almost identical between the groups, and no significant difference in time to fluorescein negativity was found. CONCLUSIONS We consider CXL a possible useful adjunct treatment of corneal stromal ulcers in horses, especially for melting ulcers and as a potential alternative to prophylactic antibiotic treatment for noninfected stromal ulcers. However, CXL should not be used alone for infected or suspected infected stromal ulcers, because topical antibiotics were required in all horses with proven infectious keratitis.
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Affiliation(s)
- Anna Hellander Edman
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Lena Ström
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Björn Ekesten
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
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22
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Deshmukh R. Commentary: PACK-CXL in fungal keratitis. Indian J Ophthalmol 2019; 67:1701-1702. [PMID: 31546518 PMCID: PMC6786226 DOI: 10.4103/ijo.ijo_993_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Rosetta P, Legrottaglie EF, Pagano L, Vinciguerra P. Corneal Cross-Linking Window Absorption (CXL-WA) as an Adjuvant Therapy in the Management of Aspergillus niger Keratitis. Case Rep Ophthalmol Med 2018; 2018:4856019. [PMID: 30643657 PMCID: PMC6311300 DOI: 10.1155/2018/4856019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/19/2018] [Accepted: 11/22/2018] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the effectiveness of corneal cross-linking window absorption (CXL-WA) as an adjuvant therapy for Aspergillus keratitis. METHODS A 90-year-old male came to our clinic complaining of hyperemic conjunctivitis and progressive visual loss in the right eye. Slit-lamp examination showed keratic precipitates, severe corneal opacity, and stromal edema. Corneal scraping culture was positive for Aspergillus niger. Because the clinical condition did not sufficiently improve with antifungal therapy, the patient underwent CXL-WA as an adjuvant therapy. RESULTS During the first week after treatment, the Tyndall effect, corneal edema, and signs of ocular inflammation progressively lessened. At the third postoperative month, the cornea was stable without signs of fungal keratitis. However, after this period, a descemetocele appeared in the cornea (2 × 2 mm in diameter), so the patient underwent a corneal penetrating keratoplasty. Histological evaluation of the removed corneal tissue revealed the presence of hyphae and fungal infection. CONCLUSIONS We reported a case of in vivo CXL-WA used as an adjuvant therapy for deep stromal Aspergillus keratitis. CXL did not completely eradicate the fungal infection which caused perforation 4 months after treatment and it still cannot be considered a definitive solution to mycotic keratitis, which maintains a poor long-term prognosis.
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Affiliation(s)
- Pietro Rosetta
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, Milano, Italy
| | | | - Luca Pagano
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, Milano, Italy
| | - Paolo Vinciguerra
- Humanitas Clinical and Research Center, Via Manzoni 56, Rozzano, Milano, Italy
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Lamarca J, Salvador-Culla B, Fernández-Vega C, Barraquer RI. Long-term Results of Corneal Cross-linking for Terrien's Marginal Degeneration. J Refract Surg 2018; 34:424-429. [DOI: 10.3928/1081597x-20180426-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 04/20/2018] [Indexed: 11/20/2022]
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Bonzano C, Di Zazzo A, Barabino S, Coco G, Traverso CE. Collagen Cross-Linking in the Management of Microbial Keratitis. Ocul Immunol Inflamm 2018; 27:507-512. [DOI: 10.1080/09273948.2017.1414856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Chiara Bonzano
- Clinica Oculistica, Di.N.O.G.M.I. University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Di Zazzo
- Department of Ophthalmology, IRCCS, GB Bietti Foundation, Rome, Italy
| | - Stefano Barabino
- Clinica Oculistica, Di.N.O.G.M.I. University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Giulia Coco
- Ophthalmology Department, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Enrico Traverso
- Clinica Oculistica, Di.N.O.G.M.I. University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
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Abstract
Corneal collagen cross-linking has become the preferred modality of treatment for corneal ectasia since its inception in late 1990s. Numerous studies have demonstrated the safety and efficacy of the conventional protocol. Our understanding of the cross-linking process is ever evolving, with its wide implications in the form of accelerated and pulsed protocols. Newer advancements in technology include various riboflavin formulations and the ability to deliver higher fluence protocols with customised irradiation patterns. A greater degree of customisation is likely the path forward, which will aim at achieving refractive improvements along with disease stability. The use of cross-linking for myopic correction is another avenue under exploration. Combination of half fluence cross-linking with refractive correction for high errors to prevent post LASIK regression is gaining interest. This review aims to highlight the various advancements in the cross-linking technology and its clinical applications.
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Subasi S, Altintas O, Kasap M, Guzel N, Akpinar G, Karaman S. Comparative proteomic analysis of amnion membrane transplantation and cross-linking treatments in an experimental alkali injury model. Int Ophthalmol 2017; 38:2563-2574. [PMID: 29170974 DOI: 10.1007/s10792-017-0770-5] [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: 07/02/2017] [Accepted: 11/16/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE In this study, by using a two-dimensional (2D) electrophoresis-based experimental approach, we aimed at understanding the nature of alkali injuries and the underlying mechanisms. A secondary aim was to compare the effects of cross-linking (CXL) and amnion membrane transplantation (AMT) on corneal protein compositions at the end of the early repair phase after injured with alkali. METHOD The right corneas of 24 rabbits were injured with a 1 N solution of NaOH. Groups were formed based on the adjuvant therapies as (1) healthy group, (2) control group, (3) CXL group, (4) AMT group. In addition to the therapies, a conventional medical treatment was applied to all groups. Left eyes were used as within-subject healthy corneas (1). The corneas were excised at day 21, and a comparative proteomic analysis was performed using 2D gel electrophoresis coupled with MALDI-TOF/TOF. RESULT 2D gel electrophoresis revealed the presence seven protein spots whose abundance changed among the groups. Those proteins were SH3 domain-binding protein, plant homeodomain finger protein 23, S100 calcium binding protein A-11(S100 A11), keratin type 2 cytoskeletal 1 and 2, transketolase and glyceraldehyde 3-phosphate dehydrogenase. Ingenuity pathway analysis predicted that the observed changes may be linked to a central metabolic pathway, transforming growth factor beta 1. Canonical pathway analysis focused our attention to two different pathways, namely nicotinamide adenine dinucleotide repair pathway and non-oxidative branch of pentose phosphate pathway. CONCLUSION Our results shed some light onto the molecular mechanisms affected by alkali injury and adjuvant treatments. Further research is needed to propose medically significant target molecules that may be used for novel drug developments for alkali injury.
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Affiliation(s)
- Sevgi Subasi
- Department of Ophthalmology, Körfez State Hospital, Kocaeli, Turkey.
| | - Ozgul Altintas
- Department of Ophthalmology, Medical Faculty, Acıbadem University, Istanbul, Turkey
| | - Murat Kasap
- Department of Medical Biology, Medical Faculty, Kocaeli University, Kocaeli, Turkey
| | - Nil Guzel
- Department of Medical Biology, Medical Faculty, Kocaeli University, Kocaeli, Turkey
| | - Gurler Akpinar
- Department of Medical Biology, Medical Faculty, Kocaeli University, Kocaeli, Turkey
| | - Suleyman Karaman
- Department of Ophthalmology, Talya Medical Center, Antalya, Turkey
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Behandlung einer schweren Keratitis mit Crosslinking bei lamellärer Ichthyose. SPEKTRUM DER AUGENHEILKUNDE 2017. [DOI: 10.1007/s00717-017-0373-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Khalili MR, Jahadi HR, Karimi M, Yasemi M. Corneal Collagen Cross-linking for Treatment of Bacterial and Herpetic Keratitis. J Clin Diagn Res 2017; 11:NC12-NC16. [PMID: 28892949 DOI: 10.7860/jcdr/2017/24863.10253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 05/19/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Optimal management of infective keratitis is a formidable challenge and subject of ongoing studies. Recently, Collagen Cross-Linking (CXL) of the cornea has been considered to be a new effective therapeutic approach for resistant infectious keratitis. AIM Aim of the study was to evaluate the effectiveness of CXL with Ultraviolet-A (UV-A) and riboflavin for treatment of the refractory bacterial and Herpes Simplex Virus (HSV) keratitis. MATERIALS AND METHODS In this prospective interventional study, eight patients with diagnosis of infectious keratitis who were referred to Khalili Hospital eye emergency room, between 2014 and 2015 were included in the study. There were six patients with bacterial keratitis and two patients with HSV keratitis; they were resistant to conventional treatment and underwent CXL. Response to the treatment was considered as good if rapid epithelialization and rapid decrease in stromal infiltration occurred. RESULTS Microbial culture in the bacterial keratitis group showed coagulase negative Staphylococcus in two patients, Staphylococcus aureus in one patient, mixed infection in one patient and Pseudomonas aeruginosa in two patients. Good response and rapid epithelialization and resolution of stromal infiltration were seen in the four out of six eyes. Two patients showed no response and underwent penetrating keratoplasty for eradication of infection. Furthermore, one patient showed a good response to CXL in the HSV keratitis group and another patient had a relative response but recurrence occurred. CONCLUSION Although, CXL seems promising in the treatment of patients with refractory bacterial keratitis, but in some cases, it is ineffective. CXL may be an alternative treatment for refractory cases of HSV keratitis but recurrence is possible.
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Affiliation(s)
- Mohammad Reza Khalili
- Assistant Professor, Department of Ophthalmology, Poostchi Ophthalmology Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Hamid Reza Jahadi
- Professor, Department of Ophthalmology, Poostchi Ophthalmology Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Mashaallah Karimi
- Ophthalmologist, Department of Ophthalmology, Poostchi Ophthalmology Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
| | - Masoud Yasemi
- Ophthalmologist, Department of Ophthalmology, Poostchi Ophthalmology Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Fars, Iran
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Wei S, Zhang C, Zhang S, Xu Y, Mu G. Treatment Results of Corneal Collagen Cross-Linking Combined with Riboflavin and 440 Nm Blue Light for Bacterial Corneal Ulcer in Rabbits. Curr Eye Res 2017. [PMID: 28644681 DOI: 10.1080/02713683.2017.1332767] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Shufang Wei
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
- Department of Ophthalmology, Liaocheng People’s Hospital, Liaocheng, China
| | - Cuiying Zhang
- Department of Ophthalmology, Liaocheng People’s Hospital, Liaocheng, China
| | - Shaoru Zhang
- Department of Ophthalmology, Liaocheng People’s Hospital, Liaocheng, China
| | - Yanyun Xu
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Guoying Mu
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
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Corneal collagen crosslinking for corneal ectasias: a review. Eur J Ophthalmol 2016; 27:253-269. [PMID: 28009397 DOI: 10.5301/ejo.5000916] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To review the published literature on corneal collagen crosslinking (CXL). METHODS Importance has been placed on seminal publications, systemic reviews, meta-analyses, and randomized controlled clinical trials. Where such evidence was not available, cohort studies, case-controlled studies, and case series with follow-up greater than 12 months were examined. RESULTS Corneal collagen crosslinking with riboflavin and ultraviolet A (UVA) 370 nm radiation appears to be capable of arresting the progression of ectatic corneal disorders, with most studies reporting significant improvements in visual, keratometric, and topographic measurements. Its mode of action at the molecular level is undetermined. Follow-up is limited to 5-10 years but suggests sustained stability and enhancement in corneal shape with time. Nearly all published long-term data and comparative studies are with epithelium-off techniques. Epithelium-on investigations suggest some efficacy but less than with epithelium-off treatments and long-term data are unavailable. Accelerated techniques with higher UVA fluencies and shorter treatments times, delivering the same UVA energy dosage, are the subject of recent investigation, with some laboratory and clinical studies suggesting reduced efficacy compared to the standard 3 mW/cm2 for 30 minutes irradiation procedure. Combined methodologies of CXL with techniques such as photorefractive keratectomy and intrastromal rings show promise but long-term follow-up is indicated. Sight-threatening complications of CXL are rare. CONCLUSIONS Studies of epithelium-off CXL with irradiation at 3 mW/cm2 for 30 minutes support its efficacy. Refinement in techniques may allow for safer and more rapid procedures with less patient discomfort but require further investigation.
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Abstract
PURPOSE OF REVIEW New treatments for corneal ulcers are needed to address challenges with antibiotic resistance, cost, and specificity requiring timely pathogen identification. This review assesses the evidence regarding safety and efficacy of corneal cross-linking (CXL) as an adjunct or stand-alone treatment. RECENT FINDINGS To date approximately 200 clinical cases of CXL used with various types of infectious keratitis have been reported in about 30 publications. Most employed the CXL protocol developed for keratoconus as an adjunct to antibiotics for resistant ulcers, and a number of cases resolved after this intervention. However, a few studies raised concerns about resurgence and perforation when CXL was utilized with deep fungal infections. The infiltrate depth is an important consideration, because the standard CXL treatment is cytotoxic (to keratocytes) to a depth of approximately 200-300 μm and 50% of the energy is absorbed within the first 100 μm. CXL was used successfully as a monotherapy in approximately 16 eyes with early bacterial or shallow fungal infections. SUMMARY Further work is needed to develop optimized CXL protocols for treatment of corneal ulcers, define the appropriate conditions for use, and determine the safety and efficacy relative to standard antibiotic treatments.
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Rose Bengal- and Riboflavin-Mediated Photodynamic Therapy to Inhibit Methicillin-Resistant Staphylococcus aureus Keratitis Isolates. Am J Ophthalmol 2016; 166:194-202. [PMID: 27016125 DOI: 10.1016/j.ajo.2016.03.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 03/07/2016] [Accepted: 03/10/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To evaluate the in vitro efficacy of rose bengal- and riboflavin-mediated photodynamic therapy for inhibition of methicillin-resistant Staphylococcus aureus (MRSA) isolates. DESIGN Experimental study. METHODS Two different multidrug-resistant, clinical MRSA isolates were grown on nutrient agar, prepared in suspension, and adjusted to concentrations of 1.5 × 10(4) colony-forming units per milliliter. Bacterial suspensions were mixed with rose bengal, riboflavin, or water according to experimental group. Tested in triplicate, groups included: Group I, MRSA control; Group II, MRSA with 0.1% rose bengal; Group III, MRSA with 0.03% rose bengal; and Group IV, MRSA with 0.1% riboflavin. All experimental groups were exposed to 3 lighting conditions: dark, ambient room light for 30 minutes, and 5.4 J/cm(2) with either green light-emitting diode (LED) or ultraviolet-A (UV-A) irradiation. Plates were photographed at 72 hours and custom software measured bacterial growth inhibition. RESULTS Complete growth inhibition of both MRSA strains was demonstrated (1) for both rose bengal concentrations under ambient and green LED irradiation, and (2) for the 0.1% rose bengal in the dark. The 0.03% rose bengal in dark conditions showed complete inhibition of strain 2 but incomplete inhibition of strain 1. Riboflavin showed almost complete inhibition with UV-A irradiation but demonstrated minimal inhibition for both strains in dark and ambient light conditions. CONCLUSIONS Rose bengal- and riboflavin-mediated photodynamic therapy demonstrated complete growth inhibition in vitro of 2 multidrug-resistant MRSA strains. Rose bengal was also effective in dark and ambient conditions. These results may have implications for in vivo therapy.
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Tabibian D, Mazzotta C, Hafezi F. PACK-CXL: Corneal cross-linking in infectious keratitis. EYE AND VISION 2016; 3:11. [PMID: 27096139 PMCID: PMC4836155 DOI: 10.1186/s40662-016-0042-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/24/2016] [Indexed: 11/24/2022]
Abstract
Background Corneal cross-linking (CXL) using ultraviolet light-A (UV-A) and riboflavin is a technique developed in the 1990’s to treat corneal ectatic disorders such as keratoconus. It soon became the new gold standard in multiple countries around the world to halt the progression of this disorder, with good long-term outcomes in keratometry reading and visual acuity. The original Dresden treatment protocol was also later on used to stabilize iatrogenic corneal ectasia appearing after laser-assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). CXL efficiently strengthened the cornea but was also shown to kill most of the keratocytes within the corneal stroma, later on repopulated by those cells. Review Ultraviolet-light has long been known for its microbicidal effect, and thus CXL postulated to be able to sterilize the cornea from infectious pathogens. This cytotoxic effect led to the first clinical trials using CXL to treat advanced infectious melting corneal keratitis. Patients treated with this technique showed, in the majority of cases, a stabilization of the melting process and were able to avoid emergent à chaud keratoplasty. Following those primary favorable results, CXL was used to treat beginning bacterial keratitis as a first-line treatment without any adjunctive antibiotics with positive results for most patients. In order to distinguish the use of CXL for infectious keratitis treatment from its use for corneal ectatic disorders, a new term was proposed at the 9th CXL congress in Dublin to rename its use in infections as photoactivated chromophore for infectious keratitis -corneal collagen cross-linking (PACK-CXL). Conclusion PACK-CXL is now more frequently used to treat infections from various infectious origins. The original Dresden protocol is still used for this purpose. Careful modifications of this protocol could improve the efficiency of this technique in specific clinical situations regarding certain types of pathogens.
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Affiliation(s)
- David Tabibian
- Laboratory for Ocular Cell Biology, University of Geneva, Geneva, Switzerland ; Department of Ophthalmology, Northampton General Hospital, Northampton, United Kingdom
| | - Cosimo Mazzotta
- Siena Crosslinking Center, Siena University Hospital, Siena, Italy
| | - Farhad Hafezi
- Laboratory for Ocular Cell Biology, University of Geneva, Geneva, Switzerland ; Department of Ophthalmology, University of Southern California, Los Angeles, CA USA ; EyeCare Laboratory Research Zurich Associates (ELZA) Institute, Webereistrasse 2, 8953 Dietikon, Switzerland
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Robaei D, Carnt N, Watson S. Established and emerging ancillary techniques in management of microbial keratitis: a review. Br J Ophthalmol 2016; 100:1163-70. [PMID: 26888977 DOI: 10.1136/bjophthalmol-2015-307371] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 01/10/2016] [Indexed: 01/20/2023]
Abstract
Microbial keratitis is a sight-threatening condition and an ocular emergency, because of the potential for rapid progression. Intensive topical antimicrobials are the mainstay and the gold standard of treatment for microbial keratitis. However, despite appropriate diagnosis and therapy, treatment failure is still common, and can result in significant morbidity due to corneal perforation and/or scarring. For this reason, clinicians continue to seek novel treatment techniques in order to expand the armamentarium of tools available to manage microbial keratitis, and in doing so improve clinical outcomes. In this review, we examine the evidence for some established, as well as a few emerging ancillary techniques used to manage microbial keratitis. These include topical corticosteroids, corneal collagen cross-linking, intrastromal antimicrobials, amniotic membrane transplantation and miscellaneous other techniques. Of these, collagen cross-linking shows some promise for selected cases of infectious keratitis, although more research in the area is required before it is accepted as mainstream treatment for this potentially blinding condition.
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Affiliation(s)
- Dana Robaei
- Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia Department of Ophthalmology, Westmead Hospital, Sydney, New South Wales, Australia Westmead Millennium Institute for Medical Research, Westmead, New South Wales, Australia
| | - Nicole Carnt
- Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Stephanie Watson
- Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia Corneal Unit, Sydney Eye Hospital, Sydney, New South Wales, Australia
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Microbiologic, Pharmacokinetic, and Clinical Effects of Corneal Collagen Cross-Linking on Experimentally Induced Pseudomonas Keratitis in Rabbits. Cornea 2015; 34:1276-80. [DOI: 10.1097/ico.0000000000000516] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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First proposed efficacy study of high versus standard irradiance and fractionated riboflavin/ultraviolet a cross-linking with equivalent energy exposure. Eye Contact Lens 2015; 40:353-7. [PMID: 25365552 DOI: 10.1097/icl.0000000000000095] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To document the first presented report in December 2008 of high irradiance riboflavin/ultraviolet A (UVA) corneal cross-linking in comparison with that of standard irradiance and of fractionated exposure to increase the time for oxygen diffusion into the cornea. METHODS After in vitro studies of oxygen depletion and cross-linking density using type 1 human collagen gels, 36 ex vivo porcine globes were deepithelialized and exposed to 0.1% riboflavin drops in carboxymethylcellulose solution every 5 min for 3 initial doses and then throughout irradiation afterward. Six eyes each were irradiated with 370-nm UVA light at 2, 3, 9, and 15 mW/cm continuously and 15 mW/cm fractionated (with alternate cycles of 30 s "ON" and 30 s "OFF" exposure) using an equivalent radiant exposure of 5.4 mJ/cm. The final six eyes received no UVA exposure as a control. The exposed corneas were then dissected and subjected to extensiometry. Analysis of variance with Bonferroni post hoc test was performed between groups. RESULTS The stress required to induce a 10% strain for the control eyes (no UVA) was 100.6±20.9×10 N/m in comparison with the stress of 3 mW/cm (standard irradiation) at 146.7±17.6×10 N/m (P=0.009). The stress at the other equidose irradiances of 2, 9, 15 continuously, and 15 mW/cm fractionated were 140±21.9, 162.8±70, 154.1±70, and 163.0±64×10 N/m, respectively. When comparing the irradiances of 15 mW/cm continuously and fractionated to the standard irradiation, the stress was not statistically different (P=0.799 and 0.643), respectively. CONCLUSION High irradiance riboflavin/UVA cross-linking with equivalent energy exposure demonstrates comparable efficacy in stiffening corneal collagen with standard irradiance, but with considerably less exposure time. Over the past 6 years, since this report was first presented, the use of high irradiance cross-linking has been gaining popularity.
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Tabibian D, Richoz O, Hafezi F. PACK-CXL: Corneal Cross-linking for Treatment of Infectious Keratitis. J Ophthalmic Vis Res 2015; 10:77-80. [PMID: 26005557 PMCID: PMC4424723 DOI: 10.4103/2008-322x.156122] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/04/2014] [Indexed: 11/04/2022] Open
Abstract
This article discusses corneal cross-linking (CXL) and how it transitioned from a modality for treating corneal ectatic disorders to an inventive means of treating infectious keratitis. Initially, CXL was successfully developed to halt the progression of ectatic diseases such as keratoconus, using the standard Dresden protocol. Later, indications were extended to treat iatrogenic ectasia developing after laser-assisted in situ keratomileusis (LASIK) and photo-refractive keratectomy (PRK). At the time, it had been postulated that the combination of ultraviolet light with riboflavin could not only biomechanically strengthen the cornea but also was capable of destroying living cells and organisms including keratocytes and pathogens. Thus a new and innovative concept of treatment for infectious keratitis emerged through the use of CXL technology. Initially only advanced infectious melting ulcers resisting standard microbicidal therapy were treated with CXL in addition to standard therapy. In subsequent studies CXL was also used to treat bacterial keratitis as first line therapy without the use of concomitant antibiotic therapy. With the increasing interest in CXL technology to treat infectious keratitis and to clearly separate its use from the treatment of ectatic disorders, a new term was adopted at the 9(th) CXL congress in Dublin for this specific indication: PACK-CXL (photoactivated chromophore for infectious keratitis). PACK-CXL has the potential to eventually become an interesting alternative to standard antibiotic therapy in treating infectious corneal disorders, and may help reduce the global burden of microbial resistance to antibiotics and other therapeutic agents.
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Affiliation(s)
- David Tabibian
- Laboratory for Ocular Cell Biology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Olivier Richoz
- Laboratory for Ocular Cell Biology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Farhad Hafezi
- Laboratory for Ocular Cell Biology, Faculty of Medicine, University of Geneva, Geneva, Switzerland ; Department of Ophthalmology, University of Southern California, Los Angeles, California, USA ; The ELZA Institute, Dietikon/Zurich, Switzerland
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Alhayek A, Lu PR. Corneal collagen crosslinking in keratoconus and other eye disease. Int J Ophthalmol 2015; 8:407-18. [PMID: 25938065 DOI: 10.3980/j.issn.2222-3959.2015.02.35] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 11/03/2014] [Indexed: 11/02/2022] Open
Abstract
Keratoconus is a condition characterized by biomechanical instability of the cornea, presenting in a progressive, asymmetric and bilateral way. Corneal collagen crosslinking (CXL) with riboflavin and Ultraviolet-A (UVA) is a new technique of corneal tissue strengthening that combines the use of riboflavin as a photo sensitizer and UVA irradiation. Studies showed that CXL was effective in halting the progression of keratoconus over a period of up to four years. The published studies also revealed a reduction of max K readings by more than 2 D, while the postoperative spherical equivalent (SEQ) was reduced by an average of more than 1 D and refractive cylinder decreased by about 1 D. The major indication for the use of CXL is to inhibit the progression of corneal ecstasies, such as keratoconus and pellucid marginal degeneration. CXL may also be effective in the treatment and prophylaxis of iatrogenic keratectasia, resulting from excessively aggressive photo ablation. This treatment has been used to treat infectious corneal ulcers with apparent favorable results. Most recent studies demonstrate the beneficial impact of CXL for iatrogenic ecstasies, pellucid marginal degeneration, infectious keratitis, bullous keratopathy and ulcerative keratitis. Several long-term and short-term complications of CXL have been studied and documented. The possibility of a secondary infection after the procedure exists because the patient is subject to epithelial debridement and the application of a soft contact lens. Formation of temporary corneal haze, permanent scars, endothelial damage, treatment failure, sterile infiltrates, bullous keratopathy and herpes reactivation are the other reported complications of this procedure.
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Affiliation(s)
- Adel Alhayek
- Department of Ophthalmology, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Pei-Rong Lu
- Department of Ophthalmology, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
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Ultraviolet A/Riboflavin Collagen Cross-Linking for Treatment of Moderate Bacterial Corneal Ulcers. Cornea 2015; 34:402-6. [DOI: 10.1097/ico.0000000000000375] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abbouda A, Abicca I, Alió JL. Infectious Keratitis Following Corneal Crosslinking: A Systematic Review of Reported Cases: Management, Visual Outcome, and Treatment Proposed. Semin Ophthalmol 2014; 31:485-91. [PMID: 25392046 DOI: 10.3109/08820538.2014.962176] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To describe the infectious complications and the group of pathogens involved in the infection following corneal crosslinking, the visual outcome, and the treatment proposed. METHODS A Medline (National Library of Medicine, Bethesda, MD, USA) search from October 2000 to October 2013 was performed to identify all articles describing infectious keratitis following corneal crosslinking treatment. Nineteen articles were selected. Ten articles reported infectious complications of corneal crosslinking treatment were included. Nine articles were excluded, because seven described sterile keratitis, one article was in German, and one reported general complication without describing the infection complication. RESULTS A total number of infections reported included 10 eyes. The infectious keratitis was associated with bacteria in five eyes (50%): gram-positive bacteria in three eyes (30%) (staphylococcus epidermidis, S. aureus and streptococcus salivarius plus S. oralis, respectively) and gram-negative bacteria in two eyes (20%) (E. coli; P. aeruginosa); there was herpes virus in two eyes, fungus in two eyes (Fusarium and Microsporidia) (20%), and Acanthamoeba in one eye (10%). CONCLUSIONS Only 10 cases of infectious keratitis following corneal crosslinking are published. The most virulent pathogens were Pseudomonas aeruginosa and Acanthamoeba. Less virulent organisms were Escherichia coli and S. epidermidis. Two cases of herpes keratitis were described, suggesting the possibility of systemic antiviral prophylaxis before corneal crosslinking treatment. The most common risk factor of infections identified was postoperative incorrect patient behavior.
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Affiliation(s)
- A Abbouda
- a Vissum Corporación Oftalmológica , Alicante , Spain .,b Division of Ophthalmology , University of Rome Sapienza , Rome , Italy , and
| | - I Abicca
- b Division of Ophthalmology , University of Rome Sapienza , Rome , Italy , and
| | - J L Alió
- a Vissum Corporación Oftalmológica , Alicante , Spain .,c Division of Ophthalmology , Universidad Miguel Hernández , Alicante , Spain
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Hafezi F, Gatzioufas Z, Seiler TG, Seiler T. Corneal Collagen Cross-linking for Terrien Marginal Degeneration. J Refract Surg 2014; 30:498-500. [DOI: 10.3928/1081597x-20140527-02] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 04/17/2014] [Indexed: 11/20/2022]
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Seiler TG, Schmidinger G, Fischinger I, Koller T, Seiler T. [Complications of corneal cross-linking]. Ophthalmologe 2014; 110:639-44. [PMID: 23760422 DOI: 10.1007/s00347-012-2682-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND More than 10 years after the clinical introduction of corneal cross-linking (CXL) the indications and contraindications are still not yet defined. Fundamental for such a list is the incidence of complications. METHODS A PubMed search for complications of corneal crosslinking published up to March 2013 was carried out. RESULTS The published complication rates ranged from 1 % to 10 % depending on the stage of keratoconus. Early postoperative complications were transient stromal haze, sterile infiltrates, endothelium decompensation, delayed epithelial healing and infectious keratitis. Stromal opacity can be a delayed postoperative event. CONCLUSIONS Complications after corneal cross-linking treatment for keratoconus are rare but the management of these complications may need keratoplasty.
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Affiliation(s)
- T G Seiler
- Institut für Refraktive und Ophthalmo-Chirurgie, Stockerstr. 37, 8002, Zürich, Schweiz.
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Abstract
Corneoplastique incorporates the entire spectrum of Vision corrective surgery including Lasik, premium cataract surgery, corneal surgery, ocular surface surgery and the full range of anterior segment surgery itself in manipulating the optics of every eye towards unaided emmetropia to define each and every eye surgeon as a "Vision Corrective Surgeon". This concept of approaching each case individually and designing vision therewith enables surgeons to correct not only virgin eyes but also approach complex cases and complications with the goal of 20/20 vision. Armed with this holistic approach, eye surgeons can use minimally invasive, aesthetically pleasing and visually focused surgery in single or staged process aiming for each patient's Best Vision Potential (BVP) raising eye surgery itself then to an Art!
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Affiliation(s)
- Arun C Gulani
- Director and Chief Surgeon, Gulani Vision Institute, 8075 Gate Parkway (W), Suite 102, Jacksonville, Florida 32216, USA
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Vitamin B2: A promising adjuvant in cisplatin based chemoradiotherapy by cellular redox management. Food Chem Toxicol 2013; 59:715-23. [DOI: 10.1016/j.fct.2013.07.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/07/2013] [Accepted: 07/08/2013] [Indexed: 11/24/2022]
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Riboflavin/UVA Photochemical Therapy for Severe Infectious Keratitis. Eur J Ophthalmol 2013; 24:21-8. [DOI: 10.5301/ejo.5000330] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2013] [Indexed: 11/20/2022]
Abstract
Purpose To describe the antibacterial activity of treatment with riboflavin and ultraviolet A light (UVA) in cases of severe infectious keratitis. Methods A retrospective analysis was performed of an interventional case series in which 6 eyes of 6 patients with severe infectious keratitis, all of whom were refractive to multidrug conventional therapy, were treated with riboflavin/UVA. The procedure was conducted according to the standardized protocol of corneal collagen crosslinking (CXL) for keratoconus. Best spectacle-corrected visual acuity and clinical outcomes were evaluated before and during the follow-up period. Results Five of the 6 patients showed rapid reduction in symptoms and decreased infiltrate size after riboflavin/UVA photochemical therapy. Signs of infection and inflammation mostly resolved within 1 to 2 weeks after the treatment. Despite this therapy, one patient continued to deteriorate, and penetrating keratoplasty was performed. Conclusions The adjunctive use of riboflavin/UVA photochemical therapy has a positive effect on refractory infectious keratitis. The treatment seems to be safe and effective and should be considered as part of the first-line therapy in severe cases of infectious keratitis.
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Hellander-Edman A, Makdoumi K, Mortensen J, Ekesten B. Corneal cross-linking in 9 horses with ulcerative keratitis. BMC Vet Res 2013; 9:128. [PMID: 23803176 PMCID: PMC3703264 DOI: 10.1186/1746-6148-9-128] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 06/13/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Corneal ulcers are one of the most common eye problems in the horse and can cause varying degrees of visual impairment. Secondary infection and protease activity causing melting of the corneal stroma are always concerns in patients with corneal ulcers. Corneal collagen cross-linking (CXL), induced by illumination of the corneal stroma with ultraviolet light (UVA) after instillation of riboflavin (vitamin B2) eye drops, introduces crosslinks which stabilize melting corneas, and has been used to successfully treat infectious ulcerative keratitis in human patients. Therefore we decided to study if CXL can be performed in sedated, standing horses with ulcerative keratitis with or without stromal melting. RESULTS Nine horses, aged 1 month to 16 years (median 5 years) were treated with a combination of CXL and medical therapy. Two horses were diagnosed with mycotic, 5 with bacterial and 2 with aseptic ulcerative keratitis. A modified Dresden-protocol for CXL could readily be performed in all 9 horses after sedation. Stromal melting, diagnosed in 4 horses, stopped within 24 h. Eight of nine eyes became fluorescein negative in 13.5 days (median time; range 4-26 days) days after CXL. One horse developed a bacterial conjunctivitis the day after CXL, which was successfully treated with topical antibiotics. One horse with fungal ulcerative keratitis and severe uveitis was enucleated 4 days after treatment due to panophthalmitis. CONCLUSIONS CXL can be performed in standing, sedated horses. We did not observe any deleterious effects attributed to riboflavin or UVA irradiation per se during the follow-up, neither in horses with infectious nor aseptic ulcerative keratitis. These data support that CXL can be performed in the standing horse, but further studies are required to compare CXL to conventional medical treatment in equine keratitis and to optimize the CXL protocol in this species.
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Affiliation(s)
- Anna Hellander-Edman
- Department of Animal Environment & Health, Swedish University of Agricultural Sciences, PO Box 234, SE-532 24 Skara, Sweden
| | - Karim Makdoumi
- Department of Ophthalmology, Örebro University Hospital, SE-701 85 Örebro, Sweden
| | - Jes Mortensen
- Department of Ophthalmology, Örebro University Hospital, SE-701 85 Örebro, Sweden
| | - Björn Ekesten
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, PO Box 7054, SE-750 07 Uppsala, Sweden
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Alio JL, Abbouda A, Valle DD, Del Castillo JMB, Fernandez JAG. Corneal cross linking and infectious keratitis: a systematic review with a meta-analysis of reported cases. J Ophthalmic Inflamm Infect 2013; 3:47. [PMID: 23718849 PMCID: PMC3671959 DOI: 10.1186/1869-5760-3-47] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 05/08/2013] [Indexed: 12/02/2022] Open
Abstract
Background Collagen cross linking (CXL) of the cornea has been developed recently as a new treatment for multidrug-resistant infectious keratitis. The aim of this study is to summarize the previously published data and evaluate the effectiveness of this treatment. Results The search identified 12 articles. The number of eyes was 104. The infectious keratitis was associated with bacteria in 58 eyes (57f%): Gram-positive bacteria in 44 (43%; 4 of which were infected with Mycobacterium (3.6%)) and Gram-negative bacteria in 14 eyes (13%), fungus in 13 eyes (12%), and Acanthamoeba in 7 eyes (7%). In 26 eyes (25%), the microbiological culture was negative or not performed. The mean time of re-epithelization after CXL was 20.7±28.1 days (minimum of 3, maximum of 145). Sixteen eyes underwent deep or lamellar keratoplasty. The pooled analysis suggested that CXL has a favorable effect on the block of corneal melting in 85% (95%; CI 0.77, 0.91) of eyes. Conclusion Although randomized controlled trials are needed, the available evidence supports the use of CXL in the treatment of infectious keratitis.
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Affiliation(s)
- Jorge L Alio
- Vissum Corporación Oftalmológica, Alicante 03016, Spain.
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