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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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Manns RPC, Achiron A, Knyazer B, Elhaddad O, Darcy K, Yahalomi T, Tole D, Avadhanam VS. Use of corneal cross-linking beyond keratoconus: a systemic literature review. Graefes Arch Clin Exp Ophthalmol 2023; 261:2435-2453. [PMID: 36881260 DOI: 10.1007/s00417-023-05994-6] [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: 07/07/2022] [Revised: 01/13/2023] [Accepted: 02/04/2023] [Indexed: 03/08/2023] Open
Abstract
PURPOSE The success of corneal collagen cross-linking in altering keratoconus' clinical course has driven a search for further uses of this procedure. This literature review aims to analyze the scientific evidence available for the benefit of cross-linking in the management of ophthalmic diseases other than progressive keratoconus or ectasia induced by corneal refractive procedures. METHODS A systemic literature review. RESULTS We reviewed 97 studies. We found that collagen cross-linking can limit the progression of several other corneal ectasias, thus reducing and limiting the need for keratoplasty. Collagen cross-linking also can reduce the refractive power of the cornea and can be considered for a moderate degree of bacterial keratitis or when the organism is unidentified, which is refractive to antibiotics alone. However, the comparative rarity of these procedures has limited the extent of evidence. In fungal, Acanthamoeba, and herpes virus keratitis, the evidence is inconclusive of the safety and efficacy of cross-linking. CONCLUSION Current clinical data is limited, and laboratory data has not fully correlated with published clinical data.
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Affiliation(s)
- Richard P C Manns
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Lower Maudlin St., Bristol, BS1 2LX, UK
| | - Asaf Achiron
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Lower Maudlin St., Bristol, BS1 2LX, UK
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Knyazer
- Department of Ophthalmology, Soroka University Medical Center, The Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Omar Elhaddad
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Lower Maudlin St., Bristol, BS1 2LX, UK
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Kieran Darcy
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Lower Maudlin St., Bristol, BS1 2LX, UK
| | - Tal Yahalomi
- Department of Ophthalmology, Samson Assuta Ashdod Hospital and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Negev, Israel
| | - Derek Tole
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Lower Maudlin St., Bristol, BS1 2LX, UK
| | - Venkata S Avadhanam
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Lower Maudlin St., Bristol, BS1 2LX, UK.
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Saad ZA, Elnashar H, Negm S, Elsayed HA, Abdallah MG, Abuamara TMM, Abd-Elhay WM, Elghonemy HM. Collagen cross-linking as monotherapy in experimentally induced corneal abscess in rabbits. BMC Ophthalmol 2023; 23:266. [PMID: 37312088 PMCID: PMC10262482 DOI: 10.1186/s12886-023-03007-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 05/31/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Collagen cross-linking (CXL) has evolved as an essential therapeutic approach for corneal infections, allowing for rapidly eliminating the infecting microorganism while reducing inflammation. This study aims to evaluate the efficacy of CXL as a monotherapy for managing infectious keratitis caused by Fusarium solani and Pseudomonas aeruginosa. MATERIALS AND METHODS Forty-eight white New Zealand rabbits weighing approximately 1.5-2 KG were included. The cornea of one eye of each rabbit was inoculated with either Fusarium solani or Pseudomonas aeruginosa. Group A served as a control and was subdivided into two subgroups, A1 and A2; each subgroup consisted of 8 eyes and was injected with either Fusarium solani or Pseudomonas aeruginosa, respectively. Group B (16 eyes) was inoculated with Fusarium solani, while group C (16 eyes) were inoculated with Pseudomonas aeruginosa. All animals in Group B and C received CXL treatment one week after inoculation of the organisms and after corneal abscess formation was confirmed. At the same time, animals in Group A were left untreated. RESULTS There was a statistically significant reduction in the number of colony-forming units (CFU) in Group B following CXL. No growth existed in any samples at the end of the 4th week. There was a statistically significant difference in the number of CFU between group B and the control group (p < 0.001). In group C, there was a statistically significant reduction in the CFU at the end of the first week after CXL. However, there was regrowth in all samples afterward. All 16 models in Group C showed uncountable and extensive growth during the subsequent follow-ups. There was no statistically significant difference between the number of CFU in Group C and the control group. Histopathology showed lesser corneal melting in CXL-treated Pseudomonas aeruginosa. CONCLUSIONS Collagen cross-linking is promising monotherapy and alternative treatment in managing infective keratitis caused by Fusarium solani but is less effective in Pseudomonas aeruginosa as monotherapy.
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Affiliation(s)
- Zeinab A Saad
- Memorial Institute of Ophthalmic Research, Giza, 12511, Egypt.
| | - Hazem Elnashar
- Memorial Institute of Ophthalmic Research, Giza, 12511, Egypt
| | - Sahar Negm
- Research Institute of Ophthalmology, Giza, Egypt
| | - Hala A Elsayed
- Memorial Institute of Ophthalmic Research, Giza, 12511, Egypt
| | - Mohamed Gaber Abdallah
- Faculty of Medicine, Department of Medical Biochemistry, Al-Azhar University, Cairo, Egypt
| | - Tamer M M Abuamara
- Faculty of Medicine, Histology Department, Al-Azhar University, Cairo, Egypt
| | - Wagih M Abd-Elhay
- Faculty of Medicine, Histology Department, Al-Azhar University, Cairo, Egypt
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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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Chen Y, Miao X, Gao M, Song L. Comparison of modified corneal cross-linking with intrastromal voriconazole for the treatment of fungal corneal ulcer. Exp Ther Med 2021; 22:786. [PMID: 34055085 PMCID: PMC8145909 DOI: 10.3892/etm.2021.10218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 03/01/2021] [Indexed: 01/14/2023] Open
Abstract
The present study aimed to evaluate the efficacy of modified corneal cross-linking (CXL) for the treatment of fungal corneal ulcers compared with that following intrastromal voriconazole injection. In total, 31 patients with fungal corneal ulcers treated at The General Hospital of Northern Theater Command between October 2017 and October 2019 were enrolled. Among them, 10 eyes were treated with ultraviolet A (UV-A)/riboflavin CXL (CXL group), whilst 21 eyes were treated with debridement combined with intrastromal voriconazole (stromal injection group). Preoperative microbiological examination was performed in both groups, and evaluated using Fisher's exact test. Postoperatively, infection control and total efficacy rates, localized lesion, ulcer healing rate 1 week after surgery, visual acuity and complications were evaluated using Fisher's exact test, however visual acuity was analyzed by mixed-model ANOVA. The results showed that the pre-operative species distribution between the CXL and stromal injection groups did not significantly differ. The infection control rate in the CXL group was notably higher compared with that in the stromal injection group (P=0.04). Furthermore, the total efficacy rate in the CXL group was also markedly higher compared with that in the stromal injection group, though no statistically significant differences were observed. Localized lesions were observed in nine eyes (90.0%) in the CXL group and nine eyes (42.9%) in the stromal injection group (P=0.02). However, the rate of ulcer healing at 1 week postoperatively and the logarithm of the minimum angle of resolution (logMAR) of visual acuity were not found to be significantly different between the two groups. In terms of complications, with the exception of one patient in the CXL group exhibiting loss of corneal transparency and one patient in the stromal injection group presenting with partial corneal thinning, no other forms of complications were observed. In conclusion, the present study suggested that CXL could have a beneficial impact for treating fungal corneal ulcers in the aspects of infection control, localized lesions and accelerated epithelialization. In addition, except the loss of corneal transparency, this treatment approach could be applied with reduced risks of adverse events.
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Affiliation(s)
- Yingxin Chen
- Department of Ophthalmology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, P.R. China
| | - Xingya Miao
- Department of Ophthalmology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, P.R. China
| | - Minghong Gao
- Department of Ophthalmology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, P.R. China
| | - Lixin Song
- Department of Dermatology, General Hospital of Northern Theater Command, Shenyang, Liaoning 110016, P.R. China
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Brekelmans J, Veugen J, Rieff K, Dickman MM, Goz A, Wolffs P, Brandis A, Berendschot TTJM, Nuijts RMMA, Scherz A, Marcovich AL. Enzymatic Digestion of Porcine Corneas Cross-linked by Hypo- and Hyperosmolar Formulations of Riboflavin/ultraviolet A or WST11/Near-Infrared Light. Transl Vis Sci Technol 2020; 9:4. [PMID: 32953244 PMCID: PMC7476657 DOI: 10.1167/tvst.9.10.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/05/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose To assess enzymatic digestion rate after Riboflavin (RF) and Water-Soluble-Taurine (WST11) based corneal cross-linking (CXL), with or without the addition of high molecular weight dextran (RF-D and WST-D). Methods Eighty-eight paired porcine corneas were cross-linked by either RF (n = 11) or RF-D (n = 11) and ultraviolet light (UVA), or WST11 (n = 11) or WST-D (n = 11) and near-infrared (NIR) light, or used as paired control (n = 44). Corneal buttons of treated and paired control eyes were placed in a 0.3% collagenase solution. Time to full digestion and remaining dry sample weight after six hours were compared. Results A strong treatment effect was seen with all four formulations, as all controls had been fully digested whilst all treated samples were still visible at the experiment's endpoint. After irradiation, central corneal thickness was significantly higher in samples treated with hypo-osmolar formulations, compared to dextran enriched formulations (P < 0.001). Dry sample weight after digestion was nonsignificantly different between corneas treated by the four different formulations (P = 0.102). Average dry sample weight was 1.68 ± 0.6 (n = 10), 2.19 ± 0.50 (n = 8), 1.48 ± 0.76 (n = 11), and 1.54 ± 0.60 (n = 9) mg, for RF, RF-D, WST11, and WST-D treated samples, respectively. Enzymatic resistance was similar for RF and WST based CXL (P = 0.61) and was not affected by the addition of dextran (P = 0.221). Conclusions Both RF and WST11 based CXL significantly increases resistance to enzymatic digestion, with similar effect for hypo-osmolar and hyperosmolar (dextran enriched) formulations. Translational Relevance Our findings indicate these formulations are interchangeable, paving the way for the development of novel PACK-CXL protocols for thin corneas and deep-seated infections.
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Affiliation(s)
- Jurriaan Brekelmans
- University Eye Clinic Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands.,Department of Plant and Environmental Sciences, the Weizmann Institute of Science, Rehovot, Israel
| | - Judith Veugen
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Koen Rieff
- Department of Plant and Environmental Sciences, the Weizmann Institute of Science, Rehovot, Israel
| | - Mor M Dickman
- University Eye Clinic Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Alexa Goz
- Department of Plant and Environmental Sciences, the Weizmann Institute of Science, Rehovot, Israel.,Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel
| | - Petra Wolffs
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Alexander Brandis
- Department of Life Sciences Core Facilities, the Weizmann Institute of Science, Rehovot, Israel
| | - Tos T J M Berendschot
- University Eye Clinic Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Rudy M M A Nuijts
- University Eye Clinic Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Avigdor Scherz
- Department of Plant and Environmental Sciences, the Weizmann Institute of Science, Rehovot, Israel
| | - Arie L Marcovich
- Department of Plant and Environmental Sciences, the Weizmann Institute of Science, Rehovot, Israel.,Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel
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Zhang C, Du T, Mu G, Wang J, Gao X, Long F, Wang Q. Evaluation and ultrastructural changes of amniotic membrane fragility after UVA/riboflavin cross-linking and its effects on biodegradation. Medicine (Baltimore) 2020; 99:e20091. [PMID: 32443319 PMCID: PMC7254827 DOI: 10.1097/md.0000000000020091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This study aims to evaluate the changes of fragility and ultrastructure of amniotic membrane after cross-linking by UVA/riboflavin.Forty-nine fresh amniotic membranes were randomly divided into 3 groups. Eighteen were in group A (CX group) and immersed in 0.1% riboflavin solution for 10 min for UVA/riboflavin cross-linking. Sixteen were in group B (B2 group), soaked for 10 min with 0.1% riboflavin. After soaking, membranes in group A and B were transferred into corneal preservation solution. Fifteen pieces were in group C, directly into corneal preservation solution. The biomechanical and ultrastructural changes of the amniotic tissue before and after cross-linking were examined (CX group = 13, B2 group = 11, C group = 15). The amniotic membrane tissue of group A (n = 5) and B (n = 5) was transplanted into 16 eyes of the rabbits, respectively, and the dissolution time of the amniotic membrane tissue was investigated.After cross-linking, compared with the control group, the elastic modulus of the low-stress area of the amniotic membrane (Elow) was higher, while the elastic modulus of the high-stress area of the amniotic membrane (Ehigh) was lower, with no significant difference in the tensile strength. Also, the collagen fibers showed coarse and bamboo-like changes. In group A, amniotic membranes began to dissolve 4 weeks after conjunctiva transplantation, and all amniotic membranes were dissolved and absorbed 6 weeks after conjunctiva transplantation. In group B, some amniotic membrane tissues were still visible 6 weeks after conjunctiva transplantation.This study suggested that after amniotic membrane cross-linking, the brittleness was increased, the hardness was enhanced, and the morphology of the collagen fiber was changed. The cross-linked amniotic membrane showed resistance to tissue dissolution.
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Affiliation(s)
| | | | | | - Jia Wang
- Shandong Provincial Hospital, Jinan
- Aier Eye Hospital Group, LiaochengAier Eye Hospital, Liaocheng
| | - Xin Gao
- Jinan Second People's Hospital
| | - Fumin Long
- People's Hospital of Taierzhuang District, Zaozhuang, China
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Corneal Collagen Cross-Linking With Photoactivated Chromophore for Infectious Keratitis After Penetrating Keratoplasty. Cornea 2019; 39:283-289. [DOI: 10.1097/ico.0000000000002210] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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