Journal of Refractive Surgery

Proceedings 

Staged Intrastromal Delivery of Riboflavin With UVA Cross-linking in Advanced Bullous Keratopathy: Laboratory Investigation and First Clinical Case

Ronald R Krueger, MD, MSE; Jerome C Ramos-Esteban, MD; A. John Kanellopoulos, MD

Abstract

PURPOSE

To evaluate the safety and efficacy of staged ultraviolet A (UVA) cross-linking following intrastromal 0.1% riboflavin administration in eyes with advanced corneal edema.

METHODS

Ten eye bank corneas divided in two groups (n=5) were placed on a pressurized artificial anterior chamber following Descemet’s membrane stripping. Two consecutive corneal pockets (350- and 150-µm depth) were sequentially created using a femtosecond laser. Sequential intrastromal injections of 0.1% riboflavin (0.2 mL) followed by either UVA irradiation (15 mW/cm2) for 7 minutes or exposure to air were performed for each pocket. Corneal clarity and central thickness were measured before and after the two UVA cross-linking steps. The same steps were clinically applied in an 84-year-old woman with bullous keratopathy prior to corneal transplantation and followed for 6 months.

RESULTS

The corneal clarity improved in the treated but not the control eyes. The mean central corneal thickness was significantly reduced by 256 µm (ultrasound, P=.0002) and 273 µm (Scheimpflug, P=.0004) in treated eyes, but only 100 µm (ultrasound, P=.048) and 107 µm (Scheimpflug, P=.075) in the control eyes. The clinical treatment of corneal edema showed improved clarity and reduced central corneal thickness from 675 to 550 µm (ultrasound) and 696 to 571 µm (Scheimpflug) at 1 month. Best spectacle-corrected visual acuity improved from finger counting to 20/80 at 1 week and beyond, postponing corneal transplantation for >6 months.

CONCLUSIONS

Staged UVA cross-linking (15 mW/cm2) with femtosecond laser facilitated intrastromal 0.1% riboflavin administration may be a safe (no corneal scarring) and effective (marked reduction of edema) temporizing alternative method for managing bullous keratopathy. [J Refract Surg. 2008;24:S730-S736.]

ABOUT THE AUTHORS

From Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio (Krueger, Ramos-Esteban); NYU Medical School, New York, NY (Kanellopoulos); and Laservision.gr Institute, Athens, Greece (Kanellopoulos).

This study was supported by a Cleveland Clinic Institutional Grant from Research to Prevent Blindness Inc, New York, NY, and with cornea tissue from the Eye Bank for Sight Restoration, New York, NY.

The authors have no financial interest in the materials presented herein.

Presented in part at the International Congress of Corneal Cross-Linking; December 7-8, 2007, Zurich, Switzerland; American Society of Cataract and Refractive Surgeons annual meeting, April 1-4, 2008, Chicago, Ill; and World Ophthalmic Congress, June 28 - July 1, 2008, Hong Kong.

Correspondence: A. John Kanellopoulos, MD, Laservision.gr Institute, 15-17 Tsocha St, Athens, Greece 11521. Tel: 30 210 7472777; Fax: 30 210 7472789; E-mail: laservison@internet.gr

Click here to read the Letter to the Editor.


Abstract

PURPOSE

To evaluate the safety and efficacy of staged ultraviolet A (UVA) cross-linking following intrastromal 0.1% riboflavin administration in eyes with advanced corneal edema.

METHODS

Ten eye bank corneas divided in two groups (n=5) were placed on a pressurized artificial anterior chamber following Descemet’s membrane stripping. Two consecutive corneal pockets (350- and 150-µm depth) were sequentially created using a femtosecond laser. Sequential intrastromal injections of 0.1% riboflavin (0.2 mL) followed by either UVA irradiation (15 mW/cm2) for 7 minutes or exposure to air were performed for each pocket. Corneal clarity and central thickness were measured before and after the two UVA cross-linking steps. The same steps were clinically applied in an 84-year-old woman with bullous keratopathy prior to corneal transplantation and followed for 6 months.

RESULTS

The corneal clarity improved in the treated but not the control eyes. The mean central corneal thickness was significantly reduced by 256 µm (ultrasound, P=.0002) and 273 µm (Scheimpflug, P=.0004) in treated eyes, but only 100 µm (ultrasound, P=.048) and 107 µm (Scheimpflug, P=.075) in the control eyes. The clinical treatment of corneal edema showed improved clarity and reduced central corneal thickness from 675 to 550 µm (ultrasound) and 696 to 571 µm (Scheimpflug) at 1 month. Best spectacle-corrected visual acuity improved from finger counting to 20/80 at 1 week and beyond, postponing corneal transplantation for >6 months.

CONCLUSIONS

Staged UVA cross-linking (15 mW/cm2) with femtosecond laser facilitated intrastromal 0.1% riboflavin administration may be a safe (no corneal scarring) and effective (marked reduction of edema) temporizing alternative method for managing bullous keratopathy. [J Refract Surg. 2008;24:S730-S736.]

ABOUT THE AUTHORS

From Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio (Krueger, Ramos-Esteban); NYU Medical School, New York, NY (Kanellopoulos); and Laservision.gr Institute, Athens, Greece (Kanellopoulos).

This study was supported by a Cleveland Clinic Institutional Grant from Research to Prevent Blindness Inc, New York, NY, and with cornea tissue from the Eye Bank for Sight Restoration, New York, NY.

The authors have no financial interest in the materials presented herein.

Presented in part at the International Congress of Corneal Cross-Linking; December 7-8, 2007, Zurich, Switzerland; American Society of Cataract and Refractive Surgeons annual meeting, April 1-4, 2008, Chicago, Ill; and World Ophthalmic Congress, June 28 - July 1, 2008, Hong Kong.

Correspondence: A. John Kanellopoulos, MD, Laservision.gr Institute, 15-17 Tsocha St, Athens, Greece 11521. Tel: 30 210 7472777; Fax: 30 210 7472789; E-mail: laservison@internet.gr

Click here to read the Letter to the Editor.


10.3928/1081597X-20080901-17

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