Macular phototoxicity after corneal cross-linking

Purpose: To assess potential vascular, structural, and functional changes to the macula in patients with keratoconus that underwent ultraviolet A (UVA)-riboflavin-mediated corneal collagen cross-linking (CXL) therapy. Patients and methods: Seventeen eyes from 17 patients of age 16 years or older with keratoconus undergoing CXL treatment were studied. The same eye served as its own control (before CXL vs after CXL). Eyes were evaluated in terms of best-corrected visual acuity (BCVA), refractive error, intraocular pressure, Amsler grid, retinography, fluorescein angiography, autofluorescence, and spectral domain optical coherence tomography (SD-OCT) prior to CXL and 7 and 30 days after treatment. Multifocal electroretinography (mfERG) was recorded prior to and 7 days after CXL. Results: Mean (SD) BCVA by logMAR chart was 0.47 (+/-0.12) pre-CXL, 0.55 (+/-0.15) 7 days post-CXL (P=0.57), and 0.46 (+/-0.10) 30 days post-CXL (P=0.87). Mean (SD) SD-OCT central macular thickness (microm) was 253.62 (+/-20.9) pre-CXL, 260.5 (+/-18.7) 7 days post-CXL (P=0.48), and 256.44 (+/-21.6) 30 days post-CXL (P=0.69). In 12 eyes, mfERG revealed a statistically significant increase (P=0.0353) in P1 latency (ms) of ring four from the pre-CXL period (39.45+/-2.05) to 7 days post-CXL (41.04+/-1.28) period. Regression analysis showed that the increase in P1 latency was correlated with the increase in central macular thickness (P=0.027). Furthermore, nine patients experienced a significant decrease in P1 amplitudes of rings 1 (P=0.0014), 2 (P=0.0029), 3 (P=0.0037), 4 (P=0.0014), and 5 (P=0.0012) from pre-CXL to 7 days post-CXL. Conclusion: In this pilot study, most of the patients exhibited slight changes in their mfERG parameters and OCT thickness, despite a lack of vascular abnormalities observed on fluorescein angiography/autofluorescence imaging, no alteration in BCVA, and no reports of symptoms. These changes could, therefore, be categorized as a mild subclinical effect of the corneal cross-linking procedure

Corneal cross-linkin : early indications and side effects on the retina

Orientador: Carlos Eduardo Leite ArietaTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: Objetivos: 1) Analisar possíveis efeitos colaterais, a curto prazo, do uso da luz ultra-violeta (UV) durante o tratamento cross-linking corneano (CXL), em pacientes portadores de ceratocone, em outras estruturas oculares não antes estudadas, especificamente, na área macular retiniana, através do estudo das alterações vasculares, estruturais e/ou funcionais, antes e após 30 dias do tratamento com CXL. 2) Analisar o benefício da indicação e tratamento com CXL, em pacientes portadores de ceratocone, com idade abaixo de 17 anos, através do estudo comparativo das características e a progressão do ceratocone após o tratamento em pacientes com 16 anos ou menos, em relação a pacientes com 17 anos ou mais de idade. Métodos: 1) No primeiro estudo, foram analisados 17 olhos de 17 pacientes (16 anos ou mais de idade), portadores de ceratocone em tratamento com CXL, submetidos à avaliação da melhor acuidade visual corrigida (MAVC), grade de Amsler, angiografia com fluoresceína (FA) e tomografia de coerência óptica (SD-OCT), teste realizado antes do CXL, 7 e 30 dias depois. A Eletrorretinografia Multifocal (mfERG) foi registrada antes e sete dias após o CXL. 2) No segundo estudo, retrospectivo, foram analisados 105 olhos, de 94 pacientes, com ceratocone, em tratamento com CXL, divididos em dois grupos, por idade: Grupo 1 (16 anos ou menos) e Grupo 2 (17 anos ou mais). Foram avaliadas a MAVC, a densidade celular endotelial da córnea (DCE), a espessura central da córnea (ECC), ceratometria (topografia) antes do CXL, e um, três, seis e doze meses depois. Resultados: 1- O primeiro estudo mostrou a MAVC média (SD) de 0,47 (± 0,12) pré-CXL, 0,55 (± 0,15) 7 dias após o CXL e 0,46 (± 0,10) 30 dias pós-CXL. A acuidade visual corrigida para pertomédia (Jaeger) (SD) foi de 2,42 (± 0,60) pré-CXL, 3,4 (± 0,63) 7 dias após o CXL e 2,58 (± 0,61) 30 dias pós-CXL. A espessura macular central média (SD) no SD-OCT (?m) foi 253,62 (± 20,9) pré-CXL, 260,5 (± 18,7) 7 dias após a CXL, e 256,44 (± 21,6) 30 dias pós-CXL. Em 12 olhos, o mfERG mostrou um aumento, estatisticamente significativo, (p = 0,0353) na latência P1 (ms) do anel 4 entre pré-CXL (39,45 ± 2,05) e 7 dias após o CXL (41,04 ± 1,28). A análise de regressão mostrou que o aumento da latência de P1 foi correlacionada com o aumento da espessura macular central no SD-OCT (p = 0,027). Além disso, 9 pacientes apresentaram uma diminuição, estatisticamente significativa, nas amplitudes P1 dos anéis 1, 2, 3, 4 e 5 entre pré-CXL e 7 dias após o CXL. 2- O segundo estudo mostrou que no grupo 1, a MAVC média (SD) foi de 0,45 (± 0,25), pré-CXL e 0,56 (± 0,29) um ano após o CXL; e os parâmetros ceratométricos médios (SD) Kmax, Ksteep e Kflat foram, respectivamente, 58,47 (± 7,16), 52,93 (± 5,42) e 47,22 (± 4,19) pré-CXL, e 58,21 (± 7,68), 52,25 (± 5,49) e 46,56 (± 4,65) um ano após o CXL. No grupo 2, a MAVC média (SD) foi de 0,50 (± 0,30) pré-CXL e de 0,56 (± 0,32) ao ano, pós-CXL; e os parâmetros ceratométricos médios (SD) Kmax, Ksteep e Kflat foram, respectivamente, 57,64 (± 7,10), 54,02 (± 6,22) e 48,60 (± 4,06) pré-CXL e 56,46 (± 8,01), 52,46 (± 5,79) e 47,85 (± 4,86) um ano após o CXL. Conclusões: 1- O primeiro estudo mostrou que a maioria dos pacientes exibia pequenas alterações nos parâmetros mfERG, apesar de nenhuma alteração na MAVC, na acuidade visual para perto, na estrutura e vascularização da região macular retiniana nas imagens do SD-OCT e FA, sendo essas alterações precoces categorizadas como leve efeito subclínico do procedimento de CXL da córnea. 2- O segundo estudo não mostrou diferenças estatísticas entre os grupos de pacientes; sendo assim, os achados apóiam-se na indicação mais precoce do tratamento com CXL, em pacientes pediátricos, para estabilização precoce da doença e melhor prognóstico em MAVC e parâmetros ceratométricosAbstract: Objectives: 1) To analyze possible short-term side effects from the use of ultraviolet (UV) light during corneal cross-linking (CXL) treatment in patients with keratoconus on other ocular structures not previously studied, specifically in the retinal macular area, by studying vascular, structural and/or functional alterations before and after 30 days of treatment with CXL. 2) To analyze the benefit of CXL indication and treatment of patients with keratoconus under 17 years of age by comparing the characteristics and progression of keratoconus after the treatment in patients 16 years or younger compared to patients 17 years old or older. Methods: 1) In the first study, 17 eyes of 17 patients (16 years of age and older) with keratoconus treated with CXL were analyzed and submitted to the evaluation of the best corrected visual acuity (BCVA), Amsler's grid, fluorescein angiography (FA) and optical coherence tomography (SD-OCT), test before CXL, 7 and 30 days later. Multifocal electroretinography (mfERG) was recorded before and seven days after CXL. 2) In the second study, retrospective, 105 eyes of 94 keratoconus patients undergoing treatment with CXL were analyzed, divided into two groups by age: Group 1 (16 years or younger) and Group 2 (17 years or older). The BCVA, endothelial corneal cell density (ECC), central corneal thickness (CCT), keratometry (topography) before CXL and one, three, six and twelve months later were evaluated. Results: 1) The first study showed a mean BCVA (SD) of 0.47 (± 0.12) pre-CXL, 0.55 (± 0.15) 7 days after CXL and 0.46 (± 0.10) 30 days after CXL. The mean near-corrected visual acuity (Jaeger) (SD) was 2.42 (± 0.60) pre-CXL, 3.4 (± 0.63) 7 days after CXL and 2.58 (± 0, 61) 30 days post-CXL. Mean central macular thickness (SD) on SD-OCT (?m) was 253.62 (± 20.9) pre-CXL, 260.5 (± 18.7) 7 days after CXL and 256.44 (± 21) 30 days post-CXL. In 12 eyes, mfERG showed a statistically significant increase (p = 0.0353) in ring 4 P1 latency (ms) between pre-CXL (39.45 ± 2.05) and 7 days after CXL (41.04 ± 1.28). Regression analysis showed that the increased P1 latency was correlated with increased central macular thickness on SD-OCT (p = 0.027). In addition, 9 patients had a statistically significant decrease in P1 amplitudes of rings 1, 2, 3, 4, and 5 between pre-CXL and 7 days after CXL. 2) The second study showed that in group 1 the mean BCVA (SD) was 0.45 (± 0.25) pre-CXL and 0.56 (± 0.29) one year after CXL and the mean keratometric parameters ( SD) Kmax, Ksteep and Kflat were, respectively, 58.47 (± 7.16), 52.93 (± 5.42) and 47.22 (± 4.19) pre-CXL, and 58.21 (± 7.68), 52.25 (± 5.49) and 46.56 (± 4.65) one year after CXL. In group 2, the mean BCVA (SD) was 0.50 (± 0.30) pre-CXL and 0.56 (± 0.32) the following year post-CXL and the mean keratometric parameters (SD) Kmax, Ksteep and Kflat were, respectively, 57.64 (± 7.10), 54.02 (± 6.22) and 48.60 (± 4.06) pre-CXL and 56.46 (± 8.01), 52.46 (± 5.79) and 47.85 (± 4.86) one year after CXL. Conclusions: 1) The first study showed that most patients exhibited minor changes in mfERG parameters, despite no change in BCVA, near visual acuity, retinal macular area anatomy and vascularization on SD-OCT and AF images, being these early changes categorized as mild subclinical effect of the CXL procedure. 2) The second study did not show statistical differences between groups and thus, the findings support the earlier indication of CXL treatment in pediatric patients for early disease stabilization and better prognosis in BCVA and keratometric parametersDoutoradoOftalmologiaDoutor em Ciências2015/23237-1001FAPESPCAPE

Repeated penetrating corneal transplantation in patients with a previous tectonic transplant

ABSTRACT Objective: To analyze, in a university hospital of reference, the rate of a new penetrating corneal transplantation in patients that had previously undergone a tectonic keratoplasty and analyze the results after one year of surgery. Methods: Retrospective review of patients undergoing penetrating corneal transplantation, from november of 2010 to november of 2014. Comparative analysis of best corrected visual acuity (BCVA), intraocular pressure and corneal transparency before surgery and after one year, in the group of patients in which it was performed a re-graft after a failed tectonic transplantation. Results: A total of 318 patients underwent penetrating corneal transplantation during the study period. Of the 199 patients who underwent tectonic transplantation, 36 were subjected to re-graft and re-grafts were performed more than once in 2 eyes, with total of 38 transplants (19,09%). The results showed improvement of BCVA in 20 (52.63%), worsening in 8 (21.05%) and unchanged in 10 (26.31%); improvement of intraocular pressure in 3 (7.89%), deterioration in 3 (7.89%) and unchanged in 32 (84.21%); improvement of corneal transparency 25 (65.78%), worsening 4 (10.52%) and 9 unchanged (23.68%) patients. Conclusion: This study demonstrated a considerable number of repeated penetrating keratoplasty in patients with a history of failed tectonic corneal transplantation. In spite of bad prognosis in cases where there is high-risk corneal recipients and history of a failed tectonic transplant, there was improvement of the corneal transparency and best corrected visual acuity even after a year of surgery