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CXL*Corneal collagen- cross-linking for veterinarians
* Collagen Cross-Linking
Dr Frank FAMOSE – [email protected] October 6th, 2016
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Collagen reticulation by cross-linkingA natural…
or industrial… … or medical process
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Collagen reticulation
Anti-infectious effects
Keratocytes apoptosis
The photochemical process
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The Dresden protocol
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A recent breakthrough…
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The CXL in human ophthalmology
Corneal ectasia:Progressive keratoconusPost-LASIK ectasiaPellucid marginal deg.
Infectious keratitis:PACK-CXL
Bullous keratopathy
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The CXL in veterinary ophthalmology
Infectious keratitis(dogs, cats, horses)
Bullous keratopathy(dogs)
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Keratomalacia« corneal melting »
MMP imbalance
Perforation
Antibiotics& anticollagenases
Tectonic surgery
CXL
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Results*
8 dogs 10 cats
*Accelerated cross-linking
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D1 D31
8/8 dogs – 10/10 cats 2/8 dogs – 3/10 cats
Corneal vascularization
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Corneal scar
D1 D31
8/8 dogs – 10/10 cats
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Discussion
Clinical and pain improvement Direct effects of UVA
Free oxygen radicals
Physical changes withinthe cornea
Biological corneal response
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Adverse effects ?
Infections
Herpesvirus reactivation
Endothelial alterations
In humans
No adverse effects attributableto the treatment
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Ulcerative keratitis in Horses(Dr Hellander-Edman)
9 cases Ulcerative keratitis(Dresden protocol)
8 good results (1-3 months)
1 enucleation (fungalkeratitis)
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Worse than dogs and cats ?
Corneal /epithelial thickness
Depth of infection
Low power UVA
RF administration?
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Protocol modifications
ConventionalProtocol
Modifications"Epi-On"
"Epi-Off"(epithelialremoval)
UV exposition3mW/cm² - 30 min.
(5,4J/cm²)
Riboflavininstillation
(30 minutes)
Low or highosmolarity RFNanostructures,adjuvants
Intrastromal injectionsIontophoresis
AcceleratedCXL9-30mW/cm²
(5,4J/cm²)
Epithelium RF distribution UVA irradiation
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Standard or accelerated ?
Standard3 mW/cm²30 minutes
« Flash »30 mW/cm²3 minutes
5,4 J/cm²
Total durationab. 1h20
Total durationab. 40 min
Same biologicaleffects ?
Same energylevel
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Iontophoresis
Use of a low intensity continuous electric current to enhance the penetration of a ionized substance through a biological tissue
2013Iontophoresisof RF forCXL(keratoconus)
From 1990
SteroidsAntibioticsAntifungal
AntimetabolitesOligonucleotides
DiscoveryWirz 1908
No veterinaryclinical use
(Bikbova et al.Mastropasqua et al.Touboul et al.)
No data forkeratitis
treatment
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IontophoresisSame therapeuticeffects (keratitis)
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Bullous keratopathy
Endothelial alterations
Corneal edema
Bullae and epithelial ulcers
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« Epi-off » Stromalcompaction UVA irradiation
Hyperosmotictopical drugs
RF +Dextran 20 %
9 mW/cm²10 minutes
Bullous keratopathy
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Results
Epithelial healing (<1 sem)
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ConclusionMain indication : infectious keratitis
2 main constraints- High fluence- Minimal corneal thickness
Secondary indication: Bullous keratopathy
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Merci
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