Elsevier

Ophthalmology

Volume 121, Issue 7, July 2014, Pages 1377-1382
Ophthalmology

Original article
Collagen Cross-Linking with Photoactivated Riboflavin (PACK-CXL) for the Treatment of Advanced Infectious Keratitis with Corneal Melting

https://doi.org/10.1016/j.ophtha.2014.01.011Get rights and content

Purpose

To investigate the efficacy and safety of corneal collagen cross-linking (CXL) with photoactivated riboflavin (photoactivated chromophore for infectious keratitis [PACK]–CXL) in the management of infectious keratitis with corneal melting.

Design

Prospective clinical trial.

Participants

Forty eyes from 40 patients with advanced infectious keratitis and coexisting corneal melting.

Methods

Twenty-one patients (21 eyes) underwent PACK-CXL treatment in addition to antimicrobial therapy. The control group consisted of 19 patients (19 eyes) who received only antimicrobial therapy.

Main Outcome Measures

The slit-lamp characteristics of the corneal ulceration, corrected distance visual acuity, duration until healing, and complications were documented in each group. The Mann–Whitney U test was used for statistical analysis. P values less than 0.05 were considered statistically significant.

Results

The average time until healing was 39.76±18.22 days in the PACK-CXL group and 46.05±27.44 days in the control group (P = 0.68). After treatment and healing, corrected distance visual acuity was 1.64±0.62 in the PACK-CXL group and 1.67±0.48 in the control group (P = 0.68). The corneal ulceration's width and length was significantly bigger in the PACK-CXL group (P = 0.004 and P = 0.007). Three patients in the control group demonstrated corneal perforation; infection recurred in 1 of them. No serious complications occurred in the PACK-CXL group.

Conclusions

Corneal CXL with photoactivated riboflavin did not shorten the time to corneal healing; however, the complication rate was 21% in the control group, whereas there was no incidence of corneal perforation or recurrence of the infection in the PACK-CXL group. These results indicate that PACK-CXL may be an effective adjuvant therapy in the management of severe infectious keratitis associated with corneal melting.

Section snippets

Methods

This prospective clinical trial was conducted between January 2010 and April 2013 at the Cornea Clinic of the Research Institute of Ophthalmology, Cairo, Egypt, in collaboration with the Department of Ophthalmology, Beni-Suef University Hospitals, Beni-Suef, Egypt; the Rowad Correction Centre, Cairo, Egypt; the Department of Ophthalmology, University of Nottingham, Nottingham, United Kingdom; and the Department of Ophthalmology, University of Geneva, Geneva, Switzerland. The Research Institute

Results

The PACK-CXL group included 21 patients (8 men and 13 women) with a mean age of 37.3 years. The control group included 19 patients (10 men and 9 women) with a mean age of 49.8 years. The baseline corrected distance visual acuity at presentation was 2.16±0.35 logarithm of the minimum angle of resolution (logMAR) units in the PACK-CXL group and 2.01±0.44 logMAR in the control group (P = 0.11). The isolated causative micro-organisms for each group are shown in Table 1 for the PACK-CXL group and in

Discussion

Infectious keratitis is a severe ocular infection and one of the leading causes of monocular blindness worldwide.18 The incidence of microbial keratitis ranges from 6.3 to 710 cases per 100 000 population per year and is even more common in contact lens wearers.19 Various micro-organisms, including bacteria, viruses, fungi, and parasites, may cause infectious keratitis. This infection and inflammatory reaction may lead to ulceration, corneal melting, and perforation if not treated adequately.

Acknowledgments

The authors thank Joerg Sommerhalder, PhD, for his support for the statistical analysis and Masood Samani, MD, for his insightful comments on the Jarisch-Herxheimer reaction.

References (30)

  • F.J. Ollivier et al.

    Proteinases of the cornea and preocular tear film

    Vet Ophthalmol

    (2007)
  • M.E. Fini et al.

    Collagenolytic/gelatinolytic enzymes in corneal wound healing

    Acta Ophthalmol Suppl

    (1992)
  • M.E. Fini et al.

    Role of matrix metalloproteinases in failure to re-epithelialize after corneal injury

    Am J Pathol

    (1996)
  • P. Vinciguerra et al.

    Intra- and postoperative variation in ocular response analyzer parameters in keratoconic eyes after corneal cross-linking

    J Refract Surg

    (2010)
  • S.A. Martins et al.

    Antimicrobial efficacy of riboflavin/UVA combination (365 nm) in vitro for bacterial and fungal isolates: a potential new treatment for infectious keratitis

    Invest Ophthalmol Vis Sci

    (2008)
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    Financial Disclosure(s): The author(s) have made the following disclosure(s): Farhad Hafezi - Coinventor - PCT/CH 2012/000090 application (ultraviolet light source).

    Both Dr. Said and Dr. Elalfy contributed equally as first authors.

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