Post on 21-Aug-2015
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EVALUATION OF ACCELERATED-CXL* AFTER
IONTOPHORESISFOR THE TREATMENT OF MELTING KERATITIS
IN 6 CATS
* Collagen Cross-Linking
Dr Frank FAMOSE – Toulouse - France
Pierre ROY – Paris - FranceLondon 2014
Melting keratitis
MMP imbalance
High perforation risk
Treatment : antibiotics& anticollagenases
Tectonic Surgery
CXL
Collagen reticulation
Anti-infectious effects
Keratocyte apoptosis
Photochemicalprocess
CXL
CXL: 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
Iontophoresis
Application of a constant electric
current to enhance penetration of a ionized substance through a tissue 2013
Iontophoresisof 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
Aim of this study
To evaluate the clinical outcome of feline melting keratitis treated by accelerated CXL
after iontophoresis of riboflavin
Inclusion criteria
Cats
Corneal melting
Poor response to
medical treatment
Inclusion criteria
Epithelial loss
Cellular infiltration andstromal dissolution
Minimal Corneal thickness
> 300 µm (OCT)
Protocol
Generalanesthesia
Cornealcleaning
Riboflavineimpregnation
ExpositionUVA 365 nm
Post-CXLtreatment
OCT
MedetomidineKetamine
Debris removalBact. sampling
PCR (FHV1)
RF 0,1% (Ricrolin TM)Iontophoresis5 min 1mA/min
30 mW/cm²3 min
5,4J/cm²
TobrexTM BID7 days
Accelerated protocol(KXLTM – Avedro)
Iontophoresisdevice
Follow-up
Inclusion D1 D4 D8 D15 D31
Pain and clinical score
Ulceration and infiltration surfaces
Follow-up
0 : absent1 : light2 : moderate3 : severe
0 : absent1 : present
Clinical score(0-18)
Pain score (0-7)
Mucopurulent discharge
Corneal edema
Corneal vascularization
Conjunctivitis
Blepharitis
Uveitis
Prostration
Aggressive behavior
Blepharospasm
Enophtalmos
Photophobia
Ocular pruritus
Defense reaction
Results Mean evolution time 40 days
Ulcer depth 21-54%
2/6 Persian
1/6 positive bacterial culture
1/6 FHV1 positive6 cats
D1 D4 D8 D15 D310
2
4
6
8
10
12
Evolution ofAverage scores
Clinical score Pain score
D1 D4 D8 D15 D310
5
10
15
20
25
30
35
Evolution of Average surfaces (mm²)
Ulcer surface Infiltration surface
Cornealvascularization
Discussion : efficacy
Reduction of clinicaland pain score
Complete Epithelial healing
Resolution of corneal melting
Comparison to conventional impregnation of RF
Distribution of RF ?
Human and rabbit studies(fluorometry, histology, HPLC, OCT…)
Clear cornea Keratitis
Anterior stroma (150 µm) :Cinstillation= 2x Ciontophoresis
Less uniform diffusion
?
Adverse effects of iontophoresis
Electric burns
Not observed in humanpatients with I < 4mA/min
High intensity current
Pain
High or low pH solutionsChemical burns
Duration of treatment ?
Instillation30 min
Iontophoresis5 min
Irradiation30 min
Accelerated CXL3-10 min
Conventional protocolDuration > 1 hour
Ionto + acc. CXL protocolDuration < 20 min.
Conclusion: IONTOPHORESIS
Results similar to conventional instillation
Resolution of corneal melting
No adverse reaction or pain
Reduction of procedure duration
Perspectives: IONTOPHORESIS
Enhanced penetration of RF…
…or other therapeutic agents
?
Thank you.