Accelerated-CXL Treatment for Infectious Keratitis
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Accelerated-CXL Treatment for Infectious Keratitis
- 1. ACCELERATED-CXL FOR THE TREATMENT OF INFECTIOUS KERATITIS Lessons from animal studies Dr Frank FAMOSE DVM – DESV ophtalmologie Toulouse - France Avedro’s 3rd International Congress on Advanced Corneal Cross-Linking Barcelona 2014 frankfamose@gmail.com
- 2. Surgical treatment Evolution of infectious keratitis in dogs & cats Medical treatment Success Failure Conjunctival grafts Enucleation Visual loss Antibiotics Anticollagenases… Observance
- 3. Unmet needs… Single treatment High rate of success Light post-op Tt Vision preservation
- 4. Background Standard Protocol 30min 3mW/cm²
- 5. Inclusion criteria Dogs and cats Corneal melting Poor response to medical treatment Minimal corneal thickness>300 μm
- 6. Protocol General anesthesia Corneal cleaning Riboflavine soaking Exposition UVA 365 nm Post-CXL treatment OCT Medetomidine Ketamine Isoflurane Debris removal Bact. sampling PCR (FHV1) RF 0,1% 20% dextran (VibexTM) 1 drop ev. 2 min 30 minutes 30 mW/cm² 3 min 5,4J/cm² TobrexTM BID 7 days Accelerated protocol (KXLTM – Avedro)
- 7. Results 8 Dogs* 10 Cats** No adverse reaction *Famose F. Veterinary ophthalmology 2013 ** Famose F. Veterinary ophtalmology 2013
- 8. Corneal infiltration 8/8 dogs – 10/10 cats 0/8 dogs – 0/10 cats D1 D8
- 9. Corneal vascularization 8/8 dogs – 10/10 cats 2/8 dogs – 3/10 cats D1 D31
- 10. Corneal vascularization 8/8 dogs – 10/10 cats 2/8 dogs – 3/10 cats D1 D31
- 11. Corneal scar 8/8 dogs – 10/10 cats D1 D31
- 12. Corneal scar 8/8 dogs – 10/10 cats D1 D31
- 13. Accelerated CXL Single treatment with high rate of success Vision preservation No specialized technical skills Shortening of procedure duration
- 14. Are antibiotics still necessary after CXL? CouldCXLbe a first intention treatment ?
- 15. Could we use higher fluences? Could we use Iontophoresis?
- 16. Thank you.
Notes de l'éditeur
- Good afternoon Ladies and Gentlement, thank you for your introduction. I’m very glad to present you the results obtained with accelerated cross-linking for the treatment of infectious keratitis in dogs and cats.
- What is the problem ? Infectious keratitis is a frequent condition in dogs and cats and is usually treated, in a first intention, by repeated instillations of antibiotics and anticollagenases such as N-Acetyl-Cystein and autologous serum. It requires frequent instillations which leads to a serious concern of observance and compliance for the owner. It leads to a success rate less than 40 %. Failures are treated by conjunctival grafts or flaps, either complete or pediculated or by enucleation. Of course, this leads, in all cases, to visual impairement.
- At this moment, what veterinary ophthalmologist are looking for is a solution which, in a perfect world, would be : A single treatment with a high rate of success Which preserves vision and requires a light post-operative treatment.
- According to the knowledge available from human and animal studies, using the conventional Dresde protocol, the aim of our studies was to evaluate the clinical outcomes of melting keratitis treated by accelerated cross-linking.
- Dogs and cats were enrolled in these studies presented with corneal melting with poor response to the previous medical treatment. For safety reasons due to the risk of endothelium lesions, animals with a minimal thickness lower than 3 hundred micrometers were excluded from the study.
- Under general anesthesia, cornea were cleaned and sampled for bacteriology and PCR before riboflavin delivery and UVA exposure at 30 mW/cm² for 3 minutes. After cross-linking the medical treatment was limited to tobramycin instillation twice a day. Animals were followed-up for 30 days after treatment
- The results of these studies showed a marked decrease of clinical and pain scores and epithelial healing within 15 days for all treated animals.
- Corneal infiltration was present in all animals on the first day and has disappeared for all of them 7 days after treatement
- Corneal vascularization was present in all cases at D1 and was light in some animals at the end of the follow-up period
- And moderate in other animals.
- All treated animals presented with a corneal scar at D31, such as this corneal fibrosis
- Or corneal melanosis in this one. All eyes had visual function at the end of the study.
- With these two small studies, accelerated cross-linking provided us with a single treatment with a high rate of success and vision preservation. Vision was preserved for all animals allthough refractive outcomes were not taken into account. It is important to note that the technique which was brand new for us required no specialized technical skills. In comparison to the conventional protocol, there was a shortening of the procedure duration. Since the treatment is conducted under general anesthesia, it is important to make is as quick as possible.
- As a conclusion, we can rise some questions. The post-operative antibiotic treatment was very light and we can wonder why should still use antibiotics after the procedure. In the studies in progress, there’s no post-operative treatment. Could cross-linking be a first intention treatment ? The answer is yes. The animal we have enrolled were intractable or desperate cases and I think we could get very good results in animals treated earlier in the evolution of their keratitis.
- In order to shorten this procedure, we could use higher fluences with shorter exposure time, as long as the devices are able to deliver it. Iontophoresis has also been studied, as described this morning, and allows us to shorten the duration of riboflavin from 30 to 5 minutes.
- Thank you for your attention. I’ll be very happy to answer to any question.