Confocal Microscopy of Cross-Linked cornea: in vivo qualitative analysis and healing process

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Gianmaria Valentino
8 anni fa
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1 Department Ophthalmology and Neurosurgery Siena University - Italy Confocal Microscopy of Cross-Linked cornea: in vivo qualitative analysis and healing process S. Baiocchi MD, PhD A. Caporossi MD II International CCL Meeting Zurich 8-9 December 2006

qualitative analysis and healing process S. Baiocchi MD, PhD A.

2 According to Wollensak, Seiler and Spoerl, We introduced CCL in Italy in the year 2004 at Siena University

3 C. Mazzotta et al. First in vivo confocal report after CCL

4 Treatment of progressive keratoconus by riboflavin-uva-induced cross-linking of corneal collagen: ultrastructural analysis by HRT II in vivo confocal microscopy in humans Cosimo Mazzotta MD, An Balestrazzi MD, Claudio Traversi, MD, Stefano Baiocchi MD, Tomaso Caporossi MD, C. Tommasi MD and Aldo Caporossi MD CORNEA accepted NOV 2006, IN PRESS C. Mazzotta et al. First in vivo confocal report after CCL

Balestrazzi MD, Claudio Traversi, MD, Stefano Baiocchi MD, Tomaso Caporossi MD, C.

5 Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS ( CE approved CBM X Linker CBM X Linker By Caporossi, Baiocchi, Mazzotta CSO Florence, Italy. CE approved

6 Better quality of epithelium in the post operative improve visual outcome after 3 m

7 Sub epithelial nerves regeneration start 1 month after CCL

8 Sub epithelial nerves regeneration become complete 6 months after CCL

9 Stromal Nerves Regeneration Pre op Anterior stromal nerves 1 month post: stromal nerves disappearance stromal nerves regeneration after 3 months

10 Depth µ: Anterior-mid corneal stroma after collagen cross-linking by HRT II in vivo real time confocal microscopy. Rarefaction of keratocytes and edema after the treatment with appeared trabecular network (A). Inside trabecular network are detectable elongated (masked necrotic keratocytes) nuclei and smaller nuclei (keratocyte apoptotic bodies) (A). Gradual keratocytes stromal repopulation at this depth after 3 months (B), almost completed at 6 month (C), with good corneal biomicroscopic clinical appearance (D).

Inside trabecular network are detectable elongated (masked necrotic keratocytes) nuclei and smaller nuclei (keratocyte apoptotic

11 Depth µ: Intermediate corneal stroma after riboflavin-uvainduced corneal collagen crosslinking. In vivo HRT II confocal microscopy, Keratocytes disappearance and stromal edema were evident, with small nuclei (keratocyte apoptosis bodies, arrows) in the fibrillar network (A). Initial signs of cell repopulation were observed at 3 months (B). Keratocytes repopulation was clearly evident and complete at 6 months (C) with good corneal clinical aspect (D).

(keratocyte apoptosis bodies, arrows) in the fibrillar network (A).

12 The depth of treatment in vivo is more frequent at 310 micron, from 270 to 350 microns. The vertical transition area (VTA) consisted in a merging from an oedematous zone poor in cells and with low reflectivity (A) to a deeper stromal zone regularly populated with keratocytes and slight oedema diffusion (B-D).

The vertical transition area (VTA) consisted in a merging from an oedematous

13 In vivo CCL depht confocal scan C. Mazzotta et al: In vivo safety evaluation by focusing real depth of treatment 1 month post CCL

14 In vivo HRT II confocal microscopy after corneal collagen cross-linking. Evaluation of lateral transition area (LTA). Laterally, beyond the central irradiated area, keratocytes had a normal appearance (A-B, green arrows,) with minimal spread of edema (A-B, yellow arrows). Typical keratoconus dark micro-striae were evident in both section (A-B, red arrows). Lateral transition (LTA) consist in a crossing lateral area regularly populated with keratocytes and slight edema diffusion with a central edematous zone poor in cells, with low reflectivity (B, blue arrows).

yellow arrows). Typical keratoconus dark micro-striae were evident in both section (A-B, red arrows).

15 Depth µ: The deep stroma beyond 350 µm (A) was not reached by cross-linking except for slight spread of stromal edema which did not extend more than µm beyond the vertical transition zone. Activated keratocytes (yellow arrows) are evident with slight edema (red arrows) at 1 (B), 3 (C) and 6 months (D).

more than 10-20 µm beyond the vertical transition zone.

16 In vivo real time HRT II confocal microscopy after collagen cross-linking. At 1 month corneal thickness is increased by edema (A). Endothelium had regular cell density and morphology at 1 (A) 3 (B), 6 (C) and 12 months (D).

17 Treatment of progressive keratoconus by riboflavin-uva-induced cross-linking of corneal collagen: healing detection by in vivo HRT II system confocal microscopy in humans Cosimo Mazzotta MD, An Balestrazzi MD, Stefano Baiocchi MD, Tomaso Caporossi MD and Aldo Caporossi MD; Clinic Exp Ophthalmol 2006, IN PRESS C. Mazzotta et al.: keratoconus banding pattern

Mazzotta MD, An Balestrazzi MD, Stefano Baiocchi MD, Tomaso Caporossi MD and Aldo

18 Keratoconic dark microstrie C. Mazzotta et al.: keratoconus banding pattern

19 Reticular pattern of dark striae Pre op Pre op Sub-clinical wound healing: haze is detectable by in vivo HRT II confocal microscopy in a case of advanced keratoconus with large dark micro-striae and deep stromal Vogt striae (A). Corneal edema at 1 month (B). Initial keratocytes repopulation after 3 months (C) Activated keratocytes nuclei (D, green arrows) with increased stromal reflectance (D, red arrows) and microscopically detectable haze after 6 months. C. Mazzotta et al.: keratoconus banding pattern as predictive haze risk factor

Initial keratocytes repopulation after 3 months (C) Activated keratocytes nuclei (D, green arrows) with increased stromal reflectance

20 Confocal Analysis Summary: Total analyzed: 40 cases Follow up > 6 m: 34 cases (m 18 months) N cases Confoc Microsc F up > 6m Confocal pre-op Dark microstrie Preop Reticular Pattern Dark microstrie Slit lamp Preop Vogt Striae Epithelial Regeneration After 5 days of Soft contact lens Subepithelial & anterior stromal nerves Regeneration Post op lacunar Edema resolution Post op Hyper Keratocytes reflect Repopulation extra cell matrix % 11 % 17 % 100 % 100 % Starting 1 month postop 94 % 2 cases Persistent edema > 6 m Post (6% 6%) 100 % 85 % Starting 3 m postop 100% Completed 6 months postop 100% Resolution After 1 month steroids 100% Indirect Completed CCL 6 months Evid? Postop Haze 5 (15% 15%) Early on 4 (11% 11%) 1-3 m Late on 1 (4% 4%) 12 m No changes in endothelial cells density and morphology after 18 months Treatment Depth: m 320 µ

reflect Repopulation extra cell matrix 34 34 4 6 34 34 32 34 29 100 % 11 % 17 % 100 % 100 % Starting 1 month postop 94 % 2 cases Persistent edema > 6 m Post (6% 6%) 100 % 85 % Starting 3 m postop

21 Age 17 Early haze development after 1 month Pre CCL: hyperactivated dense Keratocytes Haze 1 month post CCL Improved 3 month post CCL Haze 1 month post CCL After Topic preservative free steroid treatment: Desametazone sulphate for 2 months

22 1 m Clinical improvement 6 m 3 m Improved 6 month after CCL: BSCVA 10/10 after 3 months of topic NSAID: diclofenac

23 Early Onset Haze after 3 months 50 µm 80 µm 3 months after CCl: BSCVA 10/10 reduced contrast sensitivity Improved after steroids

24 Persistent edema after 6 months 6 months after CCl: BSCVA 10/10 reduced contrast sensitivity Steroids

25 Hypereflectivity of extracellular matrix with late onset haze after 12 months Pre op 1 months post op Exm 1 months post steroids Haze One year post op Exm 3 months post op Steroids

26 Clinical improvement Improved after 1 months of Steroids

27 haze and related factors Haze Age and pre op keratocytes analysis Pre op Vogt Strie at slit lamp examination Pre op Reticular Pattern Dark Microstrie at confocal microscopy 5 15 % < 22 years 1 case 20 % pre op increased number of activated keratocytes 3 60 % 3 60 % > 22 years 4 cases 80 % 100 % steroids resolution

28 Confocal summary after CCL During healing process haze is a possible complication with prevalent early onset; late onset is also possible Pre op Vogt strie at slit lamp examination or reticular pattern dark microstriae at confocal microscopy can be considered predictive risk factors for post operative haze development (relative exclusion criteria) Presence of pre operative hyperactivated keratocytes nuclei in the anterior stroma seems to be related with predictive increased risk of early haze development, somentimes age-related Topical steroids are recommended in the post operative of patients with higher risk of haze development or with haze evidence Somentimes persistent edema (> 6 months) of epithelial origin is detectable only by confocal investigation in the anterior stroma Confocal microscopy enable us to assess such pre and post operative sub clinical and clinical conditions allowing optimization of postoperative therapy for a better quality of vision after CCL

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