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Indikationsstellung zum Crosslinking und klinische Ergebnisse neuer kornealer Crosslinking-Techniken

Treatment indications for corneal crosslinking and clinical results of new corneal crosslinking techniques

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Zusammenfassung

Hintergrund

Beim Keratokonus wird die Quervernetzung der Hornhaut (korneales Crosslinking [CXL]) zur Verfestigung und Stabilisierung der Kornea eingesetzt, um einer weiteren Progression mit einhergehender Visusverschlechterung und ggf. notwendiger Keratoplastik vorzubeugen. Die korrekte Indikationsstellung ist in diesem Zusammenhang unabdingbar. Seit Einführung des ursprünglichen Dresdner Protokolls wurden weitere Crosslinking-Protokolle zur Optimierung des Behandlungserfolges vorgestellt.

Ziel der Arbeit

Es werden relevante Parameter zur Indikationsstellung und klinische Ergebnisse der neuen CXL-Protokolle erläutert.

Methoden

Derzeit gültige Indikationskriterien für ein CXL bei Keratokonus, PubMed-Recherche relevanter Arbeiten sowie eigene Erfahrungen mit verschiedenen CXL-Protokollen werden vorgestellt.

Ergebnisse

Die Reproduzierbarkeit von topographischen Parametern ist abhängig vom Stadium des Keratokonus. Das beschleunigte CXL wie auch das transepitheliale CXL mit hyperoxischer Umgebung zeigen eine vergleichbare Effizienz bei kürzerer Operationsdauer und möglicherweise niedrigerer Komplikationsrate. Das maßgeschneiderte CXL mit individualisiertem Bestrahlungsprofil liefert verbesserte Ergebnisse mit schnellerer Epithelheilung. Niedrigere UV-Energiedosen ermöglichen die Durchführung einer CXL-Behandlung bei minimaler stromaler Pachymetrie von weniger als 400 µm vor der UV-Bestrahlung. Die Kombination aus CXL mit PRK (photorefraktive Keratektomie) ermöglicht Visusverbesserungen, steigert jedoch auch das Risiko von Visusverlust.

Schlussfolgerung

Aktuelle Indikationsregeln zum CXL vernachlässigen die reduzierte Wiederholbarkeit von topo- und tomographischen Messungen bei Keratokonus. Die neuen, hier vorgestellten CXL-Techniken stellen eine Alternative mit ähnlicher und/oder besserer Wirksamkeit im Vergleich zum Standard-CXL dar. Die Kombination von CXL mit PRK bietet bei Patienten mit Kontaktlinsenintoleranz eine Möglichkeit zur Visusrehabilitation.

Abstract

Background

Corneal crosslinking (CXL) is used in keratoconus to strengthen and stabilize the cornea and to prevent further progression with subsequent visual loss and the possible need for keratoplasty. Correct treatment indications is crucial in this context. Since the introduction of the initial Dresden protocol, other modified CXL protocols have been proposed to optimize treatment success.

Objective

The relevant parameters for treatment indications are explained and the clinical results of new CXL protocols are presented.

Methods

The currently valid criteria with respect to the indications for CXL in keratoconus, PubMed search for relevant publications and own experiences with different CXL protocols are presented.

Results

The reproducibility of topographic parameters depends on the stage of the keratoconus. Accelerated CXL as well as transepithelial CXL with a hyperoxic environment show comparable efficiency with shorter surgery time and possibly lower complication rates. Customized CXL with an individualized UV irradiation profile provides improved results with faster epithelial healing. Lower UV energy doses enable CXL to be conducted in eyes with minimal stromal pachymetry of less than 400 µm before irradiation. The combination of CXL with photorefractive keratectomy (PRK) provides visual acuity improvements but also increases the risk of visual loss.

Conclusion

Current indication rules for CXL neglect the reduced reproducability of topographic and tomographic measurements in keratoconus. The latest CXL protocols presented here provide a safe alternative with similar and/or better efficacy compared to standard CXL. The combination of CXL with PRK offers an option for visual rehabilitation in patients with contact lens intolerance.

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Authors and Affiliations

  1. Klinik für Augenheilkunde, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland

    Klara Borgardts,  Johannes Menzel-Severing,  Gerd Geerling FEBO &  Theo G. Seiler FEBO

  2. Institut für Refraktive und Ophthalmo-Chirurgie (IROC), Stockerstr. 37, 8002, Zürich, Schweiz

    Theo G. Seiler FEBO

  3. Klinik für Augenheilkunde, Universitätsspital Bern, Inselspital Bern, 3010, Bern, Schweiz

    Theo G. Seiler FEBO

Authors
  1. Klara Borgardts
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  2. Johannes Menzel-Severing
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  3. Gerd Geerling FEBO
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  4. Theo G. Seiler FEBO
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Corresponding author

Correspondence to Theo G. Seiler FEBO.

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Interessenkonflikt

T.G. Seiler ist wissenschaftlicher Berater für Avedro/Glaukos und erhält Forschungsunterstützung. K. Borgardts, J. Menzel-Severing und G. Geerling geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Borgardts, K., Menzel-Severing, J., Geerling, G. et al. Indikationsstellung zum Crosslinking und klinische Ergebnisse neuer kornealer Crosslinking-Techniken. Ophthalmologe 119, 350–357 (2022). https://doi.org/10.1007/s00347-022-01579-6

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  • DOI: https://doi.org/10.1007/s00347-022-01579-6

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