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Corneal Collagen Crosslinking with Riboflavin treats Keratoconus

Thursday, November 20th, 2008

Here is an article presented in Ophthalmology Times:

Collagen crosslinking shows promise for keratoconus sill more prospective clinical data needed to characterize risks and benefits

Publish date: Oct 15, 2008
By: Cheryl Guttman
Source: Ophthalmology Times

Key Points

  • Research to date involving stress-strain measurements has shown that the collagen crosslinking procedure causes mechanical stiffening of the cornea.
  • Dr. Seiler’s current treatment protocol for collagen crosslinking involves a partial corneal abrasion performed over a diameter of 9 mm.
  • According to Dr. Seiler collagen crosslinking using ultraviolet A light and the photosensitizer riboflavin has been effective in stopping the progression of keratoconus in almost all eyes, and it has induced regression in about half of treated eyes based on reductions in keratometry readings. However, more prospective clinical data is needed to characterize its risks and benefits and to establish a list of indications and contraindications for this procedure.

Results achieved with corneal collagen crosslinking for the treatment of keratoconus are very encouraging, although the technique still must be considered investigational due to a lack of sufficient data published in the peer-reviewed literature, said Theo Seiler, MD, PhD.

“In our experience, collagen crosslinking using ultraviolet A light and the photosensitizer riboflavin has been effective in stopping the progression of keratoconus in almost all eyes, and it has induced regression in about half of treated eyes based on reductions in keratometry readings,” said Dr. Seiler, professor and chairman, Department of Ophthalmology, University of Zurich, and medical director, Institute for Refractive and Ophthalmic Surgery, Zurich, Switzerland. “However, we clearly need more prospective clinical data to characterize its risks and benefits and to establish a list of indications and contraindications for this procedure.”

Research to date involving stress-strain measurements has shown that the collagen crosslinking procedure causes mechanical stiffening of the cornea. Corneal rigidity, as assessed by Young’s modulus, increased by more than 4-fold after the procedure, Dr. Seiler said.

In addition, experiments performed with porcine corneal buttons show the treatment results in increased resistance of the extracellular matrix to enzymatic digestion compared with native corneal collagen. “The underlying mechanism for this latter effect of the crosslinking procedure is unknown, but it may play a role in the posttreatment reconstruction of the cornea,” he said.

He also said his current treatment protocol for collagen crosslinking involves a partial corneal abrasion performed over a diameter of 9 mm. Then a solution of 0.1% riboflavin in 20% dextran is dropped on the cornea approximately every 3 minutes for 30 minutes. The treated cornea is irradiated for 30 minutes with a 365-nm ultraviolet light source at a distance of 5 cm using an intensity of 3 mW/cm2.

“An alternative technique proposes using topical tetracaine to digest the epithelium and enable diffusion of the riboflavin into the stroma,” Dr. Seiler said. “However, using confocal microscopy, we found there is keratocyte damage to a depth of about 300 to 350 m using our crosslinking technique with corneal abrasion, whereas with the use of tetracaine, normal reflections from keratocyte nuclei can already be seen below the anterior 20 m of stroma. Therefore, it appears there is significantly less free radical formation and crosslinking of collagen fibers using the latter technique.”

He also noted that both the mechanical and biochemical effects of the procedure are very sensitive to the treatment parameters with respect to the concentration of the riboflavin solution used and the duration of application. Therefore, he encouraged that the efficacy of any modified protocol be investigated carefully prior to adoption in clinical use.

To date, Dr. Seiler and colleagues at the Technical University of Dresden, Dresden, Germany, have treated about 700 eyes with collagen crosslinking. Follow-up extending to 4 years shows the benefits are durable. An analysis including 21 patients with bilateral keratoconus who underwent crosslinking in only one eye showed the keratoconus index was increased in the untreated eyes after 1 year and significantly was higher than in the fellow crosslinked eyes.

“Crosslinking was not performed randomly in these patients but rather was used to treat the worse eye,” Dr. Seiler said. “Comparisons in individual patients showed there was a significant difference in the keratoconus index between the treated and untreated eye after 1 year in nearly all patients, and the difference between eyes was highly statistically significant in some cases.”

The safety profile of corneal collagen crosslinking has been favorable as well with very few complications recorded. Epithelial healing was delayed in some eyes and resulted in a subepithelial scar. More recently, in some eyes in which the procedure was repeated, a small scar in the anterior segment occurred that persisted for up to 6 months.

Happy 4th of July

Thursday, July 3rd, 2008

Turner Eye Institute wishes everyone a happy 4th of July. We would like remind everyone to use protective eyewear where appropriate in using fireworks or other celebrations. Eye safety should be on everyone’s minds when handling pyrotechnics or using fire, such as with grills.

Successful Treatments for Keratoconus

Thursday, June 26th, 2008

The new Corneal Crosslinking treatment with Riboflavin has shown success since being introduced by Dr. Stephen Turner in Northern California. Recent studies are showing that Riboflavin treatment followed by UV light can improve the cornea with keratoconus.

Patients with keratoconus should consult with a corneal specialist ophthalmologist regarding their condition. The doctor might advise Corneal crosslinking treatment with riboflavin or might suggest intacs. Many surgeons have used both with good results.

Dr. Stephen Turner practices in the San Francisco Bay area and is a corneal specialist who treats patients with keratoconus. He has offices in San Francisco, San Leandro (in the East Bay near Oakland), Concord (near Walnut Creek), and San Jose. Patients interested in discussing their vision needs should contact Turner Eye Institute for an appointment.

PR Release regarding Corneal Crosslinking corneal treatment for keratoconus

Monday, March 24th, 2008

Collagen Crosslinking Using Riboflavin and UV Light Exposure for Keratoconus — First IRB Approved Study in India Started at Apollo Hospitals, Hyderabad

Collagen Crosslinking treatment is a new hope for keratoconus patients. This treatment helps arrest the progression of the disease, and the first IRB approved study in India has been initiated at Cornea Clinic, Hyderabad, by Dr Rajesh Fogla, senior corneal surgeon. Keratoconus patients can enquire for eligibility for this treatment.

Hyderabad, India, January 19, 2007 — Keratoconus is a corneal disease affecting 1 in 2000 individuals. The disease usually starts in young adults, and is characterized by progressive thinning and outward protrusion of the cornea. (Cornea is the clear structure in front of the human eye responsible for focusing of rays of light into the eye for a clear image.)

The cornea takes a conical shape, and produces astigmatism due to which the rays of light cannot be focused properly, resulting in deterioration of the quality of vision. In the early stage of keratoconus, vision can often be improved using cylindrical correction in the glasses. However, in later stages most patients require rigid gas permeable lenses for improvement in quality of vision. Intacs are plastic ring segments which can be inserted into the mid-peripheral cornea to produce flattening of the central cornea. This results in reduction of the severity of keratoconus, and improves both vision & contact lens fitting to a certain extent. However it does not affect the progression of keratoconus. It is estimated that almost 21% of keratoconus patients ultimately progress to an advanced stage of disease requiring corneal transplantation surgery to restore corneal architecture and improve eyesight.

Dr Rajesh Fogla, Senior Consultant, Corneal Surgeon at Apollo Hospitals, Hyderabad, India, has special interest in Keratoconus & its management. He has been providing specialized contact lens fitting for keratoconus patients, and also performs deep anterior lamellar keratoplasty (DALK) surgery. Compared to conventional full thickness corneal transplantation surgery, DALK surgery has several advantages. Unlike conventional corneal transplantation surgery wherein a central disc of full thickness cornea is entirely replaced with donor tissue, in lamellar keratoplasty the healthy inner layer of the patient’s cornea is retained and not sacrificed. (This layer called the endothelium is the most vital layer of the cornea responsible for maintaining the corneal clarity). Only the outer 80 -90% of the cornea is replaced with healthy donor tissue.

The other advantage of lamellar keratoplasty, is that as the inner layer is retained, the immune cells of the body do not recognize the outer donor tissue as being foreign. Hence there is no risk of endothelial rejection with lamellar keratoplasty, unlike full thickness graft wherein steroid therapy has to be continued for years to prevent graft rejection episodes. Dr Fogla has been performing deep anterior lamellar keratoplasty since 1998, and currently performs the same in all his patients with advanced keratoconus. He has been conducting instruction courses at various national and international meetings on the same subject.

Dr Fogla, has started performing collagen crosslinking treatment using the photo-sensitizer riboflavin (Vitamin B2) and ultraviolet light (365nm) exposure for keratoconus patients. In extensive experimental studies, researchers have demonstrated a significant increase in corneal rigidity / stiffness after collagen cross-linking using this riboflavin / UVA treatment. The 3 & 5 year results of Dresden clinical study in human eyes has shown arrest of progression of keratoconus in all treated eyes. (Wollensak G. Crosslinking treatment of progressive keratoconus: New Hope. Current Opinion in Ophthalmology 2006; 17: 356 – 360).

Keratoconus patients now have a new hope, a new treatment modality which can arrest the disease progression and thereby prevent the need for surgical intervention in future. Although the procedure does not provide a cure for keratoconus, it certainly can stop its progression and patients can continue using their glasses or contact lenses for improved eyesight. Hence attempt should be made to diagnose keratoconus early enough and stop its progression using collagen crosslinking. Corneal topography can detect keratoconus much before it can be picked up on a routine eye examination. Hence this test should therefore be performed in all cases with high astigmatism, i.e., cylindrical power to detect keratoconus at an early stage. Further ongoing studies will help establish collagen cross-linking treatment as the primary modality of treatment for keratoconus.

Same Experienced Keratoconus Surgeon, New Location in San Jose

Tuesday, November 27th, 2007

Although Dr. Turner has previously been performing Keratoconus Correction in San Jose, Turner Eye Institute has a new location in Campbell, California. Dr. Stephen Turner is well-known throughout California as one of the most experienced Keratoconus surgeons. He is also known for his innovation and excellent results with intacs and other methods of keratoconus correction. Dr. Turner introduced many of todays most successful eye surgery procedures to Northern California, Oakland, San Jose, San Francisco, and Walnut Creek. The advanced Crystalens procedure for improving near vision, the exciting Visian procedure for patients with moderate to high near-sightedness, and the precision of Wavefront LASIK, Intra-Lase, and TF LASIK were all introduced by Dr. Stephen Turner.

The new location in Campbell, CA contains the same advanced technology including the upgraded VISX laser with iris tracking software. San Jose patients can therefore expect the same high level of treatment in Campbell, CA that they had at each of the Turner Eye Institute locations, including San Jose, San Francisco, Walnut Creek, and Oakland. Dr. Turner will perform keratoconus procedures at each of the four locations in Northern California.

Turner Eye Institute performs cataract surgeries and other vision corrective procedures in San Leandro, CA (South of Oakland and north of Fremont). The surgical center provides a sterile environment to provide the highest level of safety for our patients.

Curing Keratoconus – Biomaterials

Friday, September 21st, 2007

Scientists are discovering new biomaterials for use in bones, tissues, and other locations throughout the human body. We are following recent advances in corneal technology with interest.

Currently, one of the best treatments for keratoconus is through the use of intacs to help strengthen and support the cornea. While this is not a cure for keratoconus it has helped many patients with keratoconus to see more clearly and perhaps avoid the worst of this often debiltating condition.

It is likely that future technologies will follow a similar method to intacs in providing a support structure for the cornea that can help withstand the weakening effects of this collagen disorder. It can be expected that newer biomaterials will be developed that are smaller and stronger. Future advances in nanotechnology might build strong support structures within the cornea that can help delay or counteract the effects of keratoconus.

Currently, patients with keratoconus will often be advised that intacs can provide a level of relief and perhaps slow the effects of keratoconus. Some studies have shown that contact lenses might hasten the onset of keratoconus so many surgeons are suggesting that keratoconus patients using contact lenses should undergo intacs treatment before vision is substantially affected.

San Jose Keratoconus Treatment Center is moving locations

Tuesday, August 28th, 2007

Beginning October 1st, 2007, Turner Eye Institute and Horizon Vision Centers will relocate the Keratoconus Treatment Center branch in San Jose. The new San Jose Keratoconus Treatment Center will be located at 50 E. Hamilton, Suite 100, Campbell, California. The telephone number is 408-374-2020.

The new Horizon and Turner Eye Institute Keratoconus Treatment San Jose branch is located in a small mall complex inside the two-story white spanish style building that fronts Hamilton Ave.


From Santa Cruz Area:

Head North on CA-17 (signs for San Jose) Take Exit 25 towards Hamilton Ave. Turner Left at creekside Way. Turner Left at E. Hamilton Ave. End at 50 E Hamilton Ave.

From San Francisco/Peninsula

Take I-280 South towards San Jose. Merge onto CA-17 South towards Santa Cruz. Take the Hamilton Exit – Exit 25. Keep right at the fork to go on E. Hamilton Ave. End at 50 E. Hamilton Ave.

From the East Bay

Take the I-880 South towards San Jose. I-880 South becomes CA-17 South. Take the Hamilton Ave exit – Exit 25. Keep Right at the fork to go on E. Hamilton. End at 50 E. Hamilton Ave.

Welcome everyone to our new location in San Jose. The San Jose Keratoconus Treatment center in Campbell will continue to provide the same advanced treatments and excellent service as all our Keratoconus Treatment locations throughout the San Francisco Bay Area, including Oakland, San Francisco, and Walnut Creek.

Emerging technology for keratoconus

Thursday, August 23rd, 2007

The billion dollar Hubble Telescope has been assisting astronomers for nearly two decades now, gathering information about our own Milky Way galaxy and the rest of our universe. The entire project has not been without problems, however. Shortly after its launch in 1990, it was discovered that the mirror contained significant spherical aberration that affected the performance of the telescope. A system was developed called COSTAR, Corrective Optics Space Telescope Axial Replacement, which used two mirrors in the light path to correct for the aberration in the main mirror. With this adaptation, astronomers could achieve the accuracy and clarity that they were hoping for.

Adaptive optics relies upon a secondary set of mirrors that are in place to adjust for errors within the main optical system. While the Hubble is one example of this, our own eyes can benefit from the advances made through adaptive optics. The measured point spread function in our eyes is far from perfect. In people with keratoconus and other corneal diseases, these optical error are even more significant. It is possible, however, to reflect light through a mirror that adapts light to these optical errors and produce a clearer picture on the retina.

Deformable mirrors (DM’s) have become very important for this. Once a person’s point spread function is measured, a deformable mirror can adapt itself to these measurements. In modern LASIK surgery, surgeons are measuring patient’s point spread functions in order to customize the LASIK surgery to improve vision results. In keratoconus treatment, the progress of the disease can be tracked through the measurements of a patients “wavefront” or point spread function. In cataract surgery, newer lenses are using principles of optics to provide clearer vision through adaptive optics. Doctors can also use adaptive optics to view the back of a patient’s eye, the retina. In fact, adaptive optics now allows researchers to view individual photoreceptors in a live human eye.

As research continues, we expect to see greater improvement in the application of adaptive optics. Perhaps LASIK surgery will continue to improve or adjustments can be made to allow LASIK to correct not just myopia, hyperopia, and astigmatism but top also decrease the symptoms of presbyopia. Many companies are looking at multifocal or aspheric corrections with LASIK surgery. Researchers are using adaptive optics to measure the extent of the vision loss in keratoconus that is caused by the cornea and how much is caused by loss of neural information. The field of adaptive optics appears to be able to provide many new and interesting discoveries. Keratoconus is one important disease that stands to benefit from the advances in research of adaptive optics.

Ellie C. San Jose

Monday, June 18th, 2007

I am surprised that the only rating on this place is a poor one-star. I had Lasik surgery done by Dr. Steve Turner 6 years ago and loved the result (But in his San Jose office). The staffs in his office are extremely professional and calmed my nervous mind during my 1st visit. And I decided to go ahead and schedule the surgery immediately. Dr. Steve Turner is also voted as 100 top doctors in the Bay area. He was recommended to me by my coworker who had his eyes done at least 10 years ago. After my surgery, many of my friends have their Lasik done by Dr. Turner and got excellent results. I can’t recommend more about Dr. Turner and I think if u are looking for a doctor for Lasik, he is THE one. I do agree that Dr. Turner is not the social type and he doesn’t talk much, but who cares? The result speaks for everything!

Could Embryonic Stem Cell Research Cure Keratoconus?

Monday, June 11th, 2007

News has been released that British scientists are planning to use embryonic stem cells to cure age related macular degeneration, a common form of blindness. They are hoping to have the first patients receive test treatments within five years. This could be a major improvement in the methods of treating this common form of eye blindness that is experienced by millions of individuals throughout the world.

The pioneering project uses cells derived from human embryonic stem cells to repair damaged retinas. Those who support the research believe the process will involve simple surgery that could one day become as routine as cataract operations. Scientists are suggesting that the technique might be capable of restoring vision in patients with age-related macular degeneration (ARMD), a leading cause of blindness among the elderly that afflicts millions of people worldwide and is the leading cause of blindness in the USA and Europe.

If stem cell research can be used to cure age-related macular degeneration, could it also cure keratoconus? In April 2005, doctors in the UK transplanted corneal stem cells from an organ donor to the cornea of a woman who was blinded in one eye when acid was thrown in her eye at a nightclub. The cornea, which is the transparent window of the eye, is a particularly suitable site for transplants. In fact, the first successful human transplant was carried out in 1905 on a cornea by Dr. Eduard Zirm. The cornea has the remarkable property that it does not contain any blood vessels, making it relatively easy to transplant. The majority of corneal transplants carried out today are due to a degenerative disease called keratoconus which causes vision impairment and has no known cure even after corneal transplant. It is hoped that stem cell research will one day provide a cure to such debilitating corneal disorders.

The first step would be to grow corneas from a living donor. The corneas could then be transplanted into the person’s eyes. The advantage to using a patient’s own tissue would be a reduction in the possibility of rejection and a decrease in medications required to suppress a patient’s immune system.

Later steps might involve injection of healthy corneal cells into a keratoconic cornea in order to increase the strength of the cornea tissue. Stem cells could help reinforce the cornea and prevent the loss of vision that accompanies the progression of keratoconus.

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