La reticulación del colágeno corneal en Cirugía Refractiva

<div dir="ltr" style="text-align: left;" trbidi="on"> <br /> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto; text-align: center;"> <img border="0" src="https://sites.google.com/a/infolentes.com/info-lentes/_/rsrc/1345570866983/inter/lareticulaciondelcolagenocornealencirugiarefractiva/CSS.jpg" /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto; text-align: center;"> <br /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto;"> <br /></div> <div style="font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <div style="line-height: 14.4pt; margin-bottom: 4.4pt;"> <span style="background-color: white; font-family: 'Trebuchet MS', sans-serif; font-size: 12.5pt;">Reticulación del colágeno corneal en cirugía refractiva</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="margin: 0cm 0cm 0.0001pt 5pt;"> <b><span style="background-color: white; font-family: Arial, sans-serif; font-size: 9.5pt;">Información Autor</span></b></div> <div style="margin: 5.65pt 0cm;"> <span style="background-color: white; font-family: Arial, sans-serif; font-size: 8.5pt;">Departamento de Oftalmología, Albert Einstein College of Medicine, del Centro Médico Montefiore, Bronx, Nueva York, EE.UU.</span></div> <div style="margin: 5.65pt 0cm;"> <span style="background-color: white; font-family: Arial, sans-serif; font-size: 8.5pt;">Correspondencia a Prabjot Channa, MD, Departamento de Oftalmología, Montefiore Medical Center, 111 E 210a Street, Edificio Centenario, 3 º piso, Bronx, NY 10467, EE.UU.. Tel: +1 914 413 3681, e-mail: pchanna@montefiore.org</span></div> <div style="margin: 5.65pt 0cm;"> <br /></div> <div style="margin: 0cm 0cm 0.0001pt 5pt;"> <b><span style="background-color: white; font-family: Arial, sans-serif; font-size: 9.5pt;">Abstracto</span></b></div> <div style="margin: 5.65pt 0cm;"> <span style="background-color: white; font-family: Arial, sans-serif; font-size: 8.5pt;">Objetivo de la revisión: Describir el desarrollo y usos de reticulación del colágeno corneal (CXL) en asociación con los procedimientos querato así como en el tratamiento del queratocono progresivo y progresista postlaser in situ queratomileusis (post-LASIK) queratectasia.</span></div> <div style="margin: 5.65pt 0cm;"> <span style="background-color: white; font-family: Arial, sans-serif; font-size: 8.5pt;">Hallazgos recientes: CXL ha demostrado ser eficaz para retrasar, detener o revertir la ectasia progresiva tanto en el queratocono y progresiva post-LASIK queratectasia por medio de rigidización corneal. Por lo tanto, es la única opción de tratamiento disponibles en la actualidad que se refiere a la progresión subyacente de condiciones ectactic. Combinando CXL con querato procedimientos, tales como la implantación corneal intraestromal segmento de anillo y queratectomía fotorrefractiva, es una prometedora alternativa terapéutica a la queratoplastia penetrante o queratoplastia lamelar que en muchos casos puede mejorar la agudeza visual, estabilizar ectasia, y retrasar o incluso prevenir la necesidad de más invasivo procedimientos.</span></div> <div style="margin: 5.65pt 0cm;"> <span style="background-color: white; font-family: Arial, sans-serif; font-size: 8.5pt;">Resumen: El efecto de la rigidez del CXL ha convertido en una alternativa prometedora en el arsenal del oftalmólogo para el tratamiento del queratocono progresivo y progresista ectasia post-LASIK. Futuros estudios son necesarios para determinar la estabilidad a largo plazo de CXL, así como para hacer frente a las posibles complicaciones.</span></div> <div style="margin: 15.65pt 0cm 9.4pt;"> <b><span style="background-color: white; font-family: Arial, sans-serif; font-size: 9.5pt;">INTRODUCCIÓN</span></b></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Reticulación del colágeno corneal (CXL), inicialmente descrita por Sporl </span><i><span style="font-family: Arial, sans-serif; font-size: 8pt;">et al. </span></i>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P52" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[1]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> en 1997 es una técnica cada vez más utilizado que utiliza riboflavina y luz ultravioleta A (UVA) para aumentar la estabilidad biomecánica y la resistencia de la córnea mediante la inducción de la reticulación entre el colágeno fibras.</span></div> <div style="background-color: white; margin: 15.65pt 0cm 9.4pt;"> <span style="font-family: Arial, sans-serif; font-size: 9.5pt;">.</span><span style="font-family: Arial, sans-serif; font-size: 8pt;">El queratocono progresivo y postlaser in situ queratomileusis (post-LASIK) queratectasia (PPLK) se caracterizan por corneal progresivo aumento de la pendiente y adelgazamiento estromal </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P53" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">[2]</span></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> . Las opciones terapéuticas para la rehabilitación visual, tales como lentes de contacto permeables al gas rígidas o segmentos de anillo intraestromales corneales (ICRS), aunque es eficaz en la mejora de la agudeza visual, no tratan la causa subyacente de progresivos cambios en la córnea. Cuando se produce la progresión o contactar desarrolla intolerancia a las lentes, la queratoplastia penetrante o queratoplastia laminar han sido tradicionalmente el siguiente paso. CXL se ha mostrado prometedora para frenar, detener o incluso revertir la progresión tanto en el queratocono y PPLK, retrasando o evitando la necesidad de procedimientos más invasivos.</span></div> <div style="background-color: white; margin: 15.65pt 0cm 9.4pt;"> <b><span style="font-family: Arial, sans-serif; font-size: 9.5pt;">CORNEAL COLLAGEN CROSSLINKING PROCEDURE AND BIOMECHANICS</span></b></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">CXL involves the use of riboflavin and UVA light to induce photooxidative collagen crosslinking. Blue light, although not used clinically, has also been shown to be effective in producing significant corneal stiffening in laboratory research </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P54" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[3]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Although there are slight variations, the fundamental technique is as follows: under topical anesthesia, riboflavin 0.1% drops are applied to the central 7</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">mm of the cornea either with an intact epithelium or after creating a similar sized epithelial defect. Riboflavin is allowed to permeate through the cornea and is periodically reapplied during the procedure to ensure adequate corneal absorption. Riboflavin acts as a photosensitizer for subsequent UVA irradiation with two UV diodes at the desired irradiance of 4</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">mW/cm</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;">2</span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> (5.4</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">J/cm</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;">2</span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">) at a 1</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">cm distance for 30</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">min </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P55" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[4]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. It is also thought to block UVA transmission beyond the corneal stroma, thus protecting the corneal endothelium and deeper intraocular structures such as the lens and retina from unwanted side effects </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P56" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[5▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Furthermore, the UVA intensity used during crosslinking is far below the damage threshold for the corneal endothelium, iris, lens, and retina</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P58" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[6]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Additional covalent binding between collagen molecules stabilizes the collagen scaffold and has been shown to increase corneal stiffness and enhance resistance against proteolytic enzymes </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P54" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[3,7–10]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. The stiffening effect of CXL is heterogeneously distributed with more pronounced effect in the anterior 200–300</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">μm of the cornea </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P60" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[8,11,12]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. The increased stiffness and rigidity of the cornea stabilizes the corneal ectasia </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P56" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[5▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Possible reported complications of CXL, although quite rare, include sterile infiltrates, stromal scars, transient stromal haze, corneal edema, diffuse lamellar keratitis, transient endothelial damage, and herpetic keratitis with iritis </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P56" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[5▪,13,14,15▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. There has been increased interest recently in decreasing total stromal irradiation time by increasing the fluence of applied UVA light, thus possibly reducing stromal keratocyte loss. Kanellopoulos has shown similar results and adverse effects with use of higher fluence but shorter irradiation time compared to a standard CXL protocol. He has further theorized that the higher fluence protocol may have an additional ‘disinfective’ effect, reducing the risk of postoperative infectious keratitis </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P69" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[16▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; margin: 15.65pt 0cm 9.4pt;"> <b><span style="font-family: Arial, sans-serif; font-size: 9.5pt;">INTRODUCTION</span></b></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Corneal collagen crosslinking (CXL), initially described by Spörl</span><span style="font-family: Arial, sans-serif; font-size: 8pt;"> <i>et al.</i></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P52" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[1]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">in 1997 is an increasingly used technique that uses riboflavin and ultraviolet-A (UVA) light to increase the biomechanical stability and resistance of the cornea by inducing crosslinking between collagen fibers.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Keratoconus and progressive postlaser in-situ keratomileusis (post-LASIK) keratectasia (PPLK) are characterized by progressive corneal steepening and stromal thinning</span><span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P53" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[2]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Therapeutic options for visual rehabilitation, such as rigid gas permeable contact lenses or intrastromal corneal ring segments (ICRS), although effective in improving visual acuity, do not address the underlying cause of progressive corneal changes. When progression occurs or contact lens intolerance develops, penetrating keratoplasty or lamellar keratoplasty have traditionally been the next step. CXL has shown promise in slowing, halting, or even reversing progression in both keratoconus and PPLK, thus delaying or preventing the need for more invasive procedures.</span></div> <div style="background-color: white;"> <br /></div> <h4 style="background-color: white; margin: 15.65pt 0cm 9.4pt;"> <a href="http://www.blogger.com/blogger.g?blogID=3847540156974127949" name="TOC-CORNEAL-COLLAGEN-CROSSLINKING-PROCEDURE-AND-BIOMECHANICS" style="color: #0066cc; outline: none;"></a><span style="font-family: Arial, sans-serif; font-size: 9.5pt;">CORNEAL COLLAGEN CROSSLINKING PROCEDURE AND BIOMECHANICS</span></h4> <div style="background-color: white; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">CXL involves the use of riboflavin and UVA light to induce photooxidative collagen crosslinking. Blue light, although not used clinically, has also been shown to be effective in producing significant corneal stiffening in laboratory research </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P54" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[3]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Although there are slight variations, the fundamental technique is as follows: under topical anesthesia, riboflavin 0.1% drops are applied to the central 7</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">mm of the cornea either with an intact epithelium or after creating a similar sized epithelial defect. Riboflavin is allowed to permeate through the cornea and is periodically reapplied during the procedure to ensure adequate corneal absorption. Riboflavin acts as a photosensitizer for subsequent UVA irradiation with two UV diodes at the desired irradiance of 4</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">mW/cm</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;">2</span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">(5.4</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">J/cm</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;">2</span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">) at a 1</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">cm distance for 30</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">min </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P55" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[4]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. It is also thought to block UVA transmission beyond the corneal stroma, thus protecting the corneal endothelium and deeper intraocular structures such as the lens and retina from unwanted side effects </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P56" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[5▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Furthermore, the UVA intensity used during crosslinking is far below the damage threshold for the corneal endothelium, iris, lens, and retina</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P58" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[6]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Additional covalent binding between collagen molecules stabilizes the collagen scaffold and has been shown to increase corneal stiffness and enhance resistance against proteolytic enzymes </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P54" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[3,7–10]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. The stiffening effect of CXL is heterogeneously distributed with more pronounced effect in the anterior 200–300</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">μm of the cornea </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P60" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[8,11,12]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. The increased stiffness and rigidity of the cornea stabilizes the corneal ectasia </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P56" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[5▪]</span></b></a></span>}</div> <div style="background-color: white;"> <br /></div> <div style="background-color: white;"> <span style="font-family: Arial, sans-serif; font-size: 8pt; line-height: 12px;">Possible reported complications of CXL, although quite rare, include sterile infiltrates, stromal scars, transient stromal haze, corneal edema, diffuse lamellar keratitis, transient endothelial damage, and herpetic keratitis with iritis </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt; line-height: 8px;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P56" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[5▪,13,14,15▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt; line-height: 12px;">. There has been increased interest recently in decreasing total stromal irradiation time by increasing the fluence of applied UVA light, thus possibly reducing stromal keratocyte loss. Kanellopoulos has shown similar results and adverse effects with use of higher fluence but shorter irradiation time compared to a standard CXL protocol. He has further theorized that the higher fluence protocol may have an additional ‘disinfective’ effect, reducing the risk of postoperative infectious keratitis </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt; line-height: 8px;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P69" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[16▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt; line-height: 12px;">.</span></div> <div style="background-color: white;"> <br /></div> <h4 style="background-color: white; margin: 18.75pt 0cm 11.25pt;"> <a href="http://www.blogger.com/blogger.g?blogID=3847540156974127949" name="TOC-USE-IN-KERATOCONUS" style="color: #0066cc; outline: none;"></a><span style="font-family: Arial, sans-serif; font-size: 11.5pt;">USE IN KERATOCONUS</span></h4> <div style="background-color: white; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Keratoconus is a progressive and bilateral noninflammatory corneal degeneration characterized by cone-like ectasia. Mild-to-severe visual loss results from induction of irregular astigmatism by progressive corneal steepening, apical thinning, and corneal scarring </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P71" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[17]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Its estimated incidence in the general population is one in 2000 </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P72" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[18]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. The age of onset is usually at puberty, with 20% of cases eventually progressing to the degree to require penetrating keratoplasty </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P73" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[19]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Patients with keratoconus have significantly impaired quality of life that is comparable with that of patients with advanced age-related macular degeneration despite better visual acuity and younger age </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P74" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[20,21]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Although the exact pathophysiology of keratoconus is not clear, there is increasing evidence that altered enzymatic activity, such as increased levels of pepsin digestion and catalase activity, plays a significant role in degrading the stiffness of the cornea by decreasing cross links </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P76" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[22–25]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <br /></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Therapeutic options in keratoconus initially involve spectacles or rigid gas permeable contact lenses. When contact lens intolerance, severe irregular astigmatism or stromal opacities develop in advanced cases, penetrating keratoplasty may be required. CXL has emerged as an important tool in these cases to slow, halt or sometimes reverse progression of keratoconus </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P55" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[4,5▪,8,26–28]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. First introduced for use in keratoconus by Wollensak <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P55" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[4]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">in 2003, numerous studies have supported its efficacy in significantly reducing keratometric values and mildly improving visual acuity in patients with progressive keratoconus</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P55" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[4,5▪,8,26–28]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Wollensak <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P55" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[4]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">reported a mean decrease of 2.01</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D in the maximum keratometric value and of 1.14</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D in refractive error. Vinciguerra <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P80" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[26]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">reported a 6.16</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D decrease in maximum keratometric value, whereas Caporossi <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P81" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[27]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">showed improvement or stabilization of keratoconus in 92% of the cases. Wittig-Silva <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P82" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[28]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">demonstrated a mean decrease of 1.45</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D in the maximum keratometric value in a treated group compared to a mean increase of 1.28</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D in maximum keratometric value in a control group. Asri <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P56" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[5▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">explored the long-term outcomes, including complications, of CXL in eyes with progressive keratoconus. They reported a significant improvement or stabilization in best corrected visual acuity in 87.6% of eyes with only a 3.5% complication rate leading to vision loss.</span></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Although CXL has been shown to be efficacious in slowing or halting progression of keratoconus, the visual recovery, although statistically significant, is quite modest. As a result, there has been increasing amounts of attention paid to combining CXL with keratorefractive procedures to further improve vision. These surgical approaches include radial keratectomy, photorefractive keratectomy (PRK), asymmetric keratotomy, LASIK, lamellar keratoplasty and epikeratoplasty. Unfortunately, many of these alternatives are fraught with poor refractive predictability and poor stability </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P83" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[29–33]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <br /></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Recently, use of ICRS for treatment of keratoconus has become more widespread </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P88" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[34–38]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Initially employed to correct low myopia </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P93" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[39–41]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">, ICRS involves placement of two polymethyl methacrylate segments of various thickness in the corneal stroma to flatten the central cornea by an ‘arc-shortening’ effect </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P88" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[34,36]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Colin <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P88" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[34]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">demonstrated a reduction in mean keratometric of 4.85</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D and in spherical equivalent of 2.12</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D by placement of ICRS in 10 patients with keratoconus. In a cohort of 74 eyes, Boxer Wachler <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P91" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[37]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">demonstrated an improvement in visual acuity of two lines or more in 45% of eyes.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <br /></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Although ICRS has been shown to be effective in decreasing corneal abnormality to improve visual acuity, it does not prevent progression of keratoconus. Alió <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P92" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[38]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">evaluated the stability of ICRS in 13 keratoconic eyes and showed that between 6 and 36 months, there was an increase in keratometric of 1.67</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D. CXL can be a useful adjunct in ICRS to both provide stability and deliver an additive effect on improving visual acuity and topographic characteristics </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P96" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[42–44,45▪,46▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Chan <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P96" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[42]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">found improved outcomes when ICRS was combined with CXL over use of ICRS alone. There was greater flattening in the steep keratometric values and average keratometric values, as well as greater reduction in manifest cylinder. Ertan <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P97" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[43]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">report a significant improvement in uncorrected visual acuity, best corrected visual acuity, and spherical values in patients undergoing CXL an average of 4 months following ICRS placement.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <br /></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">It is not clear which of the following sequence is most advantageous: simultaneous ICRS and CXL, CXL followed by ICRS, or ICRS followed by CXL. Coskunseven <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P98" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[44]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">found that ICRS followed by CXL resulted in greater improvement in best corrected visual acuity and reduction in cylinder than vice versa. They hypothesize that the stiffer cornea produced by CXL decreases the flattening effect of ICRS implantation, thus limiting its maximal flattening potential. Additionally, El-Raggal </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P99" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[45▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">has shown that in eyes having undergone CXL 6 months prior to ICRS implantation, more energy was required for femtosecond laser channel creation for ICRS insertion, causing more severe and persistent corneal haze. In a separate study, El-Raggal</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P103" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[47▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">has shown that performing ICRS implantation and CXL on the same day resulted in greater decrease in keratometric compared to ICRS implantation followed by CXL 6 months later. More extensive studies are needed to ascertain the most ideal sequence of ICRS implantation and CXL.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <br /></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Recently, Kymionis <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P103" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[47▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">have also shown promising results combining PRK with CXL. They showed significant improvement in spherical equivalent refraction, uncorrected visual acuity, best corrected visual acuity, and mean keratometric values that remained stable throughout the follow-up period of up to 25 months. Additionally, none of the patients showed topographic or clinical signs of keratoconus progression during the follow-up period. However, as the authors note, this combination may be more appropriate for patients with early keratoconus because the thinner corneas of more advanced keratoconus would preclude the possibility of further tissue removal by topography-guided PRK.</span></div> <div style="background-color: white;"> <br /></div> <h4 style="background-color: white; margin: 15.65pt 0cm 9.4pt;"> <a href="http://www.blogger.com/blogger.g?blogID=3847540156974127949" name="TOC-USE-IN-PROGRESSIVE-POSTLASER-IN-SITU-KERATOMILEUSIS-KERATECTASIA" style="color: #0066cc; outline: none;"></a><span style="font-family: Arial, sans-serif; font-size: 9.5pt;">USE IN PROGRESSIVE POSTLASER IN-SITU KERATOMILEUSIS KERATECTASIA</span></h4> <div style="background-color: white; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">PPLK is a rare condition, first reported by Seiler <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P105" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[48]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">in 1998, characterized by a progressive corneal steepening with accompanying refractive changes, loss of visual acuity and stromal thinning </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P67" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[15▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Generally occurring within 2 years after LASIK, its incidence in a large series was found to be 660 in 100</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">000 cases </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P106" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[49–51]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. The underlying pathophysiology of PPLK is not well understood, but may in some cases involve worsening of an underlying unrecognized ectatic condition, such as forme fruste keratoconus or pellucid marginal degeneration. LASIK, in creating a corneal flap and subsequent tissue ablation, weakens the anterior stroma, which normally confers more biomechanical strength to the cornea than the posterior stroma </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P109" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[52]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Risk factors for its development are thin corneas, a thin residual stromal bed, deep ablations, enhancement treatments, and preoperative abnormalities such as forme fruste keratoconus. However, it may occur without any of the above factors </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P53" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[2,53,54]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <br /></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Therapeutic options for PPLK are similar to those available for progressive keratoconus, namely rigid gas permeable contact lenses, ICRS implantation and penetrating keratoplasty. Also similar to keratoconus, CXL has become an increasingly recognized tool to treat PPLK. Kohlhaas <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P53" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[2]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">first described the successful use of CXL to treat PPLK in 2005. Hafezi <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P111" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[54]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">soon followed in 2007 in a case series of 10 patients, demonstrating clinically meaningful improvement in keratometric readings in five of 10 patients, reduction in cylinder in all patients, and improvement in best spectacle corrected visual acuity in nine of 10 patients. Salgado <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P67" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[15▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">similarly showed regression of corneal ectasia with flattening of the cornea, as well as improvement of the spherical equivalent in a series of 22 patients up to the sixth postoperative month. Hersh <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P112" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[55▪▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">have reported 1-year outcomes of a prospective, randomized controlled clinical trial on CXL use in both keratoconus and PPLK. Although the entire cohort showed significant improvements in best corrected visual acuity and reductions in maximum keratometric values, there were notable differences in response between keratoconus and PPLK patients. PPLK patients showed a significant improvement in best corrected visual acuity at 1 year compared to preoperative levels, but not at time points in between as was the case in keratoconus patients. Also, keratoconus patients had a significant reduction in maximum keratometric value of 2.0</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D, whereas PPLK patients had a nonstatistically significant reduction of 1.0</span><span style="font-family: 'Cambria Math', serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">D. The authors do note, however, that at baseline the PPLK cohort had flatter corneas than the keratoconus cohort, possibly partially accounting for the difference seen </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P112" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[55▪▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Biomechanical differences caused by the LASIK flap may also play a role in the less dramatic response to CXL in PPLK patients. CXL preferentially strengthens the anterior stroma, including the flap in PPLK patients, which does not contribute to the mechanical stability of the cornea. Other possible explanations include differences in riboflavin diffusion rate in post-LASIK corneas and intrinsic pathophysiologic differences between keratoconus and PPLK </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P112" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[55▪▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. In a report of the same cohort published separately, four of seven topography indices (keratoconus index, minimum radius of curvature, index of surface variance, and index of vertical asymmetry) improved in the entire cohort with no significant difference between keratoconus and PPLK patients in terms of change in any topography index from baseline to 1 year, postoperatively </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P114" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[56▪▪]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Similar to progressive keratoconus, combining CXL with ICRS for PPLK has been advocated by some. Kamburoglu <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P116" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[57]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">report a case of bilateral PPLK successfully treated with initial ICRS followed by CXL, resulting in improvement in visual acuity and reduction in keratometric values. Interestingly, there was a slight decrease in the effect of ICRS in the right eye when CXL was delayed for 1 month, whereas the left eye did not suffer such a decrease in ICRS when CXL was performed the day following ICRS implantation, highlighting the fact that only CXL addresses the underlying cause of progressive ectasia.</span></div> <div style="background-color: white;"> <br /></div> <h4 style="background-color: white; margin: 15.65pt 0cm 9.4pt;"> <a href="http://www.blogger.com/blogger.g?blogID=3847540156974127949" name="TOC-FUTURE-APPLICATIONS" style="color: #0066cc; outline: none;"></a><span style="font-family: Arial, sans-serif; font-size: 9.5pt;">FUTURE APPLICATIONS</span></h4> <div style="background-color: white; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">There are several other potential uses of CXL that are increasingly being promoted, including combined CXL–orthokeratology for keratoconus, combined LASIK–CXL to stabilize the effects of LASIK and possibly prevent subsequent ectasia, combined CXL–microwave thermal keratoplasty for mild myopia, and CXL alone for mild myopia. Thus far, there is limited peer-reviewed literature on the efficacy of the above combinations.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <br /></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">Orthokeratology involves the use of a specially designed rigid contact lens to reversibly alter corneal shape to improve mild refractive error</span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P117" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[58]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">. Calossi <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P118" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[59]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">proposed the novel use of orthokeratology to reduce corneal aberration in progressive keratoconus and evaluated the efficacy of CXL in stabilizing the orthokeratology molding effect. They found that orthokeratology temporarily improved corneal shape and reduced corneal aberration in five eyes with progressive keratoconus, but this effect was more transient than that found in nonkeratoconus eyes. Furthermore, CXL after orthokeratology did not stabilize the change in corneal shape, with topography and wave-front error returning to baseline levels 1 month after orthokeratology interruption. However, both uncorrected visual acuity and best spectacle corrected visual acuity maintained an improvement over baseline levels 1 year after orthokeratology–CXL </span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P118" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[59]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;">.</span></div> <div style="background-color: white; margin: 3.15pt 0cm;"> <br /></div> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">There are no peer-reviewed publications examining CXL for mild myopia, combining CXL with LASIK, or combining CXL with microwave thermal keratoplasty. Kampik <em>et al.</em></span>^{<span style="font-family: Verdana, sans-serif; font-size: 5.5pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P119" rel="nofollow" style="color: #471264; outline: none;"><b><span style="color: #551a8b;">[60]</span></b></a></span>}<span style="font-family: Arial, sans-serif; font-size: 8pt;"> </span><span style="font-family: Arial, sans-serif; font-size: 8pt;">have shown that in enucleated porcine eyes previously treated with CXL, subsequent LASIK results in decreased refractive change and increased flap thickness. Further studies are needed to ascertain wheth</span></div> <div style="background-color: white;"> <br /></div> <h4 style="background-color: white; margin: 15.65pt 0cm 9.4pt;"> <a href="http://www.blogger.com/blogger.g?blogID=3847540156974127949" name="TOC-CONCLUSION" style="color: #0066cc; outline: none;"></a><span style="font-family: Arial, sans-serif; font-size: 9.5pt;">CONCLUSION</span></h4> <div style="background-color: white; float: left; margin: 3.15pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">In summary, CXL is a powerful tool that can induce corneal stiffening in ectatic corneas. It has been shown to be effective in halting, and sometimes reversing the progression of both keratoconus and PPLK, while having a relatively low complication rate. Its use as an adjunct with keratorefractive procedures show promise in improving visual outcomes and possibly decreasing or delaying the need for penetrating keratoplasty. However, more long-term data are required to assess the stability of change as well as long-term complication rates. In addition, more studies are needed to ascertain whether PPLK and keratoconus respond differently to CXL. Lastly, further studies are needed to determine the efficacy of potential uses of CXL in combination with other keratorefractive procedures.</span></div> <div style="background-color: white;"> <br /></div> <div style="background-color: white;"> <br /></div> <div style="background-color: white; margin: 15.65pt 0cm 9.4pt;"> <b><span style="font-family: Arial, sans-serif; font-size: 9.5pt;">REFERENCES</span></b></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">1. Spörl E, Huhle M, Kasper M, Seiler T. Increased rigidity of the cornea caused by intrastromal cross-linking. Ophthalmologe 1997; 94:902–906.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P16" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/9487761" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">2. Kohlhaas M, Spoerl E, Speck A, et al. A new treatment of keratectasia after LASIK by using collagen and riboflavin/UVA light cross-linking. Klin Monbl Augenheilkd 2005; 222:430–436.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P17" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/15912463" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1055%2Fs-2005-857950" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">3. Spoerl E, Huhle M, Seiler T. Induction of cross-links in corneal tissue. Exp Eye Res 1998; 66:97–103.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P19" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/9533835" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1006%2Fexer.1997.0410" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">4. Wollensak G, Spoerl E, Seiler T. Riboflavin/ultraviolet-A-induced collagen crosslinking for the treatment of keratoconus. Ophthalmology 1994; 101:439–447.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P19" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">5▪. Asri D, Touboul D, Fournié P. Corneal collagen crosslinking in progressive keratoconus: multicenter results from the French National Reference Center for Keratoconus. J Cataract Refract Surg 2011; 37:2137–2143.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P19" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/22108109" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2011.08.026" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><br /></span></div> <div style="background-color: white; margin: 5.65pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">This article demonstrates large-scale results of CXL in progressive keratoconus.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">6. Spoerl E, Mrochen M, Sliney D, et al. Safety of UVA-riboflavin cross-linking of the cornea. Cornea 2007; 26:385–389.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P19" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://content.wkhealth.com/linkback/etoc/pt/fulltext.00003226-200705000-00001.htm" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">View Full Text</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/17457183" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1097%2FICO.0b013e3180334f78" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">7. Raiskup-Wolf F, Hoyer A, Spoerl E, Pillunat L. Collagen crosslinking with riboflavin and ultraviolet-A light in keratoconus: long term results. J Cataract Refract Surg 2008; 34:796–801.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P20" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/18471635" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2007.12.039" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">8. Wollensak G. Crosslinking treatment of progressive keratoconus: new hope. Curr Opin Ophthalmol 2006; 17:356–360.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P20" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://content.wkhealth.com/linkback/etoc/pt/fulltext.00055735-200608000-00007.htm" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">View Full Text</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/16900027" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1097%2F01.icu.0000233954.86723.25" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">9. Spoerl E, Wollensak G, Seiler T. Increased resistance of cross-linked cornea against enzymatic digestion. Curr Eye Res 2004; 29:35–40.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P20" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/15370365" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">10. Spörl E, Schreiber J, Hellmund K, et al. Untersuchungen zur Veffestigung der Hornhaut am Kaninchen. Ophthalmologe 2000; 97:203–206.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P20" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">11. Kohlhaas M, Spoerl E, Schilde T, et al. Biomechanical evidence of the distribution of cross-links in corneas treated with riboflavin and ultraviolet A light. J Cataract Refract Surg 2006; 32:279–283.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P20" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/16565005" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2005.12.092" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">12. Wollensak G, Spörl E, Reber F, et al. Corneal endothelial toxicity of riboflavin/UVA treatment</span><span style="font-family: Arial, sans-serif; font-size: 8pt;"> <i>in vitro</i></span><span style="font-family: Arial, sans-serif; font-size: 8pt;">. Ophthalmic Res 2003; 35:324–328.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P20" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">13. Kymionis G, Portaliou D, Pallikaris I. Additional complications of corneal crosslinking. J Cataract Refract Surg 2010; 36:185.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P21" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/20117734" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2009.07.028" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">14. Kymionis G, Bouzoukis D, Diakonis V, et al. Diffuse lamellar keratitis after corneal crosslinking in a patient with postlaser in situ keratomileusis corneal ectasia. J Cataract Refract Surg 2007; 32:2135–2137.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P21" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/18053917" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2007.06.070" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">15▪. Salgado J, Khoramnia R, Lohmann C, et al. Corneal collagen crosslinking in post-LASIK keratectasia. Br J Ophthalmol 2011; 95:493–497.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P21" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://content.wkhealth.com/linkback/etoc/pt/fulltext.00002388-201104000-00015.htm" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">View Full Text</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/20679077" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1136%2Fbjo.2010.179424" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><br /></span></div> <div style="background-color: white; margin: 5.65pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">This article demonstrates the results of CXL in PPLK in 22 eyes.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">16▪. Kanellopoulos AJ. Long term results of a prospective randomized bilateral eye comparison trial of higher fluence, shorter duration ultraviolet A radiation, and riboflavin collagen cross linking for progressive keratoconus. Clin Ophthalmol 2012; 6:97–101.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P21" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/22275813" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><br /></span></div> <div style="background-color: white; margin: 5.65pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">This article demonstrates comparable results of standard CXL and higher fluence/shorter duration CXL.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">17. Kennedy R, Bourne W, Dyer J. A 48-year clinical and epidemiologic study of keratoconus. Am J Ophthalmol 1986; 101:267–273.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P23" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/3513592" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">18. Rabinowitz Y. Keratoconus. Surv Ophthalmol 1998; 42:297–319.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P23" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/9493273" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2FS0039-6257%2897%2900119-7" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">19. Tuft S, Moodaley L, Gregory W, et al. Prognostic factors for the progression of keratoconus. Ophthalmology 1994; 101:439–447.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P23" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/8127564" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">20. Kymes S, Walline J, Zadnik K, Gordon M. Quality of life in keratoconus. Am J Ophthalmol 2004; 138:527–535.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P23" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/15488776" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.ajo.2004.04.031" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">21. Clemons T, Chew E, Bressler S, McBee W. National Eye Institute Visual Function Questionnaire in the Age-Related Eye Disease Study (AREDS). AREDS report no. 10. Arch Ophthalmol 2003; 121:211–217.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P23" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://content.wkhealth.com/linkback/etoc/pt/fulltext.00000820-200302000-00007.htm" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">View Full Text</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/12583787" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1001%2Farchopht.121.2.211" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">22. Andreassen T, Simonsen A, Oxlund H. Biomechanical properties of keratoconus and normal corneas. Exp Eye Res 1980; 31:435–441.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P23" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/7449878" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2FS0014-4835%2880%2980027-3" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">23. Kenney M, Brown D, Rajeev B. The elusive causes of keratoconus: a working hypothesis; the Everett Kinsey Lecture. CLAO J 2000; 26:10–13.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P23" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/10656302" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">24. Kenney M, Chwa M, Atilano S, et al. Increased levels of catalase and cathepsin V/L2 but decreased TIMP-1 in keratoconus corneas: evidence that oxidative stress plays a role in this disorder. 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J Cataract Refract Surg 2009; 35:2084–2091.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P27" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/19969212" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2009.07.008" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">45▪. El-Raggal T. Effect of corneal collagen crosslinking on femtosecond laser channel creation for intrastromal corneal ring segment implantation in keratoconus. J Cataract Refract Surg 2011; 37:701–705.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P27" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/21420595" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2010.10.048" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><br /></span></div> <div style="background-color: white; margin: 5.65pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">This article demonstrates that CXL prior to ICRS necessitates greater energy use in femtosecond laser channel creation.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">46▪. El-Raggal T. Sequential versus concurrent KERARINGS insertion and corneal collagen cross-linking for keratoconus. Br J Ophthalmol 2011; 95:37–41.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P27" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://content.wkhealth.com/linkback/etoc/pt/fulltext.00002388-201101000-00010.htm" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">View Full Text</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/20584709" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1136%2Fbjo.2010.179580" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><br /></span></div> <div style="background-color: white; margin: 5.65pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">This article demonstrates that simultaneous CXL/ICRS yielded better outcomes than ICRS followed by CXL 6 months later.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">47▪. Kymionis G, Portaliou D, Kounis G, et al. Simultaneous topography-guided photorefractive keratectomy followed by corneal collagen cross-linking for keratoconus. Am J Ophthalmol 2011; 152:748–755.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P28" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/21794846" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.ajo.2011.04.033" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><br /></span></div> <div style="background-color: white; margin: 5.65pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">This article demonstrates the success of combining PRK with CXL.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">48. Seiler T, Koufala K, Richter G. Iatrogenic keratectasia after laser in situ keratomileusis. J Refract Surg 1998; 14:312–317.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P31" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">49. Geggel H, Talley A. Delayed onset keratectasia following laser in situ keratomileusis. J Cataract Refract Surg 1999; 25:582–586.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P31" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/10198868" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2FS0886-3350%2899%2980060-1" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">50. Rao S, Epstein R. Early onset ectasia following laser in situ keratomileusis: case report and literature review. J Refract Surg 2002; 18:177–184.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P31" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://content.wkhealth.com/linkback/etoc/pt/fulltext.00043928-200203000-00013.htm" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">View Full Text</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/11934208" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">51. Pallikaris I, Kymionis G, Astyrakakis N. Corneal ectasia induced by laser in situ keratomileusis. J Cataract Refract Surg 2001; 27:1796–1802.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P31" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/11709254" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2FS0886-3350%2801%2901090-2" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">52. Randleman J, Dawson D, Grossniklaus H,</span><span style="font-family: Arial, sans-serif; font-size: 8pt;"> <i>et al</i></span><span style="font-family: Arial, sans-serif; font-size: 8pt;">. Depth-dependent cohesive tensile strength in human donor corneas: implications for refractive surgery. J Refract Surg 2008; 24:S85–S89.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P31" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://content.wkhealth.com/linkback/etoc/pt/fulltext.00043928-200801000-00016.htm" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">View Full Text</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/18269156" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">53. Binder P. Ectasia after laser in situ keratomileusis. J Cataract Refract Surg 2003; 29:2419–2429.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P31" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/14709307" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2003.10.012" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">54. Hafezi F, Kanellopoulos J, Wilfang R, et al. Corneal collagen crosslinking with riboflavin and ultraviolet A to treat induced keratectasia after laser in situ keratomileusis. J Cataract Refract Surg 2007; 33:2035–2040.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P31" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/18053900" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2007.07.028" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">55▪▪. Hersh P, Greenstein S, Fry K. Corneal collagen crosslinking for keratoconus and corneal ectasia: One-year results. J Cataract Refract Surg 2011; 37:149–160.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P32" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/21183110" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2010.07.030" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><br /></span></div> <div style="background-color: white; margin: 5.65pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">This article describes a prospective, randomized controlled trial on CXL for both keratoconus and PPLK.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">56▪▪. Greenstein S, Fry K, Hersh P. Corneal topography indices after corneal collagen crosslinking for keratoconus and corneal ectasia: one year results. J Cataract Refract Surg 2011; 37:1282–1290.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P32" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/21700105" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1016%2Fj.jcrs.2011.01.029" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><br /></span></div> <div style="background-color: white; margin: 5.65pt 0cm;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">This article describes a prospective, randomized controlled trial on CXL for both keratoconus and PPLK.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">57. Kamburoglu G, Ertan A. Intacs implantation with sequential collagen cross-linking treatment in postoperative LASIK ectasia. J Refract Surg 2008; 21:S726–S729.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P33" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://content.wkhealth.com/linkback/etoc/pt/fulltext.00043928-200809000-00016.htm" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">View Full Text</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/18811119" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">58. Swarbrick HA. Orthokeratology review and update. Clin Exp Optom 2006; 89:124–143.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P36" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/16637967" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1111%2Fj.1444-0938.2006.00044.x" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">59. Calossi A, Romano F, Ferraioli G, Romano V. Orthokeratology and riboflavin-UVA corneal collagen cross-linking in keratoconus. J Emmetropia 2010; 1:126–131.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P36" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a></span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <br /></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;">60. Kampik D, Ralla B, Keller S, et al. Influence of corneal collagen crosslinking with riboflavin and ultraviolet-A irradiation on excimer laser surgery. Invest Ophthalmol Vis Sci 2010; 51:3929–3934.</span></div> <div style="background-color: white; margin-bottom: 0.0001pt;"> <span style="font-family: Arial, sans-serif; font-size: 8pt;"><a href="http://journals.lww.com/co-ophthalmology/Fulltext/2012/07000/Corneal_collagen_crosslinking_in_refractive.5.aspx?WT.mc_id=EMxj10x20120813xL14#P37" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">Cited Here...</span></a> | <a href="http://www.ncbi.nlm.nih.gov/pubmed/" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">PubMed</span></a> | <a href="http://dx.doi.org/10.1167%2Fiovs.09-4524" rel="nofollow" style="color: #471264; outline: none;"><span style="color: #551a8b;">CrossRef</span></a></span></div> <div style="background-color: white;"> <br /></div> </div> </div>

La reticulación del colágeno corneal en Cirugía Refractiva

Reticulación del colágeno corneal en cirugía refractiva Información Autor Departamento de Oftalmología, Albert Einstein Coll...

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Inhibición de una enzima permite optimizar el tratamiento en el Cancer

<div dir="ltr" style="text-align: left;" trbidi="on"> <br /> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto; text-align: center;"> <img border="0" height="223" src="https://sites.google.com/a/infolentes.com/info-lentes/_/rsrc/1346088571599/inter/inhibiciondeunaenzimapermiteoptimizareltratamientoenelcancer/infolentes.jpg?height=223&width=400" width="400" /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto; text-align: center;"> <br /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto; text-align: center;"> <span style="background-color: #dddddd; color: #262626; font-family: Arial; font-size: 12px; font-style: italic; line-height: 15px; text-align: start;">Estudio apunta a una doble estrategia contra el cáncer: la reducción del tumor y de las metástasis, así como la atenuación de los efectos asociados a la quimioterapia.</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto; text-align: center;"> <span style="background-color: #dddddd; color: #262626; font-family: Arial; font-size: 12px; font-style: italic; line-height: 15px; text-align: start;"><br /></span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto; text-align: center;"> <div style="border: 0px; color: #555555; font-family: arial; font: inherit; line-height: 19px; margin-bottom: 15px; padding: 0px; text-align: start; vertical-align: baseline;"> La inhibición de una enzima que normaliza el flujo sanguíneo de un tumor <strong style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">y mejora el efecto de la quimioterapia a la vez que minimiza sus impactos adversos en el organismo es el más reciente descubrimiento de un grupo de investigadores encabezado por un portugués.</strong><br /><br />El estudio, en el que participa Rodrigo Leite de Oliveira, apunta a una doble estrategia contra el cáncer: la reducción del tumor y de las metástasis, así como la atenuación significativa de los efectos secundarios asociados a la quimioterapia.<br /><br /><strong style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Leite de Oliveira y el resto de investigadores dedujeron que los vasos tumorales con una actividad reducida de la enzima PHD2 presentaban características normales</strong>, frente a los vasos sanguíneos que nutren al tumor, naturalmente irregulares, frágiles y con las funciones mermadas.<br /><br />Así, cuando se reduce la actividad de la enzima PHD2 en las células endoteliales de los tumores, los agentes de la quimioterapia "se distribuyen más eficazmente por todo el tumor" y aumenta de este modo su acción curativa, explicó a Efe Leite de Oliveira.<br /><br />El investigador, que trabaja en el centro Vesalius de la Universidad belga de Lovaina, agregó que la disminución de la enzima estudiada crea una <strong style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">"barrera más eficaz a la diseminación de células tumorales con metástasis".</strong><br /><br />"Además de más pequeños, los tumores fueron todavía más sensibles a dosis más bajas de los fármacos", con lo que puede reducirse la administración de anti-tumorales, incidió el investigador.<br /><br /><strong style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Pero la inhibición de PHD2 no solo normaliza la vasculatura tumoral sino que también aumenta las defensas antioxidantes, con lo que se evitan "los efectos nocivos de la misma quimioterapia".</strong><br /><br />En este caso, las pruebas se realizaron con las drogas farmacológicas cisplatina y doxorubicina, que tienen especial incidencia sobre las funciones cardíacas y renales del paciente.<br /><br /><strong style="border: 0px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">"El estudio abre perspectivas para poder alargar la protección de otros órganos que sean especialmente damnificados por otro tipo de agentes de la quimioterapia",</strong>argumentó Leite de Oliveira.</div> <div style="border: 0px; color: #555555; font-family: arial; font: inherit; line-height: 19px; margin-bottom: 15px; padding: 0px; text-align: start; vertical-align: baseline;"> EFE</div> </div> </div>

Inhibición de una enzima permite optimizar el tratamiento en el Cancer

Estudio apunta a una doble estrategia contra el cáncer: la reducción del tumor y de las metástasis, así como la atenuación de los efe...

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Se abrirán 14 ‘malls’ en el interior del país el próximo año

<div dir="ltr" style="text-align: left;" trbidi="on"> <span style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;">Más de siete ciudades del país tendrán su primer centro comercial en el 2013, entre ellas, Cusco, Pucallpa, Huancayo, Barranca y Pisco</span><br style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;" /><br /> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px; margin-left: auto; margin-right: auto; text-align: center;"> <img border="0" height="250" src="https://sites.google.com/a/infolentes.com/info-lentes/_/rsrc/1352574627266/inter/seabriran14mallsenelinteriordelpaiselproximoano/534706.jpg?height=250&width=400" width="400" /><br /></div> <br style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;" /><div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> Se estima que para el 2013 más de siete ciudades del país (incluyendo provincias) tendrán su primer centro comercial, ya sea de grandes superficies o de dimensiones menores como los ‘strip center’.</div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> Entre ellas destaca Cusco, donde <a href="http://elcomercio.pe/tag/166509/real-plaza" rel="nofollow" style="color: #471264; outline: none;" target="_blank">Real Plaza</a> ya trabaja para abrir sus puertas en el primer trimestre del próximo año. En este período el holding Quimera HG también espera iniciar la construcción de su ‘mall’ en la zona Wanchaq (Cusco), informó Colliers International en su reporte al tercer trimestre del año.</div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> Otras ciudades que se sumarán al ‘retail’ moderno son Pucallpa (Ucayali); Huancayo (Junín), donde Cúbica del grupo Brescia trabaja en su proyecto Paso Huancayo; Pisco y Chincha (Ica); y Cañete y Barranca, provincias de Lima.</div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> Estas últimas cuatro albergarán los ‘strip centers’ Megaplaza Express, de la sociedad entre Parque Arauco y el grupo Wiese.</div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <b>OTROS PROYECTOS</b><br />Según informó <b>El Comercio</b>, el próximo año también se desarrollarán proyectos en departamentos ya conquistados por los operadores de <a href="http://elcomercio.pe/tag/69722/mall-aventura-plaza" rel="nofollow" style="color: #471264; outline: none;" target="_blank">centros comerciales</a>, tales como Arequipa, Piura, Cajamarca, Huánuco, Ica y Trujillo.</div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> Entre los ya anunciados figuran los proyectos del holding inmobiliario EOM Group, que prepara ‘strip centers’ en Piura e Ica. Invertirán US$40 millones entre ambos, detalló Colliers International.</div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> Cencosud alista para el tercer trimestre del próximo año su primer ‘mall’ en Cerro Colorado (Arequipa). Plaza Norte es otra de las iniciativas comerciales en la Ciudad Blanca que está en ejecución por parte de Quimera HG.</div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> En el 2013 también llegará Cúbica a Huánuco. Paso Huánuco le hará la competencia a Real Plaza, que estima abrir en diciembre su centro comercial. En tanto, El Quinde completará su oferta en Ica y Penta Mall hará lo propio en Trujillo.</div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> La capital no se queda atrás. Entre los proyectos anunciados para el 2013 figuran Brasil Plaza y el proyecto mixto Paso 28 de Julio (ambos de Cúbica). El Fondo de Inversiones en Bienes Raíces (Fibra) prepara su primer ‘strip center’ en el Callao. Además Penta Mall, Parque Arauco, Cencosud, entre otros, seguirán con su crecimiento.</div> </div>

Se abrirán 14 ‘malls’ en el interior del país el próximo año

Más de siete ciudades del país tendrán su primer centro comercial en el 2013, entre ellas, Cusco, Pucallpa, Huancayo, Barranca y Pisco ...

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Top 10 Ways to Fail with Multifocal Contacts - 10 Modos en que fallan los Lentes de Contacto Multifocales

<div dir="ltr" style="text-align: left;" trbidi="on"> <span style="font-family: Arial; font-size: xx-small;">.</span><br /> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <img src="https://sites.google.com/a/infolentes.com/info-lentes/_/rsrc/1352508625211/inter/top10waystofailwithmultifocalcontacts-10modosenquefallanloslentesdecontactomultifocales/1.gif" /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <br /> <b><span style="font-size: xx-small;">Improved stereoacuity is one reason for the increased popularity of multifocal contact lenses, as seen in this patient with a well-fit aspheric multifocal gas permeable lens. </span></b><span style="font-size: xx-small;"><i>Photo: Edward S. Bennett, O.D.</i></span><b><span style="font-size: xx-small;"> </span></b></div> <br style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;" /> <h5 style="background-color: white; font-family: Arial, Verdana, sans-serif;"> <a href="http://www.blogger.com/blogger.g?blogID=3847540156974127949" name="TOC-Try-ignoring-comfort-or-raising-patient-expectations-or-not-even-offering-multifocal-lenses.-That-ll-chase-away-all-those-pesky-presbyopes." style="color: #0066cc; outline: none;"></a>Try ignoring comfort or raising patient expectations—or not even offering multifocal lenses. That’ll chase away all those pesky presbyopes.</h5> <span style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;">By Melanie Denton, O.D.</span><br /> <br style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;" /> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">With 74 million baby boomers born between the years of 1946 and 1964, it comes as no surprise that a great deal of these patients are now looking for presbyopic solutions.¹ </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">In an ideal world, our patients would love for us to just wave a magic wand and restore the accommodative ability of their crystalline lenses. But instead, we resort to running down the list of their options, each with pros and cons, and letting them choose whatever seems like the best one. The problem is, none of the options are just <i>perfect</i>. Sometimes it seems easier to stop after explaining progressive add lenses, and get them to the optical already. </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">But now more than ever, technology has advanced to a point where viable options <i>do</i> exist. And with the number of multifocal lens fits increasing more than 136% since 2005, the time to adapt your practice to this growing demographic is now.^2,3</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">So, how can you incorporate the sometimes challenging and time-consuming task of fitting your presbyopes in multifocal contact lenses (MFCLs)? </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">Unfortunately, there are many ways to go wrong. Here are some of the most commonly made mistakes (in no particular order)—and ways to circumvent them:</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <br /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;"><span style="color: mediumvioletred;"><b><span style="font-size: small;">1. Don’t tell your emerging presbyopes about multifocal lenses.</span></b></span><br />A sure way to guarantee that you won’t fit any multifocal lenses is to never talk about them! And, there’s no question that, by the time you’re done with an exam and explained the options to the patient (for the 10th time that day!), it can be tempting to just the leave out the whole discussion. </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">I understand: There just seems to be so <i>many</i> things to educate our patients about. Have you ever finished with the exam, dropped the patient off in optical, and then your optician comes back saying, “We’re all done with glasses selection, but he/she would really like a contact lens fitting, too”? How can you remedy that situation? Luckily, there are several ways to plant the idea in the patient’s head long before you’re running down the laundry list of options:</span></div> <ul style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <li><span style="font-family: Arial; font-size: x-small;"><i>Utilize your waiting room.</i> The waiting room is a perfect place to subtly inject the idea of MFCLs into the patient’s psyche. Especially if you have a sub-waiting area. At my practice, we leave the general waiting room mostly free of marketing material, and instead place those materials in the sub-waiting area. Typically, patients are more concerned with filling out paperwork or socializing with other patients when they first arrive.<br /><br />But once they’ve begun their exam, spent some time with our staff, and are dilating, they are (hopefully) in the mode of getting their eye exam. At this point, carefully placed posters, brochures, or even custom-made signage directing patients to ask you about MFCLs work nicely.</span></li> <li><span style="font-family: Arial; font-size: x-small;"><i>Utilize your support staff.</i> Think about it––do your patients spend more time with you, or more time with your staff? There are many ways staff members can let patients know that MFCLs may be an option for them. One example: while the technician enters the patient’s age or chief complaint of “blurred vision at near,” he or she may simply say, “Have you heard that there are contact lenses for that nowadays? Make sure to ask Dr. Denton if you’re a candidate.”</span></li> </ul> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;"><span style="color: mediumvioletred; font-size: small;"><b>2. Don’t address comfort issues!</b></span><br />An estimated 20 to 30 million Americans have early-stage signs or symptoms of dry eye, with the disease being more common in older individuals (45 years and older).⁴ Also, contact lenses have been shown to increase dryness. Silicone hydrogel lenses, preferred because of the health benefits they provide, are also an inherently hydrophobic material. And, despite lens manufacturers’ efforts to create a hydrophilic surface, lenses tend to revert back to being hydrophobic after a few hours of wear.</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <br /> <span style="font-family: Arial; font-size: x-small;">If we don’t have a discussion with these patients regarding comfort, we risk losing them after they get home and the lenses lose wettability, thus changing the lid interaction with the lens, the stiffness or modulus of the lens, and the comfort. It’s best to make sure the patient knows that comfort might become an issue—and if it does become an issue, what they can do to make lens wear tolerable.</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">The first variable to consider in keeping a lens comfortable is the contact lens solution. Luckily, there are several good options to enhance patient comfort. Specifically, hydrogen peroxide solutions have produced favorable results for patients with wearing discomfort. This solution seems to work even better if the patient is sensitive to solution preservatives.</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">Newly released solutions that contain surfactants and increase the wettability of lenses can also be the key to keeping patients comfortable in their lenses for the long term. </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">It’s also important to educate MFCL patients about appropriate artificial tears. In fact, there are some artificial tears that they will want to avoid, because certain tears can actually affect the lens modulus and alter vision. In general, I like to prescribe tears that contain a natural wetting agent (such as hyaluronic acid) or are preservative-free.</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <br /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <br /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;"><span style="color: mediumvioletred; font-size: small;"><b>3. Allow the patient to expect “perfect” results.</b></span><br />There’s no better way to fail at MFCL fitting than to let patients think that their lenses will do what their crystalline lens used to. </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">Also, if you don’t take the time to find out what patients spend their time doing, you will very likely miss the mark in fitting their lenses. Possibly the singlemost important step in selecting the right patients for a multifocal fit, and ensuring that they will have success, is letting them know what can be expected from these lenses. </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">I learned from some very good mentors that this phrase works well: “My goal is to get you through most tasks, most of the time. If you’re looking to settle in with a good book and read for six hours or drive a long way at night, your progressive add lenses will be a better bet. But, if you want to be able to do most things—sit down to dinner and not have to pull out reading glasses, for example—then I can most likely make you happy.”<br />In other words, make sure the bar is so low that they have to trip over it!<br /><b><span style="color: red; font-size: small;"><br /><span style="color: mediumvioletred;">4. Test monocular acuties, and allow the patient to compare acuities monocularly.</span></span></b><br />At least once a week, I encounter a patient who swears he loves his lenses, except one eye is better than the other at near/distance, or both! It reminds me of the old joke: “Doc, it hurts when I do <i>this</i>!” The inevitable punchline: “Well then, stop doing that!” </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">When fitting MFCLs, test monocular acuities and ensure neither eye is lagging behind. But, above all, emphasize to the patient that the new rule is: Use both eyes at all times! One eye may be skewed toward distance and the other toward near, but they will always perform better together.</span></div> <span style="background-color: white; font-family: Arial; font-size: x-small;"><span style="color: mediumvioletred; font-size: small;"><b>5. Don’t use real-world examples in your exam room.</b></span><br />Remember, you live in a black and white world in your exam room. When the patient leaves, she does not live in a black and white world. Color and contrast needs are extremely variable from patient to patient, and it helps to find out what their specific needs are.<br /></span><br /> <div> <span style="background-color: white; font-family: Arial; font-size: x-small;"><img border="0" src="https://sites.google.com/a/infolentes.com/info-lentes/_/rsrc/1352508625273/inter/top10waystofailwithmultifocalcontacts-10modosenquefallanloslentesdecontactomultifocales/2.gif" /></span><br /> <span style="background-color: white; font-family: Arial; font-size: x-small;"><br /></span> <span style="background-color: white; font-family: Arial; font-size: x-small;"><b><span style="font-size: xx-small;">Use visual aids and images to help better explain multifocal contact lenses to potential patients. </span></b><span style="font-size: xx-small;"><i>Image: Eyeimaginations.</i></span></span><br /> <span style="background-color: white; font-family: Arial; font-size: x-small;"><br /></span> <span style="background-color: white; font-family: Arial; font-size: x-small;"><span style="font-family: Arial; font-size: x-small;">I believe that there’s no substitute for the good ‘ole “college try”—in other words, at least one week of wearing the lenses in their world to see if they are performing well. Often, I preface a patient’s week trial of their lenses by saying, “OK, these are working well in my exam room, but let’s see how they perform in your world. Pay attention to how they are working and we will address any issues when you return.”<br />In addition, keep magazines, phone books, newspapers or other reading materials in the room for some real-world trials. Maybe you could even install a street sign at the end of a long hallway in your office? (Just kidding!)</span><span style="font-family: Arial; font-size: x-small;"><span style="color: mediumvioletred;"><b><span style="font-size: small;">6. Don’t learn about different multifocal options.</span></b></span><br />We all have our go-to lens, but what happens when it just isn’t working? If you don’t know the alternatives, you might inadvertently cause a dropout.</span></span><br /> <span style="background-color: white; font-family: Arial; font-size: x-small;"><span style="font-family: Arial; font-size: x-small;">Soft multifocal lenses are designed using the concept of simultaneous vision. This means that the patient is viewing distance and near images at the same time. When two distinct images fall on the retina concurrently, the patient loses a bit of contrast sensitivity and gains stereopsis. (Which is, by the way, something to mention when comparing these lenses to monovision.) </span></span><br /> <span style="background-color: white; font-family: Arial; font-size: x-small;"><span style="font-family: Arial; font-size: x-small;">There are currently two types of simultaneous vision lens designs: concentric and aspheric. </span></span><br /> <ul><span style="background-color: white; font-family: Arial; font-size: x-small;"> <li><span style="font-family: Arial; font-size: x-small;"><i>Concentric</i> lenses utilize a distance or near optical zone, which makes pupil size and lens centration critical for the fit. These come in distance-centered, near-centered, pupil-intelligent and aspheric-blended varieties. These lenses tend to work best for emerging or early presbyopes with low add powers.</span></li> <li><span style="font-family: Arial; font-size: x-small;"><i>Aspheric</i> designs offer a gradual change in power from the center to the periphery. They have either an anterior surface or posterior surface aspheric design, and they work particularly well for modified monovision.</span></li> </span></ul> <div> <span style="background-color: white; font-family: Arial; font-size: x-small;"><span style="font-family: Arial; font-size: x-small;"><img border="0" src="https://sites.google.com/a/infolentes.com/info-lentes/_/rsrc/1352508625322/inter/top10waystofailwithmultifocalcontacts-10modosenquefallanloslentesdecontactomultifocales/3.gif" /></span></span></div> <span style="background-color: white; font-family: Arial; font-size: x-small;"><span style="font-family: Arial; font-size: x-small;"><br /></span><b><span style="font-size: xx-small;">Soft multifocal lenses are designed for simultaneous vision, in which light rays pass through distance and near zones at the same time. Multifocal lenses are designed with aspheric curves (left) or concentric configurations (middle, right).</span></b></span><br /> <span style="background-color: white; font-family: Arial; font-size: x-small;"><br /></span></div> <span style="background-color: white; font-family: Arial; font-size: x-small;"> </span><br /> <span style="background-color: white; font-family: Arial; font-size: x-small;">The availability of two lenses of similar design having different power gradients provides the ability to overcome problems related to poor contrast sensitivity. Poor contrast sensitivity (as opposed to improper lens power) may be the indication for a particularly sensitive patient’s inability to achieve satisfactory distance vision.<br /><span style="color: mediumvioletred;"><b><span style="font-size: small;"><br />7. Don’t be selective—try MFCLs on everyone!</span></b></span><br />Before you travel down the MFCL road, be sure to know the patient’s expectations. As I said before, they work for “most patients most of the time.” But certain presbyopes may suffer from severe dry eye, work in a meticulous environment that requires perfect vision and contrast sensitivity, or just may not be good candidates for various other reasons. </span><span style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"></span><br /> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">There’s no substitute for getting to know your patients’ needs and expectations. Do this with face-to-face time or a simple questionnaire to facilitate quicker screening.</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <br /></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <br /> <span style="font-family: Arial; font-size: x-small;"><span style="color: mediumvioletred;"><b><span style="font-size: small;">8. Don’t over-refract.</span></b></span><br />As great as it would be if we could empirically select a lens and achieve visual perfection right off the bat, it is almost always necessary to implement some sort of over-refraction. I find that using the phoropter for these situations is not the most effective strategy. Nor is pulling out your entire trial lens set from optometry school and ending up with 50 loose lenses strewn about. </span></div> <span style="background-color: white; font-family: Arial; font-size: x-small;">Use simple flipper bars, purchased or acquired from various contact lens manufacturers, and perform quick trials for the patient by using real-world materials rather than black-on-white charts. Remember, we’re trying to get the patient away from focusing on these charts. Sure, I want the patient to be 20/20, but sometimes as long as they’re 20/Happy (and meeting minimum visual acuity requirements, of course), then I’ve done my job.<br /></span><br /> <div> <span style="background-color: white; font-family: Arial; font-size: x-small;"><img border="0" src="https://sites.google.com/a/infolentes.com/info-lentes/_/rsrc/1352508625367/inter/top10waystofailwithmultifocalcontacts-10modosenquefallanloslentesdecontactomultifocales/4.gif" /></span><br /> <span style="background-color: white; font-family: Arial; font-size: x-small;"><br /></span> <span style="background-color: white; font-family: Arial; font-size: x-small;"><span style="color: black; font-family: Arial; font-size: x-small;"><b><span style="font-size: small;"><span style="font-size: xx-small;">Make sure the fit is legit. This patient’s multifocal RGP, which sat nasally on the right eye, was fitting too tightly. Notice the indentation of the lens on the temporal cornea after its removal. </span></span></b><span style="font-size: small;"><span style="font-size: xx-small;"><i>Photo: Mile Brujic, O.D.<br /></i></span></span></span></span></div> <span style="background-color: white; font-family: Arial; font-size: x-small;"> </span><br /> <span style="background-color: white; font-family: Arial; font-size: x-small;"><b><span style="color: mediumvioletred; font-size: small;">9. Don’t be proactive.</span></b><br />As with just about everything, it’s up to you to ensure that you build a successful multifocal lens practice. Discuss the idea of contact lenses and offer the patient a quick trial of contacts to use in-office while picking out glasses. Once the lenses are in, and the patient sees how comfortable they are and how much more clearly they can see, you’ve planted the idea of contact lenses. </span><span style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"></span><br /> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;">Then, remove the lenses before they leave, and give them the option of scheduling a fitting.</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;"><b><span style="color: mediumvioletred; font-size: small;">10. Do it all yourself.</span></b><br />Make sure your team knows your goals in establishing your practice as the place to go for clear vision at all distances without relying on glasses. Get them excited about it by fitting your presbyopic employees and let them sing your praises. Designate your contact lens technician to do simple trial lens over-refractions when possible.</span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: x-small;"><br />Successfully fitting multifocal lenses is a big practice-builder and has the potential to generate patient referrals—while giving patients real solutions without having to leave your practice. </span></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <i><span style="font-family: Arial; font-size: x-small;">Dr. Denton is in private practice in Burnsville, N.C. She is a fellow of the American Academy of Optometry, an executive board member of the Ocular Surface Society of Optometry, and director of mentorship for Women of Vision.</span></i></div> <div style="background-color: white; font-family: Arial, Verdana, sans-serif; font-size: 13px;"> <span style="font-family: Arial; font-size: xx-small;">1. U.S. Census Bureau. U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin: 2000-2050. Available at: <a href="http://www.census.gov/population/www/projections/usinterimproj" rel="nofollow" style="color: #471264; outline: none;" target="_blank">www.census.gov/population/www/projections/usinterimproj</a>. Accessed September 2011.<br />2. inVentiv Advance Insights Contact Lens Report. Data ending December 2010.<br />3. Cleveland Research Company. 2009. Third Quarter 2009 Contact Lens Research Summary. Press Release.<br />4. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol. 2000 Sep;118(9):1264-8.</span></div> </div>

Top 10 Ways to Fail with Multifocal Contacts - 10 Modos en que fallan los Lentes de Contacto Multifocales

. Improved stereoacuity is one reason for the increased popularity of multifocal contact lenses, as seen in this patient with a well-f...

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