Transcript
Page 1: Cross linking-iontophoresis-cats famose-ecvo_v2

EVALUATION OF ACCELERATED-CXL* AFTER

IONTOPHORESISFOR THE TREATMENT OF MELTING KERATITIS

IN 6 CATS

* Collagen Cross-Linking

Dr Frank FAMOSE – Toulouse - France

Pierre ROY – Paris - FranceLondon 2014

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Melting keratitis

MMP imbalance

High perforation risk

Treatment : antibiotics& anticollagenases

Tectonic Surgery

CXL

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Collagen reticulation

Anti-infectious effects

Keratocyte apoptosis

Photochemicalprocess

CXL

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CXL: protocol modifications

ConventionalProtocol

Modifications"Epi-On"

"Epi-Off"(epithelialremoval)

UV exposition3mW/cm² - 30 min.

(5,4J/cm²)

Riboflavininstillation

(30 minutes)

Low or highosmolarity RFNanostructures,adjuvants

Intrastromal injectionsIontophoresis

AcceleratedCXL9-30mW/cm²

(5,4J/cm²)

Epithelium RF distribution UVA irradiation

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Iontophoresis

Application of a constant electric

current to enhance penetration of a ionized substance through a tissue 2013

Iontophoresisof RF forCXL(keratoconus)

From 1990

SteroidsAntibioticsAntifungal

AntimetabolitesOligonucleotides

DiscoveryWirz 1908

No veterinaryclinical use

(Bikbova et al.Mastropasqua et al.Touboul et al.)

No data forkeratitis

treatment

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Aim of this study

To evaluate the clinical outcome of feline melting keratitis treated by accelerated CXL

after iontophoresis of riboflavin

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Inclusion criteria

Cats

Corneal melting

Poor response to

medical treatment

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Inclusion criteria

Epithelial loss

Cellular infiltration andstromal dissolution

Minimal Corneal thickness

> 300 µm (OCT)

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Protocol

Generalanesthesia

Cornealcleaning

Riboflavineimpregnation

ExpositionUVA 365 nm

Post-CXLtreatment

OCT

MedetomidineKetamine

Debris removalBact. sampling

PCR (FHV1)

RF 0,1% (Ricrolin TM)Iontophoresis5 min 1mA/min

30 mW/cm²3 min

5,4J/cm²

TobrexTM BID7 days

Accelerated protocol(KXLTM – Avedro)

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Iontophoresisdevice

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Follow-up

Inclusion D1 D4 D8 D15 D31

Pain and clinical score

Ulceration and infiltration surfaces

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Follow-up

0 : absent1 : light2 : moderate3 : severe

0 : absent1 : present

Clinical score(0-18)

Pain score (0-7)

Mucopurulent discharge

Corneal edema

Corneal vascularization

Conjunctivitis

Blepharitis

Uveitis

Prostration

Aggressive behavior

Blepharospasm

Enophtalmos

Photophobia

Ocular pruritus

Defense reaction

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Results Mean evolution time 40 days

Ulcer depth 21-54%

2/6 Persian

1/6 positive bacterial culture

1/6 FHV1 positive6 cats

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D1 D4 D8 D15 D310

2

4

6

8

10

12

Evolution ofAverage scores

Clinical score Pain score

D1 D4 D8 D15 D310

5

10

15

20

25

30

35

Evolution of Average surfaces (mm²)

Ulcer surface Infiltration surface

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Cornealvascularization

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Discussion : efficacy

Reduction of clinicaland pain score

Complete Epithelial healing

Resolution of corneal melting

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Comparison to conventional impregnation of RF

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Distribution of RF ?

Human and rabbit studies(fluorometry, histology, HPLC, OCT…)

Clear cornea Keratitis

Anterior stroma (150 µm) :Cinstillation= 2x Ciontophoresis

Less uniform diffusion

?

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Adverse effects of iontophoresis

Electric burns

Not observed in humanpatients with I < 4mA/min

High intensity current

Pain

High or low pH solutionsChemical burns

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Duration of treatment ?

Instillation30 min

Iontophoresis5 min

Irradiation30 min

Accelerated CXL3-10 min

Conventional protocolDuration > 1 hour

Ionto + acc. CXL protocolDuration < 20 min.

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Conclusion: IONTOPHORESIS

Results similar to conventional instillation

Resolution of corneal melting

No adverse reaction or pain

Reduction of procedure duration

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Perspectives: IONTOPHORESIS

Enhanced penetration of RF…

…or other therapeutic agents

?

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Thank you.


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