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• W4289778759 abstract "Corneal collagen -cross-linking (CXL) as we know is a procedure to enhance the biomechanical strength of the cornea, thereby, halting the progression of corneal weakening in Keratoconus (KC). CXL has been in vogue for around two decades now, and along with newer contact lens developments, it has helped considerably in reducing the rates of keratoplasty. CXL is known to have complications such as post-CXL haze or scar, sterile infiltrates, failure, excessive flattening, and endothelial damage, among a few others. A lot of cornea practices across the world are confidently performing CXL as these complications are relatively low. However, in this upcoming era of personalized medicine, there are still a lot of unanswered questions about CXL. Predicting which kind of patients are likely to develop a haze or scarring or excessive or no flattening or failure post-CXL is not possible yet. We do not have the ability to predict the outcomes or complications after CXL to personalize care for different patients. Variables affecting the assessment of outcomes Before we delve into the known aspects that could determine the outcomes of CXL, it is very important to understand the variables that can affect the assessment of the outcomes. Assessment of topographic flattening or tomographic stability is highly dependent on the device used to measure and its repeatability of the topo/tomographic measurements.[1] Alterations in the tear film[2] and changes in corneal densitometry (haze)[3] are also important factors that alter the measurement of keratometry and pachymetry. Another well-understood variable that can alter the topography is epithelial morphology.[4] A combination of the above factors or even one of the above in isolation can falsely depict progression or mask progression post-CXL. During follow-ups, factors like the use of scleral lenses before imaging the cornea should also be taken into consideration as it can alter the topography and pachymetry.[5] In pediatric cases or patients with developmental delay, it may not be possible to obtain repeatable scans, and the overall clinical impression may be important in determining outcomes. Hence, it is important for both clinicians and researchers to at least perform three scans using their tomo/topographers, utilize ASOCT (anterior segment Ocular Coherence Tomography [OCT]), and also include clinical parameters whenever they need to ascertain a good or bad outcome following CXL. Predicting Outcomes Post-CXL At present, there are only a few factors that are known to predict visual and topographic outcomes following CXL. In general, it is known that CXL failure is higher among pediatric patients and those with active ocular allergy/eye rubbing.[6] Higher pre-operative keratometry (Kmax) and lower pre-op Best Corrected Visual Acuity (BCVA) have been shown to result in greater flattening and visual gain.[7] Central cones (Kmax within 3 mm from the center) usually have better flattening compared to peripheral cones (beyond 3 mm).[8] There have only been a few studies on the above, and the overall predictive ability is quite low. Apart from patient factors, the type of CXL is also known to help in predicting outcomes. Though all forms of epi-off CXL have been shown to halt progression, there are differences in visual and topographic outcomes. This is explained by the oxygen availability during CXL. A longer duration of UV time ensures better O2 availability/replenishment compared to a shorter duration. Even if the total energy is the same, the standard Dresden protocol (3 mW/cm2) for 30 min produces better flattening than the accelerated protocols. Among the accelerated protocols, studies have shown that reducing the fluence time to less than 5 min may not lead to good CXL outcomes.[9] Future Directions Research in the last decade has brought about so many newer perspectives to understanding CXL outcomes from a molecular and ultrastructural imaging point of view. Pre-operatively higher levels of tear inflammatory mediators like MMP9 (Matrix metalloproteinases) and certain interleukins correlate with poorer keratometric flattening and visual outcomes post-CXL.[10] Specific systemic inflammatory markers have also been shown to have a good predictive ability for KC.[11] Ocular levels of endogenous cross-linking enzyme Lysyl oxidase (LOX) have a positive correlation with keratometric flattening.[12] LOX enhancer eye drops are now under investigation,[13] and they could be utilized in a customized way in patients with lower ocular LOX levels to obtain better keratometric and visual outcomes post-CXL. Other newer biomarkers of oxidative phosphorylation and metabolomic markers are being studied concerning KC and progression.[14] Newer point-of-care diagnostic biomarkers kits are being studied that can help assess tear levels of several of the above molecular markers at the bedside without the need for costly molecular laboratories. Ultrastructural collagen density and orientation analysis using newer polarization-sensitive OCT will also be an important predictor of topographic outcomes soon.[1015] Overall, in this era of artificial intelligence and big data, a combination of the above biomarkers will pave the way for personalized medicine in the field of KC and CXL. This will help in customizing the approach to managing KC in different patient sub-groups." @default.
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• W4289778759 date "2022-01-01" @default.
• W4289778759 modified "2023-10-18" @default.
• W4289778759 title "Commentary: Predictors of outcomes after corneal collagen cross linking: Present, and future directions" @default.
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• W4289778759 doi "https://doi.org/10.4103/ijo.ijo_882_22" @default.
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