Patients with keratoconus exhibit a biomechanically weakened cornea which loses its proper shape and thereby loses its refractive power. It is usually progressive, beginning with poor visual acuity and eventually necessitating corneal transplant. The cause is likely multifactorial, but involves the weakening of the collagen structure of the corneal stroma, resulting in characteristic thinning and conical distortion. Collagen cross-linking is the first treatment to demonstrate efficacy in halting the progression of the disease. UVA radiation is used to activate riboflavin and photochemically induce cross-linking reactions among collagen and proteoglycans within the stroma, thereby stiffening and strengthening the tissue, and preventing further loss of shape. The current standard treatment, which gained FDA approval less than one year ago, has proven to be efficacious, but has been modified very little since pioneering experiments. Optimization aims to maximize clinical effect while maintaining safety and reducing total treatment time. Major procedural modifications involve increasing light intensity over a reduced exposure duration, and varying the method of delivering riboflavin to the stroma. Theoretical modeling, informed by and scaled to experimental results, has the potential to predict clinical effect as a function of treatment parameters, enabling tailoring of individual treatments to the specific needs of each patient.

The aim of this project was to analyse the cellular and biomechanical changes after collagen cross-linking (CXL) treatment on postmortem eye-banked human corneas using different UVA intensities and repeated treatments, and to explore the effects of standard collagen cross-linking on keratoconic corneal buttons, in-vitro. Preliminary studies were conducted to assess the feasibility of using eye-banked corneas to assess the effects of collagen cross-linking, and the possibility of applying scanning acoustic microscopy (SAM) to measure the speed of sound/elasticity of corneal tissue. Eye-banked human corneas were successfully cross-linked allowing the effects of CXL to be studied in-vitro and SAM was used effectively to determine the mechanical properties of corneal tissue at different depths. The results of two experiments comparing UVA intensity suggested that no statistically significant difference was found in the histological changes or in the induced stiffness after applying low and high intensity cross-linking on normal human corneas. However, the number of apoptotic cells was found to be significantly less but deeper into the posterior stroma in the high intensity cross-linked corneas. Collectively, these results confirmed the safety and efficacy of both techniques with the advantage of reducing the treatment time using the higher-intensity treatment. In another in-vitro study, keratoconic corneal tissue was used. Different histological and biomechanical outcomes were found between the cross-linked and control keratoconic tissue. The effects of cross-linking were found to penetrate deeper in the keratoconic tissue compared to in the normal corneal tissue found in previous studies. This could be due to the altered collagens and extracellular matrix of the keratoconic corneas, as they were taken from patients in advanced stages of the disease. This study confirmed the importance of having corneal thickness of at least 400μm after epithelial debriding to maintain the endothelial cell density and integrity. Finally, further cross-links were induced when collagen cross-linking treatment was repeated. However, repeating cross-linking three times a deeper cell death close to the endothelium was noticed which suggests that multiple treatments could be unsafe. Additionally, lower speed of sound than the cross-linking twice. This could be due to elimination of the induced cross-links by longer exposure to UVA irradiation. In conclusion, eye-banked human corneas were successfully used to evaluate the effects of cross-linking treatment and repeated treatment. Additionally, keratoconic corneal buttons were used to study the effects of collagen cross-linking in-vitro. This model of using eye-banked human corneas and keratoconic corneal tissue enabled us to study the effects of cross-linking treatment using different protocols and the effects of repeated treatment, and it could ultimately be used to compare the results with in-vivo studies.

We investigated attachment and migration of human retinal pigment epithelial cells (primary, SV40-transfected and ARPE-19) on nanoscopically defined, two-dimensional matrices composed of parallel-aligned collagen type I fibrils. These matrices were used non-cross-linked (native) or after riboflavin/UV-A cross-linking to study cell attachment and migration by time-lapse video microscopy. Expression of collagen type I and IV, MMP-2 and of the collagen-binding integrin subunit α2 were examined by immunofluorescence and Western blotting. SV40-RPE cells quickly attached to the nanostructured collagen matrices and aligned along the collagen fibrils. However, they disrupted both native and cross-linked collagen matrices within 5 h. Primary RPE cells aligned more slowly without destroying either native or cross-linked substrates. Compared to primary RPE cells, ARPE-19 cells showed reduced alignment but partially disrupted the matrices within 20 h after seeding. Expression of the collagen type I-binding integrin subunit α2 was highest in SV40-RPE cells, lower in primary RPE cells and almost undetectable in ARPE-19 cells. Thus, integrin α2 expression levels directly correlated with the degree of cell alignment in all examined RPE cell types. Specific integrin subunit α2-mediated matrix binding was verified by preincubation with an α2-function-blocking antibody, which impaired cell adhesion and alignment to varying degrees in primary and SV40-RPE cells. Since native matrices supported extended and directed primary RPE cell growth, optimizing the matrix production procedure may in the future yield nanostructured collagen matrices serving as transferable cell sheet carriers. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

We investigated attachment and migration of human retinal pigment epithelial cells (primary, SV40-transfected and ARPE-19) on nanoscopically defined, two-dimensional matrices composed of parallel-aligned collagen type I fibrils. These matrices were used non-cross-linked (native) or after riboflavin/UV-A cross-linking to study cell attachment and migration by time-lapse video microscopy. Expression of collagen type I and IV, MMP-2 and of the collagen-binding integrin subunit α2 were examined by immunofluorescence and Western blotting. SV40-RPE cells quickly attached to the nanostructured collagen matrices and aligned along the collagen fibrils. However, they disrupted both native and cross-linked collagen matrices within 5 h. Primary RPE cells aligned more slowly without destroying either native or cross-linked substrates. Compared to primary RPE cells, ARPE-19 cells showed reduced alignment but partially disrupted the matrices within 20 h after seeding. Expression of the collagen type I-binding integrin subunit α2 was highest in SV40-RPE cells, lower in primary RPE cells and almost undetectable in ARPE-19 cells. Thus, integrin α2 expression levels directly correlated with the degree of cell alignment in all examined RPE cell types. Specific integrin subunit α2-mediated matrix binding was verified by preincubation with an α2-function-blocking antibody, which impaired cell adhesion and alignment to varying degrees in primary and SV40-RPE cells. Since native matrices supported extended and directed primary RPE cell growth, optimizing the matrix production procedure may in the future yield nanostructured collagen matrices serving as transferable cell sheet carriers. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

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Le cross-linking du collagène cornéen (CXL) est une cornéoplastie mini-invasive reposant surun concept biomécanique difficile à objectiver physiquement et dont les preuves del’efficacité thérapeutique sont d’interprétation complexe. Les principes, les nuances et lesrésultats du CXL sont colligés dans cette thèse afin de valider l’intérêt du modèleexpérimental choisi pour tester la pertinence de notre travail de recherche sur l’élastographiecornéenne par ondes de cisaillement.Notre cheminement expérimental a abouti au choix du modèle de CXL trans-épithélial (TCXL)assisté par iontophorèse (I-CXL), réalisé in vivo, sur oeil de lapin. Les mesuresélastographiques obtenues après euthanasie ont ainsi pu démontrer une modificationsignificative du profil d’élasticité de la cornée après CXL, testé successivement de manièredynamique et statique.Nos résultats confirment donc l’efficacité biomécanique instantanée du I-CXL et donnent uneidée plus précise de la valeur de la photo-polymérisation du tissu cornéen isolée desphénomènes liés à la cicatrisation. Les enjeux technologiques de l’élastographe cornéen paranalyse des ondes de cisaillement ont pu être définis afin de développer une stratégie de miseen oeuvre d’un système pertinent pour la pratique clinique. / Corneal collagen cross-linking (CXL) is a kind of minimaly invasive corneoplasty mainlybased on a biomechanical concept, which is very difficult to measure physically, and whichthe therapeutic efficacy understanding is complex.Principles, different protocols and resultsare summarized in this thesis in order to illustrate the usefulness of the experimental modelchosen in our experimentations about elastographic corneal shear wave imaging.The pathway of our experimental work have led to the choice of trans-epithelial CXL (TCXL)assisted by iontophoresis (I-CXL), performed in vivo, on rabbits eyes. Elastographicmeasurements we obtained after animals euthanasia have shown a significant change of thecorneal elasticity profile after CXL, successively tested in a dynamic and in a static fashion.Our results do confirm the biomechanical efficacy of the I-CXL procedure and give a moreprecise idea of the sole photo-polymerization effect by avoiding any confounding healingconcern. Technological issues for corneal elastography with shear wave imaging have beenraised in this thesis to develop a realistic strategy for the launch of a clinically useful device.