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A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, in the fulfillment of the requirements for the degree of Master of Medicine in Ophthalmology. Johannesburg, February 2017 / Purpose: To evaluate if corneal collagen crosslinking carried out on patients with keratoconus, slows down or halts the progression of keratoconus. To determine which group of keratoconus patients benefited most from the procedure. Methods: A retrospective record review of 41 eyes of 29 patients. Visual acuity and keratometry measurements were recorded for the involved eye pre-crosslinking and at 3 months and 6 months post-crosslinking. A comparison of these variables pre-crosslinking and at 6 months post-crosslinking was made to determine if there was a flattening of corneal curvature (keratometry readings) and an improvement in visual acuity. Patients were further divided into 3 groups of keratoconus, based on their keratometry readings (measured in diopters): mild keratoconus (≤47 diopters), moderate keratoconus (48 – 54 diopters) and advanced keratoconus (≥55 diopters), to determine which group of keratoconus had the best keratometry reduction readings. Results: After crosslinking took place on 41 eyes, the UnVA of 16(39%) eyes showed an improvement at 6 months, 17(41%) eyes showed no change and 8(20%) eyes showed a decrease in UnVA at 6 months, compared to pre-CXL values. For BCVA, 12(29%) eyes showed an improvement at 6 months, 18(44%) eyes showed no change and 11(27%) eyes showed a decrease in BCVA at 6 months, compared to pre-CXL values. Keratometry readings however showed that 23(56%) eyes had an average flattening of corneal curvature readings of 0.7 D and the remaining 18(44%) eyes showed more steepening (worsening) of the corneal curvature readings of 0.9 D after 6 months post-CXL. 30(73%) eyes had mild keratoconus, 7(17%) had moderate keratoconus and 4(10%) had advanced keratoconus. 19 of the 30 eyes in the mild keratoconus group (73%) showed an average flattening of corneal curvature of 0.6 D. 4 of the 7 eyes in the moderate keratoconus group (17%) showed an average flattening of corneal curvature of 0.7 D. All 4 patients in the advanced group (10%) had steepening (worsening) of their corneal curvatures with an average of 1.2 D. Conclusion: Corneal collagen crosslinking performed on keratoconus patients at least halts the progress of keratoconus. 6 months after CXL most patients showed minimal change from pre-CXL to 6 months in both visual acuity and keratometry. However a longer follow up period and larger sample size is needed to determine if vision and keratometry readings can improve significantly. / MT2017

Thesis (Ph. D.)--Ohio State University, 2004. / Title from first page of PDF file. Document formatted into pages; contains x, 100 p.; also includes graphics. Includes bibliographical references (p. 91-100).

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Abstract Type XIII collagen belongs to the group of transmembrane collagens. In this thesis the plasma membrane localisation and function of type XIII collagen have been studied using cell biological methods. Type XIII collagen was found to reside in focal adhesions. It appeared in these structures at a very early stage of their assembly and disappeared from them concurrently with focal adhesion proteins talin and vinculin. Insect cells expressing type XIII collagen showed an enhanced adhesion to certain matrix components. These localisation and adhesion data suggested that the function of type XIII collagen is related to cell adhesion. Supporting this, in tissues type XIII collagen was found to localise to cell-matrix and cell-cell adhesion structures. Type XIII collagen was found to be partly present in cholesterol-enriched membrane microdomains. With other membrane proteins this localisation has been shown to be linked to ectodomain shedding. The connection between the membrane microdomain localisation and the ectodomain shedding of type XIII collagen was also characterised, and it was demonstrated that manipulation of the cellular cholesterol level affected the efficiency of the ectodomain shedding. Additionally, insights into intracellular shedding of type XIII collagen in the Golgi apparatus were obtained. The study of type XIII collagen expression in human cancers revealed that it was enhanced especially in the desmoplastic cancer stroma. Since the increased expression of type XIII collagen was detected during the dysplastic stages, type XIII collagen may be involved in the early pathogenesis of cancer. The result indicated that type XIII collagen is involved in the matrix remodelling. In support of this, the cell culture experiments showed that the soluble type XIII collagen ectodomain altered the vitronectin-rich matrix unfavourable for cell adhesion and spreading. This may enhance cancer metastasis. Type XIII collagen expression was also induced in the remodelled stroma of keratoconus and corneal wounds. Data suggested that myofibroblasts were responsible for the increased expression of type XIII collagen in these situations. Therefore both in cancer and in the corneal pathologies studied, type XIII collagen expression was induced by the activated stromal cells.

M.Sc. (Biochemistry) / Dry eye disease (DED) and keratoconus (KC) continue to affect the quality of life of many South Africans (and elsewhere) and in the case of KC often leads to blindness. It is estimated that DED affects 14% to 33% of the population worldwide, while 1 in 2000 of the worlds population is affected by KC. However, details of the etiology of these diseases and their biochemical ‘fingerprint’ remain uncertain. In this study, emphasis was placed on the investigation of immunological proteins in the precorneal tear film of DED and KC subjects and meibomian lipids in these individuals. Tear fluid and meibum were collected from control, DED and KC volunteers. Control subjects were non-contact lens wearers and free from ocular diseases, whereas DED subjects were diagnosed by means of an ocular surface disease index (OSDI) questionnaire. DED subjects were divided into two groups: ‘moderate DED’ and ‘severe DED’ based on OSDI. KC subjects were diagnosed by the use of a slit-lamp biomicroscopy exam. Enzymelinked immunosorbent assays were performed to quantitate secretory immunoglobulin A (sIgA), tumour necrosis factor-alpha (TNF-á) and matrix metalloproteinase-1 (MMP-1) in the collected tear fluid. Meibum was analysed with proton nuclear magnetic resonance (1H-NMR) spectroscopy and Fourier transform infrared spectroscopy (FTIR). Multivariate data analyses (PCA) were used to extract interpretable information from the multidimensional data generated from the aforementioned techniques and used to build a broad picture of the general lipidomic differences between DED, KC and healthy subjects. Tear levels of sIgA and MMP-1 were significantly decreased in patients with KC compared to control. In contrast, the tears of severe DED subjects were characterised by higher levels of TNF-á and lower levels of sIgA. In subjects with moderate DED, TNF-á levels were significantly elevated. The results of this study re-emphasize that KC and DED individuals are associated with differential expression of specific tear proteins and support the view that the severity of DED is reflected in the levels of immunological proteins present in basal tears. Differences in the chemical composition of meibum from subjects with severe DED and KC compared to control were observed, more specifically in the aliphatic region of 1H-NMR spectra and C-C rocking region of FTIR spectra. The results therefore point towards the saturated components of fatty acids (and their chemical environments) as key targets for future investigations to elucidate compositional differences between DED, KC and healthy meibum.

Keratoconus is an eye disease that manifests as progressive thinning and steepening of the cornea. While there is no singular cause for keratoconus, both genetic and environmental factors have been proposed to influence the onset and progression. This review aims to explore the pathogenesis, identification, classification, and treatment of this corneal disease. Since early detection is essential in treatment success, various imaging methods have been developed to analyze multiple aspects of the corneal surface. Keratoconus can be identified with a reflection based system, elevation based system, as well as a combination of the two. Once diagnosed, the Belin ABCD classification can be used to monitor the stage of keratoconus and treat it accordingly. Current treatment options prioritize halting disease progression with corneal crosslinking before considering visual rehabilitation. Individuals with mild keratoconus can improve vision with non-surgical options such as spectacles and contact lenses. As the disease progresses, patients may need surgical intervention such as intrastromal corneal ring segments or photorefractive keratectomy (PRK). In advanced keratoconus cases, the cornea may need to be replaced with partial or full-thickness keratoplasty. The goal of this review is to evaluate the more current treatment options that have become available today.

Este trabalho é parte de um projeto destinado a criar um equipamento médico, para ser aplicado com o protocolo de crosslinking de colágeno corneano, para o tratamento do ceratocone, do qual resultou o desenvolvimento de um sistema de irradiação UV-A de córneas para a aplicação clínica oftalmológica. O sistema desenvolvido neste trabalho consiste de um circuito de malha fechada, que estabiliza a potência luminosa emitida (com erro global, após a calibração, menor que 20% durante a emissão), possibilita seu ajuste até 5 mW (6,366 mW/\'CM POT. 2\') e permite selecionar a duração da emissão entre 10 s - 30 min. O sistema irradia com pico em 365 nm \'+ OU -\' 15 nm sendo que o design óptico proporciona spots homogêneos para três diâmetros selecionáveis: 10 mm; 8 mm; e 6 mm. O software desenvolvido tem a função de controlar todo o procedimento médico do crosslinking corneano, além de detectar falhas no sistema. Os resultados obtidos neste trabalho possibilitaram a criação de um equipamento robusto, flexível e estável, capaz de competir diretamente com os produtos internacionais comercializados mundialmente. Até a presente data tem-se conhecimento de apenas dois produtos, para mesma finalidade, comercializados em todo mundo, sendo ambos de empresas européias. Desta maneira, o sistema descrito nesta dissertação integra hoje o único aparelho de crosslinking totalmente projetado e produzido com tecnologia nacional. / This work is part of a project to create a medical device to be applied with the protocol for corneal collagen crosslinking for the treatment of keratoconus, which resulted in the development of an UV-A system for corneas irradiation for ophthalmic clinical application. The developed system consists of a closed loop circuit, which stabilizes the emitted light power (with global error, after calibration, less than 20% over the issue), allows its adjust up to 5 mW (6.366 mW/\'CM POT.2\') and allows to select the emission duration between 10 s - 30 min. The system irradiates with a peak wave length at 365 nm \'+ OU -\' 15 nm and the optical design provides homogeneous spots for three selectable diameter: 10 mm, 8 mm and 6 mm. The developed software has the function of controlling the medical procedure of corneal crosslinking, and detect system failures. The results of this work enabled the creation of a robust equipment, flexible, and stable that can compete directly with international products marketed worldwide. Until the present date, there has been aware of only two products for the same purpose, marketed worldwide, both from European companies. Thus, the system described in this dissertation integrates now the only unit of crosslinking completely designed and produced with national technology.

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.

Este trabalho é parte de um projeto destinado a criar um equipamento médico, para ser aplicado com o protocolo de crosslinking de colágeno corneano, para o tratamento do ceratocone, do qual resultou o desenvolvimento de um sistema de irradiação UV-A de córneas para a aplicação clínica oftalmológica. O sistema desenvolvido neste trabalho consiste de um circuito de malha fechada, que estabiliza a potência luminosa emitida (com erro global, após a calibração, menor que 20% durante a emissão), possibilita seu ajuste até 5 mW (6,366 mW/\'CM POT. 2\') e permite selecionar a duração da emissão entre 10 s - 30 min. O sistema irradia com pico em 365 nm \'+ OU -\' 15 nm sendo que o design óptico proporciona spots homogêneos para três diâmetros selecionáveis: 10 mm; 8 mm; e 6 mm. O software desenvolvido tem a função de controlar todo o procedimento médico do crosslinking corneano, além de detectar falhas no sistema. Os resultados obtidos neste trabalho possibilitaram a criação de um equipamento robusto, flexível e estável, capaz de competir diretamente com os produtos internacionais comercializados mundialmente. Até a presente data tem-se conhecimento de apenas dois produtos, para mesma finalidade, comercializados em todo mundo, sendo ambos de empresas européias. Desta maneira, o sistema descrito nesta dissertação integra hoje o único aparelho de crosslinking totalmente projetado e produzido com tecnologia nacional. / This work is part of a project to create a medical device to be applied with the protocol for corneal collagen crosslinking for the treatment of keratoconus, which resulted in the development of an UV-A system for corneas irradiation for ophthalmic clinical application. The developed system consists of a closed loop circuit, which stabilizes the emitted light power (with global error, after calibration, less than 20% over the issue), allows its adjust up to 5 mW (6.366 mW/\'CM POT.2\') and allows to select the emission duration between 10 s - 30 min. The system irradiates with a peak wave length at 365 nm \'+ OU -\' 15 nm and the optical design provides homogeneous spots for three selectable diameter: 10 mm, 8 mm and 6 mm. The developed software has the function of controlling the medical procedure of corneal crosslinking, and detect system failures. The results of this work enabled the creation of a robust equipment, flexible, and stable that can compete directly with international products marketed worldwide. Until the present date, there has been aware of only two products for the same purpose, marketed worldwide, both from European companies. Thus, the system described in this dissertation integrates now the only unit of crosslinking completely designed and produced with national technology.