“post-operative follow-up” - a.i.che. associazione … of l’aquila surgical department eye...
TRANSCRIPT
University of L’Aquila
Surgical Department
Eye Clinic
Head: Prof. Leopoldo Spadea
University of L’Aquila
Surgical Department
Eye Clinic
Head: Prof. Leopoldo Spadea
L. Spadea, B.M. Saviano,
A. Fiasca, A. Di Gregorio
L. Spadea, B.M. Saviano,
A. Fiasca, A. Di Gregorio
Siena X LINKING Siena X LINKING
Siena, February, 2nd 2007 Siena, February, 2nd 2007
“Post-Operative Follow-up” “Post-Operative Follow-up”
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
X LINKING
Therapeutic management
�PRE-SURGERY
• ORAL SUPPLEMENTATION OF AMINO ACIDS
Since 5 days before surgery
GLYCINA
1.5g/day
L-PROLYNA
1.75g/day
L-LYSINA
0.25g/day
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
X LINKING
Therapeutic management
�Ist week post-surgery
(glycina, L-prol,L-lys) ×1 •Amino acids Oral solution
(hyaluronic acid 0.3%)
×6
•Tear substitute Preservative-free eye drops
(indomethacin 0.1%) × 3 •Anti-inflammatory N.S. Preservative-free eye drops
(netilmycin 0.3%) ×3
•Antibiotic Preservative-free eye drops
× 6 days Therapeutic CL
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
�2nd week post-surgery (only with a complete re-epithelialization)
X LINKING
Therapeutic management
(hyaluronic acid 0.3%) ×6 •Tear substitute Preservative-free eye drops
(indomethacin 0.1%) × 3 •Anti-inflammatory N.S. Preservative-free eye drops
(fluorometh. ac. 0.1%) ×3 •Corticosteroid Preservative-free eye drops
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
� 3rd week post-surgery
(hyaluronic acid 0.3%) ×6 •Tear substitute Preservative-free eye drops
(fluorometh. ac. 0.1%) ×2 •Corticosteroid Preservative-free eye drops
X LINKING
Therapeutic management
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
� 4th week post-surgery
(hyaluronic acid 0.3%) ×6 •Tear substitute Preservative-free eye drops
(fluorometh. ac. 0.1%) ×1 •Corticosteroid Preservative-free eye drops
X LINKING
Therapeutic management
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
Why we used Amino Acids? they are very important for the cell life
�Epithelial cell differentiation
�Epithelial healing
�Energy producing
�Tear and serum concentrations = 4:1
Re-epithelialization is possible
and qualitatively optimal
X LINKING
Therapeutic management
(Zieske JD, 1986;
Flachmeyer, 1963)
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
High concentration of Amino Acids in
serum and tear (in vivo and in vitro)
improves corneal re-epithelialization
(Vinciguerra P. JRS 2002; Rivaud C. J Fr Ophthalmol 1987)
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
�There is an extensive interaction between the
surface epithelial cells and the stromal
keratocytes regulated by molecular signs,
cytokines and growth factors. The corneal
repair system is not perfect and collagen
opaque can be produced.
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
Molecular regulation of epithelial cells and keratocytes
in corneal wound healing
Molecular regulation of epithelial cells and keratocytes
in corneal wound healing
Epithelial damage Epithelial damage
IL-1 IL-1 Fas-L Fas-L
Apoptosis of keratocytes Apoptosis of keratocytes
PDGF PDGF
Migration and
proliferation of
keratocytes
Migration and
proliferation of
keratocytes
Transformation and
persistence of myofibroblast
Transformation and
persistence of myofibroblast TGF-β TGF-β
Epithelial
healing
Epithelial
healing EGF, TGF-α, HGF,
KGF
EGF, TGF-α, HGF,
KGF
Wilson, 1996 - Mohan, 1997 - Kim, 1999 - Jester, 1999 - Schultz 1994 - Wilson 1999 Wilson, 1996 - Mohan, 1997 - Kim, 1999 - Jester, 1999 - Schultz 1994 - Wilson 1999
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
Why we used topical steroids? �Regulation of proliferation and migration of
keratocytes
�Regulation of transformation
keratocytes/activated fibroblasts
�Regulation of fibroblastic activity
Prevention and treatment of
corneal opacities
X LINKING
Therapeutic management
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
� Keratoconic corneas are anatomically and
functionally modified
(Chi HH. Am J Ophthalmol 1956)
Epithelium
•Thinning irregular
•Basal epithelial degenerated cells
•Basal membrane destruction
Bowman’s Membrane
•Fibrillar degeneration
•Fragmentation and progressive
destruction
Stroma
•Reduction of lamellae
•Collagen production
•Amiloid deposition
•Keratocytes in various stages of
differentiation
Epithelium
•Thinning irregular
•Basal epithelial degenerated cells
•Basal membrane destruction
Bowman’s Membrane
•Fibrillar degeneration
•Fragmentation and progressive
destruction
Stroma
•Reduction of lamellae
•Collagen production
•Amiloid deposition
•Keratocytes in various stages of
differentiation
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
�Rabbit eyes that
underwent to combined
riboflavin/UVA treatment
showed apoptosis of
keratocytes down to a
depth of 50µm in the
anterior stroma
(Cho KS. IOVS, 1999)
�Riboflavin by itself is not cytotoxic, but as
photosensitizer, it increases the absorption of UVA,
which induces the cellular damage
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
� Combined riboflavin/UVA
treatment showed a dose
dependent damage of stromal
keratocytes
� Cytotoxic irradiance
threshold (Lambert-Beer low)
0.49-0.77 mW/cm2 = 0.8-1.3
J/cm2
(Wollensak G. Cornea, 2004)
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
RESULTS
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
7 days 14 days 21 days 28 days
Absent
Light
Moderate
Severe
Epithelial Defects Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
Conjunctival Hyperemia
0
10
20
30
40
50
60
70
80
90
100
7 days 14 days 21 days 28 days
Absent
Light
Moderate
Severe
steroids
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
0
10
20
30
40
50
60
70
80
90
100
7 days 14 days 21 days 28 days
Absent
Light
Moderate
Severe
Subjective Discomfort steroid
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
Reduction of the
proteolytic
activity in
trabecular cells
Deposition of
components of extra
cellular matrix
Increase of
resistance
Steroids and IOP
The increase of IOP is reversible (Shaikh S. JCRS 2002)
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)
1212
1414
1515
1616
1313
1111
Intraocular Intraocular
Pressure Pressure
15.28
14.50
14.76
14.23
mm
Hg
mm
Hg
RESULTS
Preop. (26 pz)
1 Month (26 pz)
3 Months (26 pz)
6 Months (21 pz)
Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS (www.assocheratocono.org)