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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 479-480

Crosslinking as a treatment option for lipid keratopathy


Private Practice, Buenos Aires, Luis M. Campos 250 1.O. PC 1426, Argentina

Date of Submission25-Nov-2020
Date of Acceptance27-Jan-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Esteban Santiago
Private Practice, Buenos Aires, Luis M. Campos 250 1-O. PC 1426
Argentina
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3487_20

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  Abstract 


The purpose of this case report was to present a case of a patient treated with corneal collagen crosslinking for keratoconus with the secondary benefit of improvement of an established lipid keratopathy. After one session of crosslinking in both eyes, a marked regression of the lipid keratopathy in OS was observed in the 9th month follow-up visit. To the best of our knowledge, this is the first case report of lipid keratopathy improvement with crosslinking treatment. This can be another option when treating this condition in order to prevent visual loss and more invasive treatments.

Keywords: Cornea, crosslinking, lipid keratopathy


How to cite this article:
Santiago E. Crosslinking as a treatment option for lipid keratopathy. Indian J Ophthalmol Case Rep 2021;1:479-80

How to cite this URL:
Santiago E. Crosslinking as a treatment option for lipid keratopathy. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 28];1:479-80. Available from: https://www.ijoreports.in/text.asp?2021/1/3/479/320079



Lipid keratopathy is a lipidic deposition in the corneal stroma as a consequence of stromal neovascularization and lipid leakage from the invading vessels. It can be primary or more frequently secondary after episodes of prolonged corneal inflammation, infection, trauma, etc., On slit-lamp examination, yellowish opacities on the corneal stroma surrounding blood vessels are seen. We report a case of a patient receiving corneal collagen crosslinking (CXL) for stabilization of keratoconus with a secondary benefit of regression of lipid keratopathy.


  Case Report Top


A 29-year-old woman presented to the clinic for treatment of progressive keratoconus OU previously diagnosed elsewhere. She did not receive any previous treatments and referred progressive visual loss. She had a past ocular history of ocular allergies never treated and contact lens overuse that she had discontinued 3 years ago. On examination, her BCVA was 20/30 OU. Slit-lamp examination demonstrated an ectatic cornea with inferior paracentral thinning OU, Vogt's striae OU, peripheral 360° corneal pannus in both eyes. In the left eye an inferotemporal anterior stromal corneal vascularization with lipid exudation from 3 to 6 o'clock approaching the visual axis was present [Figure 1]. Dilated fundus examination was normal. We proceeded to do Sheimpflug imaging (Pentacam; Oculus GmbH, Wetzlar, Germany) which confirmed the corneal ectasia and corneal collagen crosslinking OU was performed.
Figure 1: Lipid keratopathy affecting the inferotemporal corneal quadrant OS

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CXL was performed in the operating room under topical anesthesia. Prior to the procedure, 0.5% moxifloxacin and 2% pilocarpine drops were instilled, and the eyes prepped with povidone-iodine 5% solution. Topical anesthetic drops were instilled as needed.

The corneal epithelium was removed using a blunt spatula and multiple pachymetric measures were taken using ultrasound pachymetry (Reichert® iPac®) to confirm the desired thickness. Riboflavin 0.1% (Vibex; Avedro Inc., Waltham, MA) drops were instilled every 2 min for a total of 10 min. We used the Avedro KXL® system (Avedro Inc. Boston, MA) performing a pulsed treatment (1 sec on, 1 sec off) for a total radiation time of 4 min and a total energy of 7.2 J/cm2.

Post-operative medications where prednisolone acetate 1% in a tapering dose for 3 weeks and 0.5% moxifloxacin drops for 1 week. At the end of the surgery a bandage contact lens was placed in both eyes and was removed one week after the procedure when the cornea was fully epithelialized.

At the 3-month follow-up, the lipid keratopathy was stable, but no regression was noticed. At the 6-month follow-up, we noticed a regression of the lipidic deposits and 9 months after the surgery a striking improvement was seen. [Figure 2]. It has been 16 months since the treatment was performed and the lipid keratopathy has not recurred. During the follow-up period, she was using only non-preserved artificial tears (sodium hyaluronate 0.3 g/100 ml) and antiallergic medication (olopatadine 0.1%). The keratoconus stabilized not showing any signs of progression since the CXL was done, and BCVA of 20/30 OU has not changed after recovering from surgery. She did not restart contact lens use after the procedure.
Figure 2: Regression of lipid keratopathy OS. We can observe ghost vessels without lipid deposits

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  Discussion Top


Several options have been reported to treat this potentially sight-threatening condition. All of them aim to eradicate the vascularization in an attempt to stop the lipid exudation.

Medical treatment can be attempted during the acute setting using NSAID's or topical steroid medications. During the chronic phase, success has been reported with the use of topical, subconjunctival, or intrastromal anti-VEGF medications like bevacizumab or ranibizumab. This treatment usually requires repeated applications and different doses have been reported.[1]

Fine needle diathermy was originally described inserting a 3/4 circle side cutting needle attached to a 10-0 nylon suture parallel to the vessel to be cauterized, and a unipolar diathermy unit was used to transmit energy through the needle until the corneal stroma was blanched and the vessel occluded.[2]

Photodynamic therapy is another option using topical or systemic photosensitizing agents as verteporfin or fluorescein and then activating it by a specific wave light inducing the creation of reactive oxygen species that occlude the corneal vessels by inducing microvascular thrombosis.[3]

Severe cases may require a more invasive surgical intervention like a keratoplasty.

CXL was investigated in an in vivo rat model experiment in which the researchers induced inflammatory corneal neovascularization and treated the corneas with CXL 3 days after the induction. They showed that CXL treatment can temporarily inhibit corneal inflammatory hemangiogenesis during the acute episode.[4] The effect resembles other photodynamic therapies inducing vessel occlusion secondary to reactive oxygen species production.[5]


  Conclusion Top


To the best of our knowledge, this is the first publication demonstrating the benefit of its use in cases of established lipid keratopathy. Besides inducing occlusion of the vessels, we theorize it can accelerate the absorption of the lipidic deposits. This is a safe technique that we can add to our treatment options when dealing with cases of lipid keratopathy preventing visual loss and more invasive procedures. We understand this finding has to be confirmed by a trial in a larger population.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Doctor PP, Bhat PV, Foster CS. Subconjunctival bevacizumab for corneal neovascularization. Cornea 2008;27:992-5.  Back to cited text no. 1
    
2.
Pillai CT, Dua HS, Hassain P. Fine needle diathermy occlusion of corneal vessels. Invest Ophthalmol Vis Sci 2000;41:2148-53.  Back to cited text no. 2
    
3.
Brooks BJ, Ambati BK, Marcus DM, Ratanasit A. Photodynamic therapy for corneal neovascularization and lipid degeneration. Br J Ophthalmol 2004;88:840.  Back to cited text no. 3
    
4.
Zhu Y, Li L, Reinach PS, Li Y, Ge C, Qu J, et al. Corneal collagen cross linking with riboflavin and UVA regulates hemangiogenesis and lymphangiogenesis in rats. Invest Ophthalmol Vis Sci 2018;59:3702-12.  Back to cited text no. 4
    
5.
Shehadeh MM, Akkawi MT, Diakonis VF, Aghbar AA, Shanab AA. Extensive corneal enovascularization treatment by ultraviolet corneal collagen cross linking. Eur Ophthalmic Rev 2017:11:62-4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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