Ocular Immunology and Inflammation

ISSN: 0927-3948 (Print) 1744-5078 (Online) Journal homepage: http://www.tandfonline.com/loi/ioii20

Subclinical Inflammatory Response: Accelerated

versus Standard Corneal Cross-Linking

Alireza Hedayatfar, Hassan Hashemi, Gholamhossein Aghaei, Nahid Ashraf

& Soheila Asgari

To cite this article: Alireza Hedayatfar, Hassan Hashemi, Gholamhossein Aghaei, Nahid Ashraf &
Soheila Asgari (2018): Subclinical Inflammatory Response: Accelerated versus Standard Corneal
Cross-Linking, Ocular Immunology and Inflammation, DOI: 10.1080/09273948.2017.1420201

To link to this article: https://doi.org/10.1080/09273948.2017.1420201

Published online: 15 Jan 2018.

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Ocular Immunology & Inflammation, 2018; 00(00): 1–4
© Taylor & Francis Group, LLC
ISSN: 0927-3948 print / 1744-5078 online
DOI: 10.1080/09273948.2017.1420201

ORIGINAL ARTICLE

Subclinical Inflammatory Response: Accelerated

versus Standard Corneal Cross-Linking
1,2
Alireza Hedayatfar, MD , Hassan Hashemi, MD3, Gholamhossein Aghaei, MD
2
, Nahid Ashraf1,
and Soheila Asgari, PhD4

1
Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran, 2Rassoul Akram Hospital, Iran
University of Medical Sciences, Tehran, Iran, 3Noor Research Center for Ophthalmic Epidemiology, Noor Eye
Hospital, Tehran, Iran, and 4Department of Epidemiology and Biostatistics, School of Public Health, Tehran
University of Medical Sciences, Tehran, Iran

ABSTRACT
Purpose: To compare the subclinical inflammatory response (as measured by anterior chamber flare)
induced after standard (3 mW/cm2, 30 min) and accelerated (18 mW/cm2, 5 min) corneal cross-linking
(CXL).
Methods: In this comparative, non-randomized study, patients with progressive keratoconus who underwent
standard or accelerated CXL were studied. Laser flare photometery (FM-600; Kowa, Tokyo, Japan) was used to
measure anterior chamber flare preoperatively and at 1 week, 1 month, 3 months, and 6 months after the
procedure.
Results: Sixty eyes of 60 patients were studied; 30 eyes in each group. Mean baseline flare values were 4.15 ± 1.19
and 4.57 ± 2.17 ph/ms in standard and accelerated groups, respectively (p = 0.228).and after surgery increased in
all follow-up measurements in the both groups similarly (P > 0.05).
Conclusion: Both standard and accelerated CXL results in induction of a subclinical inflammatory response that
persists up to 6 month. The response was similar between the two groups.
Keywords: Accelerated cross-linking, flare, standard cross-linking, subclinical inflammation

INTRODUCTION METHOD AND MATERIALS

To date, many short-term and long-term studies
have demonstrated the safety and efficacy of stan-
dard and accelerated corneal cross-linking (CXL)
protocols in the treatment of progressive keratoco-
nus 1–4; however, to the best of our knowledge, no
study has compared anterior chamber flare changes
induced after these procedures. Studies have shown
that surgical procedures such as intraocular lens
implantation and laser refractive surgeries are asso-
ciated with changes in anterior chamber flare.5–8 In
this study, we aimed to study and compare changes
in anterior chamber flare as an indicator of the
amount of blood–aqueous barrier disruption after
the two commonly used protocol for CXL: standard
versus accelerated.
In this comparative, non-randomized study, patients
with progressive keratoconus who underwent standard
or accelerated CXL were studied. In addition, 10 healthy,
virgin eyes were considered as control. Inclusion criteria
were the diagnosis of progressive keratoconus based on
corneal imaging, age between 15 and 35 years, maxi-
mum keratometry (Kmax) less than 55 diopters (D),
and central corneal thickness (CCT) of at least 450 µm.
Exclusion criteria were any history of ocular trauma or
surgery, uveitis, systemic inflammatory diseases, dia-
betes, and recent use of topical or systemic medication.
The methods and objectives of the study were
explained to eligible subjects, and participants were
enrolled after obtaining written informed consents.
The study was reviewed and approved by Noor

Correspondence: Hassan Hashemi, MD, Noor Ophthalmology Research Center, Noor Eye Hospital, #96 Esfandiar Blvd., Vali’asr Ave., Tehran
196865311, Iran E-mail: research@norc.ac.ir.

1
2 A. Hedayatfar et al.
Institutional Review Board. The study adhered to the
tenets of the Declaration of Helsinki at all stages.
Before the procedure, all patients had routine vision
testing, ophthalmic examinations, and corneal imaging
using Pentacam (Oculus Optikgeräte GmbH, Wetzlar,
Germany), as well as measurement of anterior chamber
flare with laser flare photometry. Examinations were
repeated at 1 week, 1 month, 3 months, and 6 months
after CXL. The time (number of days) from surgical
procedure to contact lens removal was recorded and
referred as “epithelium healing duration.”
Quantitative Measurement of Anterior
Chamber Flare
Laser flare photometry (FM-600; Kowa, Tokyo, Japan)
was used to measure anterior chamber flare. Seven
anterior chamber flare readings in the lower third of
the anterior chamber with a background scatter less
than 10% were measured and recorded. The lowest
and highest readings were excluded, and the average
of the remaining five readings was used in the analysis.
Surgical Techniques
In the standard group, CXL was performed using the
method described by Wollensak et al. 9 After administer-
ing local anesthesia, the epithelium of the central 9 mm of
the cornea was manually removed. Then, riboflavin 0.1%
drops in dextra 20% (Streuli Pharma, Uznach,
Switzerland) were instilled onto the corneal surface. UV
irradiation at a wavelength of 370 nm and power of 3
mW/cm2 was then administered using the UVX system
(IROC, Zürich, Switzerland). Riboflavin instillation was
repeated every 3 min during the 30 min of irradiation. At
the end of this stage, the corneal surface was rinsed with
sterile balanced saline solution and a soft bandage contact
lens (Night & Day, Ciba Vision, Duluth, GA) was placed.
The postoperative regimen included Levofloxacin 0.5%
(Oftaquix, Santen, Japan) and betamethasone 0.1%
(Betasonit, Sina darou, Iran) eye drops four times daily,
and preservative free artificial tears as required. Patients
were examined on every postoperative day until the
epithelial healing was completed. After removing the
lens, levofloxacin was discontinued and betamethasone
was kept four times a day for another week. In the accel-
erated CXL group, all the steps were the same as the
standard group, except that irradiation was done at
18 mW/cm2 power for 5 min using the Peschke UV sys-
tem (Meditrade GmbH, Waldshut-Tiengen, Germany).
Statistical Analysis
Six-month changes of flare were compared between
the standard and accelerated groups using repeated
measures analysis of variance. Baseline values com-
pared between the two groups using the chi-square
test. The significance level was set at 0.05.
RESULTS
Sixty eyes of 60 patients were studied: 30 eyes in
standard CXL group and 30 eyes in accelerated CXL
group. Since the study was non-randomized, the two
groups were matched based on baseline demographics
and topographic indices (Table 1).
Mean baseline flare values were 4.15 ± 1.19 and
4.57 ± 2.17 ph/ms in standard and accelerated groups,
respectively (p = 0.228). In the group of healthy eyes,
mean flair was 3.12 ± 0.75 ph/ms, and was significantly
different from preoperative flair levels in the standard
(P = 0.002) and accelerated (P = 0.016) CXL groups.
In both groups, the flare values had a significant
increase at 1 week, 1 month, 3 months, and 6 months
follow-ups compared to baseline by repeated measures
ANOVA and bonferroni post hoc (all P < 0.05). The mean
increased values compared to baseline in the standard and
accelerated CXL groups were, respectively, 1.73 ± 2.38 and
2.57 ± 6.32 ph/ms (P = 0.532) at 1 week, 1.72 ± 1.85 and
2.02 ± 3.98ph/ms (P = 0.699) at 1 month, 2.46 ± 2.18 and
2.20 ± 3.42ph/ms (P = 0.746) at 3 months, and 1.83 ± 2.24
and 2.21 ± 353ph/ms (P = 0.702) at 6 months (Table 2).
No complications were observed during or after
surgery. Mean days elapsed from surgical procedure
to contact lens removal (epithelial healing duration)
were 3.07 ± 1.75 and 2.61 ± 1.39 in standard and
accelerated group, respectively (p = 0.464).
At 6 months, uncorrected distance visual acuity and
corrected distance visual acuity were similarly
improved in both standard and accelerated CXL
groups (both P < 0.05). Kmax and Kmean were similarly
unchanged in both groups (all P > 0.05).
DISCUSSION
Slight increase of aqueous flare following accelerated
CXL in patients with keratoconus was reported
TABLE 1. Baseline parameters in the two groups of keratoconus
patients treated with standard and accelerated corneal cross-
linking (CXL).
Standard CXL Accelerated CXL P-value*
Age (year) 25.13 ± 4.25 24.21 ± 3.98 0.124
Sex (female) 54.10% 55.4% 0.253
Kmax (D) 46.75 ± 3.10 47.04 ± 2.64 0.591
Kmin (D) 43.97 ± 2.59 44.30 ± 2.16 0.690
CCT (micron) 488.6 ± 35.2 490.7 ± 33.3 0.820
CCT, central corneal thickness.
*Based on independent sample t-test
Ocular Immunology & Inflammation

TABLE 2. Mean inflammatory proteins after corneal cross-linking (CXL) in patients with progressive keratoconus treated with
standard and accelerated protocols.
CXL Pre op 1W 1M
Standard 4.15 ± 1.19 5.93 ± 2.73 6.09 ± 2.28
Accelerated 4.57 ± 2.17 7.14 ± 7.58 6.59 ± 4.82
* Within group changes by repeated measures ANOVA and bonferroni post hoc.
** Inter-group comparison of 6-month changes by repeated measures ANOVA and bonferroni post hoc.
previously.10 However, the effect of irradiation time
and UV intensity on postoperative inflammation is
yet to be answered. The current study aims to compare
the inflammatory response after standard (3 mW/cm2,
30 min) and accelerated (18 mW/cm2, 5 min) proto-
cols administered for CXL. Our results show that the
increase of aqueous flare observed after standard and
accelerated CXL procedures was not different.
Intraocular inflammation is characterized by the
disruption of the blood–ocular barriers allowing the
influx of serum proteins and inflammatory cells into
the eye. For those inflammatory conditions producing
an apparent anterior uveitis, the slit lamp is sufficient
to determine the level of cells and flare in the anterior
chamber. However, in mild chronic inflammation the
cellular reaction is usually absent and aqueous flare
cannot be assessed accurately by clinical examination.
Laser flare photometry provides an accurate quantita-
tive assessment of anterior chamber flare by calculat-
ing the amount of back scattered light from large
colloidal particle, mostly Albumin. Its high repeatabil-
ity in the assessment of anterior chamber flare has
already been shown.11,12
The normal flare value is reported diversely in dif-
ferent studies. In one study, the normal average flare
in healthy eyes was reported 3.1 ± 1.1 ph/ms in
20–30 year age group.13 In another study, the mean
flare value in normal individual aged <30 years
amounts to 4.7 ± 1.5 ph/ms but it increases with age,
reaching 5 ± 2 ph/ms in the 55–65 years.14 Because the
normal range of flare in our population was not
known, we administered a small control group with
normal examination and topographic indices to com-
pare their aqueous flare with those of keratoconus
eyes. The average anterior chamber flare in healthy
eyes was 3.12 ± 0.75 ph/ms which fall well within of
those in other studies. However, it was different from
baseline levels of flare in keratoconus eyes (both
P < 0.001). Whether or not the flare value in keratoco-
nus eyes differs from healthy eyes in overall popula-
tion needs to be answered in studies with larger
sample size.
The effect of surgical trauma on the production of
inflammatory mediators has been addressed in pre-
vious reports.15 Mechanical excision of the corneal
surface leads to a significant increase in corneal
prostaglandins.16 In our study, similar surgical pro-
cedure (in terms of epithelial removal) and
© 2018 Taylor & Francis Group, LLC
Flare after CXL 3
3M 6M P-value* P-value**
6.76 ± 2.27 5.98 ± 1.63 0.002 0.702
6.77 ± 4.69 6.78 ± 4.68 0.018
postoperative care (including the duration of topical
steroid usage) was applied in both the standard and
accelerated groups. In addition, the “duration of
epithelial healing” was not different between the
two groups. The total energy delivered to corneal
tissue can be calculated by the product of irradiation
time and UV intensity which is similar in both pro-
tocols (3 x 30 = 18 x 5 = 90 mW minute). Although
the amount of flare was higher in the accelerated
than the standard group (at all follow-up visits),
differences were not statistically significant. We
assume that total energy delivered is a more impor-
tant factor than either irradiation time or UV inten-
sity as a predictor of postoperative inflammation.
Nonetheless, given the small sample size (30 eyes in
each group) and high standard deviations, particu-
larly in the accelerated group, the power of the com-
parison test must also be taken into account.
In both groups, we observed a significant post-
operative rise of flare. Does application of riboflavin
and its influx into anterior chamber account for this
flare increment? We are sure that the answer is “no.”
Small molecules and those which are soluble in water
cannot cause any back-scattering of light and conse-
quently cannot produce any flare. Comparing the
molecular weight of Albumin (66.5 KD) with
Riboflavin (<1 KD), it is revealed that the increase of
flare cannot be attributed to retained riboflavin in
anterior chamber. In addition, postoperative rise of
flare lasted up to 6 months after procedures which
can hardly be explained by this assumption.
In our study, the 6-month change in flare was
1.83 ± 2.24 in the standard group and was 2.21 ± 3.53
ph/ms in the accelerated group. Abell et al.17 studied
flare 1 month after cataract surgery, and the mean
increase was 5.8 ph/ms in the femto-cataract group
and 9.3ph/ms in the manual group. Taneri et al.18
assessed flare changes after IOL implantation in myo-
pic patients, and at 3 months, mean flare value had
changed from 8.3 ± 9.7 ph/ms to 14.9 ± 15.4 ph/ms
(average increase of 6.6ph/ms). In the study by Vita
et al. 19 the mean increase in flare at 2 weeks after PRK,
LASIK, and PTK were 1.8, 1.0, and 6.8 ph/ms, respec-
tively. It seems that surface surgeries such as laser
refractive surgery or various CXL procedures are asso-
ciated with a mild increase in inflammatory proteins
much less than that seen with invasive procedures
such as cataract surgery or IOL implantation.
4 A. Hedayatfar et al.
To the best of our knowledge, this is the first study
to compare the subclinical inflammatory response after
standard and accelerated protocols used for CXL. We
assumed that epithelial excision during CXL and UV-
A irradiation would probably be associated with a
chronic mild blood aqueous disruption. As the total
UV energy delivered to cornea is the same in both
protocols, the type of CXL protocol has probably no
effect on the level of postoperative inflammation.
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
paper.
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Ocular Immunology & Inflammation