Corneal collagen crosslinking failure in a patient with floppy eyelid syndrome
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Corneal collagen crosslinking failure in a patient with floppy eyelid syndrome George D. Kymionis, MD, PhD, Michael A. Grentzelos, MD, Dimitrios A. Liakopoulos, MD, George A. Kontadakis, MD, MSc, Nela Stojanovic, MD A 30-year-old man with bilateral floppy eyelid syndrome (more prominent in the left eye) and progressive keratoconus had corneal collagen crosslinking (CXL) in both eyes. No intraoperative or early postoperative complications were found. Topographic examination after CXL revealed a continuous increase in the keratometric values in the left eye in which the floppy eyelid syndrome was more prominent, indicating keratoconus progression (CXL failure). The fellow eye with the less prominent floppy eyelid syndrome remained stable during the follow-up period. Floppy eyelid syndrome could be a risk factor for CXL failure. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:1558–1560 Q 2014 ASCRS and ESCRS Corneal collagen crosslinking (CXL) is a minimally invasive surgical procedure for the treatment of keratoconus. 1 Several studies have reported stabiliza- tion and halting of keratoconus progression after CXL treatment. 1–4 However, further progression of keratoconus during the first year after CXL has been reported. 5–8 Floppy eyelid syndrome is a condition strongly associated with keratoconus. 9–11 A possible asso- ciation of laterality between these conditions in bilat- eral or unilateral cases has been demonstrated. 11 In our case, a patient with floppy eyelid syndrome who had CXL for keratoconus in both eyes, an increase in the keratometric (K) values indicating keratoconus progression (CXL failure) was seen in the eye with the more prominent floppy eyelid syndrome. CASE REPORT A 30-year-old man was referred to our institute because of progressive keratoconus. At the time of examination, the uncorrected distance visual acuity (UDVA) was 20/100 in the right eye and 20/200 in the left eye and the corrected dis- tance visual acuity (CDVA) was 20/32 (manifest refraction 6.25 2.50 70) and 20/100 (manifest refraction 4.50 3.00 120), respectively. Keratometric readings were 48.81/46.14 diopters (D) and 54.32/53.20 D in the right eye and left eye, respectively. Central corneal thickness was 445 mm and 421 mm in the right and left eyes, respectively. The patient's ocular and medical history revealed floppy eyelid syndrome (more prominent in the left eye) (Figure 1). Apart from floppy eyelid syndrome, the history was unremarkable (no atopy or eye rubbing). Slitlamp examination showed Vogt striae in both eyes and lash ptosis more prominent on the left side; pulling upward on the supercilium skin everted the eyelid on that side. Uneventful CXL was performed in both eyes according to the Dresden protocol. One month after the procedure, the slitlamp examination revealed typical mild corneal haze. The corneal stromal demarcation line depth was 289 mm using anterior segment optical coherence tomography. At 3 months, the UDVA in the left eye was 20/125 and the CDVA was 20/100 (manifest refraction 7.00 3.50 120); K readings were 53.33/50.54 D (Figure 2). Slitlamp examina- tion revealed minor corneal haze typical for a 3-month post-CXL evaluation. At 12 months, the UDVA in the left eye was 20/200 and the CDVA was 20/100 (manifest refraction 8.75 4.25 110). Slitlamp examination revealed a clear cornea. Topo- graphic examination showed steep K values of 54.51/51.34 D, an increase of more than 1.00 D (Figure 2). Submitted: January 29, 2014. Final revision submitted: February 25, 2014. Accepted: July 17, 2014. From the Vardinoyiannion Eye Institute of Crete (Kymionis, Grentzelos, Liakopoulos, Kontadakis, Stojanovic), Faculty of Medicine, University of Crete, Heraklion, Crete, Greece, and the Bascom Palmer Eye Institute (Kymionis), Miller School of Medicine, University of Miami, Miami, Florida, USA. Supported in part by the special research account of the University of Crete, Greece. Corresponding author: George D. Kymionis, MD, PhD, Vardi- noyiannion Eye Institute of Crete, University of Crete, Faculty of Medicine, 71003 Heraklion, Crete, Greece. E-mail: kymionis@ med.uoc.gr. Q 2014 ASCRS and ESCRS 0886-3350/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jcrs.2014.07.014 1558 CASE REPORT
Transcript of Corneal collagen crosslinking failure in a patient with floppy eyelid syndrome
CASE REPORT
Corneal collagen cro
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sslinking failure in apatient with floppy eyelid syndrome
George D. Kymionis, MD, PhD, Michael A. Grentzelos, MD, Dimitrios A. Liakopoulos, MD,George A. Kontadakis, MD, MSc, Nela Stojanovic, MD
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A 30-year-old man with bilateral floppy eyelid syndrome (more prominent in the left eye) andprogressive keratoconus had corneal collagen crosslinking (CXL) in both eyes. No intraoperativeor early postoperative complications were found. Topographic examination after CXL revealed acontinuous increase in the keratometric values in the left eye in which the floppy eyelid syndromewas more prominent, indicating keratoconus progression (CXL failure). The fellow eye with theless prominent floppy eyelid syndrome remained stable during the follow-up period. Floppy eyelidsyndrome could be a risk factor for CXL failure.
Financial Disclosure: No author has a financial or proprietary interest in any material or methodmentioned.
J Cataract Refract Surg 2014; 40:1558–1560 Q 2014 ASCRS and ESCRS
Corneal collagen crosslinking (CXL) is a minimallyinvasive surgical procedure for the treatment ofkeratoconus.1 Several studies have reported stabiliza-tion and halting of keratoconus progression afterCXL treatment.1–4 However, further progression ofkeratoconus during the first year after CXL has beenreported.5–8
Floppy eyelid syndrome is a condition stronglyassociated with keratoconus.9–11 A possible asso-ciation of laterality between these conditions in bilat-eral or unilateral cases has been demonstrated.11 Inour case, a patient with floppy eyelid syndrome whohad CXL for keratoconus in both eyes, an increase inthe keratometric (K) values indicating keratoconus
uary 29, 2014.ubmitted: February 25, 2014.17, 2014.
dinoyiannion Eye Institute of Crete (Kymionis,iakopoulos, Kontadakis, Stojanovic), Faculty ofersity of Crete, Heraklion, Crete, Greece, and ther Eye Institute (Kymionis), Miller School of Medicine,iami, Miami, Florida, USA.
art by the special research account of the Universitye.
author: George D. Kymionis, MD, PhD, Vardi-Institute of Crete, University of Crete, Faculty of
03 Heraklion, Crete, Greece. E-mail: kymionis@
SCRS and ESCRS
by Elsevier Inc.
progression (CXL failure) was seen in the eye withthe more prominent floppy eyelid syndrome.
CASE REPORT
A 30-year-old man was referred to our institute because ofprogressive keratoconus. At the time of examination, theuncorrected distance visual acuity (UDVA) was 20/100 inthe right eye and 20/200 in the left eye and the corrected dis-tance visual acuity (CDVA) was 20/32 (manifest refraction�6.25 �2.50 � 70) and 20/100 (manifest refraction �4.50�3.00 � 120), respectively. Keratometric readings were48.81/46.14 diopters (D) and 54.32/53.20 D in the right eyeand left eye, respectively. Central corneal thickness was445 mm and 421 mm in the right and left eyes, respectively.The patient's ocular and medical history revealed floppyeyelid syndrome (more prominent in the left eye)(Figure 1). Apart from floppy eyelid syndrome, the historywas unremarkable (no atopy or eye rubbing). Slitlampexamination showed Vogt striae in both eyes and lash ptosismore prominent on the left side; pulling upward on thesupercilium skin everted the eyelid on that side.
Uneventful CXL was performed in both eyes according tothe Dresden protocol. One month after the procedure, theslitlamp examination revealed typical mild corneal haze.The corneal stromal demarcation line depth was 289 mmusing anterior segment optical coherence tomography.
At 3 months, the UDVA in the left eye was 20/125 and theCDVA was 20/100 (manifest refraction �7.00 �3.50 � 120);K readings were 53.33/50.54 D (Figure 2). Slitlamp examina-tion revealed minor corneal haze typical for a 3-monthpost-CXL evaluation.
At 12 months, the UDVA in the left eye was 20/200 andthe CDVA was 20/100 (manifest refraction �8.75 �4.25 �110). Slitlamp examination revealed a clear cornea. Topo-graphic examination showed steep K values of 54.51/51.34D, an increase of more than 1.00 D (Figure 2).
0886-3350/$ - see front matter
http://dx.doi.org/10.1016/j.jcrs.2014.07.014
Figure 1. Floppy eyelid syndrome more prominent in the left eye.
1559CASE REPORT: CORNEAL CXL IN FLOPPY EYELID SYNDROME
There was no sign of keratoconus progression in the righteye during the follow-up period.
DISCUSSION
Corneal CXL with riboflavin and ultraviolet-A irradi-ation is a minimally invasive surgical treatment thatstrengthens the corneal tissue and increases bio-mechanical stability of the ectatic cornea.1 Theincreased stiffness (stiffening effect) after CXL arrestsprogression of the corneal ectatic disorder.1 Severalstudies have reported corneal stabilization and haltingof keratoconus progression after CXL.1–4
Despite the effectiveness of CXL, continuedprogression of keratoconus during the first postoper-ative year has been reported.5–8 Continued
Figure 2. Comparative topographic map 3 months (bottom right) and 12topographic K values.
J CATARACT REFRACT SURG - V
progression is defined as an increase in themaximum K readings of more than 1.00 D over thepreoperative value. Koller et al.5 found that theonly identified risk factor for CXL failure was preop-erative maximum K readings greater than 58.00 D.Sloot et al.6 found no specific risk factors for CXLfailure. Greenstein and Hersh7 found no indepen-dent predictors of CXL failure.
The floppy eyelid syndrome has been associatedwith a variety of ocular and systemic conditions,such as keratoconus and obstructive sleep apneasyndrome.9–11 It is a unilateral or bilateral conditioncharacterized by flaccid eyelids that easily evertduring sleeping prone on the affected side and allowmechanical contact with bed sheets, causing irritationof the cornea and conjunctiva.9–11 Several studies haveshown the association of keratoconus with floppyeyelid syndrome.9–11
In our case, a patient with floppy eyelid syndromewho had CXL in both eyes for keratoconus experi-enced an increase in the K values in the eye with themore prominent floppy eyelid syndrome 1 year aftertreatment, indicating keratoconus progression (CXLfailure). Ezra et al.11 demonstrated a possible asso-ciation of laterality between floppy eyelid syndromeand keratoconus despite the lack of statistical signifi-cance in this result. Donnenfeld et al.9 reported that
months (upper right) after corneal CXL showing an increase in the
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both conditions, floppy eyelid syndrome and kerato-conus, localized to the side of sleeping preference. Inour case, the patient described a history of sleepingwith his head facing the left side predominantly. Apartfrom floppy eyelid syndrome, there was no risk factor,such as eye rubbing and/or preoperative maximumK readings greater than 58.00 D, that could beconsidered a trigger for the keratoconus progressionafter CXL.
To our knowledge, this is the first reported case inwhich CXL failure is related to floppy eyelidsyndrome. Floppy eyelid syndrome could be a riskfactor for CXL failure. However, we cannot concludethat there is an association between floppy eyelidsyndrome and CXL failure from a single case; studieswith a large patient series are necessary to confirm thisassumption.
REFERENCES1. Wollensak G, Spoerl E, Seiler T. Riboflavin/ultraviolet-A–
induced collagen crosslinking for the treatment of keratoconus.
Am J Ophthalmol 2003; 135:620–627. Available at: http://
grmc.ca/assets/files/collagen_crosslinking_2003_wollensak.pdf.
Accessed May 27, 2014
2. Vinciguerra P, Alb�e E, Trazza S, Rosetta P, Vinciguerra R,
Seiler T, Epstein D. Refractive, topographic, tomographic, and
aberrometric analysis of keratoconic eyes undergoing corneal
cross-linking. Ophthalmology 2009; 116:369–378
3. Caporossi A, Mazzotta C, Baiocchi S, Caporossi T. Long-term
results of riboflavin ultraviolet A corneal collagen cross-linking
for keratoconus in Italy: the Siena Eye Cross Study. Am J
Ophthalmol 2010; 149:585–593
4. Kymionis GD, Grentzelos MA, Kounis GA, Diakonis VF,
Limnopoulou AN, Panagopoulou SI. Combined transepithelial
J CATARACT REFRACT SURG - V
phototherapeutic keratectomy and corneal collagen cross-
linking for progressive keratoconus. Ophthalmology 2012;
119:1777–1784
5. Koller T, Mrochen M, Seiler T. Complication and failure rates
after corneal crosslinking. J Cataract Refract Surg 2009;
35:1358–1362
6. Sloot F, Soeters N, van der Valk R, Tahzib NG. Effective corneal
collagen crosslinking in advanced cases of progressive kerato-
conus. J Cataract Refract Surg 2013; 39:1141–1145
7. Greenstein SA, Hersh PS. Characteristics influencing outcomes
of corneal collagen crosslinking for keratoconus and ectasia: im-
plications for patient selection. J Cataract Refract Surg 2013;
39:1133–1140
8. Hersh PS, Greenstein SA, Fry KL. Corneal collagen crosslinking
for keratoconus and corneal ectasia: one-year results.
J Cataract Refract Surg 2011; 37:149–160
9. Donnefeld ED, Perry HD, Gibralter RP, Ingraham HJ, Udell IJ.
Keratoconus associated with floppy eyelid syndrome. Ophthal-
mology 1991; 98:1674–1678
10. Ezra DG, Beaconsfield M, Collin R. Floppy eyelid syndrome:
stretching the limits. Surv Ophthalmol 2010; 55:35–46
11. Ezra DG, Beaconsfield M, Sira M, Bunce C, Wormald R,
Collin R. The associations of floppy eyelid syndrome: a case
control study. Ophthalmology 2010; 117:831–838
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40, SEPTEMBER 2014First author:George D. Kymionis, MD, PhD
Vardinoyiannion Eye Institute of Crete,Faculty of Medicine, Universityof Crete, Heraklion, Crete, Greece,and the Bascom Palmer Eye Institute,Miller School of Medicine, Universityof Miami, Miami, Florida, USA
