Biocompatibility evaluation of bioprinted decellularized collagen sheet implanted in vivo cornea using swept‐source optical coherence tomography

Corneal transplantation by full‐thickness penetrating keratoplasty with human donor tissue is a widely accepted treatment for damaged or diseased corneas. Although corneal transplantation has a high success rate, a shortage of high‐quality donor tissue is a considerable limitation. Therefore, bioengineered corneas could be an effective solution for this limitation, and a decellularized extracellular matrix comprises a promising scaffold for their fabrication. In this study, three‐dimensional bioprinted decellularized collagen sheets were implanted into the stromal layer of the cornea of five rabbits. We performed in vivo noninvasive monitoring of the rabbit corneas using swept‐source optical coherence tomography (OCT) after implanting the collagen sheets. Anterior segment OCT images and averaged amplitude‐scans were acquired biweekly to monitor corneal thickness after implantation for 1 month. The averaged cornea thickness in the control images was 430.3 ± 5.9 μm, while the averaged thickness after corneal implantation was 598.5 ± 11.8 μm and 564.5 ± 12.5 μm at 2 and 4 weeks, respectively. The corneal thickness reduction of 34 μm confirmed the biocompatibility through the image analysis of the depth‐intensity profile base. Moreover, hematoxylin and eosin staining supported the biocompatibility evaluation of the bioprinted decellularized collagen sheet implantation. Hence, the developed bioprinted decellularized collagen sheets could become an alternative solution to human corneal donor tissue, and the proposed image analysis procedure could be beneficial to confirm the success of the surgery.      

Non‐invasive optical method for real‐time assessment of intracorneal riboflavin concentration and efficacy of corneal cross‐linking

Keratoconus is the primary cause of corneal transplantation in young adults worldwide. Riboflavin/UV‐A corneal cross‐linking may effectively halt the progression of keratoconus if an adequate amount of riboflavin enriches the corneal stroma and is photo‐oxidated by UV‐A light for generating additional cross‐linking bonds between stromal proteins and strengthening the biomechanics of the weakened cornea. Here we reported an UV‐A theranostic prototype device for performing corneal cross‐linking with the ability to assess corneal intrastromal concentration of riboflavin and to estimate treatment efficacy in real time. Seventeen human donor corneas were treated according to the conventional riboflavin/UV‐A corneal cross‐linking protocol. Ten of these tissues were probed with atomic force microscopy in order to correlate the intrastromal riboflavin concentration recorded during treatment with the increase in elastic modulus of the anterior corneal stroma. The intrastromal riboflavin concentration and its consumption during UV‐A irradiation of the cornea were highly significantly correlated (R = 0.79; P = .03) with the treatment‐induced stromal stiffening effect. The present study showed an ophthalmic device that provided an innovative, non‐invasive, real‐time monitoring solution for estimating corneal cross‐linking treatment efficacy on a personalized basis.      

OCT layered tomography of the cornea provides new insights on remodeling after photorefractive keratectomy

OCT (optical coherence tomography) of corneal layers was generated to analyze the remodeling of the epithelium and stroma after photorefractive keratectomy (PRK). Myopic PRK was performed in 15 patients. One eye underwent manual scraping of epithelium while the other was treated with Epi clear. Epi clear allowed a gentler removal of the epithelium compared to manual scraping. Scheimpflug (Pentacam, OCULUS Optikgerate Gmbh, Wetzlar, Germany) and OCT (RTVue, Optovue Inc., Fremont, California, USA) scans of the cornea were performed before and after PRK (3 months). The OCT scanner and Pentacam acquired 8 and 25 radial 2‐D scans of the cornea, respectively. The results showed similar topographic changes on the anterior corneal surface between Scheimpflug and OCT imaging. The curvature of the underlying anterior surface of the stroma after PRK was similar to the anterior corneal surface (air‐epithelium interface), when measured with OCT. Aberrometric changes were mostly similar between Scheimpflug and OCT. However, Scheimpflug imaging reported greater changes in spherical aberration and corneal higher order aberrations than OCT after PRK. This is the first study to quantify the curvatures of the stromal layers with OCT after PRK. New insights were gained, which could be useful for refinement of surgical ablation algorithms, refractive procedures and detection of ectasia.      

In vivo noninvasive measurement of spatially resolved corneal elasticity in human eyes using Lamb wave optical coherence elastography

Current elastography techniques are limited in application to accurately assess spatially resolved corneal elasticity in vivo for human eyes. The air‐puff optical coherence elastography (OCE) with an eye motion artifacts correction algorithm is developed to distinguish the in vivo cornea vibration from the eye motion and visualize the Lamb wave propagation clearly in healthy subjects. Based on the Lamb wave model, the phase velocity dispersion curve in the high‐frequency is calculated to obtain spatially resolved corneal elasticity accurately with high repeatability. It is found that the corneal elasticity has regional variations and is correlated with intraocular pressure, which suggests that the method has the potential to provide noninvasive measurement of spatially resolved corneal elasticity in clinical practice.     

Bowman's topography for improved detection of early ectasia

The aim of this study was to evaluate whether OCT topography of the Bowman's layer and artificial intelligence (AI) can result in better diagnosis of forme fruste (FFKC) and clinical keratoconus (KC). Normal (n = 221), FFKC (n = 72) and KC (n = 116) corneas were included. Some of the FFKC and KC patients had the fellow eye (VAE‐NT) with normal topography (n = 30). The Scheimpflug and OCT scans of the cornea were analyzed. The curvature and surface aberrations (ray tracing) of the anterior corneal surface [air‐epithelium (A‐E) interface in OCT] and epithelium‐Bowman's layer (E‐B) interface (in OCT only) were calculated. Four random forest models were constructed: (1) Scheimpflug only; (2) OCT A‐E only; (3) OCT E‐B only; (4) OCT A‐E and E‐B combined. For normal eyes, both Scheimpflug and OCT (A‐E and E‐B combined) performed equally in identifying these eyes (P = .23). However, OCT A‐E and E‐B showed that most VAE‐NT eyes were topographically similar to normal eyes and did not warrant a separate classification based on topography alone. For identifying FFKC eyes, OCT A‐E and E‐B combined performed significantly better than Scheimpflug (P = .006). For KC eyes, both Scheimpflug and OCT performed equally (P = 1.0). Thus, OCT Topography of Bowman's layer significantly improved the detection of FFKC eyes.     

Mechanical characterization of porcine corneas

An experimental program has been carried out in order to investigate the mechanical behavior of porcine corneas. We report the results of inflation tests on the whole cornea and uniaxial tests on excised corneal strips, performed on 51 fresh porcine eyes. Uniaxial tests have been performed on specimens cut from previously inflated corneas. The cornea behavior is characterized by means of elastic stiffness, measured on both average pressure-apex displacement and average uniaxial stress-strain curves; and by means of transversal contraction coefficient, peak stress, and failure stress measured on uniaxial stress-strain curves. Uniaxial tests performed on excised strips allowed to measure the anisotropy in the corneal stiffness and to compare the stiffness of the cornea with the one of the sclera. Viscous properties of the cornea have been obtained through uniaxial relaxation curves on excised corneal strips. The relevant geometrical parameters have been measured and, with the aid of the elastic thin shell theory, a stress-strain curve has been derived from the average inflation test data and compared with similar data available in the literature. The experimental system has been developed in view of future applications to the mechanical testing of both porcine and human corneas.     

Revealing structural modifications in thermomechanical reshaping of collagenous tissues using optical coherence elastography

Moderate heating of such collagenous tissues as cornea and cartilages by infra‐red laser (IR laser) irradiation is an emerging technology for nondestructive modification of the tissue shape and microstructure for a variety of applications in ophthalmology, otolaryngology and so on. Postirradiation high‐resolution microscopic examination indicates the appearance of microscopic either spheroidal or crack‐like narrow pores depending on the tissue type and irradiation regime. Such examinations usually require special tissue preparation (eg, staining, drying that affect microstructure themselves) and are mostly suitable for studying individual pores, whereas evaluation of their averaged parameters, especially in situ, is challenging. Here, we demonstrate the ability of optical coherence tomography (OCT) to visualize areas of pore initiation and evaluate their averaged properties by combining visualization of residual irradiation‐induced tissue dilatation and evaluation of the accompanying Young‐modulus reduction by OCT‐based compressional elastography. We show that the averaged OCT‐based data obtained in situ fairly well agree with the microscopic examination results. The results obtained develop the basis for effective and safe applications of novel nondestructive laser technologies of tissue modification in clinical practice. PICTURE: Elastographic OCT‐based images of an excised rabbit eye cornea subjected to thermomechanical laser‐assisted reshaping. Central panel shows resultant cumulative dilatation in cornea after moderate (~45‐50°C) pulse‐periodic heating by an IR laser together with distribution of the inverse Young modulus 1/E before (left) and after (right) IR irradiation. Significant modulus decrease in the center of irradiated region is caused by initiated micropores. Their parameters can be extracted by analyzing the elastographic images.      

Clinical assessment of non carious cervical lesion using swept‐source optical coherence tomography

Non‐carious cervical lesions (NCCLs) involve various forms of tooth loss with different etiologies. This study aimed to utilize swept‐source optical coherence tomography (SS‐OCT) at 1300 nm wavelength range in vitro and in vivo to evaluate and clarify the mechanism of NCCLs. In the in vitro phase, a dentin attenuation coefficient (μ_t) derived from the SS‐OCT signal at NCCL was compared with mineral loss obtained from transverse microradiography (TMR) to determine a μ_t threshold to discriminate demineralization of cervical dentin in vivo. In the clinical study, 242 buccal surfaces were investigated in 35 subjects. Presence and dimensions of NCCLs, cervical cracking and the degree of demineralization at the exposed cervical dentin were determined using SS‐OCT. Dentin demineralization was observed in 69% of NCCLs. SS‐OCT results confirm that dentin mineral loss and occlusal attrition were associated with larger NCCLs, and can be considered as an etiological factor in formation and progress of these lesions.

( A ) We determined the attenuation coeffcient (μ_t) threshold of SS‐OCT signal for the detection of demineralization (1.21) from in vitro study. DEM: demineralized dentin, sound: sound dentin. ( B ) Using the μ_t threshold, we observed NCCLs in vivo to detect the demineralization in cervical dentin. SS‐OCT scanning was performed along the red line. ( C ) SS‐OCT image obtained along the red line in B. In SS‐OCT, brightness of dentin beneath the NCCL was increased (arrow) compared with intact zone. The cervical dentin was slightly demineralized (μ_t: 1.25). e: enamel, d: dentin, g: gingiva.     

Assessment of corneal viscoelasticity using elastic wave optical coherence elastography

The corneal viscoelasticity have great clinical significance, such as the early diagnosis of keratoconus. In this work, an analysis method which utilized the elastic wave velocity, frequency and energy attenuation to assess the corneal viscoelasticity is presented. Using phase‐resolved optical coherence tomography, the spatial‐temporal displacement map is derived. The phase velocity dispersion curve and center frequency are obtained by transforming the displacement map into the wavenumber‐frequency domain through the 2D fast Fourier transform (FFT). The shear modulus is calculated through Rayleigh wave equation using the phase velocity in the high frequency. The normalized energy distribution is plotted by transforming the displacement map into the spatial‐frequency domain through the 1D FFT. The energy attenuation coefficient is derived by exponential fitting to calculate the viscous modulus. Different concentrations of tissue‐mimicking phantoms and porcine corneas are imaged to validate this method, which demonstrates that the method has the capability to assess the corneal viscoelasticity.     

Quantification of collagen structural changes during chick corneal development

As the most abundant structural mammalian protein, collagen has been implicated in the pathogenesis of numerous diseases such as osteogenesis imperfecta, and cancer. In the case of cornea, abnormal cornea development can lead to conditions such as agenesis, megalocornea, microcornea, and cornea plana. Therefore, understanding the mechanisms of collagen assembly during development may contribute to the prevention or treatment of corneal diseases. In this study, we applied fast Fourier transform second harmonic generation microscopy to quantify parameters of corneal structures during chick development. Our results show that both the rotational pitch and overall rotational angle of corneal stroma modulate between E9 and E19. In addition, we found that corneal structures between left and right corneas are highly correlated during development.      

Constructing an in vitro cornea from cultures of the three specific corneal cell types

Summary This paper presents a reliable method for establishing pure cultures of the three types of corneal cells. This is believed to be the first time, corneal cells have been cultured from fetal pig corneas. Cell growth studies were performed in different media. Subcultures of the three corneal cell types were passaged until the 30th generation without their showing signs of senescence. For engineering an in vitro cornea, corneal epithelial cells were cultured over corneal stromal cells in an artificial biomatrix of collagen with an underlying layer of corneal endothelial cells. The morphology, histology, and differentiation of the in vitro cornea were investigated to determine the degree of comparability to the cornea in vivo. The in vitro construct displayed signs of transition to an organotypic phenotype of which the most prominent was the formation of two basement membranes.     

Absence of corneal endothelium injury in non‐human primates treated with and without ophthalmologic drugs and exposed to 2.8 GHz pulsed microwaves

Microwave‐induced corneal endothelial damage was reported to have a low threshold (2.6 W/kg), and vasoactive ophthalmologic medications lowered the threshold by a factor of 10–0.26 W/kg. In an attempt to confirm these observations, four adult male Rhesus monkeys (Macaca mulatta) under propofol anesthesia were exposed to pulsed microwaves in the far field of a 2.8 GHz signal (1.43 ± 0.06 µs pulse width, 34 Hz pulse repetition frequency, 13.0 mW/cm² spatial and temporal average, and 464 W/cm² spatial and temporal peak (291 W/cm² square wave equivalent) power densities). Corneal‐specific absorption rate was 5.07 W/kg (0.39 W/kg/mW/cm²). The exposure resulted in a 1.0–1.2 °C increase in eyelid temperature. In Experiment I, exposures were 4 h/day, 3 days/week for 3 weeks (nine exposures and 36 h total). In Experiment II, these subjects were pretreated with 0.5% Timolol maleate and 0.005% Xalatan® followed by 3 or 7 4‐h pulsed microwave exposures. Under ketamine–xylazine anesthesia, a non‐contact specular microscope was used to obtain corneal endothelium images, corneal endothelial cell density, and pachymetry at the center and four peripheral areas of the cornea. Ophthalmologic measurements were done before and 7, 30, 90, and 180 days after exposures. Pulsed microwave exposure did not cause alterations in corneal endothelial cell density and corneal thickness with or without ophthalmologic drugs. Therefore, previously reported changes in the cornea exposed to pulsed microwaves were not confirmed at exposure levels that are more than an order of magnitude higher. Bioelectromagnetics 31:324–333, 2010. Published 2010 Wiley‐Liss, Inc.     

A study of piezoelectric and mechanical anisotropies of the human cornea

The piezoelectric and dynamic mechanical properties of human cornea have been investigated as a function of drying time. As expected, the piezoelectric coefficient, d(31), and the Young's modulus, Y, were found to be extremely sensitive to water content. d(31) decreased with dehydration of the corneal tissue and Y increased with dehydration. While these results are significant, the discovery of the unprecedented mechanical and electromechanical anisotropy exhibited by the cornea are the major findings of this study and indicate that the collagen fibrils comprising the cornea are highly oriented. The piezoelectric responses of corneas observed in this study are: diagonally cut samples starting at an average piezoelectric coefficient value of 2250 pC/N, followed by the vertically cut samples, with an average starting value of about 600 pC/N and finally the horizontally cut samples with an average starting value of about 200 pC/N.     

Noninvasive detection of nanoscale structural changes in cornea associated with cross‐linking treatment

Corneal cross‐linking (CXL) using ultraviolet‐A (UVA) irradiation with a riboflavin photosensitizer has grown from an interesting concept to a practical clinical treatment for corneal ectatic diseases globally, such as keratoconus. To characterize the corneal structural changes, existing methods such as X‐ray microscopy, transmission electron microscopy, histology and optical coherence tomography (OCT) have been used. However, these methods have various drawbacks such as invasive detection, the impossibility for in vivo measurement, or limited resolution and sensitivity to structural alterations. Here, we report the application of oversampling nanosensitive OCT for probing the corneal structural alterations. The results indicate that the spatial period increases slightly after 30 minutes riboflavin instillation but decreases significantly after 30 minutes UVA irradiation following the Dresden protocol. The proposed noninvasive method can be implemented using existing OCT systems, without any additional components, for detecting nanoscale changes with the potential to assist diagnostic assessment during CXL treatment, and possibly to be a real‐time monitoring tool in clinics.     

In vivo sensing of rabbit cornea by terahertz technology

A Novel scalable approach using Terahertz (THz) waves together with the electromagnetic field simulation was applied to investigate four rabbits of eight rabbit corneas in vivo. One eye of each rabbits’ corneas was edema induced; the other eye of the corneas served as the control. The simulation revealed the propagation of THz waves at a certain distance along the sub-surface of the cornea. THz spectra have been collected close to the corneal surface by deviating the direct reflection of the THz beam for the edema cornea, the reflected wave intensity for edema corneas is generally larger compared with the control cornea. Upon edema becomes severe at the end of the observation, the reflected wave intensities obtained by detector corresponding to the corneal deep stroma layer approach to the same value for all observed corneas. Good correlation is observed between central corneal thickness measurements and THz wave reflection signal intensities. Our results demonstrated that THz spectroscopy technique could obtain the information from different corneal sublayers.     

The Incidence of Hepatitis C Virus Positive Serological Test Results Among Cornea Donors

Purpose. We have noticed that the incidence of positive serological tests of hepatitis C virus (HCV) among cornea donors in our eye bank is higher than expected. The purpose of this study was to determine the incidence of these positive findings and identify the contributory risk factors. Methods. All corneas procured between June 1993 and June 1997 were included in this retrospective study. In all cases a routine work-up, including serological testing of donors' sera and evaluation of the procured corneas, was performed prior to corneal transplantation. Donors found to be positive for HCV antibodies were compared to our general population of corneal donors, with respect to the demographic, serological and ophthalmological data obtained during the transplantation work-up. Results. All 851 corneas procured from 438 donors were included. Antibodies to HCV were found in 29 donors (6.6%). Following positive test results, 57 corneas (6.7%) were discarded. The time from donors' death to cornea procurement was significantly longer among HCV-positive patients than in the general donor population (12.3 vs. 9.3h, p<0.0003). No other differences were detected between the two groups. Conclusion. Delay in harvesting of donated corneas may give rise to false positive HCV-antibodies test results, which may be partially responsible for the high rate of positive findings among cornea donors, with consequent tissue wastage.     

Use of Fish Scale-Derived BioCornea to Seal Full-Thickness Corneal Perforations in Pig Models

The aim of this study was to test the use of BioCornea, a fish scale-derived collagen matrix for sealing full-thickness corneal perforations in mini-pigs.Two series of experiments were carried out in 8 Lan-Yu and 3 Göttingen mini-pigs, respectively. A 2mm central full thickness corneal perforation was made with surgical scissors and 2mm trephines. The perforations were sealed immediately by suturing BioCornea to the wounded cornea. The conditions of each patched cornea were followed-up daily for 3 or 4 days. Status of operated eyes was assessed with slit lamp examination or optical coherence tomography (OCT). Animals were sacrificed after the study period and the corneas operated were fixated for histological examination.Both OCT imaging and handheld slit lamp observations indicated that a stable ocular integrity of the perforated corneas was maintained, showing no leakage of aqueous humor, normal depth of anterior chamber and only mild swelling of the wounded cornea. Hematoxylin and eosin staining of the patched cornea showed no epithelial ingrowths to the perforated wounds and no severe leucocyte infiltration of the stroma.The fish scale-derived BioCornea is capable to seal full-thickness corneal perforation and stabilize the integrity of ocular anterior chamber in pre-clinic mini-pig models. BioCornea seems to be a safe and effective alternative for emergency treatment of corneal perforations.     

Geometrical Custom Modeling of Human Cornea In Vivo and Its Use for the Diagnosis of Corneal Ectasia

Aim

To establish a new procedure for 3D geometric reconstruction of the human cornea to obtain a solid model that represents a personalized and in vivo morphology of both the anterior and posterior corneal surfaces. This model is later analyzed to obtain geometric variables enabling the characterization of the corneal geometry and establishing a new clinical diagnostic criterion in order to distinguish between healthy corneas and corneas with keratoconus.

Method

The method for the geometric reconstruction of the cornea consists of the following steps: capture and preprocessing of the spatial point clouds provided by the Sirius topographer that represent both anterior and posterior corneal surfaces, reconstruction of the corneal geometric surfaces and generation of the solid model. Later, geometric variables are extracted from the model obtained and statistically analyzed to detect deformations of the cornea.

Results

The variables that achieved the best results in the diagnosis of keratoconus were anterior corneal surface area (ROC area: 0.847, p<0.000, std. error: 0.038, 95% CI: 0.777 to 0.925), posterior corneal surface area (ROC area: 0.807, p<0.000, std. error: 0.042, 95% CI: 0,726 to 0,889), anterior apex deviation (ROC area: 0.735, p<0.000, std. error: 0.053, 95% CI: 0.630 to 0.840) and posterior apex deviation (ROC area: 0.891, p<0.000, std. error: 0.039, 95% CI: 0.8146 to 0.9672).

Conclusion

Geometric modeling enables accurate characterization of the human cornea. Also, from a clinical point of view, the procedure described has established a new approach for the study of eye-related diseases.     

Evaluation of corneal epithelial thickness in glaucomatous patients using anterior‐segment optical coherence tomography

The corneal epithelium represents one of the main structures that undergo degenerative alterations due to antiglaucomatous therapy. Chronic glaucoma therapy containing benzalkonium chloride induces epithelial cellular changes and inflammatory infiltration that in turn causes ocular surface changes resulting in ocular discomfort. Also, age‐related changes can involve the tear film stability and the corneal epithelium surface with reduction of microvilli. The objective of this study is to gain insights about the changes in corneal epithelium in glaucomatous patients divided according to age, type and duration of therapy using anterior‐segment optical coherence tomography (AS‐OCT). This study evaluated a total of 81 eyes of 42 patients for whom corneal epithelium thickness (CET) was measured in different sectors of the cornea. Our results showed no significant differences in CET among patients divided according to type and duration of treatment, while younger patients showed a thinner CET in comparison with older patients. AS‐OCT results demonstrated that the physiological age‐related alterations contributed to corneal epithelium changes in patients undergo chronic antiglaucoma therapy.     

Evaluation of the Efficacy of Excimer Laser Ablation of Cross-Linked Porcine Cornea

Background

Combination of riboflavin/UVA cross-linking (CXL) and excimer laser ablation is a promising therapy for treating corneal ectasia. The cornea is strengthened by cross-linking, while the irregular astigmatism is reduced by laser ablation. This study aims to compare the efficacy of excimer laser ablation on porcine corneas with and without cross-linking.

Methods and Findings

The porcine cornea was de-epithelialized and treated with 0.1% riboflavin solution for 30 minutes. A half of the cornea was exposed to UVA-radiation for another 30 minutes while the controlled half of the cornea was protected from the UVA using a metal shield. Photo therapeutic keratectomy (PTK) was then performed on the central cornea. Corneal thickness of 5 paired locations on the horizontal line, ±0.5, ±1.0, ±1.5, ±2.0, and ±2.5 mm from the central spot, were measured using optical coherence tomography prior to and after PTK. The ablation depth was then determined by the corneal thickness. There was a 9% difference (P<0.001) in the overall ablation depth between the CXL-half corneas (158±22 µm) and the control-half corneas (174±26 µm). The ablation depths of all 5 correspondent locations on the CXL-half were significantly smaller (P<0.001).

Conclusion

The efficacy of the laser ablation seems to be lower in cross-linked cornea. Current ablation algorithms may need to be modified for cross-linked corneas.