Horses treated by PACK-CXL

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1 Horses treated by PACK-CXL Anna Hellander Edman, Jes Mortensen & Björn Ekesten Zurich December 2014 Jes Mortensen,MD Sweden 0

2 Autumn 2009 the first keratitis in a horse was treated by PACK-CXL by our group in Sweden 1

3 9 horses with ulcerative keratitis were treated by Corneal Cross-Linking at ATG s Horse Hospital in Skara, Sweden. 2

4 Horses treated by PACK-CXL The first study: Corneal cross-linking in 9 horses with ulcerative keratitis Corneal cross-linking in 9 horses with ulcerative keratitis Anna Hellander-Edman 1*, Karim Makdoumi 2, Jes Mortensen 2 and Björn Ekesten 3 BMC Veterinary Research

5 All horses, except for 2 previously untreated horses, were referred because of failure of medical therapy, defined as non-healing ulceration or aggravation of clinical signs from the eye. 4

6 Method W/ Dresden protocol Riboflavin 0,1% 25 minutes UVA 365 nanometer UVA 3 mw/cm 2 for 30 minutes 5

7 Medical therapy All horses except horse one received topical medication after CXL treatment Topical chloramphenicol atropine and autologous serum + CXL systemic NSAID 6

8 Results Clinicaldiagnosis Culture/cytology Fluorescneg days Stromalulcerkeratitis Abund.fungalhyphae - Enucleated Stromalulcerkeratitis Fungalhyphae Scedosporiumspp Stromalulcerkeratitis Β-hemstreptococcus 20 Stromalulcerkeratitis Β-hemstreptococcus 9 Stromalulcerkeratitis Pasteurellaspp 4 Stromalulcerkeratitis UntypedG+coccoid 14 Stromalulcerkeratitis UntypedG-bacteria 14 5 resp 9 Stromalulcerkeratitis Nobacteria 3,9 resp 16 Stromalulcerkeratitis (Acutestromalwound) Nobacteria 26 7

9 Scedosporium spp. 3 weeks after CXL 7 months after CXL 8

10 Conclusion CXL-treatment was readily performed in 9 sedated, standing horses The median duration epithelization was 13.5 days Stromal melting in 4 horses stopped within 24 h after CXL Postoperative corneal scarring was judged to be modest We consider CXL potentially useful for treatment of stromal corneal ulcers in the horse Further research and comparison to conventional medical treat- ment is needed 9

11 Horses treated by PACK-CXL The second study: CXL vs Medical Treatment Presented in London 2014 as a poster Corneal Cross Linking (CXL) - en klinisk studie för att utvärdera CXL som behandlingsmetod vid hornhinnesår hos häst. Björn Ekesten, Anna Hellander-Edman och Lena Ström Institutionen för kliniska vetenskaper, SLU, Uppsala

12 PACK-CXL versus Conventional Treatment Keratitis of 26 horses How the study was performed: N=26 horses with the diagnosis: Stromal ulcer in the cornea The two groups (N:13 in each) were again divided in two subgroups: With infection and without infection PACK-CXL Conventional Without infection 6 horses 4 horses With infection 7 horses 9 horses 11

13 Protocol for follow up Photographic documentation Cytology, bacteriology, mycology and herpes virus (EHV-2) Slit-lamp investigation The volume of the ulcer estimated by area measuring - pachymetry Fluorescein coloring to follow the healing 12

14 The PACK-CXL Group As it was noticed that PACK-CXL alone could not eliminate the bacteria The research protocol was changed so antibiotics was given from the start after PACK-CXL treatment 13

15 Conventional Group Antibiotics - antimycotics according to the culturing Topical treatment of the corneal with melting: auto-log serum in EDTA Uveitis treated by flunixin and atropin in both groups 14

16 Results 26 eyes were treated for corneal ulcer 16 eyes had positive culturing for bacteria, one for fungus and non for herpes virus 7 in the PACK-CXL group - 9 eyes in the conventional group 15

17 Results Melting of the cornea was seen in 10 of the 26 eyes Melting was stopped in 24 hours after one PACK-CXL treatment In the conventional treated group, melting was stopped after frequent medical treatment during the first 24 hours. Day zero Day 2 Day 22 16

18 Results The PACK-CXL group 12 of 13 ulcers healed in 2-29 days (median 15.5 days) one horse perforated and was excluded from the study The Conventional treated group 13 horses treated by antibiotics topically, atropine and systemic fluxinin All ulcers healed in 6-42 days (median 24 days) 17

19 Discussion The healing of the two groups were equal After PACK-CXL an initial improvement was seen But after 3 to 4 days a worsening was seen probably due to reinfection That made us change the protocol so if infection was suspected, antibiotics were given from the start after PACK-CXL treatment PACK-CXL immediately stabilized the cornea by stopping the corneal melting 18

20 Conclusion PACK-CXL is a complement in treating corneal ulcers in horses especially when melting is seen PACK-CXL as a single treatment cannot eradicate the bacteria safely in corneal ulcer in the horse and shall be complemented by topical antibiotics 19

21 Thank You 20