Purpose
To investigate the changes in pro- and anti-inflammatory mediators following corneal collagen cross-linking (CXL) in patients with keratoconus (KC).
Design
Systematic review.
Methods
A comprehensive literature search was conducted using Ovid MEDLINE, Embase, and the Cochrane Library from inception to September 2024. Eligibility criteria included English studies reporting pre- and post-CXL changes in cytokine, chemokine, matrix metalloproteinase (MMP), and growth factor concentrations in adult patients with KC. The primary endpoint was the change in pro- and anti-inflammatory mediator concentrations following CXL. The secondary endpoint focused on correlations between post-CXL changes in inflammatory mediators and corneal tomography measurements. Descriptive statistics were used to report findings.
Results
Six prospective cohort studies were included, encompassing 173 eyes from 168 patients diagnosed with progressive KC. The mean age of participants was 25.3 years, and 69 % were male. Three studies reported on cytokine and chemokine levels, demonstrating a significant increase in interleukin-6 (IL-6) concentrations up to three months post-CXL, followed by a decline to levels below pre-CXL at 12 months. Additionally, MMP-9 levels and growth factors, such as nerve growth factor (NGF) and epidermal growth factor (EGF), significantly decreased 12 months post-CXL in two studies, respectively. Significant positive correlations were observed between changes in cytokine levels and tomographic parameters, including keratometry (Ks and Kf) and corneal thickness.
Conclusion
IL-6 levels may rise within the first three months post-CXL, followed by a decline to below baseline levels by 12 months. In contrast, MMP-13 concentrations may decrease within days of treatment, and MMP-9 levels may decline after one year. Similarly, both EGF and NGF may show post-CXL reductions, with NGF levels potentially reflecting underlying KC severity. Altogether, these patterns suggest an initial acute inflammatory response, followed by subsequent changes likely associated with the promotion of corneal healing. However, interpretation may be limited by the relatively small number of included studies and heterogeneity in patient severity, sample sizes, sampling methods, assays, and follow-up timepoints. Further research is required to elucidate their role in monitoring treatment response in patients with KC undergoing CXL.
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