aakg presentation 1.pptx

8/18/2019 aakg presentation 1.pptx

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Corneal collagen cross-linking for treating keratoconus: a cochrane interventional review

Presenter: Dr.Arushi Goyal

Moderator: Dr. R.R.Sudhir


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Cochrane review

Cochrane Reviews aresyste&atic reviews o$ /rimary research in human heath care an" heath

/oicy, an" are internationay reco0nise" as the hi0hest stan"ar" in evi"ence-#ase" heath care+ 1hey investi0ate th

e e2ects o$ interventions $or /revention, treatment an" reha#iitation+

A systematic review is a type ofliterature review that collectsand critically analyzes multiple

research studies or papers


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'ackground

• (eratoconus : 'ilateral nonin)a&&atory

corneal ectasia• *ncidence : $ in !### eole

• Collagen cross-linking +C,:

/reat&ent to slow or halt rogression of

keratoconus


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Signi0cance

• C, :only treat&ent to halt rogression ofkeratoconus

• Ro1ust evidence on long ter& results ofe2cacy and safety of this rocedure lacking

• Standardised criteria for selection of idealatient lacking

• Review is evidence 1ased reference oint for

eole with keratoconus for validated infor&ation regarding the e2ciency of this treat&ent.


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3'45C/*65

/o assess whether there is evidence that C,is an e7ective and safe treat&ent for halting the rogression of keratoconus co&ared to n

o treat&ent+


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M5/83DS A9D R5S/S*9CS*39 A9D 5,CS*39 CR*/5R*A

• /ye of studies:

Ran"omise" controe" trias 3RC1s4 where /atients are"ia0nose" with keratoconus+

•

/ye of articiants:*ncluded A a0e /artici/ants

5;cluded with history o$ some other treatment+

• /ye of intervention:

Stu"ies that com/are" C56 with the e/itheium o2 techni7ueto no treatment

5;clusion: Stu"ies com/arin0 "i2erent ways o$ "oin0 C56

Stu"ies with no contro 0rou/

8se o$ C56 $or ectasias other that keratoconus


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M5/83DS and R5S/S+cont.

Search &ethods for identi0cation of studies:

Eectronic searches A eectronic "ata#ases ti%9th au0ust %&':

% review authors ES an" RK reviewe" a stu"ies


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*ncluded studies:

< RC/S!$= eyes > $$= cases and $## controls

Australia +?ittig-Silva !##"@ the nited(ingdo& +3'rart !#$$@ and the nited State

s +8ersh !#$$.


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/ye of intervention +C, with eitheliu& o7techniBue

Epithelium removed undertopical anaesthesia

Isotonic ribofavin solution o0.1% applied

Cornea treated with UVradiation !"#0 nm at "

m$cm&' or "0 minutes.


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• Assess&ent of risk of 1ias in includedstudies

8sin0 cochranes too $or assessin0 risk o$ #ias 3as a/ercenta0e4 havin0 the $oowin0 criterias


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BIAS

ttrition refers to thereduction of

experimental participants leaving an experiment or

study for reasons,

Selective reporting

Concealed allocation isa procedure implementedin a randomized control

trial where the individualsscreening and separatingthe candidates into two

(or more) arms of a studyare linded!

(andomisation is the estmethod

removingselection iasetween two

groups ofpatients


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3utco&e &easures:

Pri&ary outco&e: Disease rogression at $!&onths after treat&ent

• *ncrease (&a; $. D

• ?orsening in uncorrected 6A #.! logMAR


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Secondary Measures+$! &onths aftertreat&ent:

• Mean average corneal ower

• Mean corneal achy&eter at thinnest artof cornea

• Mean sherical eBuivalent

•

Contact lens intolerance• Adverse e7ects of C, included in these

studies

• Euality of life outco&es

•

5cono&ic data


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M5/83DS andR5S/S+cont.

Measure of treat&ent e7ect

Pri&ary outco&es +dichoto&ous data : risk

ratio+RRSecondary outco&es +continuous data :Mean di7erence)ichotomous variabl

es are nominalvariables which haveonly two cate+ories

or levels. ,ore-ample i we wereloo/in+ at +ender

we would mostprobably cate+oriesomebody as eithermale or emale.

2he ris/ ratio !orrelative ris/' is

the ratio othe ris/ o an event

in the two +roups avalue o 1 indicatesthat the estimated

e3ects are the sameor both

interventions.


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4ro+ression at 1& months o 5ma-

6tudy C78 Control

+roup

(is/

ratio

Con9denc

e interval"#Brart$%&&

%'$$ '$$ %!& %!%&,$!*&

+ittig Silva$%%

%'- '&% %!&$ %!%&,$!%%

4ro+ression at ": months o 5ma-

+ittig Silva$%%

%'* &-' %!% %!%%,%!

;o study too/ the other primary outcome i.e

UCV as their outcome

4rimary outcome analysis

M5/83DS d


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dverse outcomes

6tudy participants

dverse event

+itting Silva$%% ( *months)

&! 1orneal edema withparacentral in2ltrate$! 3eripheral cornealvascularisation, ! Suepithelial in2ltrates withacIn4ammation

"#Brart $%&&(&$ months)

1orneal edema, acin4ammation, recurrent cornealerosion

5uality of life

6ersh $%&& 7eported it for treated eye ut


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;vera 7uaity o$ evi"ence usin0 ery ow 3 ?e are uncertain o$ the

estimate4

• 1he main reasons $or "own0ra"in0 the evi"ence

incu"e" risk o$ #ias in the incu"e"

stu"ies, im/recision, in"irectness an" /u#ication #ias+


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Su&&ary of &ain results

• 3nly < RC/s@ out of which $ +8ersh !#$$ had very littleusa1le data.

• 9ot ossi1le to ool data due to di7erences in &easuringand reorting outco&es

• 8igh overall risk of 1ias

• "#-=#F reduction in relative risk for rogression ofkeratoconus 1ut this result is very uncertain

• Adverse e7ects not unco&&on

• S&all sa&le sie

• Risk of visual acuity loss@ Buality of life outco&es andecono&ic data not reorted

• 3nly $ study followed u for &ore than $ year

• Children not included in any of the studies

• Euality of evidence low@ the &ain reasons 1eing risk of 1ias @i&recision@ indirectness and u1lication 1ias.


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•/his syste&atic review is not a &etaanlysis:

as few studies

Studies did not reort reBuired outco&es in correct

for&at to ena1le data to 1e ooled 1here$ore it is a 7uaitative anaysis not7uantitative3metaanaysis4


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D)SC8SS);N

;ther systematic reviews6tudy> ;ICE &01" > C78 is e3ective inhaltin+ pro+ression

;law

Increase in nown

A study y

6enri?uez $%&&

7andom allocation of

treatment not done


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A / 8 3 R S C 3 9 C S * 3 9 S

Desite the nu&erous rosective and retrosective studies

availa1le in the literature and the fact that C, see&s to 1e

acceted worldwide as a 1reakthrough treat&ent in the &anage

&ent of keratoconus@ evidence is li&ited due to the lack of roe

rly conducted RC/s. *f strict criteria are used and only data fro&

RC/s acceted@ then there is a lack of evidence that C, is indeed

an e7ective treat&ent in halting the rogression of keratoconus+

8igher-Buality studies are needed 1efore an aroriate

&etaanalysis can 1e conducted to con0r& the i&ortance of this

treat&ent


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?hy is stu"y si0ni=cant


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Ma@or /ositives an"ne0atives


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examined! Lhe mainoutcome measures wererefractive error, visual

acuity, cornealtopographic>eratometry, ultrasonicpachymetry, andtopography.derivedcorneal wavefront!(E6U826>

At 0 years compared topreoperative values,mean sphericale?uivalent refractive

error (S85) increased


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;uture

research

Jap in literature

8xisting

Eiterature

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aakg presentation 1.pptx