Evaluation of intrastromal riboflavin concentration in human corneas after three corneal cross-linking imbibition procedures: A pilot study

Purpose. To compare stromal riboflavin concentration after three corneal cross-linking (CXL) imbibition procedures: standard (EpiOff), transepithelial corneal (EpiOn), and iontophoresis-assisted technique (Ionto) using 0.1% hypotonic riboflavin phosphate. Methods. Randomized open-label pilot clinical study. Twelve corneas/12 patients with advanced keratoconuswere randomly divided into 4 groups for CXL (n = 3). The corneas underwent imbibition with standard riboflavin EpiOff and with enhanced riboflavin solution (RICROLIN+) EpiOff, EpiOn, and iontophoresis techniques. Thereafter, deep anterior lamellar keratectomy procedurewas performed and the obtained debrided corneal tissueswere frozen. Themaximal intrastromal riboflavin concentrationwas measured by high-performance liquid chromatography/mass spectrometry (mcg/dg). Results. The mean stromal concentration of riboflavin was 2.02 +/- 0.72 mcg/dg in EpiOff group, 4.33 +/- 0.12 mcg/g in EpiOff-RICROLIN+ group, 0.63 +/- 0.21 mcg/dg in EpiOn-RICROLIN+ group, and 1.15 +/- 0.27 mcg/dg in iontophoresis RICROLIN+ group. A 7-fold decrease in intrastromal riboflavin concentration was observed comparing EpiOn-RICROLIN+ and EpiOff-RICROLIN+ groups. Conclusion. The present pilot study indicates that both transepithelial CXL techniques in combination with hypotonic enhanced riboflavin formulation (RICROLIN+) were still inferior to the standard CXL technique; however, larger clinical studies to further validate the results are needed and in progress.