Efficacy and Safety of Transglutaminase-Induced Corneal Stiffening in Rabbits

PURPOSE: To evaluate the biomechanical efficacy and safety of in vivo microbial transglutaminase (Tgases)-induced corneal crosslinking in a rabbit model. METHODS: A total of 34 white New Zealand rabbits were divided into two groups, a biochemistry group and a photochemistry group. The right eye of every rabbit was treated and left eyes served as negative controls. In the biochemistry group, a 1 U/mL solution of crosslinking agent microbial Tgases (Tgases CXL) was applied to the corneal surface, while in the photochemistry group, clinical ultraviolet A-riboflavin crosslinking (UVA/RF CXL) was used. Efficacy and safety evaluated on the 14th day after the procedures. Twelve pairs of corneal strips were harvested from the eyes of 12 euthanized rabbits in every group, and uniaxial tensile tests were performed to evaluate ex vivo biomechanical effects. The CXL-treated eye to its corresponding untreated eye ratio of tangent modulus were calculated. Another five pairs of corneal button were excised from euthanized animals in every group for corneal stroma and endothelium staining to evaluate changes in keratocyte distribution and endothelial cell damage. RESULTS: In tensile tests, tangent modulus was statistically higher in the Tgases CXL groups under 1.0 MPa (26.59 ± 4.54 vs. 21.47 ± 4.72 MPa, P = 0.04) and 1.5 MPa (29.75 ± 5.01 vs. 20.47 ± 6.63 MPa, P = 0.00). The tangent modulus ratio of Tgases group (1.72 ± 1.0 vs. 1.05 ± 0.22, P = 0.04) was significantly higher than that of UVA/RF under 1.5-MPa stress. The distribution of keratocytes in the corneal stroma and the morphologies of endothelial cells were similar in Tgases CXL-treated and untreated corneas. However, in the UVA/RF CXL group, keratocytes in the anterior half of stromal thickness were lost, and clear endothelial cell apoptosis was observed. CONCLUSIONS: Tgases-CXL effectively stiffened the cornea and caused no damage to the endothelium and keratocytes in the cornea. This crosslinking method could be useful as a next-generation treatment for corneal ectasia and could replace CXL of photochemistry. TRANSLATIONAL RELEVANCE: These findings may give a new hope to biomechanically compromised corneal disease due to mechanical forces, such as corneal ectasia and keratoconus. A next-generation treatment to these corneal diseases due to mechanical forces may be designed based on the new findings.