Turkiye Klinikleri Journal of Ophthalmology

.: REVIEW
Kornea Ektazisine Yaklaşım ve Tedavi
Approach to Corneal Ectasia and Treatment
Evin SİNGARa
aSağlık Bilimleri Üniversitesi Ankara Eğitim ve Araştırma Hastanesi, Göz Hastalıkları ABD, Ankara, TÜRKİYE
Turkiye Klinikleri J Ophthalmol.2021;30(1):55-74
doi: 10.5336/ophthal.2020-75540
Article Language: TR
Full Text
ÖZET
 Kornea ektazisi, korneanın dikleşmesi ve incelmesi ile giden progresif bir hastalıktır. Keratokonus, pellusid marjinal dejenerasyon, keratoglobus gibi hastalıklarda spontan olarak gelişebileceği gibi refraktif cerrahi ve keratoplasti gibi cerrahilerden sonra da gelişebilmektedir. Korneanın, yeni gelişen topografik cihazlarla haritalanmasının yapılabilmesi nedeniyle kornea ektazisinin daha önce bilindiği kadar nadir olmadığı görülmüştür. Spontan gelişen ve cerrahi ile indüklenen kornea ektazisi, her yaştan bireyde görülebilmektedir. Hem cerrahiye bağımlı hem de cerrahiden bağımsız olarak gelişen kornea ektazisi, sonuçta benzer histopatolojik bulgularla sonuçlanmaktadır. Ektazi gelişiminin etiyolojisinde; genetik faktörler, kromozom ve enzim anormallikleri ve çevresel faktörler yer almaktadır. Kornea ektazileri, etiyolojik nedene göre unilateral, bilateral ve/veya asimetrik olarak görülmektedir. Hastalık, klinik olarak saptanamayan veya ''subklinik'' formdan ileri hastalığa kadar farklı şiddette görülmektedir. Her 2 cinsiyette de görülebilen kornea ektazisinin genel semptomları; görme bulanıklığı, görüş kalitesinde azalma ve değişen astigmatizma nedeni ile gözlük numarasının sık değişimidir. Ektazinin erken tanı ve tedavisindeki amaç; görme kaybının önlenmesi, görme keskinliğinin artırılması, kornea ektazisinin belirti ve semptomlarının azaltılması ve kornea nakil gereksiniminin geciktirilmesidir. Tedavinin cerrahi ya da medikal olması, her tedavi seçeneğinin görme düzeyinin etkisine ve hasta için yapılan risk/fayda analizine bağlıdır. Bu derlemede, kornea ektazisinin nedenleri, risk faktörleri, tanı konulurken dikkat edilecek parametreler ve en güncel tedavi seçenekleri, literatürde bulunan makale ve olgu bildirimleri ile paylaşılmıştır.

Anahtar Kelimeler: Kornea topografisi; kornea nakli; keratokonus; refraktif cerrahi işlemler; kontakt lensler; kornea
ABSTRACT
 Corneal ectasia is a progressive disease that goes with the steepining and thinning of the cornea. It can develop spontaneously in diseases such as keratoconus, pellucid marginal degeneration, keratoglobus, as well as after surgeries such as; refractive surgery and keratoplasty. Since the cornea can be mapped with newly developed topographic devices, it has been observed that corneal ectasia is not as rare as previously known. Corneal ectasia, spontaneously developed and surgically induced, can be seen in individuals of all ages. Corneal ectasia that develops both surgically and spontaneously results in similar histopathological findings. Genetic factors, chromosomal and enzyme abnormalities and environmental factors are included in the etiology of ectasia. Corneal ectasias are seen as unilateral, bilateral and/or asymmetric according to the etiological reasons. The disease is not clinically detectable or has a different severity from the "subclinical" form to the advanced disease. General symptoms of corneal ectasia, which can be seen in both genders are; blurred vision, decreased quality of vision, and frequent changes in the number of glasses due to the changing astigmatism values. The purpose of early diagnosis and treatment of ectasia are; preventing vision loss, increasing visual acuity, reducing the signs and symptoms of corneal ectasia and delaying the need for corneal transplantation. Whether the treatment is surgical or medical depends on the effect of each treatment option on vision and the risk/benefit analysis for the patient. This review outlines the causes of corneal ectasia, risk factors, parameters of the diagnosis, and the most recent treatment strategies are shared with the articles and case reports in the literature.

Keywords: Corneal topography; corneal transplantation; keratoconus; refractive surgical procedures; contact lenses; cornea
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  100. Raiskup-Wolf F, Hoyer A, Spoerl E, Pillunat LE. Collagen crosslinking with riboflavin and ultraviolet-a light in keratoconus: long-term results. J Cataract Refract Surg. 2008;34(5):796-801.[Crossref] [PubMed] 
  101. Elbaz U, Shen C, Lichtinger A, Zauberman NA, Goldich Y, Chan CC, et al. Accelerated (9-mW/cm2) corneal collagen crosslinking for keratoconus-a 1-year follow-up. Cornea. 2014;33(8):769-73.[Crossref] [PubMed] 
  102. Medeiros CS, Giacomin NT, Bueno RL, Ghanem RC, Moraes HV Jr, Santhiago MR, et al. Accelerated corneal collagen crosslinking: technique, efficacy, safety, and applications. J Cataract Refract Surg. 2016;42(12):1826-35.[Crossref] [PubMed] 
  103. Shetty R, Pahuja NK, Nuijts RM, Ajani A, Jayadev C, Sharma C, et al. Current protocols of corneal collagen cross-linking: visual, refractive, and tomographic outcomes. Am J Ophthalmol. 2015;160(2):243-9.[Crossref] [PubMed] 
  104. Marino GK, Torricelli AA, Giacomin N, Santhiago MR, Espindola R, Netto MV, et al. Accelerated corneal collagen cross-linking for postoperative lasik ectasia: two-year outcomes. J Refract Surg. 2015;31(6):380-4.[Crossref] [PubMed] 
  105. Mazzotta C, Baiocchi S, Bagaglia SA, Fruschelli M, Meduri A, Rechichi M, et al. Accelerated 15 mW pulsed-light crosslinking to treat progressive keratoconus: two-year clinical results. J Cataract Refract Surg. 2017;43(8):1081-8.[Crossref] [PubMed] 
  106. Filippello M, Stagni E, O'Brart D. Transepithelial corneal collagen crosslinking: bilateral study. J Cataract Refract Surg. 2012;38(2):283-91. Erratum in: J Cataract Refract Surg. 2012 Aug;38(8):1515.[Crossref] [PubMed] 
  107. Stulting RD. Corneal collagen cross-linking. Am J Ophthalmol. 2012;154(3):423-4.e1.[Crossref] [PubMed] 
  108. Vinciguerra P, Albé E, Frueh BE, Trazza S, Epstein D. Two-year corneal cross-linking results in patients younger than 18 years with documented progressive keratoconus. Am J Ophthalmol. 2012;154(3):520-6.[Crossref] [PubMed] 
  109. Hovakimyan M, Guthoff RF, Stachs O. Collagen cross-linking: current status and future directions. J Ophthalmol. 2012;2012:406850.[Crossref] [PubMed] [PMC] 
  110. Arbelaez MC, Sekito MB, Vidal C, Choudhury SR. Collagen cross-linking with riboflavin and ultraviolet-a light in keratoconus: one-year results. Oman J Ophthalmol. 2009;2(1):33-8.[Crossref] [PubMed] [PMC] 
  111. Asri D, Touboul D, Fournié P, Malet F, Garra C, Gallois A, et al. Corneal collagen crosslinking in progressive keratoconus: multicenter results from the French National Reference Center for Keratoconus. J Cataract Refract Surg. 2011;37(12):2137-43.[Crossref] [PubMed] 
  112. Sandvik GF, Thorsrud A, Råen M, Østern AE, Sæthre M, Drolsum L, et al. Does corneal collagen cross-linking reduce the need for keratoplasties in patients with keratoconus? Cornea. 2015;34(9):991-5.[Crossref] [PubMed] 
  113. Godefrooij DA, Gans R, Imhof SM, Wisse RP. Nationwide reduction in the number of corneal transplantations for keratoconus following the implementation of cross-linking. Acta Ophthalmol. 2016;94(7):675-8.[Crossref] [PubMed] 
  114. Hersh PS, Stulting RD, Muller D, Durrie DS, Rajpal RK; United States Crosslinking Study Group. United States multicenter clinical trial of corneal collagen crosslinking for keratoconus treatment. Ophthalmology. 2017;124(9):1259-70. Erratum in: Ophthalmology. 2017;124(12 ):1878.[Crossref] [PubMed] 
  115. Jones MN, Armitage WJ, Ayliffe W, Larkin DF, Kaye SB; NHSBT Ocular Tissue Advisory Group and Contributing Ophthalmologists (OTAG Audit Study 5). Penetrating and deep anterior lamellar keratoplasty for keratoconus: a comparison of graft outcomes in the United kingdom. Invest Ophthalmol Vis Sci. 2009;50(12):5625-9.[Crossref] [PubMed] 
  116. Ertan A, Karacal H, Kamburoğlu G. Refractive and topographic results of transepithelial cross-linking treatment in eyes with intacs. Cornea. 2009;28(7):719-23.[Crossref] [PubMed] 
  117. Jia HZ, Peng XJ. Efficacy of iontophoresis-assisted epithelium-on corneal cross-linking for keratoconus. Int J Ophthalmol. 2018;18;11(4):687-94.[PubMed] [PMC] 
  118. Vinciguerra P, Randleman JB, Romano V, Legrottaglie EF, Rosetta P, Camesasca FI, et al. Transepithelial iontophoresis corneal collagen cross-linking for progressive keratoconus: initial clinical outcomes. J Refract Surg. 2014;30(11):746-53.[Crossref] [PubMed] 
  119. Liao K, Hu M, Chen F, Li P, Song P, Zeng QY, et al. Clinical and microstructural changes with different iontophoresis-assisted corneal cross-linking methods for keratoconus. Int J Ophthalmol. 2019;18;12(2):219-25.[PubMed] [PMC] 
  120. Kymionis GD, Kontadakis GA, Kounis GA, Portaliou DM, Karavitaki AE, Magarakis M, et al. Simultaneous topography-guided PRK followed by corneal collagen cross-linking for keratoconus. J Refract Surg. 2009;25(9):S807-11.[Crossref] [PubMed] 
  121. Kymionis GD, Portaliou DM, Kounis GA, Limnopoulou AN, Kontadakis GA, Grentzelos MA, et al. Simultaneous topography-guided photorefractive keratectomy followed by corneal collagen cross-linking for keratoconus. Am J Ophthalmol. 2011;152(5):748-55.[Crossref] [PubMed] 
  122. Stojanovic A, Zhang J, Chen X, Nitter TA, Chen S, Wang Q, et al. Topography-guided transepithelial surface ablation followed by corneal collagen cross-linking performed in a single combined procedure for the treatment of keratoconus and pellucid marginal degeneration. J Refract Surg. 2010;26(2):145-52.[Crossref] [PubMed] 
  123. Reinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM, et al. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty a report by the american academy of ophthalmology. Ophthalmology. 2011;118(1):209-18.[Crossref] [PubMed] 
  124. Feizi S, Javadi MA, Jamali H, Mirbabaee F. Deep anterior lamellar keratoplasty in patients with keratoconus: big-bubble technique. Cornea. 2010;29(2):177-82.[Crossref] [PubMed] 
  125. Caporossi A, Balestrazzi A, Simi C, Caporossi T, Traversi C. Manual deep lamellar keratoplasty: alternative methods and air-guided technique. Transplant Proc. 2005;37(6):2697-701.[Crossref] [PubMed] 
  126. Buzzonetti L, Laborante A, Petrocelli G. Refractive outcome of keratoconus treated by combined femtosecond laser and big-bubble deep anterior lamellar keratoplasty. J Refract Surg. 2011;27(3):189-94.[Crossref] [PubMed] 
  127. Farid M, Steinert RF. Deep anterior lamellar keratoplasty performed with the femtosecond laser zigzag incision for the treatment of stromal corneal pathology and ectatic disease. J Cataract Refract Surg. 2009;35(5):809-13.[Crossref] [PubMed] 
  128. Price FW Jr, Price MO, Grandin JC, Kwon R. Deep anterior lamellar keratoplasty with femtosecond-laser zigzag incisions. J Cataract Refract Surg. 2009;35(5):804-8. Erratum in: J Cataract Refract Surg. 2009;35(7):1325.[Crossref] [PubMed] 
  129. American Academy of Ophthalmology Cornea/External Disease Panel. referred practice Pattern® guidelines. Corneal edema and opacification. San Francisco, CA: American Academy of Ophthalmology; 2018.[Link] 
  130. Ardjomand N, Hau S, McAlister JC, Bunce C, Galaretta D, Tuft SJ, et al. Quality of vision and graft thickness in deep anterior lamellar and penetrating corneal allografts. Am J Ophthalmol. 2007;143(2):228-35.[Crossref] [PubMed] 
  131. Al-Torbak AA, Al-Motowa S, Al-Assiri A, Al-Kharashi S, Al-Shahwan S, Al-Mezaine H, et al. Deep anterior lamellar keratoplasty for keratoconus. Cornea. 2006;25(4):408-12.[Crossref] [PubMed] 
  132. Fontana L, Parente G, Sincich A, Tassinari G. Influence of graft-host interface on the quality of vision after deep anterior lamellar keratoplasty in patients with keratoconus. Cornea. 2011;30(5):497-502.[Crossref] [PubMed] 
  133. Fontana L, Parente G, Tassinari G. Clinical outcomes after deep anterior lamellar keratoplasty using the big-bubble technique in patients with keratoconus. Am J Ophthalmol. 2007;143(1):117-24.[Crossref] [PubMed] 
  134. Han DC, Mehta JS, Por YM, Htoon HM, Tan DT. Comparison of outcomes of lamellar keratoplasty and penetrating keratoplasty in keratoconus. Am J Ophthalmol. 2009;148(5):744-51.e1.[Crossref] [PubMed] 
  135. Javadi MA, Feizi S, Yazdani S, Mirbabaee F. Deep anterior lamellar keratoplasty versus penetrating keratoplasty for keratoconus: a clinical trial. Cornea. 2010;29(4):365-71.[Crossref] [PubMed] 
  136. Cohen AW, Goins KM, Sutphin JE, Wandling GR, Wagoner MD. Penetrating keratoplasty versus deep anterior lamellar keratoplasty for the treatment of keratoconus. Int Ophthalmol. 2010;30(6):675-81.[Crossref] [PubMed] 
  137. Bahar I, Kaiserman I, Srinivasan S, Ya-Ping J, Slomovic AR, Rootman DS, et al. Comparison of three different techniques of corneal transplantation for keratoconus. Am J Ophthalmol. 2008;146(6):905-12.e1.[Crossref] [PubMed] 
  138. Chen G, Tzekov R, Li W, Jiang F, Mao S, Tong Y, et al. Deep anterior lamellar keratoplasty versus penetrating keratoplasty: a meta-analysis of randomized controlled trials. Cornea. 2016;35(2):169-74.[Crossref] [PubMed] 
  139. Kim KH, Choi SH, Ahn K, Chung ES, Chung TY. Comparison of refractive changes after deep anterior lamellar keratoplasty and penetrating keratoplasty for keratoconus. Jpn J Ophthalmol. 2011;55(2):93-7.[Crossref] [PubMed] 
  140. Cheng YY, Visser N, Schouten JS, Wijdh RJ, Pels E, van Cleynenbreugel H, et al. Endothelial cell loss and visual outcome of deep anterior lamellar keratoplasty versus penetrating keratoplasty: a randomized multicenter clinical trial. Ophthalmology. 2011;118(2):302-9.[Crossref] [PubMed] 
  141. Fogla R, Padmanabhan P. Results of deep lamellar keratoplasty using the big-bubble technique in patients with keratoconus. Am J Ophthalmol. 2006;141(2):254-9.[Crossref] [PubMed] 
  142. Kubaloglu A, Koytak A, Sari ES, Akyol S, Kurnaz E, Ozerturk Y, et al. Corneal endothelium after deep anterior lamellar keratoplasty and penetrating keratoplasty for keratoconus: a four-year comparative study. Indian J Ophthalmol. 2012;60(1):35-40.[Crossref] [PubMed] [PMC] 
  143. Kubaloglu A, Sari ES, Unal M, Koytak A, Kurnaz E, Cinar Y, et al. Long-term results of deep anterior lamellar keratoplasty for the treatment of keratoconus. Am J Ophthalmol. 2011;151(5):760-7.e1.[Crossref] [PubMed] 
  144. Sarnicola V, Toro P, Sarnicola C, Sarnicola E, Ruggiero A. Long-term graft survival in deep anterior lamellar keratoplasty. Cornea. 2012;31(6):621-6.[Crossref] [PubMed] 
  145. Keane M, Coster D, Ziaei M, Williams K. Deep anterior lamellar keratoplasty versus penetrating keratoplasty for treating keratoconus. Cochrane Database Syst Rev. 2014;22;(7):CD009700.[Crossref] [PubMed] 
  146. Olson EA, Tu EY, Basti S. Stromal rejection following deep anterior lamellar keratoplasty: implications for postoperative care. Cornea. 2012;31(9):969-73.[Crossref] [PubMed] 
  147. Mashor RS, Rootman DB, Bahar I, Singal N, Slomovic AR, Rootman DS, et al. Outcomes of deep anterior lamellar keratoplasty versus intralase enabled penetrating keratoplasty in keratoconus. Can J Ophthalmol. 2011;46(5):403-7.[Crossref] [PubMed] 
  148. Chamberlain WD, Rush SW, Mathers WD, Cabezas M, Fraunfelder FW. Comparison of femtosecond laser-assisted keratoplasty versus conventional penetrating keratoplasty. Ophthalmology. 2011;118(3):486-91.[Crossref] [PubMed] 
  149. Chan CC, Ritenour RJ, Kumar NL, Sansanayudh W, Rootman DS. Femtosecond laser-assisted mushroom configuration deep anterior lamellar keratoplasty. Cornea. 2010;29(3):290-5.[Crossref] [PubMed] 
  150. Farid M, Kim M, Steinert RF. Results of penetrating keratoplasty performed with a femtosecond laser zigzag incision initial report. Ophthalmology. 2007;114(12):2208-12.[Crossref] [PubMed] 
  151. Farid M, Steinert RF. Femtosecond laser-assisted corneal surgery. Curr Opin Ophthalmol. 2010;21(4):288-92.[PubMed] 
  152. Cheng YY, Tahzib NG, van Rij G, van Cleynenbreugel H, Pels E, Hendrikse F, et al. Femtosecond laser-assisted inverted mushroom keratoplasty. Cornea. 2008;27(6):679-85.[Crossref] [PubMed] 
  153. Pramanik S, Musch DC, Sutphin JE, Farjo AA. Extended long-term outcomes of penetrating keratoplasty for keratoconus. Ophthalmology. 2006;113(9):1633-8.[Crossref] [PubMed] 
  154. Javadi MA, Naderi M, Zare M, Jenaban A, Rabei HM, Anissian A, et al. Comparison of the effect of three suturing techniques on postkeratoplasty astigmatism in keratoconus. Cornea. 2006;25(9):1029-33.[Crossref] [PubMed] 
  155. Javadi MA, Motlagh BF, Jafarinasab MR, Rabbanikhah Z, Anissian A, Souri H, et al. Outcomes of penetrating keratoplasty in keratoconus. Cornea. 2005;24(8):941-6.[Crossref] [PubMed] 
  156. Patel SV, Malta JB, Banitt MR, Mian SI, Sugar A, Elner VM, et al. Recurrent ectasia in corneal grafts and outcomes of repeat keratoplasty for keratoconus. Br J Ophthalmol. 2009;93(2):191-7.[Crossref] [PubMed] 
  157. Unal M, Yücel I, Akar Y, Akkoyunlu G, Ustünel I. Recurrence of keratoconus in two corneal grafts after penetrating keratoplasty. Cornea. 2007;26(3):362-4. Erratum in: Cornea. 2007;26(5):646. Gültekin, Ismail [corrected to Ustünel, Ismail].[Crossref] [PubMed] 

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1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

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