EyeWorld Asia-Pacific June 2020 Issue

EWAP JUNE 2020 47 CORNEA of airplane air, or the continuous staring accompanying prolonged computer or cell phone use are all to be minimized.” Dr. Sheppard also instructs patients to roll their globes around under the lids before opening their eyes upon awakening. This helps avoid sudden shear stress on the epithelium with exposure to a dry ambient atmosphere, he said. “So many attacks at night À wÀÃÌ Ì} Ìi À} V> be avoided by this simple self- lubricating maneuver.” Dr. Hatch reminds doctors to listen to their patients. This is a painful condition, and a lot of patients are suffering, she said. It affects how she approaches these cases in the clinic. For instance, she’ll consider whether checking eye pressure is necessary. While it might be important when patients are on steroids, she won’t routinely applanate them, considering risk of causing a recurrence as well as the patient’s comfort. “Patients don’t typically lose their vision from this condition, fortunately, but it’s important to take their concerns seriously,” she said. EWAP Editors’ note: Dr. Hatch is assistant professor of ophthalmology, Harvard Medical School, Boston, Massachusetts. Dr. Sheppard is president, Virginia Eye Consultants, Norfolk, Virginia, and declared relevant interests with Allergan, AbbVie, Bausch + Lomb, Allysta, Oyster Point, Novartis, Shire, Novaliq, Aldeyra, Johnson & Johnson Vision, Mallinckrodt, and Dompe. Dr. Swan practices at Vance Thompson Vision, Bozeman and Billings, Montana. Dr. Talley Rostov practices at Northwest Eye Surgeons, Seattle, Washington. Dr. Hatch, Dr. Swan, and Dr. Talley Rostov declared no relevant ƂPCPEKCN KPVGTGUVU ADVERTISER LISTING Alcon Page 20-22 www.alcon.com Haag-Streit Page 25 www.haag-streit.com Oculus Page 31 www.corneal- biomechanics.com ASCRS Page 59 www.ascrs.org APACRS Page 2, 5, 7, 19, 56, 60 www.apacrs.org Dr. Sheppard’s three-tiered approach There are three tiers of therapy for recurrent corneal erosion in Dr. Sheppard’s practice. He said the success rate with this protocol approaches 100% and prepares the patient’s topography for cataract biometry, penetrating keratoplasty, or refractive surgery, when indicated. Tier 1 À° -i««>À` ÃÌ>ÀÌÃ ÜÌVÃiÀÛ>ÌÛi] vwVi >>}iiÌ] VÃÃÌ} of hypertonic tears (5% sodium chloride) and a therapeutic bandage contact lens. Prior to placing the bandage contact lens, he assesses the epithelium with a dry Weck-Cel spear sponge and topical proparacaine. If the epithelium does not slide over the basement membrane, he doesn’t do any epithelial debridement. After placing the bandage contact lens, he’ll consider a punctal plug to increase moisture during contact lens use. Dr. Sheppard carefully replaces the contact lens, if needed, on a monthly basis. Many patients resolve under this protocol over 1–3 months, he said. Tier 2 An obvious epithelial defect requires a debridement, Dr. Sheppard said. He called patient comfort essential and said he will take anxious, blepharospasm, or vagal candidates to a minor procedure room to «iÀvÀ > ÃÕ«iÀwV> iÀ>ÌiVÌÞ Üi ÌiÞ >Ài >Þ} `Ü ÜÌ> ` speculum in place. He said clinicians may be surprised at how loosely adherent epithelium often extends beyond the lesion all the way to the limbus, and frequently all is removed. Dr. Sheppard said in addition to bandage contact lenses, cryopreserved, sutureless amniotic membrane (Prokera, BioTissue) can Li LiiwV>° i Ã>`i½ ` > Ìi«À>ÀÞ Ì>ÀÃÀÀ>«Þ Üi ÕÃ} the amniotic membrane in some patients. He cautioned against using Prokera in patients with glaucoma shunts due to the potential for erosion of the tube from the product’s outer ring but said dried amniotic membrane (Katena) under the bandage contact lens could be used. In general, while using the bandage contact lens, Dr. Sheppard provides a daily drop of azithromycin for antibiotic support and anti- collagenolytic effects. When the amniotic membrane is removed (5–7 days later), Dr. Sheppard said he keeps the patient in a bandage contact lens until fully healed. Tier 3 *>ÌiÌÃ Ü ÀiVVÕÀ À Ü>Ûi Ã}wV>Ì ÃV>ÀÀ}] iiÛ>ÌÃ] ->â>½Ã `ÕiÃ] wLÀÃÃ] À w>iÌ>ÀÞ iÀ>ÌÌÃ ÀiµÕÀi > ÌÀ« Ì Ìi ASC, Dr. Sheppard said. He will use sedation and a retrobulbar block with cycloplegia to “enable a nearly pain-free postoperative course following extensive aggressive lamellar keratectomy, which may on not so rare an occasion create a miserable or even combative situation in Ìi vwVi°» He patches these patients for a day, places a Prokera amniotic iLÀ>i Ìi vwVi] i>ÛiÃ Ì vÀ > Üii] >`>Ã Ìi > L>`>}i contact lens (exchanged monthly for 3 months). These patients are on a topical antibiotic course, and rarely require oral analgesia beyond acetaminophen or naproxen.