EyeWorld India June 2020 Issue

CORNEA 46 EWAP JUNE 2020 preserved drop formulations available, limiting their usefulness for chronic, routine use in sensitive eyes. Muro 128 (sodium chloride hypertonicity ophthalmic solution, Bausch + Lomb) is available in a preservative-free 5% ointment, which many patients tolerate well, especially before bedtime, he said. Hypertonics are, however, “very useful for epithelial basement membrane disease, which produces poor adhesion of the epithelium to the underlying basement membrane,” he said. “When the epithelial cells slough off in that particular scenario, it becomes a suddenly acutely painful situation for the patient unless they are also neurotrophic. 7i w˜` ̅>̅ޫiÀ̜˜ˆV `Àœ«Ã promote osmotic thinning of corneal epithelial cells and therefore the adhesion of these cells to the underlying basement membrane, thereby reducing the risk of epithelial sloughing creating symptoms and delaying healing.” Dr. Sheppard follows a tiered approach that also guides his surgical management (see sidebar). Surgical management Dr. Hatch emphasized that she prefers to not perform a surgical procedure while a patient is suffering an acute attack, waiting ՘̈ ̅i ̈ÃÃÕià >Ài ˜œÌ ˆ˜y>“i`° Regarding surgical intervention, she does not perform anterior stromal micropuncture. All the doctors cited concern for scarring and limited results with the procedure; Dr. Sheppard called it a temporizing procedure at best. Instead, Dr. Hatch opts vœÀ ÃÕ«iÀwVˆ> ŽiÀ>ÌiV̜“Þ and, for refractory cases, phototherapeutic keratectomy (PTK). These are also Dr. Swan’s preferred surgical approaches, while Dr. Talley Rostov performs PTK for all cases needing surgical therapy. “PTK is 98% successful in my practice for eliminating recurrent corneal erosions,” she said. “It is a quick procedure and resolves the problem nicely.” However, Dr. Sheppard noted that surgical therapy with PTK in his practice is generally unwarranted unless concomitant to a refractive procedure such as photorefractive keratectomy (PRK). “Removal of the surface i«ˆÌ…iˆÕ“ ˆ˜ ̅i œvwVi ˆÃ ȓ«i with a spatula or Weck-Cel spear sponge,” he said. “In the ASC, cicatricial epithelial lesions or nodules are readily removed with the 64 Beaver blade. Excimer laser PTK is >˜ iÝ«i˜ÃˆÛi ÃÕ«iÀy՜Õà intervention that adds a cost to the overhead. If there are no scars or nodules, a small refractive error can also be corrected with an excimer PRK, which removes not only the central epithelium but the basement membrane and some anterior stroma. The refractive advantage is obvious, but the inability of PRK or PTK to reach all the way to the limbus may leave non-adherent epithelium and therefore a residual nidus for recurrence.” Postoperative management Postoperatively, Dr. Hatch said, “it’s important to make sure patients are comfortable.” She will prescribe pain medication as well as antibiotics and steroids. She also said she leaves the bandage contact lens on for about 2 weeks. Dr. Swan’s short-term management for PTK includes 1 week of a broad-spectrum >˜ÌˆLˆœÌˆV ܈̅y՜ÀœµÕˆ˜œœ˜i therapy four times a day and topical steroid four times a day for 1 week weaning to two times a day for 1 week. “Careful examination in the postoperative state is required to rule out steroid-induced ocular hypertension and to ensure a patient does not need longer steroid treatment for the cornea,” he said. “I also continue to emphasize to patients the importance of long-term ocular surface disease management to reduce the risk of recurrence.” Dr. Sheppard also highlighted the importance of ocular surface management, stating that “appropriately aggressive management of concomitant ocular surface disease is warranted, addressing dry eye, allergy, and meibomian gland disease according to standard protocols.” Dr. Talley Rostov’s postop care is similar to what she employs for PRK, with a bandage contact lens, antibiotics QID until the bandage lens comes off, tapering steroid doses, and NSAID drops. She has patients continue ointment at night when the bandage contact lens is removed and use topical VÞVœÃ«œÀˆ˜i >˜` >À̈wVˆ> Ìi>Àð Pearls Dr. Swan thinks it is important to emphasize the chance of recurrence, even after surgical intervention, to patients. They need to know that ongoing monitoring is important, he said. Dr. Sheppard detailed the importance of environmental control. “Most importantly, direct water into the eyes must be avoided, be it swimming, in the shower, or as a form of self- prescribed treatment,” he said. “The hypotonic water creates boggy epithelium through osmotic gradients, reducing adhesion to the underlying basement membrane, and a much higher likelihood of a new or recurrent erosion. “Similarly, extremely low- humidity environments should be avoided, like fans, open ܈˜`œÜÃ] >˜` wÀi«>ViÃ] especially at night,” he said. “Dust, toxic fumes, the abysmally low-humidity content Hereditary ABMD slit lamp image with OCR FQV ƂPIGTRTKPV CIITGICVGU Source: John Sheppard, MD