Cocaine-Assisted Epithelial Debridement for the Treatment of Anterior Basement Membrane Dystrophy

Superficial Keratectomy: A Review of Literature

Superficial keratectomy (SK) is the manual dissection of the superficial corneal layers (epithelium, Bowman's layer, and sometimes superficial stroma). SK is done using a surgical blade or diamond burr. Some surgeons use intraoperative mitomycin C 0.02% or amniotic membrane transplantation to improve surgical outcomes. This literature review shows that SK remains an effective method for different indications, including tissue diagnosis, excision of corneal degenerations, dystrophies, scarring, recurrent corneal erosions, and retained corneal foreign body.

Treatment of Epithelial Basement Membrane Dystrophy to Optimize the Ocular Surface Prior to Cataract Surgery

Purpose

To assess the effectiveness of cryopreserved amniotic membrane (CAM) after debridement in treating epithelial basement membrane dystrophy (EBMD) prior to cataract surgery.

Methods

This pilot study included 2 treatment groups: a prospective study group of 9 subjects with significant EBMD who received debridement followed by self-retained CAM, and a retrospective, control group of 10 consecutive subjects who received debridement followed by a bandage contact lens (BCL). Slit-lamp photography after fluorescein staining were used to monitor healing. Corneal topography and IOL calculation were compared at baseline and 1 month after the procedure. Refraction and ocular surface stability were also compared after cataract surgery.

Results

Corneal reepithelialization after debridement occurred in 4.6 ± 0.8 days in the study group and 6.8 ± 0.6 days in the control (p < 0.05). Corneal topography showed changes in curvature from 43.5 ± 1.2D at baseline to 44.6 ± 1.2D at 1 month in the study group and from 45.0 ± 0.6D to 45.7 ± 0.8D in the control (p = 0.38). Average change in IOL calculation was 1.56 D in the study group, compared to 0.95 D in control (p = 0.29). Post-cataract refraction in both groups was within ±0.5 Diopter of the anticipated, and corneal surface remained stable without EBMD recurrence.

Conclusion

Management of ocular surface disorders prior to cataract surgery stabilizes IOL calculation and reduces postoperative refractive surprises. CAM relatively accelerated healing after debridement; however, it was not better than BCL in stabilizing the ocular surface and improving visual outcome. The use of CAM in cases of EBMD remains speculative.

Topical use of alcohol in ophthalmology - Diagnostic and therapeutic indications

Alcohol (ethanol) has been used in medicine since time immemorial. In ophthalmic practice, besides as an antiseptic, it was given as retrobulbar injections to relieve severe ocular pain. Alcohol can be applied topically to the surface of neoplastic or suspicious lesions to kill cells that might desquamate and seed during surgical excision, to treat epithelial ingrowth that can occur following corneal surgeries, particularly laser in situ keratomileusis (LASIK), and to treat superficial infectious keratitis. In view of its ability to achieve a smooth cleavage plane between the epithelium and the Bowman's layer, alcohol-assisted delamination (ALD) of the corneal epithelium has been used widely and effectively for a variety of diagnostic and therapeutic indications, at times delivering both outcomes. Diagnostically, ALD yields an intact epithelial sheet which can be fixed flat to provide excellent orientation for histopathological evaluation. Therapeutically, it is most commonly used to treat recurrent corneal erosion syndrome, where its efficacy is comparable to that of phototherapeutic keratectomy but with several advantages. It has also been used to treat various forms of epithelial/anterior stromal dystrophies, which can obviate or delay the need for corneal transplantation for several years. In addition, ALD is performed in corneal collagen cross-linking and corneal refractive surgery for relatively atraumatic removal of the epithelium. In this review, we aimed to provide a comprehensive overview of the diagnostic and therapeutic use of topical alcohol in ophthalmology, to describe the surgical and fixation techniques of ALD, and to highlight our experience in ALD over the past decade.

Rare stromal corneal dystrophic diseases in Oman: A clinical and histopathological analysis for accurate diagnosis

INTRODUCTION

Corneal dystrophy (CD) encirclements a heterogeneous group of genetically determined corneal diseases. Many features still remain unknown.

AIM

The purpose of this study was to highlight the clinical and the histopathological aspects of rare stromal CDs and to assess the clinical and the histopathological roles in their diagnosis.

PATIENTS AND METHODS

This study incorporated 10 eyes of six patients, clinically diagnosed as follows: four patients with bilateral lattice stromal CD (8 eyes) and two patients, each one eye, one with macular and the other with granular-type CD. Histopathological examination with applications of many special stains was done in four eyes (4 patients) after penetrating keratoplasty.

RESULTS

The histopathological examination was in concordance with the clinical diagnosis of three examined corneas and revealed first eye with lattice dystrophy, second eye with macular dystrophy, and third eye with granular dystrophy. The fourth examined cornea was not that in concordance with the clinical diagnosis of lattice CD as it showed mixed stromal CD patterns of granular, macular, and lattice types.

CONCLUSION

Histopathological assessment of corneal dystrophy cases, subjected to keratoplasty is recommended to avoid missing cases with mixed stromal corneal dystrophy. Also, using low magnification slit lamp alone in the clinical assessment of the corneal opacity appeared to be limited mode and thus, the imaging corneal methods such confocal microscopy and high-definition optical coherence tomography are recommended for future cases especially in cases with unclassic query diagnosis.

Recurrent corneal erosion: a comprehensive review

Purpose

To comprehensively review the literature regarding recurrent corneal erosion (RCE) and to present treatment options and recommendations for management.

Overview

RCE usually presents with sharp, unilateral pain upon awakening, in an eye with an underlying basement membrane dystrophy, prior ocular trauma, stromal dystrophy or degeneration, or prior surgery for refractive errors, cataracts, or corneal transplantation. Making the correct diagnosis requires a careful slit-lamp examination of both eyes coupled with a high degree of suspicion. Several treatments are commonly used for RCE but new therapies have been introduced recently. Conservative treatment consists of antibiotic and preservative-free lubricating drops, with topical cycloplegics and oral analgesics to control pain. Patients who are unresponsive to these therapies may benefit from therapeutic bandage contact lenses (BCL). Newer therapies include oral matrix metalloproteinase (MMP) inhibitors, blood-derived eye drops, amniotic membrane graft application, and judicious application of topical corticosteroids. Once the epithelium is healed, a course of hypertonic saline solution and/or ointment can be used. Surgical procedures may be performed in patients who fail conservative therapy. Punctal occlusion with plugs increases the tear film volume. Epithelial debridement with diamond burr polishing (DBP), anterior stromal puncture (ASP), or alcohol delamination should be considered in selected patients. DBP can be used for patients with basement membrane dystrophies and is the preferred treatment overall due to a low recurrence rate. ASP can be used for erosions outside the central visual axis. Excimer laser phototherapeutic keratectomy is an attractive option in eyes with central RCE since it precisely removes tissue while preserving corneal transparency. In patients with RCE who are also candidates for refractive surgery, photorefractive keratectomy can be considered.

Summary

Newly introduced therapies for RCE enable therapy to be individualized and lower the recurrence rate.

Superficial keratectomy: indications and outcomes

INTRODUCTION

To evaluate the indications and outcomes of manual blade superficial keratectomy STUDY DESIGN: Retrospective, nonrandomized, consecutive case series METHODS: Database search of patients from 2012-2017 who underwent superficial keratectomy was conducted at a tertiary care hospital cornea clinic. Charts of 121 patients (156 eyes) were reviewed who had at least 4 weeks of follow-up and both preoperative and postoperative measurements of best-corrected visual acuity or corneal cylinder. Outcome measures included: patient demographics, surgical indication, prior ocular history, best-corrected visual acuity (BCVA) changes, corneal and refractive astigmatism changes, recurrence of pathology, additional treatments required, and intraoperative and postoperative complications.

RESULTS

Mean patient age at time of operation was 63.3 (±14.8), 39% were male. Indications included epithelial basement membrane dystrophy, recurrent corneal erosion syndrome, Salzmann nodular degeneration, band keratopathy, and suspected ocular surface neoplasia. In eyes with epithelial basement membrane dystrophy, mean BCVA (20/47 to 20/40, P = 0.033), refractive astigmatism (1.76 ± 1.83 D to 1.15 ± 1.08 D, P = 0.010), and corneal astigmatism (1.44 ± 0.88 D to 1.06 ± 0.88 D, P = 0.022) significantly improved. Twenty-four percent (5/21) of eyes with recurrent erosions had symptoms return at a mean 6.5 months follow-up. No intraoperative complications were noted. The epithelium healed completely in all 156 eyes at final follow-up.

CONCLUSION

Superficial keratectomy is a simple, safe procedure that can be performed for a variety of conditions to improve visual acuity, reduce corneal astigmatism, and alleviate symptoms secondary to ocular surface pathology.

Active Pedicle Epithelial Flap Transposition Combined with Amniotic Membrane Transplantation for Treatment of Nonhealing Corneal Ulcers

Introduction. The objective was to evaluate the efficacy of active pedicle epithelial flap transposition combined with amniotic membrane transplantation (AMT) in treating nonhealing corneal ulcers. Material and Methods. Eleven patients (11 eyes) with nonhealing corneal ulcer who underwent the combined surgery were included. Postoperatively, ulcer healing time was detected by corneal fluorescein staining. Visual acuity, intraocular pressure, surgical complications, and recurrence were recorded. Corneal status was inspected by the laser scanning confocal microscopy and anterior segment optical coherence tomography (AS-OCT). Results. The primary diseases were herpes simplex keratitis (8 eyes), corneal graft ulcer (2 eyes), and Stevens-Johnson syndrome (1 eye). All epithelial flaps were intact following surgery, without shedding or displacement. Mean ulcer healing time was 10.8 ± 3.1 days, with a healing rate of 91%. Vision significantly improved from 1.70 to 0.82 log MAR (P = 0.001). A significant decrease in inflammatory cell infiltration and corneal stromal edema was revealed 2 months postoperatively by confocal microscopy and AS-OCT. Corneal ulcer recurred in 1 eye. None of the patients developed major complications. Conclusion. Active pedicle epithelial flap transposition combined with AMT is a simple and effective treatment for nonhealing corneal ulcers.

Characteristics of corneal dystrophies: a review from clinical, histological and genetic perspectives

Corneal dystrophy is a common type of hereditary corneal diseases. It includes many types, which have varied pathology, histology and clinical manifestations. Recently, the examination techniques of ophthalmology and gene sequencing advance greatly, which do benefit to our understanding of these diseases. However, many aspects remain still unknown. And due to the poor knowledge of these diseases, the results of the treatments are not satisfoctory. The purpose of this review was to summarize the clinical, histological and genetic characteristics of different types of corneal dystrophies.