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10/04/2016 1 Corneal Tattooing 10/04/2016 Faculty David Rootman, Allan Slomovic, Ocular Surface Procedures in the MD, FRCSC MD, FRCSC Treatment Room Clara Chan, MD, Randall Ulate, MD Neera Singal, MD, FRCSC, FACS FRCSC University of Toronto Zach Ashkenazy, Armand Borovik, Mario Saldanha , Mahmood Showail, MD MD FRCS, FRCOphth MD Financial Disclosures • Clara Chan, MD, FRCSC, FACS: Consultant for Alcon, Allergan and Bausch & Lomb • Off-label use of fibrin tissue glue, Anti-VEGF agents, and • Neera Singal, MD, FRCSC: no disclosures mitomycin C, will be mentioned in presentations • David Rootman, MD, FRCSC: Consultant for AMO • Allan Slomovic, MD, FRCSC: Consultant for Alcon, Allergan, Bausch & Lomb • Zach Ashkenazy, MD, Randall Ulate, MD, Mario Saldanha ,MD, Mahmud Showail, MD,Armand Borovik,MD: no disclosures When? Corneal Tattooing • To improve eye cosmetic appearance David Rootman, MD • Reduce glare from large iridotomies 1 10/04/2016 What do we need? Step by step • Operating 1)Topical anesthetic microscope 2)Betadine prep, drape, lid speculum • Coloring agents 3)Mix dye according to patient’s iris color. • Needle (21G) Postoperative management • Topical antibiotics and steroids (Tobradex qid) for 1 week. • Bandage contact lens for 1 week • Continue steroid topical drops for another 2-3 weeks Results Pocket Tattoo David S. Rootman, MD, FRCSC Professor, University of Toronto Adjunct Professor, Ben Gurion University 2 10/04/2016 Technique • Vertical, corneal incision 50% depth • Lamellar pocket • Insertion of pigment on crescent knife blade Femto-Tattoo • Discussion • Questions What is conjunctivochalasis? • Consider it “inferior SLK” • Excess conjunctival folds between globe and lid Conjunctivochalasis margin Clara Chan, MD, FRCSC, FACS University of Toronto Department of Ophthalmology and Vision Sciences 3 10/04/2016 Why does it happen? Risk Factors • Conjunctiva is no longer adherent to tenon’s capsule • Increased age • Absence of tenon’s capsule and conjunctiva does not adhere • Chronic ocular surface inflammation to sclera • Dry eye, blepharitis, allergic conjunctivitis WITH • Post-operative chemosis • Thinning and stretching of conjunctiva • Post-traumatic chemosis What problems does this cause? What do patients complain about? • Irregular tear film • Asymptomatic to severe discomfort • Poor tear outflow mechanism • “My eyelids feel stuck to my eye ball” • Hinders lid pump function • “I find it hard to blink” • Mechanical blockage of puncta • “My eyes feel so tired” • Recurrent subconjunctival hemorrhages • FBS, tearing, discomfort, pain When do I treat? Treatment options First: Symptomatic and signs of: • Optimize dry eye, MGD, allergies • “Effortful” blinking • Optimize lid abnormalities (ectropion) Surgical Intervention: • Positive “Rub test” or “Thumb test” • Cautery to shrink the excess conjunctival folds • Conjunctival resection with amniotic membrane • Apply gentle upward pressure to the eyeball • Conjunctival resection with suture closure through lower lid, ask the patient to look in • "Paste-Pinch-Cut” with fibrin glue* different direction to replicate symptoms *Doss LR, Doss EL, Doss RP. Cornea 2012;31:959-62. 4 10/04/2016 "Paste-Pinch-Cut” Step by Step • My preferred technique 1) Topical anesthetic • Fibrin glue provides hemostasis 2) Betadine prep, drape, lid speculum • Much less inflammation 3) Weck cell pledgets soaked with topical anesthetic applied to • Improved patient comfort inferior bulbar conjunctiva x 30 seconds • Efficient procedure 4) Draw up fibrinogen in 1 cc syringe with 25 gauge short needle and • Faster recovery thrombin in another 1 cc syringe with 30 gauge short needle Post-operatively • Tobradex ointment and patch x 4 hours • Tobradex and artificial tears qid x 1 week • Tylenol PRN for pain • Follow-up at 1 week • Finish the Tobradex, then Maxidex 1 drop qid tapering 1 drop every 2 weeks • Follow-up at 6 weeks post op • Questions Superficial Keratectomy • Discussion Neera Singal, MD, FRCSC Director of Cornea, Kensington Eye Institute University of Toronto Department of Ophthalmology and Vision Sciences 5 10/04/2016 Indications Indications • Anterior basement • In combination with other procedures membrane dystrophy – Band keratopathy – Pterygium Excision and conjuctival autograft • Salzmann’s nodular degeneration Prior to procedure Instruments • Topical anaesthetic • Establish the diagnosis • slit lamp/minor procedure room • Informed consent • Speculum – Explain postop course • .12 forceps – Time off work • Beaver blade • Bandage contact lens Post Operative Instructions • Bandage contact lens X 1 week • Topical antibiotics and steroid qid X 1 week • Oral analgesic • FU 1 week and 1 month 6 10/04/2016 Case Case • 20/80 • 75 y.o. male referred for consideration of • Salzmaan nodules cataract surgery by the optometrist for • Irregular astigmatism declining vision • Mild NS • • 20/25 Questions • Discussion Indications Corneal gluing • Corneal perforation < 3 mm • Impending perforation Dr Armand Borovik University of Toronto • Post trauma Department of Ophthalmology and Vision Sciences 7 10/04/2016 Requirements Technique 1 • Tetracaine • Topical anesthetic • Lid speculum ensuring no pressure on globe • Lid speculum (preferable) • Debride necrotic tissue 2mm around perforation • 15 blade • Prepare glue • Cyanoacrylate glue • Cut disc of sterile drape with skin punch • Weckcels • Apply ointment to cue tip • Sterile cue tips • Place drape on cue tip • Apply small amount of glue to disc • Ointment e.g. tobradex or erythromycin • Dry perforation and surrounding area thoroughly • Sterile drape • Apply disc directly over the area of perforation • Skin punch 3mm or 4mm • BCL Technique 2 Post gluing • Topical anesthetic • Lid speculum ensuring no pressure on globe • Debride necrotic tissue 2mm • Reassess 1 hour post gluing to ensure AC deepening around perforation • Prepare glue • Treatment regimen based on underlying etiology • Apply small amount of glue to back of Weckcel • Dry perforation and surrounding area thoroughly • Leave glue/BCL in place until “pushed out” by underlying • Touch back of Weckcel to perforation healed stroma • Can build up layers as needed to seal • BCL Keys to success • Dry the area to be glued thoroughly • Don't use too much glue Corneal Biopsy • Place a BCL Mario Saldanha, MD University of Toronto • Don’t glue the lashes! Department of Ophthalmology and Vision Sciences 8 10/04/2016 Indications Requirements • Infections • Speculum • Dystrophies • 2-4 mm diameter punch (skin) • Degenerations • 0.12 mm forceps • Manifestations of systemic diseases • Crescent blade • Drug-induced changes Technique – cut down Technique Split specimen in half: 1) ½ for pathology 2) ½ for microbiology 50-70% positive results on culture negative specimens Post-operatively • Tobradex ointment and patch x 4 hours • Tobradex and artificial tears qid x 1 week • Discussion • Tylenol or Ibuprofen PRN for pain • Questions • Follow-up at 1 week 9 10/04/2016 Types of conjunctival biopsy Conjunctival biopsy • Excisional Randall Ulate, MD • Incisional University of Toronto Department of Ophthalmology and Vision Sciences Indications for Excisional Biopsy Indications for Incisional Biopsy Lesions that: • • Threaten vision OCP suspect • • Cause irritation Obtain sample to aid in diagnosis of a larger area of • Are related to systemic disease abnormality • Possible malignancies Step by Step 1) Topical anesthetic 5) 0.12 forceps and westcott scissors used to excise conjunctiva 2) Betadine prep, drape, lid speculum 6) Place specimen onto piece of paper indicating orientation (blue 3) Mark area of conjunctiva to be biopsied paper from weck cell packaging) 4) Weck cell pledgets soaked with topical anesthetic (proparacaine or 7) Hemostasis with weck cells pressure +/- handheld cautery tetracaine) applied to area of conjunctiva x 30 seconds +/- 8) Primary closure using 9-0 vicryl or fibrin glue subconjunctival injection of 2% lidocaine with epinephrine to balloon up the area 9) If large area, then use amniotic membrane 10 10/04/2016 Post-operatively • Tobradex ointment and patch x 4 hours • Tobradex and artificial tears qid x 1 week • Tylenol PRN for pain • Follow-up at 1 week • Finish the Tobradex, then Maxidex 1 drop qid tapering 1 drop every 1 -2 weeks • Follow-up again after 4-6 weeks Amniotic Membrane Transplant for Persistent • Discussion Epithelial Defect • Questions Mahmood Showail MD, FRCSC Clara Chan MD, FRCSC Introduction – Amniotic Membrane • Amniotic membrane transplant promotes ocular • It surrounds the developing fetus surface healing by suppressing inflammation, fibrosis 1 (inner most layer of the fetal and neovascularization of the cornea • It consists of: membrane) – A single layer of cuboidal epithelial cells • Derived from fetal tissue – Basement membrane • It is a translucent structure that is – Avascular stroma located adjacent to amniotic fluid (loosely attached to the Chorion 1. Liu J,Sheha H, Fu Y, Liang L, and Tseng SC. • The stroma exhibits anti-inflammatory, anti-scarring Update on amniotic membrane transplantation. Expert Rev Ophthalmol. 2010 Oct; 5(5): 645–661. and anti-antiangiogenic properties1 11 10/04/2016 Indications for AM Transplant Instruments and Disposables 1. Non healing epithelial defect 2. Neurtrophic ulcer (HSV, VZV) • Corneal tray 3. Shield ulcer 2ed to vernal keratoconjunctivitis • Sterile drape 4. Chemical injuries • Speculum 5. Steven-Johnson syndrome • Alcaine 0.5 % drops 6. Limbal Stem deficiency (combined with limbal stem cell transplant) • Weck cells 7. Mooren’s ulcer • Amniotic membrane tissue
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