Jules Stein Eye Institute UCLA Clinical Update January 2003 Volume 12, Number 1 Rethinking Management of Recurrent Corneal Erosions — anterior basement membrane dystro- phy, dystrophies of Bowman’s layer, or lattice or granular dystrophies — will experience recurrent erosions (Figure 1). Other predisposing factors include ocular rosacea and diabetes mellitus. “Any minor trauma may launch a cycle of recurrent erosions in such patients,” notes Dr. Aldave. Acute management aims to speed healing and limit patient discomfort by patching the eye with a bandage soft contact lens and/or by instilling hyper- tonic, antibiotic, or artificial tear drops or ointments. Cycloplegia can decrease light sensitivity. For subsequent prophylaxis, says Dr. Aldave, instilling a hypertonic solution or a lubricating ointment in the Figure 1: Slit lamp photograph of Cogan’s microcysts, representing foci of aggregated, eyes at bedtime can minimize any shear- degenerated epithelial cells. These epithelial microcysts, in junction with intraepithelial map ing force exerted by the upper lid on the and fingerprint lines, are characteristic features of anterior basement membrane dystrophy. corneal epithelium upon awakening. “However, effective as nightly ointment otwithstanding lasers and other may be, many patients find this regimen N major advances, low-tech solutions burdensome long term, and the second- are still worthwhile for recurrent ary blurred vision may increase the risk corneal erosions, says Anthony J. of falls when the patient gets out of bed Aldave, MD, Assistant Professor of during the night,” he observes. Ophthalmology and Director of the Cornea and External Disease Fellowship Next Phase Program at Jules Stein Eye Institute. Medical therapy for refractory cases “Although excimer laser phototherapeu- includes corticosteroid eye drops or oral Our web site address is tic keratectomy (PTK) has enamored tetracycline. Both have activity against http://www.jsei.org clinicians, and I use PTK for selected matrix-metaloproteinases (collagenases, patients with recurrent erosions, simpler elastases) — enzymes that may weaken Physician’s Direct and less expensive modalities can be attachment of the epithelial cells to the Referral Line: comparably effective,” he says. underlying basement membrane. Explains Dr. Aldave, “In one very small (310) 794-9770 Basic Care but placebo-controlled trial, two months Factors predisposing a patient to of oral doxycycline was given followed recurrent corneal erosions typically dic- by three weeks of topical steroids to tate the most appropriate management. patients with intractable corneal erosions; Many patients with corneal dystrophies no patient experienced a recurrence (continued on page 2) 2 JSEI Clinical Update January 2003

RECURRENT CORNEAL EROSIONS (continued from page 1)

Figure 2: Slit can be repeated if necessary, but a lamp photograph shift to farsightedness, albeit slight, with cobalt blue is a consideration,” he notes. illumination Dr. Aldave describes another pro- demonstrating cedure, combination epithelial flourescein- stained, large, debridement with polishing of recurrent corneal Bowman’s layer, as “fairly crude.” This erosion in a procedure uses a Weck cell sponge to patient with global remove non-adherent epithelium and epithelial dysad- a 2.5 to 5 mm diamond-dusted spher- herence secondary ical burr to roughen Bowman’s layer. to anterior base- “About 90 percent successful after one ment membrane treatment, this procedure is easy to dystrophy. perform at the slit lamp, has a low incidence of haze formation, and throughout follow-up of over one stromal micropuncture with 25-gauge rarely reduces best corrected visual year. Despite questioning why bene- needle to a depth of .1mm, causes acuity. Best of all, it can be repeated fits lasted so long after therapy just enough scarring to effectively without changing the patient’s refrac- ceased, I’ll consider oral tetracycline/ improve adherence of the epithelial tive status,” he says. doxycycline or steroids prior to or in basement membrane to Bowman’s conjunction with surgical intervention.” layer. A variation using neodymium Suspects and Solutions Surgical treatment may be need- YAG laser to scar the cornea, Dr. Resolving recurrent corneal ero- ed if the patient fails to respond to Aldave considers “somewhat overkill; sions demands meticulous care. medical therapy, has a corneal dys- the needle works just as well. The “Findings of anterior basement trophy, or has global epithelial problem with micropuncture, howev- membrane dystrophy,” says Dr. dysadherence. “These patients are far er, is scarring, which can be signifi- Aldave, “are often subtle and more likely to have chronic, multifo- cant. This procedure is best reserved evanescent. I take a full history and cal erosions and a more difficult-to- for the patient with localized, usually closely examine both the involved manage course,” says Dr. Aldave. He posttraumatic, erosions in the periph- and unaffected corneas. Erosion leaves the timing of intervention to ery of the cornea, with no underly- recurrence raises suspicion of global the patient: “If the patient lives in ing dystrophy predisposing to chron- epithelial dysadherence.” (Figure 2) fear of erosion recurrence and has ic multifocal erosions.” Dr. Aldave believes that disabling pain, surgery makes sense. For patients whose recurrent although the mechanisms of some To be free from erosions, these erosions are related to an epithelial, treatments for recurrent corneal patients will accept the slight risk of Bowman’s layer or stromal dystro- erosions remain hypothetical and haze with diminished visual acuity or phy, excimer laser PTK is about 75 lack scientific explanation, “any mild night-vision disturbance associ- to 90 percent successful in prevent- modality that is clinically effective, ated with some procedures.” ing recurrences. Explains Dr. with negligible side effects, is Aldave, “Theoretically, removing worth trying.” Surgical Approaches about 5 microns of Bowman’s layer The least invasive modality — creates a smooth surface for forma- RECENT PUBLICATIONS: bandage soft contact lens — may tion of a new basement membrane Sridhar MS, Rapuano CJ, Cosar CB, Cohen EJ, be used for symptomatic relief of and migration of epithelial cells.” Laibson PR. Phototherapeutic keratectomy ver- discomfort associated with a recur- The very low incidence of haze sus diamond burr polishing of Bowman’s membrane in the treatment of recurrent rent erosion. Longer use (three after PTK is seldom visually signifi- corneal erosions associated with anterior months or more) may help promote cant. What concerns Dr. Aldave is basement membrane dystrophy. stronger adherence of epithelial that removing even a little tissue in Ophthalmology. 2002 Apr;109(4):674-9. cells to the underlying basement the central cornea may produce a Soong HK, Farjo Q, Meyer RF, Sugar A. membrane, Dr. Aldave notes. hyperopic shift — usually negligible Diamond burr superficial keratectomy for Another low-tech procedure easi- after a single treatment but measur- recurrent corneal erosions. Br J Ophthalmol. ly performed in the office, anterior able after repeated treatment. “PTK 2002 Mar;86(3):296-8. January 2003 JSEI Clinical Update 3 Case Report: Glaucoma Care in a Patient Who Underwent a Refractive Procedure for Presbyopia

The following report was submitted by Simon K. Law, MD, PharmD, Assistant Professor of Ophthalmology, in the Glaucoma Division of the Jules Stein Eye Institute at UCLA.

A 59-year-old Caucasian male presented with complaints of ocular discomfort and evidence of a bleb leak in the left eye. About two years prior to consultation, he underwent an anterior ciliary sclerotomy procedure (ACS) for presbyopia of his left eye. Six months after the procedure, he was noted to have increased intraocular pressure (IOP) requiring glauco- ma eye drops. As a result of regression from the initial cor- rective effect with ACS, and the added possibility of a pres- sure reduction effect, he subsequently underwent implanta- tion of four silicone scleral expansion bands in the perilim- bal quadrants. The patient’s IOP remained uncontrolled, however, and he later required trabeculectomy. Initial examination of his left eye revealed visual acuity of 20/100 and IOP of 10 mm Hg. A small, superior conjunc- Figure 1: Left eye one month after operation. tival bleb was present and noted to be cystic, thin and leak- ing. The surrounding conjunctiva was injected and scarred. The bleb with the scleral expansion proce- extended 3 mm anteriorly onto the superior cornea. The remainder of dure (SEP) have been the topics of the limbal conjunctiva was retracted. There were four deep conjunctival heated debate in the ophthalmology scars corresponding to the insertion sites of the scleral expansion bands. community for the last five years. The superior-nasal and inferior-temporal bands were exposed. The con- There are conflicting reports that junctiva near the inferior-nasal band was hyperemic with granulation SEP may have an IOP reduction tissue. The superior-temporal conjunctiva area had a depressed scar of effect. Fukasaku et al. and Marmer 1.5 x 3 mm and the expansion band at that location appeared to have have reported, separately, a dramatic extruded. IOP reduction of almost 10 mm Hg postoperatively. The method of the Treatment technique based on the Schachar study, results and analysis were not Surgical revision was performed model of accommodation and pres- reported in detail. On the contrary, a to repair the bleb leak. The anterior byopia. ACS involves radial scleral peer reviewed, prospective small extension and the leaky avascular incisions overlying the ciliary body case series by Malecaze et al. report- portion of the bleb were excised. in the four oblique quadrants. ed that IOP was not modified after The surrounding conjunctiva was Limbal peritomies are usually SEP. The speculated mechanisms of undermined and mobilized to the required. According to the Schachar IOP reduction range from creation limbus to cover the trabeculectomy theory, ACS may restore the zonular of a localized ciliochoroidal detach- site. The conjunctiva overlying the tension lost to normal lens growth, ment to expansion of the anterior expansion bands was dissected and thereby allowing accommodation to chamber angle with facilitation of the bands were removed. function again. Because of rapid aqueous outflow. It is uncertain Four weeks post-operatively, regression of the surgical effect in whether reported IOP reduction is best-corrected visual acuity general, silicone scleral expansion only an artificial effect; decreased improved to 20/30 with resolution bands can be inserted at the depth sclera rigidity as a result of the inci- of the patient’s ocular discomfort. of the sclerotomy to keep the inci- sions may result in an artificially Intraocular pressure was controlled sion open or even tunneled into the lowered IOP by applanation. at low to mid teens (Figure 1). sclera to achieve the theoretical However scarring and hardening of effect. The true mechanism of sclera, or closure of the proposed Discussion accommodation and the effective- ciliochoroidal space, may ultimately ACS is a relatively new surgical ness of restoring accommodation reverse the initial effect. (continued on page 4) 4 JSEI Clinical Update January 2003

GLAUCOMA CARE (continued from page 3)

implant is near the limbus. Scleral may lead to migration of the bleb or pericardial grafts are frequently or conjunctiva onto the cornea. used to cover the extraocular por- One could argue that a tube tion of glaucoma drainage devices shunt procedure should be the anterior to the equator before clo- glaucoma procedure of choice in sure of the conjunctiva. Even with eyes with previous SEP. However, this additional protection, glauco- with continuous foreign body reac- ma specialists frequently observe tion in all limbal quadrants, the thinning of the overlying graft and success of a tube shunt procedure conjunctiva over time. In our may be limited. The expansion patient, three implanted bands bands should be removed to Figure 2: Left eye with conjunctiva hyper- emia and scarring, exposed superior-nasal were exposed or extruded. improve the chance of success with scleral expansion band, and anteriorly Extensive conjunctiva scarring glaucoma surgery. The need for migrated bleb onto the cornea. is a common risk factor for failure glaucoma surgery in patients with of glaucoma surgery. In this previous SEP will be a new chal- Implantation of any foreign patient the previous peritomies, lenge in the refractive era. body close to the limbus is known with their resultant conjunctival to cause ocular irritation. The retraction, and the implanted RECENT PUBLICATIONS: implantation of tube shunt devices bands, with their associated for- Marmer R. The surgical reversal of presby- and scleral buckles has shown that eign body reaction, led to aggres- opia: a new procedure to restore accommoda- foreign body reaction to the sive scarring of tissue surround- tion. Int Ophthalmol Clin. 2001;41:123-32. implanted materials is virtually ing the bleb (Figure 2). Tight Fukasaku H, Marron J. Anterior ciliary sclero- inevitable regardless of their inert scarring of the surrounding con- tomy with silicone expansion plug implanta- properties. While encapsulation of junctiva limits filtration of the tra- tion: effect on presbyopia and intraocular a foreign body occurs when the beculectomy and is frequently pressure. Int Ophthalmol Clin. 2001;41:133-41. implant is placed posterior to the associated with progressive thin- Malecaze FJ, Gazagne CS, Tarroux MC, Gorrand equator, erosion through the con- ning and bleb leakage. Multiple JM. Scleral expansion bands for presbyopia. junctiva is common when the episodes of leakage and healing Ophthalmology. 2001;108(12):2165-71.

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