- Email: [email protected]
May Consultation # 4
CONSULTATION SECTION
acetate 1%) 4 times a day, tapered over 4 months, along with the topical medicines described above. Should the patient manifest haze or scarring postoperatively, topical thiotepa1 may improve the situation. Because the left is the better-sighted eye, it is probably best to treat it medically until the right eye can be stabilized. The most difficult portion of this patient’s care may be the psychosocial aspects. Managing expectations while maintaining a positive outlook is very important in view of the long recovery time this patient will likely experience. Jason K. Darlington, MD David R. Hardten, MD Minneapolis, Minnesota, USA REFERENCE 1. Anderson Penno E, Braun DA, Kamal A, et al. Topical thiotepa treatment for recurrent corneal haze after photorefractive keratectomy. J Cataract Refract Surg 2003; 29:1537–1542
- This is a case of a woman in her fifth decade of life with dry eyes who had hyperopic LASIK in which a large, thick, superior-based hinge flap was created. The procedure was uneventful including the absence of epithelial defect intraoperatively. In the very early postoperative period, flap displacement occurred and a large epithelial defect was noticed. The patient received medical and surgical treatment, including multiple artificial drops, topical steroids, a bandage contact lens, epithelial debridement, PTK with MMC 0.02%, and topical cyclosporine. After almost 2 years, there is a loss of 4 lines of BCVA with central haze and formation of microcysts in the central cornea. The questions are what is the cause of the microcysts, what is the potential treatment, and should the flap be removed? Every attempt should be made to prevent flap removal or another kind of keratoplasty. The treatment should be focused on treating the cause. I am not sure whether the medical approach to the patient was appropriate to start with, and this is the typical example of a growing snowball. First, it is important to note that women of presbyopic age with dry eyes and who have hyperopic LASIK are at the highest risk for developing malignant dry-eye syndrome with significant epithelial central scarring. These patients should be treated very aggressively preoperatively with nonpreserved topical artificial tears and cyclosporine A; lacrimal plugs should also be use. If the dry-eye condition improves, and even in normal conditions, I recommend using a thin flap with a nasal hinge to allow rapid recovery of the baseline corneal sensation. I do not believe the patient has corneal basement membrane dystrophy. If so, the
712
epithelium would likely have detached during the Hansatome keratectomy. The case became more problematic after flap dislocation. It likely it took hours or even a day to reposition the flap, causing a great deal of epithelial damage. Early, very aggressive treatment is needed. Only nonpreserved topical medications should be used that include hourly artificial tears, cyclosporine A 2 times a day, and steroids 4 times a day. A frequent underdiagnosed condition is rosacea. The use of oral tetracycline or doxycycline is useful. I tend not to overreact with surgical maneuvers such as epithelial debridement and even less with the use of MMC. Any type of trauma to the epithelium or the flap will worsen the postoperative course in cases such as this. At this stage of the postoperative period (2 years), I would consider an intensive medical treatment that includes the following: (1) extensive patient counseling; (2) hourly use of nonpreserved artificial tears such as Refresh Plus (carboxymethylcellulose sodium 0.5%), (3) Restasis (cyclosporine) 2 times a day for at least 6 months; (4) prednisolone acetate 1% every 2 hours and tapered as soon as possible; (5) oral tetracycline 500 mg 3 times a day or oral doxycycline 100 mg 2 times a day (if patient compliance allows, I prefer tetracycline); (6) lacrimal plugs to the superior and inferior canaliculus; (7) referral to an internist, rheumatologist, or both. Using the above therapy, I would wait at least 6 months before considering a different approach. Arturo S. Chayet, MD La Jolla, California, USA
- Most likely, the patient has basement membrane dystrophy as underlying genetic disease/disorder. The basement membrane dystrophy as part of the epithelial dystrophies of the corneas has a coincidence of intracorneal microcysts varying in number and density. Overall, most basement membrane dystrophies remain asymptomatic and can rarely be diagnosed in a routine examination. But any kind of trauma and lamellar refractive surgery (eg, LASIK) may lead to cases such as the 1 described in the case report. Unfortunately, not much remains that could be tried to resolve the corneal problems; all kinds of artificial tears, steroids, abrasion, PTK, and MMC have been applied to influence the basal epithelial cells and the basal lamina without success. The only thing I would try in the left eye is another debridement of the epithelium, which is certainly still loosely adherent; put a bandage contact lens on for 5 days; and start autologous serum eyedrops from the first day. I would not do anything in the right eye but wait. The area of haze could decrease within another 3 to 6 months. I would not remove the flap. If there were further
J CATARACT REFRACT SURG - VOL 32, MAY 2006
CONSULTATION SECTION
improvement over time, the only option I can think of for the right eye would be lamellar keratoplasty. Bettina Jendritza, MD Mannheim, Germany
- This appears to be an extraordinary case of anterior basement membrane dystrophy, compounded by preoperative keratitis sicca and the added stress of post-flap neurotrophic keratitis. Although it is unlikely, it would be prudent to obtain a specular or confocal microscopic endothelial cell count to make sure that some of the reported edema does not stem from poor endothelial pump reserve. In general, I have had excellent results with PTK in patients with recalcitrant anterior basement disease that is unresponsive to the usual conservative steps of tear supplementation, punctal occlusion, and bandage contact lenses, all of which were used in this case. No mention is made of meibomian gland disease, which will compound tear-film instability and is often subtle to diagnose. Lid hygiene, warm compresses, an antibiotic such as bacitracin ointment at night, and a trial of systemic doxycycline 100 mg daily for several months would be advisable. The details of the PTK performed without success in the right eye are needed to determine whether there might be benefit in repeating it, as a focal treatment (approximate 2.0 mm zone) to the area of haze and elevation or more broadly. The use of MMC in the original treatment was probably unnecessary and may be causing some of the ongoing problems. For anterior basement disease, the proven regimen is to debride epithelium, use a broad-beam laser at a maximum optical zone (eg, 6.5 mm), and apply 20 to 25 pulses, with the goal of removing only about 5 mm of tissue. No masking fluids are needed, and MMC is not necessary. I would remove the flap in the right eye only as a last resort if all of the above steps fail. Roger Steinert, MD Irvine, California, USA
- This patient’s situation confirms that no LASIK case can be considered routine. The patient appears to have had few warning symptoms or signs of the difficulties that were to follow. The only significant preoperative finding is ‘‘borderline dry eyes,’’ which is common in women of this age. The postoperative photographs indicate diffuse punctate fluorescein staining, which can be a sign of postoperative disruption of tear dynamics. Laser in situ keratomileusis is known to induce dry eye and decreased blinking with resultant increased tear evaporation.1 The effects of LASIK on the tear film and ocular surface usually improve within a few months, but they may persist. Therefore, aggressive
management of this aspect of the patient’s condition should continue. If she does not already have punctal plugs, they should be inserted. However, treatment of the dry eye with lubricants has not improved her condition to date. All patients who have LASIK have reduced corneal sensation postoperatively, which may persist for a year in some cases. Neurotrophic epitheliopathy induced by LASIK is associated with reduced corneal sensation, reduced tear production, reduced blink rates, and increased tear evaporation. Such neurotrophic epitheliopathy is more common and severe in patients with preexisting dry-eye disease and usually resolves in the first 6 months postoperatively.2 However, reduced sensation can persist for longer than 6 months; therefore, LASIK-induced neurotrophic epitheliopathy may also persist, specifically in this patient. However, the patient also appears to have anterior basement membrane dystrophy. She had an abrasion after a flap lift. Later, the epithelium was easily removed intraoperatively, and the microcysts may be similar to the cysts of Cogan’s microcystic dystrophy. She is older than 40 years, and anterior basement membrane dystrophy epithelial adhesion reduces with increasing age. The visual acuity and number of microcysts improved with hypertonic saline in the left eye. Therefore, the patient may have an element of anterior stromal edema. Therefore, this patient appears to have 4 simultaneous pathologies; namely, dry eye, LASIK-induced neurotrophic epitheliopathy, anterior basement membrane dystrophy, and anterior stromal edema. Perhaps they are all interlinked pathophysiologically and exacerbate each other. Laser in situ keratomileusis is known to disrupt the tear film, causing among other effects a reduction in the aqueous component, fibronectin, epidermal growth factor, and vitamin A.3 The lack of growth factors in tear substitutes may affect regeneration of nerves and the epithelium, causing ongoing neurotrophic epitheliopathy and microcysts. The microcysts may affect the epithelial fluid barrier, permitting anterior stromal edema. Therefore, the left eye of this patient may benefit from autologous serum. This would replace the reduced growth factors and other components from the tears that have been shown to be beneficial for the ocular surface and improve healing of epithelial defects.4 However, regulatory restrictions limit the study and use of autologous serum. It also has a short shelf life and must be prepared frequently. Albumin has also been shown to be beneficial to the ocular surface. Because these products are not readily available, each component of this patient’s problem should be treated. The hypertonic saline and dry-eye therapy should be continued in the left eye. In the right eye, PTK with a longer MMC application time could be considered to remove the scarring. Avulsion of the flap is a possibility; however, there
J CATARACT REFRACT SURG - VOL 32, MAY 2006
713
acetate 1%) 4 times a day, tapered over 4 months, along with the topical medicines described above. Should the patient manifest haze or scarring postoperatively, topical thiotepa1 may improve the situation. Because the left is the better-sighted eye, it is probably best to treat it medically until the right eye can be stabilized. The most difficult portion of this patient’s care may be the psychosocial aspects. Managing expectations while maintaining a positive outlook is very important in view of the long recovery time this patient will likely experience. Jason K. Darlington, MD David R. Hardten, MD Minneapolis, Minnesota, USA REFERENCE 1. Anderson Penno E, Braun DA, Kamal A, et al. Topical thiotepa treatment for recurrent corneal haze after photorefractive keratectomy. J Cataract Refract Surg 2003; 29:1537–1542
- This is a case of a woman in her fifth decade of life with dry eyes who had hyperopic LASIK in which a large, thick, superior-based hinge flap was created. The procedure was uneventful including the absence of epithelial defect intraoperatively. In the very early postoperative period, flap displacement occurred and a large epithelial defect was noticed. The patient received medical and surgical treatment, including multiple artificial drops, topical steroids, a bandage contact lens, epithelial debridement, PTK with MMC 0.02%, and topical cyclosporine. After almost 2 years, there is a loss of 4 lines of BCVA with central haze and formation of microcysts in the central cornea. The questions are what is the cause of the microcysts, what is the potential treatment, and should the flap be removed? Every attempt should be made to prevent flap removal or another kind of keratoplasty. The treatment should be focused on treating the cause. I am not sure whether the medical approach to the patient was appropriate to start with, and this is the typical example of a growing snowball. First, it is important to note that women of presbyopic age with dry eyes and who have hyperopic LASIK are at the highest risk for developing malignant dry-eye syndrome with significant epithelial central scarring. These patients should be treated very aggressively preoperatively with nonpreserved topical artificial tears and cyclosporine A; lacrimal plugs should also be use. If the dry-eye condition improves, and even in normal conditions, I recommend using a thin flap with a nasal hinge to allow rapid recovery of the baseline corneal sensation. I do not believe the patient has corneal basement membrane dystrophy. If so, the
712
epithelium would likely have detached during the Hansatome keratectomy. The case became more problematic after flap dislocation. It likely it took hours or even a day to reposition the flap, causing a great deal of epithelial damage. Early, very aggressive treatment is needed. Only nonpreserved topical medications should be used that include hourly artificial tears, cyclosporine A 2 times a day, and steroids 4 times a day. A frequent underdiagnosed condition is rosacea. The use of oral tetracycline or doxycycline is useful. I tend not to overreact with surgical maneuvers such as epithelial debridement and even less with the use of MMC. Any type of trauma to the epithelium or the flap will worsen the postoperative course in cases such as this. At this stage of the postoperative period (2 years), I would consider an intensive medical treatment that includes the following: (1) extensive patient counseling; (2) hourly use of nonpreserved artificial tears such as Refresh Plus (carboxymethylcellulose sodium 0.5%), (3) Restasis (cyclosporine) 2 times a day for at least 6 months; (4) prednisolone acetate 1% every 2 hours and tapered as soon as possible; (5) oral tetracycline 500 mg 3 times a day or oral doxycycline 100 mg 2 times a day (if patient compliance allows, I prefer tetracycline); (6) lacrimal plugs to the superior and inferior canaliculus; (7) referral to an internist, rheumatologist, or both. Using the above therapy, I would wait at least 6 months before considering a different approach. Arturo S. Chayet, MD La Jolla, California, USA
- Most likely, the patient has basement membrane dystrophy as underlying genetic disease/disorder. The basement membrane dystrophy as part of the epithelial dystrophies of the corneas has a coincidence of intracorneal microcysts varying in number and density. Overall, most basement membrane dystrophies remain asymptomatic and can rarely be diagnosed in a routine examination. But any kind of trauma and lamellar refractive surgery (eg, LASIK) may lead to cases such as the 1 described in the case report. Unfortunately, not much remains that could be tried to resolve the corneal problems; all kinds of artificial tears, steroids, abrasion, PTK, and MMC have been applied to influence the basal epithelial cells and the basal lamina without success. The only thing I would try in the left eye is another debridement of the epithelium, which is certainly still loosely adherent; put a bandage contact lens on for 5 days; and start autologous serum eyedrops from the first day. I would not do anything in the right eye but wait. The area of haze could decrease within another 3 to 6 months. I would not remove the flap. If there were further
J CATARACT REFRACT SURG - VOL 32, MAY 2006
CONSULTATION SECTION
improvement over time, the only option I can think of for the right eye would be lamellar keratoplasty. Bettina Jendritza, MD Mannheim, Germany
- This appears to be an extraordinary case of anterior basement membrane dystrophy, compounded by preoperative keratitis sicca and the added stress of post-flap neurotrophic keratitis. Although it is unlikely, it would be prudent to obtain a specular or confocal microscopic endothelial cell count to make sure that some of the reported edema does not stem from poor endothelial pump reserve. In general, I have had excellent results with PTK in patients with recalcitrant anterior basement disease that is unresponsive to the usual conservative steps of tear supplementation, punctal occlusion, and bandage contact lenses, all of which were used in this case. No mention is made of meibomian gland disease, which will compound tear-film instability and is often subtle to diagnose. Lid hygiene, warm compresses, an antibiotic such as bacitracin ointment at night, and a trial of systemic doxycycline 100 mg daily for several months would be advisable. The details of the PTK performed without success in the right eye are needed to determine whether there might be benefit in repeating it, as a focal treatment (approximate 2.0 mm zone) to the area of haze and elevation or more broadly. The use of MMC in the original treatment was probably unnecessary and may be causing some of the ongoing problems. For anterior basement disease, the proven regimen is to debride epithelium, use a broad-beam laser at a maximum optical zone (eg, 6.5 mm), and apply 20 to 25 pulses, with the goal of removing only about 5 mm of tissue. No masking fluids are needed, and MMC is not necessary. I would remove the flap in the right eye only as a last resort if all of the above steps fail. Roger Steinert, MD Irvine, California, USA
- This patient’s situation confirms that no LASIK case can be considered routine. The patient appears to have had few warning symptoms or signs of the difficulties that were to follow. The only significant preoperative finding is ‘‘borderline dry eyes,’’ which is common in women of this age. The postoperative photographs indicate diffuse punctate fluorescein staining, which can be a sign of postoperative disruption of tear dynamics. Laser in situ keratomileusis is known to induce dry eye and decreased blinking with resultant increased tear evaporation.1 The effects of LASIK on the tear film and ocular surface usually improve within a few months, but they may persist. Therefore, aggressive
management of this aspect of the patient’s condition should continue. If she does not already have punctal plugs, they should be inserted. However, treatment of the dry eye with lubricants has not improved her condition to date. All patients who have LASIK have reduced corneal sensation postoperatively, which may persist for a year in some cases. Neurotrophic epitheliopathy induced by LASIK is associated with reduced corneal sensation, reduced tear production, reduced blink rates, and increased tear evaporation. Such neurotrophic epitheliopathy is more common and severe in patients with preexisting dry-eye disease and usually resolves in the first 6 months postoperatively.2 However, reduced sensation can persist for longer than 6 months; therefore, LASIK-induced neurotrophic epitheliopathy may also persist, specifically in this patient. However, the patient also appears to have anterior basement membrane dystrophy. She had an abrasion after a flap lift. Later, the epithelium was easily removed intraoperatively, and the microcysts may be similar to the cysts of Cogan’s microcystic dystrophy. She is older than 40 years, and anterior basement membrane dystrophy epithelial adhesion reduces with increasing age. The visual acuity and number of microcysts improved with hypertonic saline in the left eye. Therefore, the patient may have an element of anterior stromal edema. Therefore, this patient appears to have 4 simultaneous pathologies; namely, dry eye, LASIK-induced neurotrophic epitheliopathy, anterior basement membrane dystrophy, and anterior stromal edema. Perhaps they are all interlinked pathophysiologically and exacerbate each other. Laser in situ keratomileusis is known to disrupt the tear film, causing among other effects a reduction in the aqueous component, fibronectin, epidermal growth factor, and vitamin A.3 The lack of growth factors in tear substitutes may affect regeneration of nerves and the epithelium, causing ongoing neurotrophic epitheliopathy and microcysts. The microcysts may affect the epithelial fluid barrier, permitting anterior stromal edema. Therefore, the left eye of this patient may benefit from autologous serum. This would replace the reduced growth factors and other components from the tears that have been shown to be beneficial for the ocular surface and improve healing of epithelial defects.4 However, regulatory restrictions limit the study and use of autologous serum. It also has a short shelf life and must be prepared frequently. Albumin has also been shown to be beneficial to the ocular surface. Because these products are not readily available, each component of this patient’s problem should be treated. The hypertonic saline and dry-eye therapy should be continued in the left eye. In the right eye, PTK with a longer MMC application time could be considered to remove the scarring. Avulsion of the flap is a possibility; however, there
J CATARACT REFRACT SURG - VOL 32, MAY 2006
713