Eyeworld

EW CORNEA 84 September 2018 eye are discomfort, foreign body sensation, visual disturbance, and tear film instability that may in turn cause damage to the ocular sur- face, if left untreated. It can affect different parts of the ocular surface, including the meibomian glands, the main lacrimal gland, and the ocular surface nerves. Dry eye is triggered by stress to the ocular surface, antigens, and genetic fac- tors. It is perpetuated through the body's inflammatory response and is associated with the long-term use of certain medications, advanced age and female gender, allergies, prolonged screen time, laser surgery, diabetes, and autoimmune disorders like Sjögren's syndrome and rheu- matoid arthritis. Dr. Morral said that in patients with OSD, cataract, and Fuchs' dystrophy, it is essential to treat the inflammation with steroids, cyclosporine, and lifitegrast, when available. EW References 1. Anitua E, et al. Plasma rich in growth fac- tors (PRGF-Endoret) stimulates corneal wound healing and reduces haze formation after PRK surgery. Exp Eye Res. 2013;115:153–161. 2. Anitua E, et al. Plasma rich in growth factors for the treatment of ocular surface diseases. Curr Eye Res. 2016;41:875–82. 3. Anitua E, et al. Plasma rich in growth factors (PRGF-Endoret) stimulates prolifer- ation and migration of primary keratocytes and conjunctival fibroblasts and inhibits and reverts TGF-beta1-induced myodifferentiation. Invest Ophthalmol Vis Sci. 2011;52:6066–73. 4. Kheirkhah A, et al. Patients with dry eye disease and low subbasal nerve density are at high risk for accelerated corneal endothelial cell loss. Cornea. 2017;36:196–201. Editors' note: Dr. Morral has financial interests with Shire (Lexington, Massa- chusetts), Alcon (Fort Worth, Texas), and AVX Pharma (Barcelona, Spain). Contact information Morral: Merce.morral@gmail.com in enhancing tissue regeneration to be safe and efficient. 2 In yet another investigation, results suggested that PRGF could reduce scarring while stimulating wound healing of the ocular surface. 3 Ocular surface wound healing is mediated by different growth factors. PRGF is an autologous platelet-enriched plasma obtained from the patient's own blood, which is activated by calcium chloride to release different biologically active proteins that influence and promote processes such as cell recruitment, cell growth, and cell differentiation. After OSD is stabilized PRGF demonstrated corneal healing effects, allowing Dr. Morral to con- sider the next step in her patient's treatment. The patient's corrected distance visual acuity was 0.2 (right eye) and 0.4 (left eye), and the IOP was 15 mm Hg. With the cornea stabilized, she took the next step to carry out cataract surgery, with toric IOL implantation. She explained that toric IOLs were considered only because the topography and ker- atometry were consistent, measured on the same devices and stable over time from one visit to the next. She noted postoperative edema for 1 month after surgery, which slowly resolved. She also observed a tempo- rary worsening of the ocular surface disease, which was expected and also resolved. "We kept the patient on plasma rich in growth factor eye drops four to five times daily, along with a ste- roid, that we slowly tapered down, lubricants, an ocular hypertensor, and hyperosmotic ointment at bed- time to help the cornea recover after the surgery, as she also had Fuchs' dystrophy," Dr. Morral explained. "By 6 months postoperatively, she was asymptomatic with absolutely no photophobia, although she still had a few bad days here and there. We have kept her on low-dose steroids and plasma rich in growth factor, and there has been no IOP increase." She explained that endothe- lial cell loss and the corneal nerve density were related. One study that evaluated the changes in corneal endothelial cell density in dry eye patients showed that endothelial malfunction could affect the ocular surface. The study implicated the potential supportive role of nerve derived molecules for cornea endothelial cells in dry eye disease patients with a reduced corneal nerve density as causing an accel- erated corneal endothelial cell loss over time. 4 Dry eye is common in elderly patients and being multifactorial in nature, has proven to be tough to manage. The hallmarks of dry Reversing continued from page 83 The patient underwent treatment with PRGF eye drops for 2 months. A significant improvement in symptoms (especially photophobia) and signs was observed. Minimal fluorescein staining was seen and complete resolution of filamentary keratitis. Source: Merce Morral, MD, PhD Indispensable femto Tal Raviv, MD, discusses complex cases for which femto is indispensable.

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