Eyeworld

I THERAPEUTIC REFRACTIVE CORNEAL SURGERY N FOCUS 82 | EYEWORLD | APRIL 2020 continued from page 81 Swan's preferred surgical approaches, while Dr. Talley Rostov performs PTK for all cases need- ing surgical therapy. "PTK is 98% successful in my practice for eliminating recurrent corneal erosions," she said. "It is a quick procedure and resolves the problem nicely." However, Dr. Sheppard noted that surgical therapy with PTK in his practice is generally unwarranted unless concomitant to a refractive procedure such as photorefractive keratectomy (PRK). "Removal of the surface epithelium in the office is simple with a spatula or Weck-Cel spear sponge," he said. "In the ASC, cicatricial epithelial lesions or nodules are readily removed with the 64 Beaver blade. Excimer laser PTK is an expensive superfluous intervention that adds a cost to the overhead. If there are no scars or nodules, a small refractive error can also be corrected with an excimer PRK, which removes not only the central epithelium but the base- ment membrane and some anterior stroma. The refractive advantage is obvious, but the inability of PRK or PTK to reach all the way to the limbus may leave non-adherent epithelium and therefore a residual nidus for recurrence." Postoperative management Postoperatively, Dr. Hatch said, "it's important to make sure patients are comfortable." She will prescribe pain medication as well as antibiotics and steroids. She also said she leaves the ban- dage contact lens on for about 2 weeks. Dr. Swan's short-term management for PTK includes 1 week of a broad-spectrum antibiotic with fluoroquinolone therapy four times a day and topical steroid four times a day for 1 week weaning to two times a day for 1 week. "Careful examination in the postopera- tive state is required to rule out steroid-induced ocular hypertension and to ensure a patient does not need longer steroid treatment for the cornea," he said. "I also continue to emphasize to patients the importance of long-term ocular surface disease management to reduce the risk of recurrence." Dr. Sheppard also highlighted the impor- tance of ocular surface management, stating that "appropriately aggressive management of concomitant ocular surface disease is warrant- ed, addressing dry eye, allergy, and meibomian gland disease according to standard protocols." Dr. Talley Rostov's postop care is similar to what she employs for PRK, with a bandage contact lens, antibiotics QID until the bandage lens comes off, tapering steroid doses, and NSAID drops. She has patients continue oint- ment at night when the bandage contact lens is removed and use topical cyclosporine and artificial tears. Pearls Dr. Swan thinks it is important to emphasize the chance of recurrence, even after surgical in- tervention, to patients. They need to know that ongoing monitoring is important, he said. Dr. Sheppard detailed the importance of environmental control. "Most importantly, direct water into the eyes must be avoided, be it swimming, in the shower, or as a form of self-prescribed treatment," he said. "The hypo- tonic water creates boggy epithelium through osmotic gradients, reducing adhesion to the underlying basement membrane, and a much higher likelihood of a new or recurrent erosion. "Similarly, extremely low-humidity envi- ronments should be avoided, like fans, open windows, and fireplaces, especially at night," he said. "Dust, toxic fumes, the abysmally low-hu- midity content of airplane air, or the continu- ous staring accompanying prolonged computer or cell phone use are all to be minimized." Dr. Sheppard also instructs patients to roll their globes around under the lids before opening their eyes upon awakening. This helps avoid sudden shear stress on the epithelium with exposure to a dry ambient atmosphere, he said. "So many attacks at night or first thing in the morning can be avoided by this simple self-lubricating maneuver." Dr. Hatch reminds doctors to listen to their patients. This is a painful condition, and a lot of patients are suffering, she said. It affects how she approaches these cases in the clinic. For instance, she'll consider whether checking eye pressure is necessary. While it might be important when patients are on steroids, she won't routinely applanate them, considering risk of causing a recurrence as well as the patient's comfort. "Patients don't typically lose their vision from this condition, fortunately, but it's import- ant to take their concerns seriously," she said. About the doctors Kathryn Hatch, MD Assistant professor of ophthalmology Harvard Medical School Boston, Massachusetts John Sheppard, MD President Virginia Eye Consultants Norfolk, Virginia Russell Swan, MD Vance Thompson Vision Bozeman and Billings, Montana Audrey Talley Rostov, MD Northwest Eye Surgeons Seattle, Washington Relevant disclosures Hatch: None Sheppard: Allergan, AbbVie, Bausch + Lomb, Allysta, Oyster Point, Novartis, Shire, Novaliq, Aldeyra, Johnson & Johnson Vision, Mallinckrodt, Dompe Swan: None Talley Rostov: None Contact Hatch: Kathryn_hatch@meei.harvard.edu Sheppard: docshep@hotmail.com Swan: Russell.swan@ vancethompsonvision.com Talley Rostov: atalleyrostov@nweyes.com

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