Eyeworld

I Contact Name: by Title Swan also considers augmentation with punctal occlusion and would add inhibition of matrix metalloproteinase-9 (MMP-9) and environmen- tal modification. Dr. Talley Rostov treats every- one for dry eye disease, using artificial tears and topical cyclosporine during the day and preser- vative-free ointment at night. She also considers hypertonic drops or ointments but doesn't find them more helpful than regular tears. Regarding the use of hypertonic drops, Dr. Sheppard noted that there are no non-preserved drop formulations available, limiting their usefulness for chronic, routine use in sensitive eyes. Muro 128 (sodium chloride hypertonicity ophthalmic solution, Bausch + Lomb) is avail- able in a preservative-free 5% ointment, which many patients tolerate well, especially before bedtime, he said. Hypertonics are, however, "very useful for epithelial basement mem- brane disease, which produces poor adhesion of the epithelium to the underlying basement membrane," he said. "When the epithelial cells slough off in that particular scenario, it be- comes a suddenly acutely painful situation for the patient unless they are also neurotrophic. We find that hypertonic drops promote osmotic thinning of corneal epithelial cells and therefore the adhesion of these cells to the underlying basement membrane, thereby reducing the risk of epithelial sloughing creating symptoms and delaying healing." Dr. Sheppard follows a tiered approach that also guides his surgical management (see sidebar). Surgical management Dr. Hatch emphasized that she prefers to not perform a surgical procedure while a patient is suffering an acute attack, waiting until the tissues are not inflamed. Regarding surgical intervention, she does not perform anterior stromal micropuncture. All the doctors cited concern for scarring and limited results with the procedure; Dr. Sheppard called it a temporizing procedure at best. Instead, Dr. Hatch opts for superficial ker- atectomy and, for refractory cases, photother- apeutic keratectomy (PTK). These are also Dr. Dr. Sheppard's three-tiered approach amniotic membrane in some patients. He cautioned against using Prokera in patients with glaucoma shunts due to the potential for erosion of the tube from the product's outer ring but said dried amniotic membrane (Katena) under the bandage contact lens could be used. In general, while using the bandage contact lens, Dr. Sheppard provides a daily drop of azithromycin for antibiotic support and anti-collag- enolytic effects. When the amniotic membrane is removed (5–7 days later), Dr. Sheppard said he keeps the patient in a bandage contact lens until fully healed. Tier 3 Patients who reoccur or who have significant scarring, elevations, Salzmann's nodules, fibrosis, or fila- mentary keratitis require a trip to the ASC, Dr. Sheppard said. He will use sedation and a retrobulbar block with cycloplegia to "enable a nearly pain- free postoperative course following extensive aggressive lamellar keratec- tomy, which may on not so rare an occasion create a miserable or even combative situation in the office." He patches these patients for a day, places a Prokera amniotic membrane in the office, leaves it for a week, and has them in a bandage contact lens (exchanged monthly for 3 months). These patients are on a topical antibiotic course, and rarely require oral analgesia beyond acet- aminophen or naproxen. Tier 1 Dr. Sheppard starts with conserva- tive, office management, consisting of hypertonic tears (5% sodium chloride) and a therapeutic bandage contact lens. Prior to placing the bandage contact lens, he assesses the epithelium with a dry Weck-Cel spear sponge and topical proparacaine. If the epithelium does not slide over the basement membrane, he doesn't do any epithelial debridement. After placing the bandage con- tact lens, he'll consider a punctal plug to increase moisture during contact lens use. Dr. Sheppard carefully replaces the contact lens, if needed, on a monthly basis. Many patients resolve under this protocol over 1–3 months, he said. Tier 2 An obvious epithelial defect requires a debridement, Dr. Sheppard said. He called patient comfort essential and said he will take anxious, bleph- arospasm, or vagal candidates to a minor procedure room to perform a superficial keratectomy while they are laying down with a lid speculum in place. He said clinicians may be surprised at how loosely adherent epithelium often extends beyond the lesion all the way to the limbus, and frequently all is removed. Dr. Sheppard said in addition to bandage contact lenses, cryopre- served, sutureless amniotic mem- brane (Prokera, BioTissue) can be beneficial. He said he'll do a tem- porary tarsorrhaphy when using the There are three tiers of therapy for recurrent corneal erosion in Dr. Sheppard's practice. He said the success rate with this protocol approaches 100% and prepares the patient's topography for cataract biometry, penetrating keratoplasty, or refractive surgery, when indicated. continued on page 82

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