EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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52 EW CORNEA August 2012 Haze query prompts advice on looking for dry eye and special treatment tips by Matt Young EyeWorld Contributing Writer Ocular surface disease and autologous serum among possible causes and solutions, respectively A case was presented in an internet forum regarding the appearance of late- onset corneal haze after photorefractive keratec- tomy (PRK). One physician requested advice on the following case: A previous PRK patient treated for –10 D presented with grade 2 haze in his left eye at 6 months post- op. The patient was 20/30 with no improvement with refraction. This patient had been spending a signifi- cant amount of time in the south- western United States for business and did not use post-op sunglasses as instructed. William B. Trattler, M.D., di- rector, Cornea, Center for Excellence in Eye Care, Miami, and David R. Edmison, M.D., founder and medical director, Focus Eye Centre, Ottawa, Canada, both in the forum and in subsequent interviews responded with a series of useful tips that should help inform PRK surgeons in treating significant cases of haze. Treat haze and ocular surface disease "Since your patient is traveling to the southwestern United States, you have to consider that dry eye may be playing a role besides UV exposure, as the southwest is pretty dry," Dr. Trattler said. "In addition, I would also assume that your patient is fly- ing on an airplane frequently, which is a very dry environment." One of the risk factors in developing haze is dry eye, said Dr. Trattler. More continued from page 51 have two OCTs in the office," Dr. Safran joked. EW Reference 1. Werner L, Michelson J, Ollerton A, Leish- man L, Bodnar Z. Anterior segment optical coherence tomography in the assessment of postoperative intraocular lens optic changes. J Cataract Refract Surg. 2012;38:1077-1085. Editors' note: Dr. Safran is a non-paid consultant for Heidelberg. Dr. Werner has no financial interests related to this article. Contact information Safran: 215-962 5177, safran12@comcast.net Werner: 801-581-6586, liliana.werner@hsc.utah.edu An eye with corneal haze Source: Parag A. Majmudar, M.D. "The key for treating late-onset corneal haze involves topical steroids as well as treating even mild ocular surface disease," Dr. Trattler said. "You way to make sure there's no ocular irritation and inflamma- tion leading to the haze." The same goes for meibomian gland disease, which would affect the ocular surface and could lead to haze, Dr. Trattler said. "I would look carefully at the meibomian gland secretions as well as the ocular surface and consider treatment if even mildly present," Dr. Trattler said. That said, a critical factor in treating haze is intervening early and treating aggressively with strong topical steroids as well as treating the surface, Dr. Trattler said. "I typically see these patients every 2-3 weeks, and at each visit they are refracted so that we can measure their refractive error and BCVA," Dr. Trattler said. "Typically at 2 weeks there will be a slight im- provement, and then over the next 4-6 additional weeks there will be continued improvement in BCVA and reduced refractive error. When patients end up not improving fur- ther, I will typically cut back on the topical steroids." Usually, when treatment starts early enough, surgery is not required, he said. "Occasionally, I have had to per- form surgical removal, and I prefer PTK with mitomycin-C while others prefer scraping," Dr. Trattler said. "The advantage of aggressively treat- ing as much haze as possible with topical steroids is that even if sur- gery is required in the end, there is less haze to remove." A working protocol Meanwhile, Dr. Edmison, who has been performing PRK since 1992, said he has a protocol for treating haze that works 95% of the time. He wanted to remind readers, however, that haze can be well prevented in the first place. "If you have a patient more than –6 D, I always use mitomycin- C," Dr. Edmison said. "If the patient is more than –9 D, I will break the ablation up into two parts and put on some cooling [eye drops], just to theoretically cool the cornea down. Even though the excimer laser is not supposed to have any thermal effects, an acoustic buildup of en- ergy can cause extra heating prob- lems. So I will cool the cornea in between ablations for anything more than –9 D." If a patient gets haze, Dr. Edmison said he aggressively treats with steroids. "I will start steroids every 2 hours for at least 2 weeks and see if there is regression of haze," Dr. Edmison said. "That usually works pretty well." He also recommended slowly tapering those steroids after 2-3 weeks. On the rare occasion that sur- gery is required, Dr. Edmison opts for PTK along with mitomycin-C usage, cold drops, and cold contact lenses after treatment. Dr. Edmison said he does know of patients heading down to Florida and becoming exposed to UV light, which triggers fairly significant haze—and sometimes these patients do need PTK. "A short trial of steroids may help, but those situations often go straight to PTK to eliminate the haze," he said. "If haze continues to recur, start the patient on autolo- gous serum tears. This seems effec- tive in a large number of patients in significantly reducing the amount of haze post-op." One thing to note about this patient is the failure to use post-op sunglasses as prescribed, which might suggest the patient has compliance issues. "Compliance is a big issue in treating haze," Dr. Edmison said. "You have to have the patient's co- operation. There's no sense in doing a PTK if [the patient isn't] using ap- propriate medication afterward. Any patient who doesn't take instruc- tions is going to be problematic." Still, ophthalmologists must deal with what they are presented with, Dr. Edmison said. Hopefully, if a patient is treated with PTK for haze and did not take steroids post-op as instructed, a second PTK may reinforce compliance, he said. EW Editors' note: Dr. Edmison has no financial interests related to this article. Dr. Trattler has financial interests with Allergan (Irvine, Calif.) and Merck (Whitehouse Station, N.J.). Contact information Edmison: 613-724-3937, edmison@focuseye.com Trattler: 305-598-2020, wtrattler@gmail.com