Eyeworld

EW CORNEA 120 March 2018 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer A complicated case study demonstrated how an experienced surgeon managed cyst removal and epithelial ingrowth elimination I t is not uncommon to find epithelial cells creeping into and proliferating along corneal wounds. Depending on the nature of the wound and its lo- cation within the cornea, epithelial ingrowth can be visually debilitating and challenging to manage. Some corneal wounds are more difficult to handle than others. Ingrowth associated with smoother corneal perforations caused by inorgan- ic substances are likely to be less problematic to treat than wounds created by uneven, fibrous, organic materials. In a case study involving a deep, corneal tree branch injury that was presented at the XXXV Congress of the ESCRS, A. John Kanellopoulos, MD, medical direc- tor, LaserVision.gr Institute, Athens, Greece, and clinical professor of ophthalmology, New York Uni- versity Medical School, New York, discussed the surgical steps he took and his decision-making process in resolving his patient's post-traumat- ic visual impediment. Case of complex penetrating corneal trauma Dr. Kanellopoulos' patient was a 35-year-old male who experienced a deep corneal injury from a tree branch. OCT revealed a large corne- al wound and a steepening around the area of penetration, and Pen- tacam (Oculus, Wetzlar, Germany) scans identified deep stromal pene- tration with significant irregularity on transverse section. Six months following the injury, the patient's visual acuity had improved to 20/60. Despite evidence of epithelial cells within a pocket created by the tree branch penetration within the cornea, Placido disc images showed improvements at 6 months, as did corneal visualization on Pentacam maps, and Dr. Kanellopoulos decid- ed to put off treatment with topo- graphic guided PRK and wait to see if things changed any further. Eight months later (14 months after the original incident), diagnos- tics revealed an improved superficial wound with a pronounced pocket of epithelial ingrowth within the cornea. There was substantial epi- thelial remodeling to compensate and a large epithelial cyst within the traumatic pocket. Dr. Kanellopoulos used Cassini (i-Optics, The Hague, the Netherlands) maps to visualize the irregularity of the trauma in the deep layers of the corneal stroma. Treatment "We had very few options in this situation," Dr. Kanellopoulos said. "This was an exploratory case, as we Epithelial ingrowth from penetrating corneal wound with cyst formation Epithelial ingrowth, corneal cyst, and corneal opacity visible on slit lamp examination Source: A. John Kanellopoulos, MD Topography showing significant steepening at the point of penetration of a tree branch Presentation spotlight were not sure what the exact point of entry was. However, it was clear that we had to address the problem manually. OCT showed us where the slice across the corneal surface occurred, but I spent quite a bit of time trying to find the area of injury 14 months after the original injury." He implemented the ORA System (Alcon, Fort Worth, Texas) to help with establishing the most likely point of entry and gained access to the wound tract. Then, by creating an opening to the traumat- ic pocket with a crescent blade, just large enough to fit a blunted Sinskey hook, Dr. Kanellopoulos was able to begin removing the epithelium, first gently, then more aggressively and thoroughly. He was able to corrob- orate that the traumatic pocket was quite large, more than 2 mm in each meridian, as shown by the differ- ent diagnostic imaging techniques he used in this case. Eventually he was able to remove the epithelial cyst and rid the pocket of epithelial cells. "Obviously a PRK would have improved the visualization," he said. "However, the epithelial cyst within the cornea created significant glare and had the potential to change,

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