topical cocaine debridement for epithelial basement membrane dystrophy authors: paul b. kouyoumjian,...
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Topical Cocaine Debridement for Epithelial Basement Membrane Dystrophy
Authors:Paul B. Kouyoumjian, MD1
Rony R. Sayegh, MD1
Geetha G. Vedula, MD2
Verinder S. Nirankari, MD1,3
1 Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
2 Jules Stein Eye Institute and Department of Ophthalmology, UCLA School of Medicine, Los Angeles, CA, USA
3 Eye Consultants of Maryland, Baltimore, MD, USAThe authors have no financial interest in the subject matter of this poster.
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Introduction• Epithelial basement membrane dystrophy (EBMD) is the most
common type of corneal dystrophy, affecting 2% of the population
• Although most patients are asymptomatic, approximately 10% of affected individuals experience corneal erosions or degradation of vision
• Erosions result from poor epithelial adhesion to the underlying basement membrane whereas visual symptoms are attributable to irregular astigmatism and abnormal tear break-up
• When conservative medical treatment fails, surgical intervention is indicated
• Surgical treatment options include simple epithelial removal, needle or Nd:YAG laser induced anterior stromal puncture, superficial keratectomy with either lamellar dissection or with diamond burr polishing, and excimer laser phototherapeutic keratectomy
• In the present study, we reviewed the outcomes of topical cocaine-assisted epithelial debridement and superficial lamellar keratectomy for the treatment of symptomatic EBMD
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MethodsSubjects
• Retrospective chart review of patients treated between 2002 and 2007
• Diagnosis was established by a single clinician on the basis of slit-lamp examination
• The indications for surgical intervention were decreased vision secondary to irregular astigmatism and/or recurrent corneal epithelial erosions
• 3 subgroups of patients, based on whether they presented with erosion symptoms alone, visual symptoms alone, or both, were analyzed.
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MethodsSurgical Technique
• All were performed by the same surgeon (VSN)
• Sterile prep and drape, insertion of eyelid speculum, topical anesthesia using tetracaine eye drops.
• Specially cut Weck-Cel sponges soaked in 4% topical cocaine are placed on the cornea for 3 to 5 minutes, loosening the epithelium.
• Epithelial debridement of almost the entire cornea is performed, leaving intact an approximately 0.5mm narrow rim of peripheral epithelium.
• Areas of subepithelial fibrosis in different parts of the cornea (central/paracentral) are removed with blunt and sharp dissection using a Paufique and/or Gill corneal knife.
• Epithelium is sent for histopathology.
• Eye is copiously irrigated with balanced salt solution.
• Therapeutic bandage contact lens (BCL) is placed, followed by topical antibiotic eye drops.
• Postoperatively, all patients were treated with topical antibiotic eye drops. Topical mid-strength steroid drops were initiated after about a week, noting that the cornea had re-epithelialized, and at which time the BCL was discontinued.
• Two cases received adjunctive treatment with mitomycin C in addition to above.
• 3 eyes of 2 patients underwent concomitant cataract extraction with PCIOL implant
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MethodsData Collected
• Subjective symptoms
• Perioperative and postoperative data– surgical technique
– complications (such as subepithelial haze)
– post-op treatment
– evidence of recurrence
• Pre-op visual acuity = Best Spectacle-Corrected Visual Acuity (BSCVA) at last visit prior to procedure
• Early post-op visual acuity = BSCVA closest to one month after surgery
• Last post-op visual acuity = BSCVA at most recent follow-up visit
• Pre-op and post-op corneal topography were reviewed. Surface regularity index (SRI) values were collected
• Recurrence was defined as any postoperative findings of epithelial maps, dots, or fingerprints, or symptoms consistent with recurrent erosions.
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ResultsPreoperative and Demographic Data
• 36 eyes of 30 patients• 12 males and 18 (60%) females• Mean patient age: 63 years (range, 42 to 89 years)• Mean follow-up: 19 months (range, 6 days to 6
years)• Subgroup analysis
– Group 1 (n=14): erosion symptoms alone– Group 2 (n=17): visual symptoms alone– Group 3 (n=5): both erosion and visual symptoms
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ResultsVisual Acuity
Group 1: erosion symptoms alone
Group 2: visual symptoms alone
Group 3: both erosion and visual symptoms
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ResultsTopographic information, i.e. Surface Regularity Index (SRI)
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ResultsRecurrence
• Recurrence was observed in 4 out of 36 eyes (11%)
• All belonged to the recurrent erosion subgroup (group 1)
• Recurrences occurred as early as 15 months and as late as 4 years after the procedure
– The “early” recurrence occurred in an eye treated with adjunctive mitomycin C due to preoperative suspicion of epithelial dysplasia, and which had persistent subepithelial haze
– The eye with “late” occurrence showed subtle map, dot, fingerprint changes
– Another case of recurrence was subsequently treated with PRK, almost 3 years later. The eye had previous history of anterior stromal puncture, the only one in our study
– The 4th eye with recurrence (2 years, 5 months later) warranted retreatment, which was pending at the time of this writing.
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Conclusions• Our study strongly suggests that the surgical technique of topical
cocaine-assisted broad epithelial debridement followed by manual superficial keratectomy is a safe, simple, and effective treatment for visual disturbances and recurrent epithelial erosions associated with EBMD.
• Amongst eyes with erosion symptoms, treatment resulted in relief of symptoms in all patients during the first 15 months, with only 4 out of 16 experiencing symptoms in the subsequent 4 ¼ years of follow-up; of these, 2 warranted retreatment.
• All eyes treated for visual symptoms secondary to EBMD alone (16) experienced a sustained improvement in vision for the duration of follow-up. Furthermore, in regards to corneal topography, this group exhibited substantial diminishment of irregular astigmatism as evidenced by the improved mean SRI.
• Other than faint subepithelial haze, which was usually transient and not visually significant, no complications occurred in any of the 36 eyes treated.
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Conclusions
• On review of the literature, this simple technique is at least comparable in efficacy to other well-established surgical treatments for EBMD
• Debridement of most of the epithelium as opposed to just the central 6-8 mm may result in decreased recurrence of disease
• Superficial lamellar keratectomy to remove subepithelial fibrosis likely is superior to simple epithelial debridement alone
• Cocaine may act in a similar way to alcohol, leaving behind a smooth corneal surface for regenerating epithelial cells to attach firmly
• Because of its simplicity and effectiveness, without the need for expensive instruments, we suggest this as an option for symptomatic patients
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