Eyeworld Daily News

30 | EYEWORLD DAILY NEWS | APRIL 23, 2022 ASCRS ANNUAL MEETING DAILY NEWS I n a session that covered a variety of challenging cornea cases, includ- ing infections, inflammations, and tumors, Beeran Meghpara, MD, presented on nonsurgical treatments for the impending perforation. It's important to determine why it's "about to blow," he said. There are various underlying causes, but some of the most common reasons are infec- tious—either bacterial or viral—or inflammatory causes. He also discussed options to "plug it up." Dr. Meghpara noted that corneal gluing is an option and said that the best candidates for this option have relatively small perforations (about 1–2 mm). Those with central perforations are also good candidates. The best can- didates may also have a divot-shaped perforation because the glue would have a hard time attaching to a bulging perforation. Gluing should ideally be done under a microscope but can also be done at the slit lamp. There are different adhesives avail- able, all variations of cyanoacrylate. Dr. Meghpara likes to use a micropi- pette, which will help deliver a small, controlled amount of glue that can be applied precisely to the area you want. Describing how the gluing pro- cedure works, he said to debride the necrotic epithelium as well as the epi- thelium 1–2 mm surrounding the ulcer, dry the area with a cellulose sponge, use one small drop of tissue adhesive using a 30-gauge needle or micropi- pette, and allow the glue to polymerize and place the bandage contact lens. Dr. Meghpara warned not to use too much glue, don't touch the wet glue with the cellulose sponge, and don't replace the bandage contact lens too frequently. Postoperatively, he said to use top- ical aqueous suppressants, prophylactic topical antibiotic, protective shield or glasses at all times, preservative-free artificial tears, and to balance frequent topical medications against manipulat- ing the eye as little as possible. He also said you can reglue if dislodged early. The glue should stay there for weeks to months, and it's important to leave it until it becomes loose or dislodges spontaneously. Typically, you would replace the bandage contact lens every 1–3 months. James Chodosh, MD, presented on current management strategies for herpetic eye diseases. He first men- tioned herpes simplex virus (HSV) and the varicella zoster virus (VZV), which are leading causes of infectious corneal blindness. However, he noted that existing classification schemes for HSV and VZV keratitis are confusing, and that leads to poor treatment in the com- munity. Dr. Chodosh prefers anatomic classification, with manifestations including epithelial keratitis, stromal keratitis without ulceration, stromal keratitis with ulceration, or endothelial keratitis. In order to classify the kerati- tis, you need to examine the corneal epithelium, corneal stroma, corneal endothelium, and anterior chamber. He went on to mention HSV kerati- tis in the setting of atopy, which he said is more common, more likely bilateral, and more likely recurrent and harder to treat. HSV keratitis in children is more likely to present at different times with different manifestations and more like- ly recurrent and difficult to treat. HSV keratitis follow penetrating keratoplasty is usually epithelial, he said. It is complicated by use of post- operative corticosteroids. Dr. Chodosh said to consider oral antiviral pro- phylaxis for all patients undergoing corneal transplant for HSV-related corneal scarring. Dr. Chodosh also discussed various initial therapy options. For epithelial keratitis, you would treat with anti- virals, he said, adding that there is no role for corticosteroids in these cases. For stromal keratitis without ulceration, Dr. Chodosh mentioned using therapeutic corticosteroid dosing with prophylactic antiviral dosing. But for stromal keratitis with ulceration, he suggested therapeutic dosing of antiviral with minimal-touch dosing of corticosteroid. Finally, for endothelial keratitis, Dr. Chodosh mentioned using therapeutic dosing of both antiviral and corticosteroid. When discussing prophylaxis for HSV keratitis, specific indications for oral prophylaxis are not determined. Reasonable indications may be for multiple recurrences of HSV stromal keratitis necessitating corticosteroid treatment, recurrent inflammation with scar/vascularization approach- ing the visual axis, for more than one episode of HSV stromal keratitis with ulceration, or for post-keratoplasty performed for HSV-related scarring/ astigmatism. He suggested using vala- cyclovir 500 mg once daily. Dr. Chodosh added that therapy for VZV keratitis can be guided by a similar algorithm, and he said that prophylaxis against VZV keratitis is currently under study in the Zoster Eye Disease Study (ZEDS). Editors' note: Drs. Chodosh and Meghpara have no relevant financial interests. Cornea Day wraps up with focus on challenging cornea cases Dr. Chodosh discusses current management strategies for herpetic eye diseases.

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