Office and Minor Procedures for Ocular Surface Disease

These strategies can prevent the need for more aggressive surgery.

BY CHRISTOPHER J. RAPUANO, MD

OCULAR SURFACE DISEASES are very common in clinical practice, and we have at our disposal a variety of first-line medical treatments we can employ. For patients who don’t respond to medical treatment, office and minor surgical procedures can be extremely effective and often allow us to delay or avoid more aggressive surgeries. Here, I briefly describe a few such scenarios.

Molluscum contagiosum: The dome-shaped, umbilicated lesions associated with this viral skin infection can appear on the eyelid or eyelid margin. These mainly occur in children, but I have seen two adults with this condition in recent months. If the lesions are on or near the eyelid margin, they can cause follicular conjunctivitis.

We can treat with shave excisional biopsy, cautery, cryotherapy or curettage. Curettage can usually be performed without anesthesia. Using a small chalazion scoop, #15 blade or jeweler’s forceps, core out the central umbilication, enough to cause bleeding. This works very nicely. The lesion usually disappears in a couple of weeks, and the follicles go away in approximately 4 to 6 weeks.

Vernal keratoconjunctivitis (VK): We have many medical treatment options for VK: allergy drops, steroids, cyclosporine and antibiotics. We run into problems, however, when a shield ulcer develops. When the ulcer is white and fibrotic, with an almost calcified appearance, it usually requires surgical treatment. The fibrotic mass needs to be debrided away. Under topical anesthesia, aggressively scrape the area with a blade. Remove the superficial matter down to Bowman’s membrane, which ideally is relatively smooth. The epithelial defect should heal as quickly as 1 week with antibiotics and steroids.

Superior limbic keratoconjunctivitis (SLK): With SLK, we see thickened, inflamed superior conjunctiva, papillae on the superior palpebral conjunctiva and superior corneal filaments and pannus. Medically, we can try lubricants, steroids, mast cell stabilizers or cyclosporine. Surgically, we can consider punctal plugs or punctal cautery, silver nitrate solution, conjunctival cautery or conjunctival recession or resection with or without amniotic membrane transplantation.

I often choose conjunctival cautery, which can be performed in an exam room chair or minor surgery setting. I balloon up the superior conjunctiva with local anesthetic (e.g., lidocaine). This is helpful because it moves your cautery application away from the sclera. I then use a handheld, battery-operated unit to apply cautery to the superior conjunctiva (Figure 1). Obviously, we need to have a cooperative patient to safely perform this procedure. Patients tend to be a little uncomfortable but not too terribly, and the conjunctival defects typically heal within a week. The results may not last indefinitely, but patients’ symptoms improve significantly.

FIGURE 1. Conjunctival cautery is an effective in-office treatment for superior limbic keratoconjunctivitis.

Chronic epithelial defect: Often related to exposure or a neurotrophic cause, what we see with this condition is generally an inferocentral epithelial defect with thickened, rounded edges. Several types of medical treatment can be tried, such as lubricants, antibiotics, pressure patching, cyclosporine or bandage contact lens. Lateral tarsorrhaphy is an extremely effective surgical solution; unfortunately, patients usually don’t like it. Amniotic membrane graft is also an option. Most amniotic membrane products require us to glue or suture the grafts over the epithelial defect. When the membrane is placed stromal side down, epithelium grows over the top of it. When it is placed stromal side up, epithelium grows underneath it.

Slightly different, easier-to-use, platforms for in-office use are also available. AmbioDisk (IOP Ophthalmics, www.iopinc.com/store/ambiodisk), for example, can be retained on the ocular surface with a bandage contact lens rather than glue or sutures. Prokera (BioTissue, www.prokerainfo.com) is another in-office option that works well. Prokera is a piece of amniotic membrane tissue held in between two clear, flexible plastic rings, which holds itself in place on the ocular surface. The rings are slightly thicker than an average contact lens, so patients may be aware of the device’s presence, but most are fairly comfortable.

I recently had a patient come to my practice with corneal melt after having a third DSEK done elsewhere. In one area of the cornea, the stroma melted nearly all the way down to the DSEK plane. It just was not healing until we inserted a Prokera. Once we did, the defect healed nicely over the next several weeks.