The Ophthalmic Office Procedures Handbook

SECTION 5 Cornea and Conjunctiva


medications responsibly can help with pain control. 1 Delayed epithelial healing, RCE, and recurrences of the treated condition have been reported as well. These cases may require alter native therapies including specialty contact lenses or more aggressive therapy such as deep an terior lamellar keratoplasties or partial tarsorrhaphies if corneal scarring or persistent epithelial defects develop. 3 Microbial keratitis is a rare but possible complication. Topical antibiotics may need to be adjusted quickly should infection be suspected. In patients who have had a history of recurring herpetic keratitis, prophylactic oral antivirals may be necessary. VIDEOS OF PROCEDURES Video 25-1 —Corneal debridement + Diamond burr polish (DBP) + amniotic membrane (AM) insertion (epithelial basement membrane dystrophy [EBMD]). Prior to the procedure, the patient is fully numbed with topical ophthalmic anesthetic drops, lids and lashes cleaned with standard povidone–iodine 10% swab stick (Betadine), and draped for a sterile environment. Topical ophthalmic antibiotic drops should be instilled prior to starting the procedure. This video shows loose epithelium gently debrided using a dry surgical spear sponge, leaving behind roughly 1 to 1 ½ mm of tissue from the limbus. Special care is taken to remove any redun dant epithelial layers and basement membrane islands. Clumps of debrided epithelial tissue are seen being removed with a surgical spear sponge. Rolled edges at the edge of the debridement zone are shown being cleaned up with a foreign body golf spud. The diamond burr polishing is shown with smooth circular motions. Rotations of the diamond burr are made away from the limbus, toward the center. Any residual islands of epithelial tissue or defective basement membrane are removed at this step. A cryopreserved AM is shown being inserted into the patient’s eye after corneal debridement and diamond burr polishing. Video 25-2 —Salzmann nodule removal + DBP + cryopreserved AM insertion. This video shows loose epithelium around a Salzmann nodule being debrided. Then, forceps are used to grasp the edge of the Salzmann nodule, lifting it away while using a foreign body golf spud to detach the nodule from the underlying layers. Salzmann nodules can often extend to the limbus. Special care is taken not to tear conjunctival tissue. Provided that there are neighboring areas or sources of limbal stem cells, focal debridement to the limbus can be performed, as it is here. Wescott scissors can be used to cut the tissue as well. This could have been an option here. Diamond burr polishing is shown next over the areas where the debridement and Salzmann nod ules were removed. Smooth motions no more than 30 seconds are made, being careful not to apply too much pressure onto the cornea and being careful not to disrupt the limbal area too much. An AM is inserted following the procedure. Video 25-3 —Salzmann nodule removal + DBP + dehydrated AM and BCL insertion. This video shows a large Salzmann nodule being debrided using a golf spud and forceps. An other area of the cornea affected by EBMD is also shown being debrided. Diamond burr polishing is performed, including gentle polishing at the limbus where the Salzmann nodule was previously located. A dehydrated AM disc is placed onto the cornea and carefully rehydrated to allow for proper po sitioning and covering. A BCL is then inserted overtop. Video 25-4 —Corneal debridement + DBP (gelatinous drop-like corneal dystrophy). This patient had a gelatinous drop-like corneal dystrophy appearance, which affected the entire cornea, resulting in significant ocular surface discomfort and decreased visual acuity.

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