We report a case of recurrent erosion and corneal opacification after using a new synthetic ocular sealant (OcuSeal; Becton Medical) following alcohol-assisted PRK for the correction of low myopia.
A 37-year-old woman with a preoperative BCVA of 1.0 asked for correction of her refractive error (OD: -3.00 -0.50 X 15°; OS: -2.25 -0.50 X 0°). Her medical history and aberrometry exam (Zywave; Bausch + Lomb) were unremarkable, and corneal topography (Orbscan; Bausch + Lomb) confirmed that both corneas were steep with normal thicknesses (Figure 1). Except for her dry eyes, no other pathology was noted on slit-lamp examination.
We performed routine wavefrontguided PRK after alcohol-assisted epithelial removal in both eyes, applying bandage contact lenses at the conclusion of the procedure. The only difference from our standard PRK technique in this otherwise uneventful initial surgical procedure was that we applied OcuSeal to the ablated cornea of the patient’s right eye before inserting a bandage contact lens. OcuSeal was applied on the stroma, according to the manufacturer’s recommendation (video available at eyetube.net/?v=migak), to shorten visual recovery and lower pain perception. We prescribed antibiotic and fluorometholone eye drops four times daily until epithelial closure, which is our routine practice in these cases. Thereafter, our routine protocol includes artificial tears and tapering of fluorometholone over 12 weeks.
ADDRESSING POSTOPERATIVE COMPLAINTS
The first postoperative days were unremarkable, with slightly more pain in the patient’s left eye than in her right. Pain disappeared on day 4. Distance UCVA was slightly better in the patient’s right eye on day 1, identical in the eyes on day 2, and better in her left eye on day 4. Smooth epithelial closure in both eyes was confirmed on day 4, and the bandage contact lenses were removed.
The next day, however, the patient presented with blurred vision and pain in her right eye. She had no discomfort in her left eye. At the slit lamp, a central 2 X 3 mm2 erosion was detected in the right eye, and a new bandage contact lens was placed. The patient removed the lens on the following night because of intolerable pain. During the next 6 weeks, she had several recurrent erosions. We placed a third bandage contact lens 2 weeks after PRK, which could not be found on the eye at slit-lamp exam a week thereafter. (The patient was managed by two other ophthalmologists during that period.) When she returned to our facility 7 weeks after the initial PRK procedure, she had significant haze in her right eye (Figure 2), and vision was reduced to 0.2, corrected and uncorrected.
At that time, we discussed limited phototherapeutic keratectomy (PTK) with mitomycin C for removal of the subepithelial opacification that was also causing an irregular anterior surface in this eye for the first time. The patient chose conservative treatment with preservativefree dexamethasone eye drops because of fear of a recurrent haze formation after PTK. However, 7 months after primary laser ablation, after no significant improvement was noted, she opted for PTK (Figure 3).
ENHANCEMENT METHOD, RESULTS
Our next course of action was to perform mechanical epithelial removal, which revealed an irregular stromal surface at the opaque areas that could not be removed by scraping with a surgical blade. Subsequently, laser ablation of only 15 μm depth with a 7-mm optical zone and 3-mm transition zone was performed. The corneal surface was rinsed with ice-cold saline solution before mitomycin C 0.02% was applied for 20 seconds. Another bandage contact lens was then placed. Some opacification was still visible at the end of surgery; however, to avoid refractive changes, we did not perform a deeper ablation. Antibiotic and cortisone eyedrops were administered as usual.
After PTK, the irregular elevation of the recurrent opacifiaction subsided, but the haziness showed only a weak tendency of clearing up (Figures 4 and 5). Because of the central location of the opacity, UCVA and BCVA remained around 0.4. After evaluating the cornea with anterior segment optical coherence tomography, we suggested a second PTK with deeper ablation and longer exposure to mitomycin C. However, although the patient is still unsatisfied with this less-than-optimal outcome, she does not want further treatment that involves pain. We still hope that the residual haze will disappear and vision will improve over time. Fortunately, vision has been optimal in the fellow eye from the time of epithelial closure.
In the first few postoperative days, OcuSeal had beneficial effects on pain and visual recovery. After full epithelial closure and removal of the bandage contact lens on day 4, however, several recurrent erosions occurred, leading to corneal opacification. These were recalcitrant to cortisone eye drops. A limited PTK has only slightly improved symptoms thus far.
We have seen similar results to the case described here in six patients treated with OcuSeal in one eye. This most severe example highlights our limited knowledge about the role of ocular sealants after PRK. On one hand, it is desirable to have an immediate covering of the stroma to facilitate visual recovery and alleviate pain perception; on the other, we cannot be sure what role the liquid ocular sealant may have played in these recurrent erosions. Further investigations are warranted before the use of OcuSeal after surface ablation can be recommended.
Saskia Oehler, Dipl Ing, is a Research Assistant at the Center for Refractive Surgery, St. Francis Hospital, Münster, Germany. Ms. Oehler states that she has no financial interest in the material presented in this article. She may be reached at e-mail: email@example.com.
Suphi Taneri, MD, is the Director of the Center for Refractive Surgery, Eye Department, St. Francis Hospital, Münster, Germany. Dr. Taneri states that he has no financial interest in the material presented in this article. He may be reached at tel: +49 251 987 7890; fax: +49 251 9877898; e-mail: firstname.lastname@example.org.