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BLOG: YAG laser treatment of corneal basement membrane dystrophy-associated erosions
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In my Oct. 25 column, I discussed the confounding problem of corneal basement membrane dystrophy in the treatment of dry eye disease. Sometimes you do everything you can possibly think of to treat DED, and literally every objective measure you can obtain confirms that you got robbed at the last Mensa election; you normalized them all. Your patient didn’t get the memo, though. After she continues to complain of pain despite your obvious clinical brilliance, you notice that she has corneal basement membrane dystrophy. But you really are a smart cookie, and you brought her back for an early morning visit and confirmed your suspicion of a recurrent corneal erosion.
There are conservative measures you can take (topical NSAID, nighttime hypertonic ointment), but sometimes this physical problem demands a physical solution. The most elegant option is to treat Bowman’s layer in the area under the erosion with your YAG laser. The earliest mention I can find in the literature is Geggel and Maza in 1990 (although I should note that we did this at Bellevue in the ’80s). They treated with epithelial debridement (which in and of itself is sometimes therapeutic), but a transepithelial technique is preferable in my opinion. Katz et al and Tsai have shown that you can use much less energy, and because you left the epithelium intact, your patient is likely to be more comfortable.
Leaving the epithelium in place allows you to more precisely define the target area. Use topical anesthetic, high mag and no contact lens. Start with 0.4 mJ pulses and slowly raise the power until you get a tiny “crack” in Bowman’s. Place the laser spots approximately 0.25 mm apart; do not overlap spots. Treat the area of the erosion, being sure to encircle it at the end with spots just outside the affected cornea as a sort of barrier. Post-laser treat with a topical steroid and NSAID, adding an antibiotic if you have infection concerns. A bandage contact lens can be used if the epithelium is particularly loose.
No treatment is 100% successful, especially for a problem that is as variable as corneal basement membrane dystrophy-associated erosions, but YAG laser stromal puncture appears to be more effective than needle puncture. The laser causes less scarring and seems to be associated with fewer side effects as well. It is easy to repeat if necessary. You can utilize a piece of equipment that is ubiquitous in ASCs all across the country, one that you quite likely already own.
And there’s no click fee.
Editor's note: Dr. White advises this is an off-label use of the YAG laser.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations; is on the speakers board for Bausch + Lomb, Allergan and Shire; and has a financial interest in TearScience.