Challenging cornea cases may require complex treatment course
In this issue of Healio | OSN, a roundtable discusses the management of epithelial ingrowth after LASIK, neurotrophic keratitis and Demodex blepharitis with marginal keratitis.
A few thoughts after decades of treating these often challenging patients.
Epithelial ingrowth is rare after primary LASIK with an incidence of less than 1%, looking at multiple published series. Unfortunately, epithelial ingrowth is much more common after flap lift LASIK enhancements, and once epithelial ingrowth occurs, it is extremely high following flap lift treatments. Flap lift enhancements in the first year after LASIK have a lower incidence of epithelial ingrowth than late flap lift enhancements a year or more after the primary surgery. For this reason, if a patient is undercorrected or overcorrected, a flap lift enhancement is safer when performed early, as soon as the refraction is stable.
The high incidence of epithelial ingrowth after late flap lift LASIK enhancements leads me to prefer surface ablation/PRK as my approach when a patient is more than a year out from their primary LASIK surgery. Unfortunately, there is significant compensatory epithelial hyperplasia and hypoplasia after refractive corneal surgery that reduces the refractive outcome accuracy of a surface ablation/PRK enhancement in an eye with previous laser refractive corneal surgery of any kind. My solution to this challenge is to utilize a transepithelial PRK approach, also advocated by Karl Stonecipher, MD. The details of his technique are available online.
Once epithelial ingrowth has occurred, I find the most effective procedure to be fastidious removal of the epithelium from the corneal stromal bed and underside of the flap along with removal of the epithelium within 2 mm of the flap edge on the peripheral cornea and flap surface followed by suturing the flap, as one would a lamellar keratoplasty with radial interrupted sutures. Some favor an anti-torque running suture as advocated by Jose Barraquer, MD, but I find interrupted sutures simpler and equally effective. I prefer to place a bandage contact lens for a week and then remove it in the office. Selective suture removal can begin 2 months after the procedure, and I like to remove half the sutures a month apart in two sessions. Patients need to be counseled that their vision will be reduced until the sutures are removed. I agree with Marguerite McDonald, MD, that small amounts of epithelial ingrowth that are not visually significant enough to generate an unhappy patient are best left alone. A small peripheral corneal melt in an 8-mm-diameter-plus LASIK flap is not visually significant, whereas overly aggressive treatment can result in a serious sight-threatening course of serial epithelial ingrowth events resulting in eventual LASIK flap amputation.
My thoughts on neurotrophic keratitis (NK) were published in the Jan. 10, 2025, issue of Healio | OSN. Briefly, every patient with significant corneal staining needs to have their corneal sensation tested. If the patient has “stain without pain,” a diagnosis of NK is high on the differential diagnosis list, as is herpes. For me, as Oxervate (cenegermin-bkbj, Dompé) at Walgreens is priced at $29,501.61 for an 8-week course of six drops a day, a trial of lacrimal outflow occlusion, frequent non-preserved topical lubricants, a bandage contact lens, serum tears and, in recalcitrant cases, a temporary lateral tarsorrhaphy offer a less expensive option. In unresponsive cases, Oxervate is a wonderful addition to our treatment options.
Blepharitis with itchy eyelids should prompt a careful look at the slit lamp with the patient looking down for the pathognomonic collarettes of Demodex blepharitis. Bacterial blepharitis and seborrheic blepharitis usually cause a burning sensation worse in the morning and chronic dry eye syndrome a gritty foreign body sensation worse in the evening. Allergic conjunctivitis tends to itch right over the caruncle. Patients with Demodex blepharitis have itching along their eyelid margins, especially the upper eyelid, and tend to scratch using their fingernails scraping along the upper eyelid margin. While marginal keratitis is more classically associated with staphylococcal blepharitis, it can be associated with Demodex blepharitis, and in many patients, staphylococci are present along with Demodex infestation. The treatment for Demodex is a 6-week course of Xdemvy (lotilaner ophthalmic solution 0.25%, Tarsus Pharmaceuticals) twice daily. I also prescribe eyelid hygiene with hypochlorous acid spray. A short course of a topical steroid will hasten resolution of the infiltrates associated with marginal keratitis and eyelid margin itching. If coincident staphylococcal infection is suspected or confirmed with culture or PCR, bacitracin ophthalmic ointment at bedtime is effective and inexpensive.
According to the RAND study 3 decades ago, 40% of patients seen in the office of an eye care professional have at least one ocular surface disease. The only more common pathology seen by an eye care professional is a refractive error. Fortunately, every year we have better ways to properly diagnose and effectively treat the many types of ocular surface disease encountered every day in practice.
- For more information:
- Richard L. Lindstrom, MD, can be reached at rllindstrom@mneye.com.
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