 Okay, it's eight o'clock. We're going to get started. Welcome to Cornea Grand Rounds. Our first presentation is by our Cornea fellow, Dr. Betz. Thanks. Let's go back. So we have a case. Hopefully it's interesting for everyone here. That Dr. Mitho and I saw a couple of weeks ago. So we had a lady came in. Her main complaint was she had pain when she blinked her eye. She was 66, had this form body sensation for about two months when she blinked. Completed photophobia and tearing, kind of, you know, low-grade pain. And this was her fourth opinion. She'd been all over. She's from Idaho, but she'd been to Colorado and Montana and all over. So she was kind of frustrated. Past ocular history was significant for LASIK. She had a hypochorection about 15 years ago. But as you can see, she wasn't out of glasses for very long. At some point, five years ago, she had some chronic irritation and there's kind of a, you know, we weren't sure of the diagnosis, but she said she'd been told she had a viral infection and then staph keratitis at the same time. And she said her symptoms improved with some kind of drops, but she wasn't sure what it was. Past medical history, she has autonomic neuropathy, mainly like peripheral neuropathy in her hands and feet, and then some GI symptoms. It takes anis and lysine to braille, you know, kind of diabetes, heart disease in her family history. She's single and not a smoker. Her examination, visual cutie in the right and left eye were pretty good. You can see she has a hypochrobic refraction. And then everything else was pretty normal. I'll show you a slid lamp photo of her left anterior segment, but everything else was pretty unremarkable. You could see her LASIK flap in her right eye, mild cataract. But you can see here, this is a slid lamp photo of her left eye and kind of attention is drawn to this well circumscribed area of whitening in the cornea. This spot here was about 1.5 millimeters in diameter. It was slightly elevated, had like a little bit of, you know, pigment. Maybe this was from her makeup. But you can see it caused some shadowing, so it does block light a little bit. And then I have some more photos here. It's kind of a closer view. You can you can see here. It doesn't appear that there's any, you know, surrounding haze or edema. It doesn't look really that, it doesn't look infected. The depth, so it looked, you know, it was pretty fairly anterior, kind of anterior stroma. And also incorporated the epithelium too. Just one more photo, not super great, but you can kind of see it there. And we got anterior segment OCT because we wanted to see what layers of the cornea this was including. And so I have the single shot here. You can see your attention is drawn to the center of the image where you have this hyperreflectivity in the anterior stroma and epithelium. You can kind of appreciate if I can convince you here that there's a lacy flap and maybe it gets a little thicker right here, maybe there's some inflammation, but then it thins out. And so, and there's a lot of shadowing into the posterior cornea. We felt that this was kind of supporting evidence that there was involvement of the stroma, of the anterior stroma flap from lacy. So we thought, well, we should scrape it and see what it is. And, you know, you can see my medical term, mushy epithelium. It was just kind of ratty and came off really easy. And then there was some mild calcification underneath, but didn't appear there was active epithelial ingrowth that we could see kind of a classic nest of cells or anything like that. But we gave her a working diagnosis of like a chronic lacy flap necrosis. Possibly due to some folk epithelial ingrowth. There are some case reports of that that I'll kind of discuss a little bit. But it's something that's pretty uncommon, more commonly. And I'm going to talk a little bit about lacy flap necrosis in general, but usually it occurs in the early post-operative period. The nice thing about lacy is we've created this nice new potential space for bad things to happen. And lots of good things happen too, but rarely you can get these bad things that can cause lacy flap necrosis. So I'll go through these briefly and then talk about what we thought was going on with our patient. So infectious keratitis, typically it occurs kind of within the first two to three days post-operatively, but up to two weeks. The early form is typically strep or staph species. You kind of treat them classically by lifting up the flap and irrigating with broad spectrum antibiotics and then treating with fortified antibiotics. There was an outbreak years ago of rare atypical mycobacterium. That's kind of a chronic smoldering infection. And you kind of treat it the same way except you use amicacin instead. Predispositor factors include blepharitis, poor hygiene, contaminated instruments. You can also get fungal infections, but those are pretty rare. We actually had a case here. This wasn't our case, but the patient came in. This was back in 2009, but you can see here there's diffuse corneal haze. There's kind of this multifocal infiltrate. I have a silt lamp photo of this. And you can appreciate right in the center there's some thinning. Most of the infiltrates kind of located where the flap interface is, but one thing that's important to differentiate between infectious keratitis and another antibiotic to talk about is that infectious keratitis can spread beyond the flap itself, the flap interface. It can go into the posterior show and then into the flap itself. This patient ended up getting better and she's actually getting cataracts or during a couple weeks. The other thing that's kind of you have to differentiate from infectious keratitis is diffuse laminar keratitis. It's this non specific white blood infiltrate in the flap interface. And it's usually just in that area. It usually doesn't spread into the flap itself or into the posterior stroma. It's typically seen earlier. So like one day after surgery, and there are four stages and I don't have pictures of all of them. But it's basically, you know, going from from pretty mild case to something that's really bad like flat necrosis. There was a case of flat necrosis that was referred to us a couple years ago. And this was when it was resolving. DLK is kind of classically called like the sands of Sahara because you get this kind of linear pattern. It looks like maybe, you know, the rolling sandhills that you'd seen sand dunes. But you can appreciate here that centrally, you have this white blood cell infiltrate, maybe a little bit of Dima. And then you can kind of see that maybe when you get to the center here, the flap is thinned some. And this patient had stage four DLK and so they had flat necrosis. And the treatment for DLK is aggressive corticosteroid use. First, you start topically, then you do systemic, and then lifting the flap and irrigating is another thing that people have recommended also. And then that's what I said. Epithelial ingroth is the other thing that can cause LASIK flat necrosis. It's the numbers are kind of all over the place, but in general, BCSC says that 3% of eyes can get epithelial ingroth after LASIK. It's more common with a microkeratone blade for cutting LASIK flap than a femtosecond plate flap creation. More common hyperopyr correction, which our patient had, LASIK after RKA and epithelial defects after surgery. It generally is kind of this has a pretty classic appearance to get these nests of epithelial cells in the flap interface. Typically, it's peripheral, so the peripheral flap, but you can get kind of focal central nests, which are less common. Here's another case and you can really appreciate there's the edge of the LASIK flap and you can appreciate all these nests of epithelial cells in the periphery. Most of the time they stay there and they're asymptomatic and you can just observe them, but if they get into the visual axis, then you have to lift up the flap and scrape the cornea. So there's kind of some theories why epithelial ingroth would cause a flat melt. Some of the original theories were that maybe the epithelial ingroth blocked aqueous diffusion to the stroma, so you get like this focal necrosis from the stroma not getting enough nutrition. And then also we know that epithelial cells release inflammatory cytokines and they can cause like a focal inflammation. And our theory in our patient was maybe she had some small nests of epithelial cells that over time just kind of smoldered and caused this slowly progressing flap necrosis and that's why maybe have that nice, well circumscribed circular appearance because there might have just been a little bit of a cell and it kind of spread out and you get diffusion, like an even diffusion of inflammatory cytokines causing that chronic smoldering necrosis. So there's lots of different ways you can manage this. I mentioned you can lift up the flap and scrape it. Some more exotic things that I've been tried and may or may not work is using a Yag laser to if you have a focal ingroth area, you can zap it. But there are a couple of case reports where people zapped it and they caused a buttonhole in the lacy flap and then you get more epithelial ingroth. So it's not really recommended. But I put it on there for historical purposes. Also more extreme things after you've tried to lift the flap and scrape all the epithelial cells and then you've sutured the flap. If that doesn't help or if you glued the flap, you can do PTK or you can truncate the flap and then do PRK on top of it to try to blade all the epithelial cells and give someone a decent correction. And then people have tried other things like mitomycin C to stop fibro-bascular growth. And some of these things have worked great. Some reports and other reports they haven't worked that well. So our patient, you know, we had kind of a lot of management considerations. She had, she was 20, 25 corrected. You know, we didn't want to be super aggressive and cause her vision to go down. And the mel was outside the visual axis and that kind of plays into good visual acuity. She also had this, you know, possible history of herpes simplex. And so we didn't know if that was playing a role. And like I said, we were wondering how aggressive we should be. So Dr. Miffin scraped it. And then just for kind of diagnostic purposes, we decided to go with a bandaged contact lens. Our thought was maybe a bandaged contact lens, if it was especially if it was kind of a little tighter fitting, it could induce some hypoxia and cause some scarring in that area of necrosis. And then she'd have a nice scar there and she wouldn't have the irritation anymore. Other things that we considered were using tissue glues you can use to seal other fibro-glues. Sealants, like for sure, have been described in literature recently for kind of stopping epithelial ingrowth. And then you can also use cyan or acrylate gruelu too and just put a bandaged contact lens on top. More extreme things, which we didn't really consider in her, you can actually amputate a flap and you can do a lamellar transplant. And sometimes people with trefine outside of the where the flap was originally created and then do like a really thin lamellar dissection. And then you can use a femtosecond laser to do create a lamellar flap out of a donor cornea. But like I said, we were conservative. So we put on antibiotics until she went back to Idaho in a couple of weeks and was going to see her local ophthalmologist and he removed it. And then we put on a prednisone taper and covered her with antiviral during that time. I talked to the patient last night and it's been a month since we saw her. And she said she feels great when the contacts in, but when they took it out, I was irritated. So her ophthalmologist put it back in and kind of kept her on the same protocol here. And my impression from talking to her is that if it wasn't better in a month or two, we were going to be seeing her again, just to talk about their management considerations because she's pretty irritated. It's been bothering her for a long time. So take home points. This is a weird and usual case like chronic necrosis of elastic flap is very, very rare. It's important kind of for residents and just in general to differentiate this diffuse laminar keratitis from infectious keratitis because the treatment's a lot different. And so you can see where the inflammation is. If it's just localized to the interface of the flap itself, it's probably DLK, especially if it just showed up in the first day after surgery. But if they have pain, photophobia, and it looks angry, then you should treat prophylactic with antibiotics. And then epithelial growth, the vast majority of time can be observed. We always have LASIK study going on in our last study. I think in the last year we had one patient who had some in growth, but it was just in periphery. And we just watched it in her vision, the visual QD of the patient was really good. And so I can take any questions if anyone has any. Yeah, so be more aggressive. I think we'll probably go the the the glue route. We've we talked about doing brochure because it's easy, but you know this is a chronic smoldering problem. Reshure sealant only lasts about a week and so it may not be long enough. And we have a really the cyanoraculate glue that we use here is pretty mild even if your contact lens comes out. It doesn't even it doesn't really irritate an eye. And so we thought about doing that and just letting it sit there until it gets better. We did discuss that, you know, extreme lamellar transplant, but I think because her visual QD is good we'd like to avoid doing something extreme like that. And I think hopefully a poor fitting contact lens covered by antibiotics will help her scar down. I think one other possibility is just putting a little small in the eye number patch in that area to manage contact lenses. Dr. Orson, why as long ago was bluing some contact lenses on babies who were born with congenital cataracts and trying to give them some vision before they started doing this diagnosis. And the epithelium would go right between the contact lens and the cornea. It doesn't seem to be enough to see the barrier. It wasn't then in that situation so there's a word of caution on that. Okay. I'm sure it could. Yeah, and of course we have to always think of NSAIDs too. NSAIDs are really, I would say, inappropriately prescribed things that you always need to think of. Really prevalent in the ER setting. And, you know, not typically would cause something that looks like this, which is very vocal, but certainly I think by NSAID use and incense both. Good point. Thank you.