Transcript Recurrent pterygium에서 Bevacizumab injection의 효과

Early Changes in Corneal Sensation, Ocular
Surface Integrity, Tear-Film Function, and
Conjunctival Impression Cytology After
Photorefractive Keratectomy
Byeong Hee Lee, M.D.
Young Jeung Park, M.D. Ph.D.
Kyoo Won Lee, M.D. Ph.D.
Cheil Eye Hospital , Daegu, Korea
The authors have no financial interest
Background and purpose
• There are some reports detailing the course of corneal
sensation, ocular surface integrity, and tear-film
function after myopic surface ablation(PRK, LASEK)
• No previous reports on morphological alteration of the
ocular surface after myopic surface ablation.
• To investigate the morphological alteration of the
ocular surface, corneal sensation, ocular surface
integrity, and tear-film function after photorefractive
keratectomy (PRK)
Materials and Methods
 Prospective study: Included patients having myopic PRK
surgery (25 patients, 50 eyes)
 PRK procedure
 Removal of corneal epithelium by Amoils epithelial scrubber®
 Technolas 217z 100® flying spot excimer laser was used on
tissue saving mode
 Chilled balanced salt solution (BSS®) was used to irrigate, and
bandage contact lenses were used to cover the cornea
 Antibiotics and anti-inflammatory eye drops were used until
reepithelization of the cornea is completed, and bandage contact
lenses were removed (3~5 days post-op.).
 Topical steroids were administered 4 times daily, and tapered to
abstinence in span of 4 months
Evaluation





Ocular surface disease index (OSDI) questionnaire
Corneal sensation (Cochet-Bonnet esthesiometer)
Tear-film breakup time (BUT)
Schimer test without anesthesia (Schimer Ⅰ)
Corneal fluorescein staining score (CFS):
Using 4-point scale: 0 = no staining of the cornea, 1 = less than one-third staining, 2 = less
than two-third staining, 3 = more than two-third staining
 Conjunctival impression cytology (CIC):
– Use filters composed of mixed esters of cellulose with submicroscopic pores (ML-Millipore)
– Instill anesthesia and then applied to the superior bulbar conjunctiva with forceps and
pressed usually for 3-5 sec.
– After PAS stain, evaluated degree of squamous metaplasia, density of goblet cells
(cell/mm2), snake-like chromatic change : Nelson’s classification
 Followed up at pre-op, 2nd week, 1, 2, 3, and 6 months
post-op.
Patient and ocular characteristics.
PRK
Number of eyes (patients)
Male/Female
Mean age of patients (years)
(Range)
CL history (years)
50 (25)
6/19
25.56±4.35
(19~35)
4.81±5.36 (0~20)
Preoperative SE (Diopter)
-4.80±1.64 (-1.75~-8.5)
Preoperative pachymetry (μm)
543.7±30.2 (484~608)
Ablation depth (μm)
82.39±22.04 (41~127)
Ablation diameter (mm)
6.54±0.30 (6.0~7.2)
‡
Clinical parameters before and after PRK .
Postoperative
Preoperative
2 Week
1 Months
2 Months
3 Months
6 Months
0.72±0.74
1.74±0.56*
1.82±0.54*
1.23±0.65*
0.96±0.69
0.51±0.49
Goblet cell count
(cell/mm2)
226.2±154.2
77.0±56.3*
135.7±133.5*
205.6±111.1
265.0±168.1
348.4±188.3†
Corneal sensation
(mm)
56.00±4.30
50.00±5.20*
52.00±5.20*
56.80±2.84
57.20±3.84
59.00±2.04†
Corneal fluorescein
staining
0.72±1.21
1.6±1.22*
0.48±0.65
0.48±0.71
0.36±0.76*
0.44±0.77
29.16±22.71
36.86±13.79*
27.53±13.77
25.01±13.13
21.25±10.65
20.84±12.42
BUT∥
(seconds)
4.00±3.66
4.60±2.89
4.92±2.60
4.04±2.62
4.88±3.00
5.00±3.07
Schimer I (mm)
13.6±12.25
11.28±9.24
10.88±8.14
9.16±7.59*
8.32±9.32*
9.60±5.35
Parameter
Conjunctival epithelial
metaplasia
OSDI§
Significantly worse than the preoperative value (p<.05, Wilcoxon signed-rank test); † Significantly better than
the preoperative value (p<.05, Wilcoxon signed-rank test); ‡ PRK = photorefractive keratectomy;
§ OSDI = ocular surface disease index; ∥ BUT = tear break-up time
*
Grade of conjunctival epithelial metaplasia as time progresses.
Conjunctival epithelial
metaplasia
2.00
1.50
1.00
grade
0.50
0.00
Grade:0 N/C 1:2↓
A: pre-op
Grade:1 N/C 1:3
D:2 months post-op
Graph shows that epithelial metaplasia
grade worsens drastically up to two
weeks post-op, maximizing at 4 weeks
post-op.
Then it improves gradually, returning to
pre-op level at 3 months post-op, yet to
improve further all the way to 6 months
post-op.
Grade:2 N/C 1:4
Snake-like chromatin
B:2 weeks post-op
C:1 month post-op
Grade:0 N/C 1:2
Grade:0 N/C 1:2↓
E:3 months post-op
F:6 months post-op
Goblet cell densities from pro-op to 6 months post-op.
(Cell/mm2)
Goblet cell density
400
350
300
250
200
150
100
50
0
G-density
Graph exhibits a sharp reduction in goblet
cells at 2 weeks post-op, then shows a
gradual recovery returning to pre-op level at
between 2 ~ 3 months post-op. The increase
in goblet cell numbers continues to 6 months
post-op
A:pre-op
B: 2 weeks post-op
C: 1 month post-op
D: 2 months post-op
E: 3 months post-op
F: 6 months post-op
Snake-like chromatin pattern
eyes, %
60%
50%
52%
40%
30%
44%
32%
32%
40%
32%
20%
10%
0%
pre-op 2weeks 1months2months3months 6months
The relative percentage
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
The number of snake-like
chromatin patterns: the
relative percentage in the
cell layers of the specimens
obtained ranging from 0 to
more than 75% (0= no
snakes; Ⅰ= 1-10%; Ⅱ= 1125%; Ⅲ= 26-50%; Ⅳ= 5175%; Ⅴ= >75%)
pre-op 2weeks 1months 2months 3months 6months
Snake-like chromatin pattern increase 20.0% between 1~3 months post-op. However,
it decreases back to pre-op level at 6 months post-op. Snake-like chromatin pattern
also showed increase in amount in individual case in afore mentioned period.
conclusions
• Corneal sensation decrease all the way to 2 weeks post-op, then
bounces back gradually to pre-op level 2 months post-op.
• CFS was the highest at 2 weeks post-op. It decrease to even
below the pre-op level at 4 weeks post-op.
• OSDI was the highest at 2 weeks post-op, then gradually
decreasing all the way to 6 months post-op.
• BUT showed minimal changes throughout the period of pre-op and
follow-ups.
• Schimer Ⅰtest decrease gradually. It shows marginal drop
between 2~ 3months post-op when compared against pre-op level.
• As seen on this research corneal sensation, CFS, and OSDI
turned out to be good indicator of clinical progress after PRK,
whereas BUT and Schimer Ⅰtest turned out insufficient clinical
indicators.
conclusions
• The first drastic change on conjunctival impression
cytology(CIC) after PRK is the decrease in goblet cell count,
which bottoms out at 2 weeks post-op. Then the conjunctival
epithelial metaplasia grade increase drastically and peaks out at
4 weeks post-op.
• Goblet cell count recovers to pre-op level at 2~ 3 months postop, whereas conjunctival epithelial metaplasia grade returns to
pre-op level at 3~6 months post-op.
• Follow up of ocular surface health after 6 months of PRK seems
necessary; although, corneal sensation and healing for corneal
surface show improvement two months after PRK, conjunctival
surface morphology shows improvement at least after six
months of PRK.
• It seems further study on precise mechanism of ocular surface
modulation after PRK is essential.
The End
Thank you for your attention