Topical Cocaine Debridement for Epithelial Basement Membrane Dystrophy Authors: Paul B. Kouyoumjian, MD 1 Rony R. Sayegh, MD 1 Geetha G. Vedula, MD 2 Verinder S. Nirankari, MD 1,3 1 Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, MD, USA 2 Jules Stein Eye Institute and Department of Ophthalmology, UCLA School of Medicine, Los Angeles, CA, USA 3 Eye Consultants of Maryland, Baltimore, MD, USA The authors have no financial interest in the subject matter of this poster.

Introduction Epithelial basement membrane dystrophy (EBMD) is the most common type of corneal dystrophy, affecting 2% of the population Although most patients are asymptomatic, approximately 10% of affected individuals experience corneal erosions or degradation of vision Erosions result from poor epithelial adhesion to the underlying basement membrane whereas visual symptoms are attributable to irregular astigmatism and abnormal tear break-up When conservative medical treatment fails, surgical intervention is indicated Surgical treatment options include simple epithelial removal, needle or Nd:YAG laser induced anterior stromal puncture, superficial keratectomy with either lamellar dissection or with diamond burr polishing, and excimer laser phototherapeutic keratectomy In the present study, we reviewed the outcomes of topical cocaine- assisted epithelial debridement and superficial lamellar keratectomy for the treatment of symptomatic EBMD

Methods Subjects Retrospective chart review of patients treated between 2002 and 2007 Diagnosis was established by a single clinician on the basis of slit- lamp examination The indications for surgical intervention were decreased vision secondary to irregular astigmatism and/or recurrent corneal epithelial erosions 3 subgroups of patients, based on whether they presented with erosion symptoms alone, visual symptoms alone, or both, were analyzed.

Methods Surgical Technique All were performed by the same surgeon (VSN) Sterile prep and drape, insertion of eyelid speculum, topical anesthesia using tetracaine eye drops. Specially cut Weck-Cel sponges soaked in 4% topical cocaine are placed on the cornea for 3 to 5 minutes, loosening the epithelium. Epithelial debridement of almost the entire cornea is performed, leaving intact an approximately 0.5mm narrow rim of peripheral epithelium. Areas of subepithelial fibrosis in different parts of the cornea (central/paracentral) are removed with blunt and sharp dissection using a Paufique and/or Gill corneal knife. Epithelium is sent for histopathology. Eye is copiously irrigated with balanced salt solution. Therapeutic bandage contact lens (BCL) is placed, followed by topical antibiotic eye drops. Postoperatively, all patients were treated with topical antibiotic eye drops. Topical mid-strength steroid drops were initiated after about a week, noting that the cornea had re-epithelialized, and at which time the BCL was discontinued. Two cases received adjunctive treatment with mitomycin C in addition to above. 3 eyes of 2 patients underwent concomitant cataract extraction with PCIOL implant

Methods Data Collected Subjective symptoms Perioperative and postoperative data –surgical technique –complications (such as subepithelial haze) –post-op treatment –evidence of recurrence Pre-op visual acuity = Best Spectacle-Corrected Visual Acuity (BSCVA) at last visit prior to procedure Early post-op visual acuity = BSCVA closest to one month after surgery Last post-op visual acuity = BSCVA at most recent follow-up visit Pre-op and post-op corneal topography were reviewed. Surface regularity index (SRI) values were collected Recurrence was defined as any postoperative findings of epithelial maps, dots, or fingerprints, or symptoms consistent with recurrent erosions.

Results Preoperative and Demographic Data 36 eyes of 30 patients 12 males and 18 (60%) females Mean patient age: 63 years (range, 42 to 89 years) Mean follow-up: 19 months (range, 6 days to 6 years) Subgroup analysis –Group 1 (n=14): erosion symptoms alone –Group 2 (n=17): visual symptoms alone –Group 3 (n=5): both erosion and visual symptoms

Results Visual Acuity Group 1: erosion symptoms alone Group 2: visual symptoms alone Group 3: both erosion and visual symptoms

Results Topographic information, i.e. Surface Regularity Index (SRI)

Results Recurrence Recurrence was observed in 4 out of 36 eyes (11%) All belonged to the recurrent erosion subgroup (group 1) Recurrences occurred as early as 15 months and as late as 4 years after the procedure –The “early” recurrence occurred in an eye treated with adjunctive mitomycin C due to preoperative suspicion of epithelial dysplasia, and which had persistent subepithelial haze –The eye with “late” occurrence showed subtle map, dot, fingerprint changes –Another case of recurrence was subsequently treated with PRK, almost 3 years later. The eye had previous history of anterior stromal puncture, the only one in our study –The 4 th eye with recurrence (2 years, 5 months later) warranted retreatment, which was pending at the time of this writing.

Conclusions Our study strongly suggests that the surgical technique of topical cocaine-assisted broad epithelial debridement followed by manual superficial keratectomy is a safe, simple, and effective treatment for visual disturbances and recurrent epithelial erosions associated with EBMD. Amongst eyes with erosion symptoms, treatment resulted in relief of symptoms in all patients during the first 15 months, with only 4 out of 16 experiencing symptoms in the subsequent 4 ¼ years of follow- up; of these, 2 warranted retreatment. All eyes treated for visual symptoms secondary to EBMD alone (16) experienced a sustained improvement in vision for the duration of follow-up. Furthermore, in regards to corneal topography, this group exhibited substantial diminishment of irregular astigmatism as evidenced by the improved mean SRI. Other than faint subepithelial haze, which was usually transient and not visually significant, no complications occurred in any of the 36 eyes treated.

Conclusions On review of the literature, this simple technique is at least comparable in efficacy to other well-established surgical treatments for EBMD Debridement of most of the epithelium as opposed to just the central 6-8 mm may result in decreased recurrence of disease Superficial lamellar keratectomy to remove subepithelial fibrosis likely is superior to simple epithelial debridement alone Cocaine may act in a similar way to alcohol, leaving behind a smooth corneal surface for regenerating epithelial cells to attach firmly Because of its simplicity and effectiveness, without the need for expensive instruments, we suggest this as an option for symptomatic patients

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