Treatments for Terrien's marginal degeneration?
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Treatment
Practitioners can treat many of these conditions or co-manage them if surgery becomes necessary. You can treat some on an individual layer basis, but treatment often can affect multiple layers.
The most effective way to treat anterior corneal conditions is to provide a good surface environment. Lubricating drops are often the initial treatment and ease most patients, whether by a placebo effect or because most of these patients have an underlying dry eye.
Lubricating drops are not created equal. Patients often state that one type of drop works better for them than another. Instillation is frequent for patients who have diseased eyes, so prescribe non-preserved drops to reduce potential cytotoxic effects. Some transiently preserved formulas, which lose their preservative effect upon instillation, may be effective. However, they require sufficient tear volume to break down the preservative compound, and this tear quantity is often missing in patients who have diseased eyes. Preparations that contain preservatives that activate only when pathogens are present seem to make the most sense.
Artificial lubrication should also provide electrolytes that help the eye heal more effectively, such as sodium, potassium, calcium and magnesium. Finally, the media makes a difference. Patients enjoy longer relief with gels, but they often prefer the non-blurry effect of liquids. Incorporating characteristics that react favorably and biologically with the ocular surface into a solution should provide the best relief.
Several new treatment modalities are available for advanced cases of ulcerative keratitis, including cyclosporine (Allergan's Restasis) and autologous serum treatment.
Cyclosporine is an immune modulator that inhibits T-lymphocytic activity, which reduces inflammation. It recently became commercially available by prescription. Cyclosporine facilitates apoptosis of lacrimal gland lymphocytes while suppressing apoptosis of lacrimal and epithelial cells.
Autologous serum therapy resembles personalized tear replacement in which the patient's own serum (blood devoid of cells and clot factors) is formulated into a topical supplement. These customized tears contain epithelial growth factors, vitamin A, anti-proteases and fibronectin that help the healing process. A 40-mL blood sample can produce a three-month supply of "artificial tears" that have natural bacteriostatic characteristics.
Figure 6. The centrally located vesicles of Posterior Polymorphous Dystrophy cause significant visual disturbance.
Tear retention via punctal occlusion may also help these patients. Remember that using punctal plugs is a responsibility. Written consent may be warranted just as with other procedures, and proper followup is essential. Allergy to silicone can result in an uncomfortable patient. Plug downward migration may result in a pyogenic granuloma, while upward migration might cause much frustration. Recent advancements in punctual occlusion include a thermodynamic acrylic polymer that reacts to body temperature and changes shape to conform to the patient's puncta.
Use BCLs to treat corneal conditions that affect both the anterior and posterior surfaces. BCLs protect the eye from mechanical irritation, provide comfort, act as a mechanism for dehydration and improve vision by providing a more uniform surface. Make sure that the lenses have sufficient oxygen permeability to allow for continuous wear. The lenses should not interfere with the healing process or hinder the use of therapeutic agents. They should be comfortable for the patient, allow you to see corneal structures without removal and be cost effective.
BCLs technically should also have approval for treating corneal disease, but the standard of care and accountability of the practitioner are important deciding factors. Higher water content lenses may help with dehydration and may serve as a drug delivery device for some agents by releasing them slowly onto the corneal surface. Full corneal coverage with minimal movement helps prevent disruption of the healing process. Disposable silicone hydrogel lenses may best meet the overall requirements.
It is well accepted that contact lenses are the best treatment for most keratoconics, whose irregular anterior corneal surface does not properly focus light. Replacement of this irregular corneal surface with a more regular contact lens surface significantly improves the focusing of light on the retina and patients' visual acuity. Gas permeable (GP) corneal lenses are most often used. Other options are GP scleral lenses, piggyback GP lenses on a soft lens carrier, GP lens in a well in a soft lens, a central rigid lens with a soft lens skirt combination (Softperm, CIBA Vision) and specially designed contact soft lenses.
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