An injury to the outer layer of the cornea, the Epithelium, usually heals with in a few days, and results in no long term damage. However, if the Epithelium does not fully reattach to the underlying layer, Bowman’s Layer, then that focal point may be a source of future problems. This is called a Recurrent Corneal Erosion, RCE.

An individual wakes up in the morning in severe pain upon opening their eyes. The affected eye is red and extremely light sensitive. It improves as the day progresses, but takes several days to fully remediate. This event re-occurs every few weeks, or months each time being worse then the time before. Lasting longer, hurting more, and not fully remediating. This is a typical course of action for RCE. Since the Epithelium did not fully re-attach to the Bowman’s layer after the injury, it gets pulled off at the point of injury. During sleep, it gets stuck to the inner layer of the eye lid and tears as a result of REM sleep. These events can be mild or extremely painful resulting in decreased vision, and constant foreign body feelings in the eyes.

Treatment varies substantially from using lubricating ointment at bedtime to keep the cornea from getting stuck to the eye lids during sleep; to Anterior Stromal Puncture. This involves sticking a needle into the cornea at the affected site in the hope of forcing the epithelium to re-heal, thereby attaching to Bowman’s membrane. It has proven to be moderately successful. The newest treatment has come about as a result of refractive surgery.

Photo therapeutic Refractive Keratotomy (PRK) has been used to fully treat this condition. The corneal area is first bathed in alcohol to delaminate the epithelium, or remove the top layer. Then PRK is performed to treat the damaged area. Upon healing, the epithelium is now fully re-attached to Bowman’s membrane.

While there have not been a significant number of these cases as of yet, this treatment has shown dramatic results. Ultimately PRK may prove to be the treatment of choice in severe cases of RCE.

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In the hands of a well trained, experienced, and seasoned refractive surgeon, LASIK is a very good procedure with excellent results. IntraLASIK which is the same procedure that employs a laser to create the flap is even better. An often over looked complication of the procedure is the affect that the oil glands have on the final results.

Meibomian(oil) glands, or Tarsal glands as they are sometimes known are sebaceous glands located in the tarsal plate of the eye lids. These are found near the rim of the lids, and are responsible for the production of sebum which is an oily material. This very important component of the tear film prevents evaporation of the tears by maintaining tear /cornea contact evenly over the entire surface. Since it thickens the tears, it also functions to prevent the tears from spilling over the eye lids. The final affect of the sebum is creating a tight lid-lid seal keeping the eyes moist at night.

The upper eye lid has approximately 50 glands and the lower 25. These very important organs were first named in the late 1600s by the German physician Heinrich Meibom. So how and why do these glands affect LASIK?

The Meibomian glands produce the sebum 24 hours per day, and will secrete it into the eye upon every blink. Squeezing the eye lids tight will force out more sebum making the eyes oilier.

The cornea is completely transparent, and must remain that way in order to see clearly. The most important point that must always be maintained during LASIK is to make sure that when the flap is placed back in position it goes back exactly as it was before, and that the area under it is clear of any debris. Unfortunately, if the patient squeezes his/her eyes during the surgery the Meibomian glands will secrete more sebum into the eye and coat the exposed surface. If this occurs while the flap is lifted up, the sebum will coat the inside area of the cornea and cause distorted vision. When the flap is put back into position, it traps this excessive sebum under the flap. While there is no health risk to this trapped sebum, is does leave an oily residue in the middle of the cornea.

The final result is an imperfect cornea. When examining these post operative patients one can see oily, hazy areas. The affect on one’s vision will vary from mild to severe haziness, photophobia (glare and light sensitivity), and decreased vision. If the oil slick is out of the visual axis then glare will be the only visual side affect. If it is in the line of sight then most patients complain of decreased vision. In severe cases, the surgeon must go back into surgery, lift the flap, and clean out the area.

The best way to prevent this surgical complication is to listen to the doctor during surgery and not force a blink or squirm around during the procedure. That is often more easily said then done.

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Chlamydia is a sexually transmitted, urogenital disease that frequently goes un or misdiagnosed. As a result of this under diagnosing many individuals suffer from Adult Inclusion Conjunctivitis(A.I.C.). The reason for the misdiagnosing is the lack of desire by many eye doctors to raise the sensitive subject of sexually transmitted diseases. Often, these individuals may be reluctant to be forthright about their sexual encounters since they are extramarital in nature.

A.I.C. is caused by the bacteria Chlamydia trachomatis, and is the most common cause of persistent conjunctivitis. According to recent studies, 54% of males and 74% of females have A.I.C. secondary to a Chlamydia infection. According to a study done in 1996, Chlamydia is the leading cause of preventable blindness worldwide.

According to the Centers of Disease Control, CDC, Chlamydia is the most common sexually transmitted disease in the US, and is estimated to affect approximately 3 million Americans per year. This gram negative microorganism often presents with few, or no symptoms, and may lie dormant for many months or years. While the most commonly affected age group is 16-34, it can be seen in the young and old alike. The common denominator is being sexually active according to Dr. Jay Stockman a practicing eye doctor in NYC.

Most individuals will present to their eye care provider with a red eye and discharge which looks like any garden variety bacterial conjunctivitis. The doctor will prescribe a topical ocular antibiotic, and a week later the eye will appear normal. This may have presented in one eye, but often seems to spread to the other eye. Then one to three weeks later the patient returns to the eye doctor with a recurrence of the condition. What separates this conjunctivitis from many other types is the presence of follicles, or little bumps in the lower area of the conjunctiva called the palpebral conjuctiva. A culture should always be done which confirms the diagnosis. In addition, frequently there will be swelling of some of the lymph nodes; such as the ones in front of the ears or under the chin.

Confirming the diagnosis is accomplished through following the follicles, cultures and conjunctival scrapings. Treatment includes oral Doxycycline which must be continued until there is full remediation of the conjunctival follicles; which may take several weeks. In certain situations such as pregnancy, a single does of Azithromycin is an affective treatment.

In short, conjunctivitis is often caused by Chlamydia which is a sexually transmitted bacteria. Patients must be honest with their eye doctors when asked about their history since untreated Chlamydial infections can be sight threatening.

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For people over the age of forty, reading becomes increasingly difficult. This inability to focus up close is called Presbyopia. It is a normal part of aging, and can not be prevented. As LASIK and PRK have increased in popularity, researchers have looked for ways to eliminate the need for reading glasses for those over 40.

Until recently, the options have been limited to mono vision LASIK, which is still the most selected option among refractive surgery patients. It involves surgically correcting one eye for the distance, and the other for near. While it is a viable option, there are still those who can not adjust to the difference in visual acuities between the two eyes. In those cases the near eye must be re-corrected for the distance, and reading glasses are required.

Another option has been a multi focal intraocular implant. It is basically a cataract operation, with an implant that has concentric rings of refractive power. One power is for the distance and the other for near. Again, there are those that are happy with the total vision, but many still complain of a lack of complete visual acuities at the distances they require. Also, glare and poor night vision are common complaints.

A relatively new procedure to attempt to address these issues, is called CK or Conductive Keratoplasty. It involves using radio waves to steepen the cornea of an individual who sees well in the distance, but wants to have better near vision. It creates a nearsighted shift in one eye and is essentially the same as mono vision with LASIK or PRK. The results will vary as well. Thus, with out a complete and very successful procedure for all patients the search continues.

The newest procedure, which is still in clinical trials, is called a Corneal Inlay. It involves lifting a flap in the cornea similar to LASIK, and placing a bio compatible disk in the middle of the tissue. It is done in one eye only and is similar to a disk with many pin holes in it. The pin holes increase the depth of field in that eye, and increases one’s ability to see at near. The test results are still incomplete, although initial data seems to indicate that there is less visual discomfort. One problem exists if the patient has a light colored iris, it will appear dark after the implant is inserted. The disk is removable simply leaving a surgical scar behind. The current clinical trials are using an Acufocus ACI 7000 implant. Only time will tell if this procedure will let all of us ‘old folks’ get rid of our reading glasses.

Tech Tags: Presbyopia LASIK PRK Conductive Keratoplasty Corneal Inlay reading glasses

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