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Prof. Gong Lan: Clinical features and treatment strategies of corneal epithelial lesions

Posting time:2022-12-03 11:04:18

Prof. Gong Lan: Clinical features and treatment strategies of corneal epithelial lesions

Editor's note Corneal epithelial disease refers to a pathological state in which the corneal epithelial barrier function and integrity are destroyed due to various factors under the premise of normal corneal limbal stem cells, resulting in partial or full loss of the corneal epithelial cell layer. Clinically, corneal epithelial lesions are very common and can be caused by a variety of etiologies. Corneal epithelial injury caused by different factors has different clinical characteristics. "International Ophthalmology News" specially invited Professor Gong Lan from the Eye and ENT Hospital of Fudan University to explain in detail the clinical characteristics of corneal epithelial damage caused by different factors, and to share the treatment strategies for corneal epithelial lesions. Analysis and analysis: different risk factors and clinical characteristics of corneal epithelial lesions Corneal epithelial lesions can be divided into primary corneal epithelial lesions and secondary corneal epithelial lesions. Primary corneal epithelial lesions are rare and are mostly related to genetics, such as: 1. Corneal epithelial basement membrane dystrophy (also known as map-point-fingerprint dystrophy), which is due to abnormal development of the corneal epithelial basement membrane, 2. Corneal lattice-like dystrophy, which is clinically characterized by irregular branch-like white strips and cloudy spots in the superficial parenchyma and Bowman's layer, which gradually expand, thicken, and interweave into a grid; with recurrent epithelial defects. Figure 1. Primary corneal epithelial lesions, the left picture shows corneal epithelial basement membrane dystrophy, and the right picture shows corneal lattice dystrophy Secondary corneal epithelial lesions are more common clinically, and are commonly seen in various mechanical injuries, infections, immune factors, etc. Corneal epithelial lesions caused by different factors have different clinical features. 1. Repeated corneal epithelial erosion, often with a history of abrasions such as nails, pieces of paper, and plants. Mechanical trauma can lead to abnormalities in the basement membrane junction complex, which loosens the adhesion of the basal epithelial cell layer and eventually causes recurrent corneal epithelial denudation. Mechanical damage to the corneal epithelium is often manifested as sudden eye pain, photophobia, and tearing in the morning. Figure 2. Acquired structural abnormalities of the epithelial basement membrane due to mechanical injury, manifesting as "finger-like" repeated epithelial denudation. 2. Pathogen infection of the cornea can also lead to epithelial lesions. The most common is corneal epithelial lesions caused by herpes simplex virus. The virus activates and replicates in epithelial cells, causing necrosis and disintegration of epithelial cells, and then epithelial shedding. Typical HSV corneal ulcers have a dendritic shape with bifurcated ends and nodular enlargement. Figure 3. Corneal epithelial dendritic ulcer caused by herpes simplex virus 3. Corneal epithelial lesions after corneal refractive surgery belong to the secondary corneal epithelial damage caused by surgery. Possible causes of corneal epithelial lesions after refractive surgery include: intraoperative nerve severance, decreased consciousness, and decreased expression of neurotrophic factors. Clinical symptoms of surgically induced corneal epithelial injury include eye irritation, dryness, and abnormal discharge from the corner of the eye. Figure 4. Case 1 year after LASIK: intensive corneal epithelial exfoliation is still seen Pseudo-dendritic exfoliation of the epithelium with a long history of eye drops application. Figure 5. Drug-toxic corneal epithelial damage, showing pseudodendritic epithelial defects 5. Neurogenic corneal epithelial lesions are often caused by the destruction of the trigeminal nerve by surgery, trauma, tumors, etc. , the protective mechanism of the cornea is weakened and easily damaged. At the same time, denervation leads to dystrophic corneal epithelium and weakened repair mechanisms. The typical clinical feature is that signs outweigh symptoms, and most patients do not have severe eye pain, tearing and other irritation symptoms, which are related to the decreased corneal perception after trigeminal nerve injury. Figure 6. A 56-year-old female patient complained of redness in the right eye, but no eye pain and tearing. She had a history of surgery for trigeminal neuralgia 3 years ago and was diagnosed with neurotrophic keratitis. 6. Corneal epithelial lesions can also be secondary to systemic immune system diseases. Autoimmune diseases such as Sjögren's syndrome and secondary Sjögren's syndrome caused by rheumatoid arthritis are prone to long-term immune inflammation on the ocular surface, leading to corneal epithelial erosion. Figure 7. A 52-year-old female patient with red eyes, sandy feeling, and photophobia for more than 3 years, and a history of rheumatoid disease for 10 years; Schirmer test in both eyes is 0mm/5min, and the tear film rupture time is 1s. Corneal epithelial damage caused by autoimmune diseases. 7. Exposure corneal epithelial injury refers to the dry and repeated exfoliation of the corneal epithelium caused by incomplete closure of the eyelid. Eyelid insufficiency is mostly caused by proptosis, ectropion, abnormal eyelid structure and facial nerve palsy. Figure 8. The patient underwent intracranial tumor resection for a craniocerebral tumor 1 year ago. After the operation, he developed left facial paralysis. Recently, his left eye has been dry, and he has a foreign body sensation for half a month. He was diagnosed with exposure keratitis. The treatment strategy ‍Professor Gong shared four strategies for the treatment of corneal epithelial lesions: 1. Removal of the cause: Corneal epithelial damage caused by different factors has different causes, and removal of the cause is the most important for corneal epithelial repair. For example, for pathogen infection, sensitive drug treatment should be given on the basis of a clear diagnosis of the nature of the pathogen. Corneal epithelial damage caused by drug toxicity should be promptly discontinued or the use of related eye drops should be reduced. For neurotrophic keratitis, nerve growth factor can be tried. For the corneal epithelial damage caused by autoimmune diseases, attention should be paid to the systemic control of the primary disease. 2. Improve the microenvironment of epithelial repair: The "ocular surface microenvironment" relies on comprehensive factors such as tears, cells, nerves, and immunity to maintain a balance. Once one or more factors are out of balance, a series of chain reactions may occur on the ocular surface, leading to Ocular surface dysfunction; corneal epithelial damage is mostly accompanied by an imbalance of the ocular surface microenvironment. Improving the ocular surface environment can be divided into anti-inflammatory and improving tear film. When there is a clear inflammatory reaction on the ocular surface, anti-inflammatory drugs such as glucocorticoids and immunosuppressants can be administered locally; at the same time, high-quality artificial tears can be given to improve tear film stability and help corneal epithelial repair. 3. Promote epithelial repair through external forces: For the treatment plan to promote corneal epithelial repair, the principle of gradual progression is adopted, which can be divided into "four steps". The first step is basic medication, which can provide the energy, nutrition and growth factors needed for epithelial repair; the second step is to wear a bandage lens to provide mechanical support and protection, seal the corneal wound, and relieve pain; the third step Covering the amniotic membrane, equivalent to a "biological contact lens", provides protection for the corneal epithelial defect area and creates a repair space; the fourth step is blepharoplasty, which protects the cornea by gluing the upper and lower eyelids and avoiding exposure factors, suitable for other treatments Ineffective lid closure or neurotrophic keratitis. 4. Prevention of infection: Corneal epithelial damage weakens the ability of the cornea to resist pathogens, and extensive epithelial erosion may lead to secondary corneal infection, resulting in serious consequences. While repairing the corneal epithelium, administration of topical antibiotic eye drops to prevent corneal infection is an important adjuvant therapy. Conclusion Corneal epithelial injury is a common disease in ophthalmology, and its etiology can be divided into mechanical injury, pathogen infection, post-refractive surgery, drug toxicity, neurotrophic, immune and exposure. Diagnosis of the type of corneal epithelial injury depends on the medical history and typical symptoms and signs, and the treatment strategies mainly include removing the cause, rebuilding the ocular surface microenvironment, promoting corneal epithelial repair, and preventing infection. Correct diagnosis and intervention of the type of corneal epithelial injury can help to repair the corneal epithelium, relieve the symptoms of patients, and improve the prognosis. Expert Profile Gong Lan, Chief Physician, Professor, Doctoral Supervisor, Deputy Director of Ophthalmology, Fudan University Affiliated Eye and ENT Hospital, Director of the Department of Ocular Surface Diseases, Fudan University Affiliated Eye and ENT Hospital, Director of the Office of Drug Clinical Trials Institute Expert member of the Ophthalmology Branch Member of the Cornea Group of the Ophthalmology Branch of the Chinese Medical Doctor Association Member of the Ophthalmology Professional Committee of the Chinese Medical Doctor Association Integrative Chinese and Western Medicine Branch Member of the Ophthalmology Branch of the Cross-Strait Medical and Health Exchange Association Deputy Head of the Study Group

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