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Cornea editor's corner of the world Herpes simplex keratitis (HSV) is one of the most challenging entities that faces ophthalmologists. A geographic ulcer with fluorescein staining of the base of the ulcer and rose bengal staining of the peripheral terminal end bulbs Source: Vincent P. Herpes ocular infection is one of the leading causes of infectious corneal blindness in the United States and Europe, according to Vincent P. With these older medications, practitioners were seeing corneal epithelial toxicity in the form of punctate keratitis and even more serious effects. With the availability of ganciclovir gel, treatment preferences for HSV keratitis are now somewhat in flux. The fact that toxicity is less of a factor makes the decision to use topical therapy alone easier. PROKERA® PROKERA® products are the only FDA-cleared therapeutic tissue products that reduce inflammation and promote healing of the ocular surface. Meanwhile, he pointed out that one product, acyclovir ointment, the standard in Europe and Asia for treating epithelial keratitis, remained off U.S. GlaxoSmithKline] were frequently used especially in people who had other comorbid conditions such as dry eye, blepharitis, and ocular surface disease to try to reduce the toxicity of the topical trifluridine," he said. When it came to stromal keratitis, oral agents were at the hub of treatment, according to John D.
For stromal keratitis, steroids are essential to prevent scarring and blood vessel formation. Pre-owned equipment, practices for sale, open positions, helpful practice management resources and more! Among the major determinants of ocular surface health, specifically tears, lids, blinks, stem cells and sensation, the latter is frequently the most important.
Apart from seeing specific etiologic cause(s)(Table 1), careful clinical evaluation is vital to assess risk factors and concomitant contributory conditions as well as to devise and optimize management.
Conventional penetrating keratoplasty procedures have variable success due to the poor healing capabilities of neurotrophic tissues, the risks of persistent epithelial defect and sterile ulcerative stromalysis being of greatest concern. Amnion membrane extract: Recognizing the exceptional benefits of amnion membrane (AM) to promote corneal epithelial wound healing as well as to suppress ocular surface inflammation and corneal neovascularization, Ghinelli devised a technique whereby fresh human AM could be minimally manipulated to form a lyophilized extract.

Clinical experience with AMX has been positive in its ability to reduce inflammation and promote epithelial healing (Figure 2). Lamellar keratoplasty plus amnion membrane graft: Conventional penetrating keratoplasty in the neurotrophic keratopathy setting presents a high-risk scenario due to chronic inflammation plus surface epithelium and stromal wound-healing complications. The surgical techniques per se are standard and post-op management involves only moderate (e.g. Given the management challenges of neurotrophic keratopathy with vision-threatening risks of corneal PED, stromal ulceration and perforation, a multi-faceted strategy must be devised to promote corneal epithelial defect healing and to prevent stromalysis. Topical antivirals have had significant toxicity, and the more recent trend has been to use oral antiviral agents to manage HSV keratitis. Hovanesian finds that because ganciclovir is not toxic to the epithelium, successful healing of HSV keratitis is evident to both the patient and the physician at an earlier stage.
Hovanesian pointed out that the new ganciclovir gel, while a real step up for HSV keratitis, is not likely to be a moneymaker for the pharmaceutical company like an antibiotic would be. Whether managing disease, trauma, or post-operative care, healing of the ocular surface is of paramount concern because it directly affects your patient’s comfort and appearance, and most importantly their vision.
Sheppard thinks that it would be nice to introduce an ointment preparation that would allow for less frequency of usage. With loss of sensory function of the nasociliary branch of the trigeminal nerve, neurotrophic keratopathy will develop and result in degenerative corneal and conjunctival changes of varying severity.1 Minor manifestations include conjunctival and corneal punctate epithelial irregularity (fluorescein or rose bengal staining) with or without decreased tear production or decreased tear film stability (accelerated breakup time).
The AM extract (AMX, KEERA srl, Italy) has been demonstrated to retain its growth factor activity in vitro & vivo, and can be applied topically. This was confirmed in a European multicenter, open-label clinical trial that demonstrated 100% safety and 96% efficacy in healing persistent corneal epithelial defects (Kenyon, Ghinelli et al., presented at Italian Ophthalmological Society, 2011). Kenyon, MD, is the founder of Cornea Consultants International and is Clinical Professor of Ophthalmology at Tufts Medical School, Associate Clinical professor of Ophthalmology at Harvard Medical School and Senior Clinical Scientist at Schepens Eye Research Institute, Boston, Mass.
Kenyon has a financial interest in KEERA, srl (Italy), the developer of amnion membrane extract. The right balance of clinical and practice management skills is critical for a practice to flourish. But he acknowledged that this is less convenient and is a form that many patients don't like.

However, such abnormalities can also progress to involve persistent corneal epithelial defects, stromal inflammatory reaction and most ominously, enzymatic stromalysis with ulceration potentially leading to perforation (Figure 1).
AMX prolongs and increases the effect of an AM graft, while avoiding the operative time and costs of surgical AM implantation. Initial findings (upper left) include vision reduced to counting fingers with conjunctival inflammation, corneal PED 3x6 mm (lower left), stromal infiltrate with 50% thinning and sterile hypopyon. Therapeutic effect of deep anterior lamellar keratoplasty for active or quiescent herpetic stromal keratitis. Each month only one publication delivers the essential strategies needed to navigate and grow today’s ophthalmology practice. Part of the toxicity, in addition to the drug being a non-selective antiviral agent, was likely the thimerosal preservative in the trifluridine. One downside was that until 2 years ago this was an expensive medication that would cost hundreds and hundreds of dollars for a 1-month dose.
We also believe that when DALK is not applicable, the results of conventional penetrating keratoplasty (PK) are substantially improved by the adjunctive utilization of AM overlay grafting and mini-tarsorrhaphy.
Led by Chief Medical Editor Larry Patterson, MD, Ophthalmology Management provides all the tools ophthalmologists need to succeed, bringing them the latest practice management pearls, clinical advancements and medical economics they need to help their practices grow.
I have asked two corneal experts to comment on their approach to HSV keratitis and how, if at all, this new medication has changed their management.
However, in doing this he cautions against pushing too deeply with the swab since this could push the viral antigen deeper into the stroma. Stromal opacity also contains dense cholesterol and lipid deposits consequent to vascular leakage.

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