Exposure keratopathy often progresses even with conventional various treatments and needs plastic surgery. However, plastic surgery of eye lid is often difficult in cases with poor general condition by cerebrovascular disorders. We will propose a novel method using synthetic rubber sheet to manage the exposure keratopathy under poor general conditions.
We treated with synthetic rubber sheet on 9 eyes of 9 patients who suffered from refractory exposure keratopathy due to cerebrovascular disorders. Sheets cut from sterile surgical gloves made of synthetic rubber (SR sheets) were placed directly onto the ocular surface with antibiotic ointment and fixed with gauze and tape. Severity of the exposure keratopathy was scored before and after the application of SR sheet. Covered ocular surface with SR sheet could keep an adequate moist environment and exposure keratopathy was improved in all the cases with no adverse effects during an average observation period of 166.2 days.
Conclusions and importance
Sterile synthetic rubber sheet cut from surgical gloves is an effective, safe, easy, and economical material to maintain better condition of ocular surface and especially useful for refractory exposure keratopathy under poor general condition.
Exposure keratopathy due to lagophthalmos is mainly caused by central or peripheral facial cranial nerve paralysis. A peripheral paralysis called Bell’s palsy is usually transient and will resolve with time. In contrast, central facial nerve paralysis caused by cerebrovascular disorders is permanent, resulting in severe exposure keratopathy. Once exposure keratopathy becomes refractory, it will lead to corneal ulceration which will progress to perforation. There are many patients suffering from exposure keratopathy caused by central paralysis in intensive care units (ICU), coronary care units (CCU), and nursing facilities. Lagophthalmos was present in 17–25% of the patients admitted to ICUs. , In cases with paralysis by cerebral infarction, exposure keratopathy will remain for the patients’ entire life. However, plastic surgery is often difficult in various reasons under poor general conditions or it sometimes fails in vain. Various treatments keeping the ocular surface moist have been reported, e.g., Geliperm dressing, eye patches, hypoallergenic tapes, saline-soaked gauzes, and suturing the eyelids (tarsorrhaphy) combined with eye drops and/or ointments. Nevertheless, the corneal erosion often persists and progresses to corneal perforation. Thus, another method to manage exposure keratopathy easily is necessary to improve corneal condition of the patients under poor general condition. Purpose of this study is to show that covering the ocular surface with a rectangular piece of synthetic rubber sheets cut from a sterile surgical glove (SR sheets) is a simple and effective method to improve the corneal condition in exposure keratopathy.
Subjects and methods
We studied 9 eyes of 9 patients who had persistent corneal ulcers due to lagophthalmos at JCHO Hoshigaoka Medical Center and Nagata Eye Clinic. Their average age was 59.6 years with a range of 47–88 years. All the patients had cerebrovascular disorders, e.g., brainstem hemorrhage and/or cerebral infarction, and all of them used wheelchairs due to physical disabilities. Their referring doctors had applied artificial tears, ophthalmic ointments, and gauze eye patches and some plastic surgery for the lagophthalmos. However, because the exposure keratopathy had not improved, the patients were referred to our hospitals.
Protocol for this study was approved by the Ethics Committee of the JCHO Hoshigaoka Medical Center and Nagata Eye Clinic, Kansai Medical University and the procedures conformed to the tenets of the Declaration of Helsinki. After obtaining a signed written informed consent from the patients, we started the treatment with SR sheet. The sheet was cut into 20 × 30 mm square from a sterile surgical gloves (Sensi-Touch Pro Sensoprene® Soft Toray Medical) and kept into the sterile container ( Fig. 1 a and b). The SR sheet was placed onto the ocular surface with antibiotic ointment, covered with surgical gauze and attached with surgical tape ( Fig. 2 ). The SR sheet and gauze were changed three times/day at beginning of application.
Status of the cornea was graded by the severity of four signs, viz., conjunctival injection and vascular invasion, corneal thinning, corneal opacity, and corneal erosion ( Table 1 ). The severity of each was scored from 0 to 3, and the total score was calculated at each time point. The quality of the ocular surface was scored by two doctors from photographs of the ocular surface without being informed on the clinical course of the patient, i.e., in a masked manner.
|corneal thinning||<1/2 of the corneal stromal thickness||≧1/2 of the corneal stromal thickness||descemetocele|
|corneal opacity||slight||<1/4 of the entire corneal surface||≧1/4 of the entire corneal surface|
|erosion||slight||<1/4 of the entire corneal surface||≧1/4 of the entire corneal surface|
Representative cases (Case1&7)
Case 1 was a 54-year-old woman who had bone dysplasia accompanied by cerebral hemorrhage and infarction. During the period of pain due to lagophthalmos (approximately 36 months), she was treated with taping and a gauze patch with antibiotic ointment. The condition of the ocular surface fluctuated during this conventional procedure, and the conjunctiva of her right eye gradually became more severely hyperemic and the condition progressively deteriorated. She was referred to our department and was initially treated with topical hyaluronic acid adding to antibiotic ointment and gauze patch. However, the corneal thinning progressed ( Fig. 3 a). The total score of her right eye was 12 points at this time (vessel invasion 3, corneal thinning 3, corneal opacity 3, corneal erosion 3). Because of the progression of severeness, we decided to apply a SR sheet with antibiotic ointment to keep the moisture of the ocular surface. The sheet was covered with a gauze patch and held in place with surgical tape. SR sheet with the antibiotic ointment was changed several times a day, and hyaluronic acid eye drops were also applied three times a day. After one month, the epithelial defect was completely healed, the corneal opacity was improved, and the inflammation gradually subsided and total score improved to 3 points (vessel invasion 1, corneal thinning 1, corneal opacity 1, corneal erosion 0) ( Fig. 3 b). A SR sheet was applied continuously with shorter wearing times until she was transferred to another hospital.