The most common serious post op intraocular complication is a permanent bullous keratopathy. As we all know, patients with corneal edema are not happy campers --- discomfort, tearing, redness, foreign body sensation, poor vision, etc., etc. In North America now days these bullous keratopathy patients are sent off for an endothelial keratoplasty but this option is not usually available in the developing world. My current treatment for bullous keratopathy in the developing world involves first washing my hands and applying proparacaine or tetracaine drops and a topical antibiotic. Then perform multiple corneal micropunctures with a sterile 22 or 23 G needle. Some ophthalmologists recommend a 18 G needle as they feel it is actually safer. Do a lot [ 50 -75 ] especially in any area of epithelial edema. Be careful or avoid any areas of corneal thinning / softening. If the epithelium is " loose ", then debridge [ remove ] with sterile blade, Q tip damp with rubbing alcohol, etc. Apply again a topical antibiotic.
You can use a Nd - Yag to treat [ blast ] Bowmans layer. You want to create a little scarring. Start with a low power in the periphery and titrate upwards. You can also apply heat [ cautery ] to Bowmans but you may need a peribulbar. Be prepared for a " pop " which can be a little scary the patient and surgeon. Cut on the cautery, l<><>et it cool slightly, and gently touch the peripheral cornea. Just doing the micropunctures is usually enough.
Afterwards apply any loose fitting soft bandage contact. I rarely have any specially designated bandage contact available. I give them cyclopentolate or atropine drops bid and a combination antibiotic - steroid drop 4 to 6 times daily. See them back in a week. You can often leave the contact in place for many months.
Often this will relieved the pain which is what you are trying to achieve. Tell the patient this will not make them see better. However the contact can " fall out ". You can get a secondary corneal ulcer with pannus but relieving the pain is often a big help. Patients are often quite appreciative.
Of course you can make a good case for not inserting a bandage contact with bullous keratopathy : this is perhaps only a stop - gap measure; the contact may fall out; you run the risk of a corneal ulcer/ pannus , etc.; no improvement in vision; what happens when the drops run out; etc. All true. However I have seen many patients wearing the same contact for many months with a marked decrease in pain, redness, tearing, photophobia, foreign body sensation, etc. Relieving a patient's pain is a good thing.
So If you are working overseas for 10 days or a year, bring along some bandage soft contacts. You may use them. Peace, Baxter
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