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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 4  |  Page : 1167-1170

Riboflavin and fluorescein stain before argon laser in the treatment of resistant corneal ulcer


Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission10-Mar-2020
Date of Decision03-Apr-2020
Date of Acceptance05-Apr-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Ghada M Atta
Ashmoun, Elmonofia, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_57_20

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  Abstract 


Objective
To evaluate the effectiveness and safety of argon laser in resistant corneal ulcers with the aid of fluorescein stain or riboflavin.
Background
The use of argon laser irradiation of refractory keratitis has proved beneficial in the treatment of these particular corneal ulcers as an adjunctive treatment.
Patients and methods
In all, 40 cases were divided into two groups. The first group included 20 patients stained with fluorescein sodium 0.25% before argon laser and the second group included 20 patients stained with riboflavin 0.1% before argon laser. Before laser treatment, a drop of benoxinate hydrochloride 0.4% and a single drop of fluorescein sodium 0.25% were instilled in the first group and riboflavin 0.1% in the second group. Argon laser irradiation of the affected cornea was performed using argon frequency doubled yttrium aluminum garnet laser, spot size of 500 μm, pulse duration of 0.2 s, and power of 900 mW. All cases were followed up within 4 months in four visits.
Results
A total of 17 cases healed within 4 months in the riboflavin 0.1% stained group, while only 16 cases healed within 4 months in the fluorescein sodium 0.25% stained group.
Conclusion
Argon laser treatment seems to be an effective adjuvant method for dealing with resistant corneal ulcers. The use of fluorescein sodium 0.25% stain or riboflavin 0.1% solution enhances visualization as well as uptake of laser shots. The difference in the healing rate between both the groups, although statistically significant, carries no clinical significance due to the small sample size.

Keywords: argon laser, corneal ulcers, fluorescein, riboflavin


How to cite this article:
Wagdy FM, Sarahan AR, Atta GM, Abdel Aziz MS. Riboflavin and fluorescein stain before argon laser in the treatment of resistant corneal ulcer. Menoufia Med J 2020;33:1167-70

How to cite this URL:
Wagdy FM, Sarahan AR, Atta GM, Abdel Aziz MS. Riboflavin and fluorescein stain before argon laser in the treatment of resistant corneal ulcer. Menoufia Med J [serial online] 2020 [cited 2021 Apr 19];33:1167-70. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1167/304511




  Introduction Top


Resistant corneal ulcer is a deep ulcer that heals poorly, and cannot respond to its specific medical treatment after 3 days to 1 week of continuous treatment and tends to recur[1]. Management of infective keratitis requires proper clinical diagnosis, laboratory investigation, timely initiation of antimicrobial therapy, initial treatment modification according to laboratory results, and when to terminate therapy[2],[3]. Argon lasers produce a coherent, focused, monochromatic, high-energy form of light. The wavelength of light emitted by the laser and the time sequence for delivery are important determining factors that obviously control the effect of laser light on the eye tissue. Argon laser produces thermal damage of the cell through heating, denaturation, and coagulation of its proteins[4],[5]. Argon laser causes heating and denaturation that lead to cell death and coagulation. Argon laser may have a fungicidal action because of the thermal effect on the infected tissue. It can be absorbed by fluorescein dye when staining the corneal epithelial defect producing its thermal damaging effect. Overheating of corneal tissues causes suppression of cellular enzymes (40–45°C), damage of the cellular proteins (above 60°C), and damage of DNA (above 70°C). Overheating damage affects both the host tissue and the organism itself. It has been reported that the temperature in the corneal tissue rises over 90° due to argon laser[6],[7],[8]. Riboflavin ophthalmic is also used together with ultraviolet light as part of a procedure called corneal collagen cross-linking[9]. Fluorescein stain is the most efficient, objective, noninvasive, and directly visible means for identifying and tracking ocular structures at the cellular level. They particularly are useful as both diagnostic modalities and as therapeutic adjutants in the anterior and posterior segment disorders[10]. The aim of this study is to evaluate the effectiveness and safety of argon laser in resistant corneal ulcers using fluorescein stain or riboflavin.


  Patients and Methods Top


This study was a prospective, interventional case series. Patients were recruited from the Eye Outpatient Department at Menoufia University Hospital, Egypt. The study protocol was approved by the Ethics Committee of Menoufia Medical School. The study protocol was explained to the patients and all patients provided a written informed consent. The study was performed in the Ophthalmology Department of Menoufia University Hospital, Egypt. The study included 40 patients. Inclusion criteria: cases with corneal ulcers resistant to medical treatment after 3 weeks of continuous specific treatment.

Exclusion criteria

Corneal thinning, Systemic disease, or Uncooperative patient.

Preprocedural assessment

Patients are selected randomly from those coming to Menoufia University Outpatient Ophthalmology Clinic. All participants in this study were subjected to the following: a full medical history was taken (present and past). A comprehensive ophthalmic examination by using slit-lamp biomicroscope with documentation of the full description of the ulcer (location, severity, and size of the stromal infiltrate) was recorded. Ulcer margin, floor, thinning, satellite lesions, pigmentation on the ulcer surface, and any impacted foreign body was noted. The presence of hypopyon was recorded and its height was measured in millimeters. Best-corrected visual acuity testing was also done.

Procedure

Before laser treatment, the eye was medicated with benoxinate hydrochloride 0.4% and a single drop of fluorescein sodium 0.25% in one group and riboflavin 0.1% (MedioCross M) in the second group were administered. Argon laser irradiation of the affected cornea was performed using argon blue-green wavelength (Carl Zeiss Meditec AG. 07740, Jena, Germany). A spot size of 500 μm, pulse duration of 0.2 s, and power up to 900 mW were used.

Postprocedural follow-ups

Recording data from four follow-up visits within 4 months after the procedure and after first, second, third, and fourth months. Follow-up assessment was included the following: assessment of symptoms (pain, photophobia, lacrimation, redness, vision) asking if there is improvement or not. Slit-lamp biomicroscopic examination for detection of healing signs: stromal reaction, stromal infiltrates (density and size), hypopyon and if decreased or not, stromal edema or vascularization, best-corrected visual acuity, and photographic documentation of the ulcer.

Statistical analysis

Demographic data, preprocedural data, rates of success, failure, and complications were statistically analyzed. Data were fed to the computer and analyzed using International Business Machines Corporation (IBM) SPSS software package, version 20.0.(IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percentage. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Significance of the obtained results was judged at the 5% level.


  Results Top


In all, 40 cases of corneal ulcers were included in this study after performing full clinical and laboratory workup; results can be presented as follows.

The age ranged from 10 to 74 years, with a mean age of 42 years. Sex distribution showed that 25 (62.5%) cases were men while 15 (37.5%) cases were women.

The socioeconomic state of the studied patients was 30 (75%) cases rural, while 10 (25%) cases were urban.

The occupational state of the cases was as follows: 16 (40%) cases were farmers. There were 24 (60%) cases of students, housewives, employers, and workers.

Risk factors were present in 37 (85%) of cases and we had three (15%) cases with no definite risk factors. It was found that ocular trauma (mainly of plant origin, foreign body, or insect) was the most frequent risk factor as it occurred in 20 (50%) cases, followed by contact lens (CL) wearers in seven (17.5%) cases, five cases with cosmetic CL of teenaged women and three cases with refractive CL. Diabetic patients were seven (17.5%) cases.

Healing was achieved in the riboflavin 0.1% stained group after the first month in about 11 (55%) cases, about three (15%) cases after the second month, three (15%) cases after about the third month and in three (15%) cases after the fourth month of follow up. Three cases did not improve after laser therapy [Table 1] and [Figure 1], [Figure 2], [Figure 3].
Table 1: Percentage and duration of healing of resistant corneal ulcers in the riboflavin stained and the fluorescein sodium 0.25% stained groups

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Figure 1: Resistant corneal ulcer stained with fluorescein.

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Figure 2: Resistant corneal ulcer stained with riboflavin before laser application.

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Figure 3: Number of cases and duration of healing of resistant corneal ulcers in both groups.

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At the time of first presentation of riboflavin 0.1% stained group, visual acuity in 18 cases ranged from hand motion to 0.2 (decimal system) and there were two cases who achieved 0.7 at the first visit (peripheral viral ulcer). No visual acuity improvement was achieved in eight (40%) cases. Visual acuity improvement was achieved with a gain of one line in six (30%) cases. Visual acuity improvement was achieved with a gain of two lines or more in six (30%) cases [Table 2] and [Figure 4].
Table 2: Visual acuity improvement in both groups

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Figure 4: Visual acuity improvement in both groups.

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Healing was achieved in the fluorescein sodium 0.25% stained group after the first month in about 10 (50%) cases, after about the second month in two (10%) cases, after about the third month in four (20%) cases, and in the fourth month in four (20%) cases [Table 1] and [Figure 3].

At the time of first presentation of the fluorescein sodium 0.25% stained group, visual acuity in all cases ranged from hand motion to 0.1. No visual acuity improvement was achieved in nine (45%) cases. Visual acuity improvement was achieved with a gain of one line in six (30%) cases. Visual acuity improvement was achieved with a gain of two lines or more in five (25%) cases.


  Discussion Top


Corneal ulcer is considered an ophthalmologic emergency, as it is a sight threatening condition. It may be sterile but it is often microbial in origin: bacterial, fungal, viral, or parasitic[11]. A new technique with the use of argon laser irradiation of refractory infective keratitis has proved beneficial in the treatment. Fromer and L'Esperance reported the treatment of pseudomonas keratitis in rabbit corneas by using argon laser in 1971.

When we compared the results of riboflavin 0.1% stained group and fluorescein sodium 0.25% stained group we found that complete healing was achieved in 85% of cases in riboflavin 0.1% stained group before argon laser in a period ranging from 1 to 4 months without the need for other adjunctive procedures. In the fluorescein sodium 0.25% stained group, healing was achieved in l6 (80%) cases in a period ranging from 1 to 4 months with a significant P value of 0.006 when the results of both groups were compared using the χ2 test.

As regards visual acuity results, improvement was achieved in 60% of cases 12 cases with one or more line gain (decimal system) and eight (40%) cases did not show visual acuity improvement in the riboflavin-stained group. This was in agreement with the Thomas P et al.[12] study in which 45% of cases treated with argon laser did not show any improvement. In the fluorescein sodium 0.25% stained group, only 11 (55%) cases showed improvement with one or more line gain. Also, a significant P value of 0.014 was obtained when the visual acuity results were compared by using a χ2 test[13]. This was in agreement with a study carried out by Khater et al.[14] that investigated the use of argon laser as an adjunctive treatment in 20 cases of resistant corneal ulcers using the same parameters. Also Pellegrino and Carrasco[15] found that a power of 900 mW was able to induce scars in the posterior stroma of pig corneas. Two signs were observed during the procedure: blanching of the corneal stroma and small cavitations that may have reached the middle stroma. Also, Khater et al.[14] reported these signs in their study. The same results were found in a case study carried out by Pellegrino and Carrasco[15], on two eyes with fungal keratitis.


  Conclusion Top


Argon laser treatment seems to be an effective adjuvant method for dealing with resistant corneal ulcers. Before argon laser application, stain the cornea with fluorescein sodium 0.25% or riboflavin 0.1% in which riboflavin 0.1% stained have shown good result than fluorescein.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sun S, Lui Q, Han L, Ma Q, He S, Li X, et al. Identification and characterization of Fusarium proliferatum, a new species of fungi that cause fungal keratitis. Sci Rep 2018; 8:4859.  Back to cited text no. 1
    
2.
Ou JJ, Acharya NR. Epidemiology and treatment of fungal corneal ulcers. Int Ophthalmol Clin 2007; 47:7–16.  Back to cited text no. 2
    
3.
Jones DB. Decision-making in the management of microbial keratitis. Ophthalmology 1981; 88:814–820.  Back to cited text no. 3
    
4.
Sandinha T, Zaher S, Roberts F, Devlin H, Dhillon B, Ramaesh K. Superior forniceal conjunctival advancement pedicles (SFCAP) in the management of acute and impending corneal perforations. Eye 2006; 20:84–89.  Back to cited text no. 4
    
5.
Saad-Hussein A, El-Mofty H, Hassanien M. Climate change and predicted trend of fungal keratitis in Egypt. East Mediterr Health J 2011; 17:468–473.  Back to cited text no. 5
    
6.
Krauss JM, Puliafito CA, Steinert RF. Laser interactions with the cornea. Surv Ophthalmol 1986; 31:37–53.  Back to cited text no. 6
    
7.
Loh AR, Hong K, Lee S, Mannis M, Acharya NR. Practice patterns in the management of fungal corneal ulcers. Cornea 2009; 28:856–859.  Back to cited text no. 7
    
8.
Nishida T, Saika S. Fundamentals of cornea and external disease. St Louis: Cornea Mosby-Year Book Inc.; 1997:3–26.  Back to cited text no. 8
    
9.
Kim J. The use of vital dyes in corneal disease. Curr Opin Ophthalmol 2000; 11:241–247.  Back to cited text no. 9
    
10.
Gordon YJ, Mann RK, Mah TS, Gorin MB. Fluorescein-potentiated argon laser therapy improves symptoms and appearance of corneal neovascularization. Cornea 2002; 21:770–773.  Back to cited text no. 10
    
11.
Khater MM, Selima AA, El-Shorbagy MS. Role of argon laser as an adjunctive therapy for treatment of resistant infected corneal ulcers. Clin Ophthalmol 2014; 8:1025.  Back to cited text no. 11
    
12.
Thomas P. Tropical ophthalmomycoses. In: Seal D, Pleyer U, eds. Ocular infection, 2nd ed. New York: Informa Healthcare; 2007. 271–305.  Back to cited text no. 12
    
13.
Fromer C, L'Esperance F. Argon laser phototherapy of pseudomonas corneal ulcers. Investig Ophthalmol Vis Sci 1971; 10:1–8.  Back to cited text no. 13
    
14.
Khater MM, El-Shorbagy MS, Selima AA. Argon laser photocoagulation versus intrastromal voriconazole injection in treatment of mycotic keratitis. Int J Ophthalmol 2016; 9:225.  Back to cited text no. 14
    
15.
Pellegrino F, Carrasco MA. Argon laser phototherapy in the treatment of refractory fungal keratitis. Cornea 2013; 32:95–97.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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