Skripnik R.L., Tikhonchuk N.A., Greben N.K.

Bogomolets National Medical University, Kyiv, Ukraine

 

Optimization of the treatment of traumatic keratitis

 

First published: Ophthalmology. Eastern Europe. — 2021. — V. 11. — No. 4. — P. 502–507. 

 

Summary. The article presents the results of studies of combined eye drops in the complex therapy of traumatic keratitis. The composition of the eye drops includes dexpanthenol and hypromellose, which have different effects on the structure of corneal regeneration. The inclusion of combined eye drops promotes corneal regeneration and restoration of basic properties, acceleration of lesions epithelialization which allows reducing significantly the development of severe outcomes after injuries.

Keywords: keratitis, foreign bodies, corneal regeneration, combined eye drops.

 

Introduction

In the modern world, eye injuries remain one of the reasons for the decline and loss of visual functions. Eye trauma is one of the most common causes of disabling visual disorders leading to blindness, ranking third after degenerative myopia and glaucoma. The high incidence of eye trauma is explained by the anatomical features of the eyeball and the course of pathological processes. According to many researchers, the consequences of eye injuries account for 1/4 of all cases of patients' referral to an ophthalmic medical and social examination and are the cause of disability in 25.4–58.0% of patients [3; 6; 10; 11]. Analysis of the outcomes of eye injuries indicates that only 54% of patients are discharged from the hospital with visual acuity equal to 1.0; 5% — with light perception with incorrect light projection; in 5.7% of patients, the injured eye is removed. More often, patients of working age are prone to eye injuries (according to the literature, in 70% of cases), which causes not only medical and social but also psychological aspects of the problem [1; 13; 23].

More frequently, the outer parts of the eye are involved in the traumatic process. So, the first obstacle for foreign objects and substances, light, energy, and temperature radiation is the cornea, which is due to its anatomical location. Constantly being in contact with the environment and staying less protected from the effects of external factors than other eye membranes, the cornea is the most vulnerable part of the eyeball and tends more likely to be inclined to various injuries [2; 4; 12; 14].

The severity of the corneal injury and the outcome of recovery are not always interrelated, and even a minor injury to the superficial layers of the cornea does not always have a favorable outcome and can lead to the death of the eyeball, etc. [8; 15].

Among non-penetrating wounds of the cornea, superficial and deep ones are distinguished, as well as with the introduction of foreign bodies (FB) and without the presence of these. It is known that corneal foreign bodies can be single and multiple, superficial and occurring at different depths in the thickness of the cornea, of various sizes. The nature of damage during the impregnation of foreign bodies can largely depend on the properties of the damaging agent — fragments of metal, glass, ceramics, wood, particles of sand, or gunpowder.

With the introduction of metallic foreign bodies, not only mechanical destruction of corneal areas occurs but also starts necrosis of the tissue zone damaged by metal oxides, which leads to a slowdown in the processes of epithelialization and tissue regeneration.

Untimely, for several reasons, removal of FB from the surface of the cornea can lead to a pathological process, which is accompanied by the development of inflammation in the layers of the cornea [8; 17; 19].

The literature describes a variety of pathogenetic reactions to the introduction of FB, expressed in different forms and with different strengths. In some cases, an almost non-reactive tissue behavior is observed in response to the introduction of a foreign body. As a rule, the pathogenesis of corneal damage during the introduction of FB begins with tissue alteration and exudative phase with symptoms of edema followed by demarcating suppuration with tissue melting. Less often, even in the early stages, there is a picture of proliferative phenomena, accompanied by perifocal edema [2; 9; 16; 18; 22].

The nature of the development of the pathological process in response to the ingress of a foreign body is determined by chemical activity, the size, and shape of the fragment, local tissue reactivity of the eye, as well as the general state of the body. A rather pronounced inflammatory reaction is caused by organic foreign bodies, for example, wood particles, a bee sting, a spikelet [9; 10; 20].

In cases of infected foreign bodies, untimely treatment, there is a high probability of progression of the pathological process in the cornea and the transition to the deep-lying parts of the eyeball [7; 10; 24].

A significant role in the outcome of eye trauma is assigned to the level and timing of specialized care. It has been established that when a foreign body is introduced into the cornea, the therapeutic tactics are determined depending on the size of the fragment, its physicochemical properties, localization of the depth of occurrence, as well as the time from the moment of injury [21; 25]. Restoration of the integrity and functional activity of the cornea damage in the process of regeneration is one of the conditions for maintaining its optical properties, given that even minor damage to the cornea can lead to persistent opacities of varying severity from a barely noticeable cloudy to total leucorrhoea and cause a decrease in visual functions. Therefore, the search for drugs to improve epithelialization and reduce post-traumatic corneal opacities is of great importance.

Of interest are combined drugs, in which the components potentiate each other, thereby enhancing the reparative effect. One of these drugs is “Keratostil” — eye drops produced by “Bruschettini S. p. L.”, Italy, containing dexpanthenol 5% (D-panthenol) and hydroxypropyl methylcellulose 0.3% (hypromellose).

Dexpanthenol is widely used in ophthalmic practice. It is a synthetic analogue of pantothenic acid, has similar biological activity, but is better resorbed when applied topically. Pantothenic acid is a water-soluble B vitamin that participates in various metabolic processes in the form of coenzyme A.

Dexpanthenol participates in the processes of acetylation, carbohydrate and fat metabolism, in the synthesis of acetylcholine, corticosteroids, porphyrins. It stimulates the regeneration of the skin, mucous membranes, normalizes cell metabolism, accelerates mitosis, and increases the strength of collagen fibers; has a weak anti-inflammatory effect [4; 5].

Preparations containing hydroxypropyl methylcellulose (hypromellose) are used in ophthalmology. Thus, hypromellose is a water-soluble derivative of a natural polymer of cellulose. This substance protects the corneal epithelium, provides a lubricating and softening effect, has a high viscosity, which increases the duration of contact of the solution with the cornea, restores, stabilizes, reproduces the optical characteristics of the tear film, promotes epithelialization, reduces hyperemia and the size of lesions. Hypromellose affects the bioavailability of the drug, although it does not itself have a characteristic pharmacological action. The refractive index of the solution is similar to natural tears [5; 9].

With a combination of these substances, hypromellose increases the duration of contact of dexpanthenol with the cornea, thereby prolonging its action, forms a gel of high purity in a minimum concentration on the cornea, creating, in a way, an artificial contact lens.

As a preservative, the drug contains 0.1% cetrimide, an antiseptic used to cleanse the skin and wounds, sterilize surgical instruments and baby diapers. It is one of the safest preservatives in ophthalmology, which are used in ophthalmic medicines to maintain the stability of the active substance of the drug, its pH, and prevent the development of microflora with prolonged use.

 

Purpose of the study

Improving the treatment of traumatic keratitis, optimizing regeneration, and reducing post-traumatic corneal opacities.

 

Materials and methods

We examined 34 patients (34 eyes) aged from 21 to 62 years with diagnosed traumatic keratitis caused by the ingress of a foreign body, of varying severity.

By the nature of the damaging agent, in 21 patients the injury was caused by a metal foreign body, in 7 patients — by a tree branch, 3 people noted the ingress of sand particles into the eye, a midge got into the eye of 2 patients, and a piece of ceramic tile — in 1 patient.

The degree of occurrence of foreign bodies was also different. So, metal bodies lay deeper and were localized at the border of the epithelium and the anterior border membrane, sand particles, midges, and a piece of ceramic tiles were limited to the corneal epithelium.

Depending on the etiology, in 14 patients the injury was industrial, in 20 people the injury happened in everyday life.

The seasonality of injuries was dominated by summer — 16 people, spring — 8 patients, autumn — 6 patients, and 4 people were injured in winter.

18 patients applied for specialized medical care on the first day, 9 people — on days 2–3, 7 patients — after more than 4 days.

Injection of the vessels of the eyeball was assessed on a point scale, where 0 points — no injection, 1 point — mild, 2 points — moderately expressed, 3 points — pronounced.

Data on the localization of foreign bodies are presented in table 1.

 

Table 1

Dynamics of visual acuity in patients with traumatic corneal injuries

(before and after treatment)

Groups	Damage location	Visual acuity					Number of eyes
		0,06–0,1	0,2–0,4	0,5–0,7	0,8–0,9	1,0
Main	Optical	2/–	4/–	3/–	3/5	–/7	12
	Para-optic	–/–	–/–	2/–	5/1	3/9	10
Control	Optical	1/–	2/–	3/–	1/2	–/5	7
	Para-optic	–/–	–/–	1/–	2/1	2/4	5

 

During optical coherence tomography (OCT) of the cornea, all patients showed subepithelial hyperreflectivity in the affected area and hyperreflectivity of the stroma under the affected area.

With differentiation between the affected and healthy areas of the cornea, in 18 patients there was a loss of differentiation of the epithelial layer, in 7 patients — a loss of differentiation of the Bowman's membrane. The thickness of the cornea in the affected area ranged from 827 to 882 microns, the thickness of the infiltrate varied from 126 to 254 microns.

The patients were divided into two groups depending on the method of treatment. The control group — 12 patients (12 eyes) — received the main therapy. It included antiseptic, anti-inflammatory, and trophiс-improving drugs. The main group — 22 patients (22 eyes) — to improve reparative regeneration, was prescribed, in addition to those listed, a drug containing a combination of dexpanthenol with hypromellose, 1 drop 3 times a day.

The condition of the eyes was assessed according to the indicators of visual acuity, the severity of the eyeball injection, biomicroscopy on a slit lamp with staining by sodium fluorescein solution, and according to the data of optical coherence tomography of the cornea.

The criteria for the effectiveness of treatment were: an increase in visual acuity, the timing of the disappearance of the injection of the eyeball, epithelialization of the cornea, the presence of residual opacities, restoration of corneal layers according to OCT data, and a decrease in the duration of treatment.

 

Results and discussion

In 20 (58.8%) patients, there was a complete restoration of visual functions with suppression of inflammatory reactions and restoration of corneal transparency against the background of conservative therapy. According to OCT data, the corneal defect was filled with hyporeflective epithelium, the presence of a hyperreflective underlying stroma, and a demarcation line between the restored and healthy stroma. In the presence of infiltrates in 12 patients as a result of the prolonged presence of a foreign body in the cornea, the process ended in the formation of opacities in the subepithelial layers in all cases. According to OCT data, an uneven hyporeflective epithelium and a homogeneous hyperreflective stroma were observed. This influenced functional outcomes and the choice of further treatment tactics (Table 2).

 

Table 2

The results of complex treatment of patients with traumatic corneal injuries

Patient groups	Number of eyes	Clinical parameters (day)
		End of corneal epithelization	Residual opacities	Average duration of treatment
Main	22	4,3±0,1	6,2±0,1	5,3±0,1
Control	12	5,9±0,1	8,3±0,2	8,2±0,2

 

 

Conclusions

The medicine “Keratostil”, containing a combination of 5% dexpanthenol with 0.3% hypromellose, improves the clinical picture, enhances the regeneration of damaged epithelium, prevents the development of corneal edema and gross opacities, which ensures the restoration of the basic properties of the cornea and achieves a clinical effect.

 

 

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