Jurnal English Jhuvan
Jurnal English Jhuvan
Jurnal English Jhuvan
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ABSTRACT
Introduction : Adjuvant Treatment : treatment that is given in addition to primary
(initial) treatment, is an addition designed to help reach the ultimate goal. The goal
in corneal ulcer cases is to improve visual acuity, anatomical (epithelial healing)
outcomes and to reduce complications. the treatment usually use for non healing /
refractory corneal ulcers depend on the facilitation and type of the ulcers, some
adjuvant treatment common use daily for corneal ulcer not wait until the term of
non healing corneal ulcer.
Purpose : To report some adjuvant treatment for corneal ulcer
Method : Theoretical and clinical appearance for corneal ulcer management
Result : Adjuvant treatment for corneal ulcer can divided in 4 groups
1. Medical Treatment: 1. Povidone Iodine (PVI), 2. topical coenzyme Q 10, 3.
collagenase inhibitor, 4. platelet-rich plasma, 5. topical corticosteroids, 6. other:
cycloplegic, anti glaucoma medicine , analgesics, and supplement. 2. Non Invasive
Treatment: 1. tissue adhesive: cayanoacrylate glue, fibrin glue, 2. hyperbaric
oxygen therapy, 3. corneal cross linking (CXL), 4. Cryotheraphy, 5. bandage
contact lense. 3. Surgical Treatment: 1. debridement/ remove necrotic tissue, 2.
conjunctival Flap, 3. anterior chamber parasentese , 4. amnion membran
transplantation, 5. Keratoplasty. 4. Radiotherapy.
Conclusion: the adjuvant treatment is not fixed , depends on facilitation , type of
corneal ulcer, patient and surgeon. devided on 4 groups and we can combine some
adjuvant treatment depends on indication, and clinical manifestation of ulcer, and
can reappearance if necessary.
Keywords: adjuvant hyperbaric, corneal cross Linking (CXL), cryotheapy,
keratoplasty
Introduction :
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Methods
A. Medical Treatment
1. Povidone Iodine (PVI)
Broad-spectrum micro biocidal effect against bacteria, virus, parasites
and fungi. Solution 1%, 5%, is strong oxidizing agent that inhibits cell
growth and destabilize membrane integrity of host cells and can use every
day for spooling/cleaning the ulcer. Single application of 5% PVI drop did
not reduce bacterial load, must be continue spooling every day or about two
days. The poor effect is deep penetration into the deep corneal stromal , and
more than 5% PVI, is corneal toxic.
3. Collagenase Inhibitors
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4. Platelet-Rich Plasma
Human serum contains collagenase inhibitors, the clinical impression
that autologous serum can sometimes arrest ulceration, because contain
human α1 antitrypsin (α1-at) and human α2 -microglobin (α2-m) to prevent
ulceration. PRP rich in growth factors, neurotrophin, neuropeptides, nerve
growth factor (NGF) substance P (SP), and thymosin beta-4, platelet-
derived growth factors (PDGF), TGF,VEGF,EGF, insulin - like growth
factors IGF, α2-macroglobin (α2-m) directly injected into the stromal
cornea can prevent ulceration compare to topical use.
5. Topical Corticosteroids
Role of topical corticosteroids eye drops for bacterial corneal ulcers is
controversial, and are not recommended in any case of fungal; if steroids
are used it should be with great caution and close observation. Topical
chorticosteroids are known to inhibit neutrophil chemo taxis and believe to
reduce collagenase and cytokine burden that leads first to ulceration, and
then to inhibit neovascularization and scaring.
Delayed epithelial healing and neutrophil inhibition may exacerbate the
infection, particularly if the inadequate antibiotics. Pseudomonas corneal
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6. Other Medicine
Cycloplegic
Anti glaucoma medication
Analgesics
Supplements
4. Cryotherapy
Cryotherapy produces a stimulus causes a sudden decrease local tissue
temperature and metabolism, which results bacterial death and may activate
an immune response. cell death is not only dependent on the level of
cooling, also the rate of warming, the osmotic environment, duration of time
held at low temperature, and the growth phase of the organism have all been
shown to be critically important in determining cell survival after freezing.
For experimental, -790 for six seconds applied directly in infected
cornea, 99.9% reduction in bacteria, and endothelial death by six hours,
stromal death by ten hours, use probes cooled with CO or a fluorinated
refrigerant (Freon).
Cryotherapy (Ø 4mm) to central corneal, cause corneal thickness
increased and returned to normal after 10-12 days, cause by abnormality of
the intercellular junctions, and descement membrane was recovered by
endothelium after 3 days. Temperature of - 80oC for 2-3 seconds, by
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C. Surgical Treatment
1. Debridement / Removal of Necrotic Tissue
Removal necrotic or maceration of corneal tissue with sterile cotton
is used full for corneal scraping, decrease microorganism colony, to easy
passage eye drops, to decrease conjunctivalization, to promote corneal,
epithelialization, to relieve corneal pain. remove secrete and waste product
and washing with povidone iodine 3% solution, and sterile water. Serious
complications: corneal perforation, bleeding and when suspect foreign body
in ulcer.
2. Conjunctival Flaps
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5. Keratoplasty
Penetrating Kkeratoplasty (PK) has been the gold standard for
rehabilitating cornea transparency cause by infaction, degeneration, or
dystrophy. PK has much problems: astigmatism related to multiple sutures,
endothelial rejection, and poor log term graft survival. PK is usually used for
impending or for perforation corneal ulcer.
Intraoperative risk: poor graft centration, suprachordial hemorrhage,
infection, damage to surounding ocular structures can occur.
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D. Radiotherapy
1. Radiation treatment for Non-Neoplastic Disease:
The relieve symptoms, particularly pain
To promote healing, by resololution of inflammatory process,
absorption hemorrhages, to epithelialization ulcerated surface,
organization and removal of granulation tissue
To affect blood vessels: to reduce blood vascular engorgement
and congestion by inflammation, to obliterate or reduce in size
newly vessels invading the cornea
To reduce intra-ocular tension
To restore function of the cornea
2. The used Radiotherapy in Ophtalmology: Inflammatory Processes:
Pyogenic: Blepharitis
Granulomatous: Tuberculosis, Sarcoidosis
Allergic: Vernal Catharr, Phlyctenic Kerato-Conjunctivitis
Viruses: Superficial Punctate keratitis, Post Herpetic Pain,
Dendritic Ulcer, Diform Keratitis. Trachoma
Unknown Etiology: Rosacea Keratitis, Marginal Ulcerative
Keratitis.
3. Miscellaneous
Corneal lesions: Ulcers (including Mooren’s), Opacities
following infection or trauma. Dystrophies and degenerations
(including Pterygium). Traumatic lesions and recurrent erosions.
Epithelial Downgrowths
Vascular Anormalities: Corneal Vascularization (particularly
after grafting), Eale’s Disease. Retinal Hemorrhage. Venous
Thrombosis
Raised intra-ocular Tension , Secondary Glaucoma
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Conclusion
Adjuvant Treatment are treatment that is given in addition to primary
(initial) treatment, is an addition designed to help reach the ultimate goal. The goal
in corneal ulcer cases is to improve visual acuity, anatomical (epithelial healing)
outcomes and to reduce complications. The adjuvant treatment is not fixedp,
depends on facilitation , type of corneal ulcer, patient and surgeon. devided on 4
groups and we can combine some adjuvant treatment depends on indication, and
clinical manifestation of ulcer, and can reappearance if necessary.