Nonpreserved amniotic membrane transplantation for bilateral toxic keratopathy caused by topical anesthetic abuse: a case report.

Abstract

Corneal damage associated with abuse of topical anesthetics is a rare clinic entity. Topical anesthetic abuse is one of the causes of ring keratitis. Ring keratitis is easily overlooked because it can mimic acanthamoeba keratitis or other infectious keratitis. The outcome is often poor, leading to persistent epithelial defects, corneal scarring, and perforations.
We report the clinical presentation, diagnosis, and treatment of a 65-year-old Caucasian man, who worked as a health care worker, with bilateral toxic keratopathy caused by topical anesthetic abuse. Nonpreserved amniotic membrane transplantation was performed for both eyes of the patient.
It is important to identify and treat patients who abuse topical anesthetics before permanent vision loss ensues. Nonpreserved amniotic membrane transplantation may be useful in relieving pain and improving corneal surface in anesthetic agent abusers.

Full text

Page 1

CASE REPORTOpen Access
Nonpreserved amniotic membrane
transplantation for bilateral toxic keratopathy
caused by topical anesthetic abuse: a case report
Ayse Asyali Altinok*, Melike Balikoglu, Emine Sen, Kurtulus Serdar
Abstract
Introduction: Corneal damage associated with abuse of topical anesthetics is a rare clinic entity. Topical anesthetic
abuse is one of the causes of ring keratitis. Ring keratitis is easily overlooked because it can mimic acanthamoeba
keratitis or other infectious keratitis. The outcome is often poor, leading to persistent epithelial defects, corneal
scarring, and perforations.
Case presentation: We report the clinical presentation, diagnosis, and treatment of a 65-year-old Caucasian man,
who worked as a health care worker, with bilateral toxic keratopathy caused by topical anesthetic abuse.
Nonpreserved amniotic membrane transplantation was performed for both eyes of the patient.
Conclusion: It is important to identify and treat patients who abuse topical anesthetics before permanent vision
loss ensues. Nonpreserved amniotic membrane transplantation may be useful in relieving pain and improving
corneal surface in anesthetic agent abusers.
Introduction
Corneal damage associated with abuse of topical anes-
thetics has been reported by various sources [1-3]. Topi-
cal anesthetic abuse is one of the causes of ring keratitis
[2]. This rare clinic entity is easily overlooked because it
can mimic acanthamoeba keratitis or other infectious
keratitis. The outcome is often poor, leading to persistent
epithelial defects, corneal scarring, and perforations [1-3].
A case of bilateral toxic keratopathy caused by topical
anesthetic abuse that was treated with nonpreserved
amniotic membrane transplantation (NP-AMT) has
been reported. To the best of our knowledge, this is the
first report of NP-AMT use for the treatment of bilat-
eral toxic keratopathy caused by topical anesthetic
abuse.
Case presentation
A 65-year-old Caucasian man, who worked as a health
care worker, was admitted to our hospital with a history
of severe eye pain, redness, and blurred vision in both
eyes. His complaints had started with a mild eye itching
six weeks prior to admission. He had a history of psy-
choactive substance carbamazepine and topical propara-
caine abuse of three years. Our initial ocular
examination showed bilateral intense conjunctival injec-
tion, corneal edema, diffuse corneal vascularization, and
ring shaped stromal infiltration. There were also central
epithelial defects of 3 × 1 mm with mid-stromal ring
infiltrates in the right eye (Figure 1) and 6 × 8 mm with
mid-stromal ring infiltrates in the left eye. Visual acuity
of the right and left eyes was hand motions and finger
counting at a distance of one meter, respectively.
The cultures of corneal scrapings were negative. Propar-
acaine drops were discontinued, and our patient was pre-
scribed preservative-free artificial tear drops and
prophylactic topical antibiotic (ciprofloxacin 0.3%) five
times a day. For his pain, oral indomethacin (75 mg three
times a day) and topical ketorolac tromethamine (0.5%
four drops a day) were added. Psychiatric counseling
revealed psychoactive substance abuse and psychiatric dis-
turbances. Despite medical treatment and conservative
approach, the condition of our patient did not improve.
Then, to achieve rapid epithelization, NP-AMT was
planned for both eyes of our patient, as was previously
described [4]. Initially, NP-AMT was used on the right
* Correspondence: ayse_altinok@yahoo.com.tr
Eye Clinic I, Ulucanlar Eye Education and Research Hospital, Ankara, Turkey
Altinok et al. Journal of Medical Case Reports 2010, 4:262
http://www.jmedicalcasereports.com/content/4/1/262
JOURNAL OF MEDICAL
CASE REPORTS
© 2010 Altinok et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

Page 2

eye. Owing to the pain in the right eye of our patient and
persistent corneal epithelial defect decreased during the
follow-up period, we performed NP-AMT on the left eye
from another donor. At this stage, our patient’s visual
acuity was hand motions in both eyes. Three weeks after
NP-AMT, a rapid regression of the external inflammatory
signs, progressive clearing of the membrane, and a closed
corneal epithelium were noted in the right eye. However,
hypopyon was detected in the left eye (Figure 2). Repeat
cultures of the corneal scrapings were negative. An ultra-
sound of this eye showed no vitreous infiltration. Because
of suspected sterile hypopyon iritis, our patient was admi-
nistered 100 mg hydrocortisone and 2.0 g ceftriaxon intra-
venously. Subsequently, the hypopyon resolved within
three days. In the second week, systemic steroid use was
tapered, and the use of antibiotic eye drops was ended. In
the fifth week, our patient was caught trying to steal a
bottle of proparacaine. The psychiatry clinic was consulted
for further investigation and treatment. Because of poor
compliance our patient was re-hospitalized and kept
under close surveillance.
At two months, our patient had no pain and no
epithelial defects in the right eye (Figure 3). He had
impending corneal perforation in the left eye. The visual
acuity in the right eye was finger counting at a distance
of four meters with residual corneal scarring, and in the
left eye, it was limited to finger counting at a distance of
one meter. Our patient was referred to the eye bank for
penetrating keratoplasty, which was required to treat
corneal perforation in his left eye (Figure 4).
Discussion
Topical anesthetic abuse is a serious disorder, which
involves persistent epithelial defects, corneal stromal
Figure 1 Photograph demonstrating a central epithelial defect
of 3 × 1 mm with mid-stromal ring infiltrates in the right eye.
Figure
transplantation, hypopyon was detected in the left eye.
2
Afternonpreservedamnioticmembrane
Figure 3 In the final examination, the patient had no pain and
no epithelial defect in the right eye.
Figure 4 In the final examination, he had impending corneal
perforation in the left eye.
Altinok et al. Journal of Medical Case Reports 2010, 4:262
http://www.jmedicalcasereports.com/content/4/1/262
Page 2 of 3

Page 3

ring infiltrates, anterior segment inflammation, dispro-
portionate pain, visual loss, and a history of psychoactive
substance abuse [1-3]. Rosenwasser et al. determined
poor visual acuity in six patients [3]. Another study
demonstrated that all topical anesthetics caused a reduc-
tion in the rate of epithelial healing in an animal model
[4]. Management of this disorder depends on the dis-
continuation of the anesthetic agent, which is very diffi-
cult for the patients because of psychoactive substance
abuse. Topical anesthetic abuse occurs mostly in
patients with access to medication, for example nurses
and pharmacists [2,3]. Similarly, our patient was a health
care worker. Since patient compliance to conservative
approaches was poor, we chose to perform NP-AMT in
our patient.
This surgery has been successfully performed many
times at our institution, and no post-operative intra-
ocular inflammation has been encountered to date [5].
Hypopyon occurred rarely after amniotic membrane
transplantation for ocular surface disorders [6]. Most
types of anterior uveitis are sterile inflammatory reac-
tions [7]. A hypopyon was determined in our patient’s
left eye. An ultrasound of this eye showed no vitreous
infiltration. In light of these findings, our patient’s con-
dition was considered to be a case of sterile inflamma-
tion, and additional intravenous steroid use was
preferred. Then, the hypopyon resolved within three
days.
Clinical evidence indicates that amniotic membrane
cells do not express histocompatibility (HLA) antigens
A, B, C, or DR. Although the amniotic membrane pre-
paration, the surgical procedure applied, and the sur-
geon were the same, hypopyon occurred in one eye
after NP-AMT. Contrary to what has been suggested
in the literature [6], we used amniotic membrane from
different donors. This may account for local immuno-
reaction after NP-AMT.
The outcome of topical anesthetic abuse cases is poor
because of continued drug use after keratitis commences
[1,3]. This is because the attending physician may not
suspect drug abuse and/or dishonesty on the part of the
patient. Anesthetic abusers frequently continue to self-
administer anesthetic agents, often covertly, even when
informed of the consequences of their actions. Thus,
long-term anatomical and functional results are very
poor. Despite NP-AMT, in our patient, the right eye
healed with residual corneal scarring, and the left eye
required a penetrating keratoplasty.
Psychiatric consultation is extremely helpful and
should be considered in the management of these
patients. We recommend that the patients be hospita-
lized and treated under close supervision. It is important
to identify and treat patients who abuse topical anes-
thetics before permanent vision loss develops.
Conclusions
It is important to identify and treat patients who abuse
topical anesthetics before permanent vision loss ensues.
In addition, close medical supervision and psychiatric
consultation should be considered. As a final option,
NP-AMT may be considered in relieving pain and
improving corneal surface in resistant anesthetic agent
abusers. However, the efficiency of NP-AMT cannot be
determined based on this single case alone. Further stu-
dies, which will investigate the changes after NP-AMT,
compare its clinical outcomes, and evaluate safety and
efficacy of NP-AMT to treat anesthetic abuse keratopa-
thy, are needed.
Abbreviations
NP-AMT: nonpreserved amniotic membrane transplantation.
Consent
Written informed consent was obtained from the patient for publication of
this case report and any accompanying images. A copy of the written
consent is available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AAA and MB were major contributors in writing the manuscript and
reviewed the patient’s notes. EMS drafted and revised the manuscript
critically for important intellectual content. KS collected the psychiatric data,
observed the patient closely. All the authors read and approved the final
manuscript.
Received: 21 October 2009 Accepted: 10 August 2010
Published: 10 August 2010
References
1.Pharmakakis NM, Katsimpris JM, Melachrinou MP, Koliopoulos JX: Corneal
complications following abuse of topical anesthetics. Eur J Ophthalmol
2002, 12:373-378.
2.Varga JH, Rubinfeld RS, Wolf TC, et al: Topical anesthetic abuse ring
keratitis: report of four cases. Cornea 1997, 16:424-429.
3. Rosenwasser GO, Holland S, Pflugfelder SC, et al: Topical anesthetic abuse.
Ophthalmology 1990, 97:967-972.
4.Smith RB, Everett WG: Physiology and pharmacology of local anesthetic
agents. Int Ophthalmol Clin 1973, 13:35-60.
5.Ucakhan OO, Koklu G, Firat E: Nonpreserved human amniotic membrane
transplantation in acute and chronic chemical eye injuries. Cornea 2002,
21:169-172.
6.Srinivasan R, T SS, Gupta A, Kaliaperumal S: Hypopyon iritis after primary
fresh amniotic membrane transplantation. Cornea 2007, 26:1275-1276.
7.American Academy of Ophthalmology: Clinical approach to uveitis
Intraocular inflammation and uveitis. San Francisco, Leo 2005, 106.
doi:10.1186/1752-1947-4-262
Cite this article as: Altinok et al.: Nonpreserved amniotic membrane
transplantation for bilateral toxic keratopathy caused by topical
anesthetic abuse: a case report. Journal of Medical Case Reports 2010
4:262.
Altinok et al. Journal of Medical Case Reports 2010, 4:262
http://www.jmedicalcasereports.com/content/4/1/262
Page 3 of 3