Transcript Taking the mystery out of abnormal pupils

Topical Application of Autologous Platelet-Rich Plasma
for Acute Ocular Chemical Burn
Mohit Jain MD, Anita Panda MD, Murugesan Vanathi MD,
Sudarshan Khokhar MD, Tanuj Dada MD
Dr Rajendra Prasad Centre for Ophthalmic Sciences
All India Institute of Medical Sciences, New Delhi, India
The authors have no financial interest in the subject matter of this poster
Introduction
Biological agents like autologous serum, umbilical cord serum have
been used for restoration of ocular surface and control of
inflammatory process owing to presence of significant
concentrations of growth factors 1,2
Autologus PRP contain 5 t0 6 times higher concentration of growth
factors 3 which are constantly released from α granules present in
platelets
Before activation Topical PRP is used in
Contains 3- 4 times more
platelets
ocular surface disorder
following LASIK, dry eye
and dormant corneal
ulcers1,2,3,4,5
Platelets remain viable for
3-4 days
Starts coagulation process
and provides fibrin scaffold
Has a lubricating property
After activation
Clinically used among
musculoskeletal
physicians, orthopedic
surgeons, maxillofacial
and plastic surgeons and
dermatologists
Aim of the study
Comparative evaluation of topical autologous PRP given along with
standard medical treatment with standard medical treatment alone in
acute ocular chemical burns
Materials and methods
Randomized prospective comparative double blind case control study
The study population was recruited from a university-based cornea clinic
and ophthalmology emergency department
Institutional Ethical Committee approval was sought and written
informed consent was taken from participants
Inclusion criteria:
Patients with grade III, IV & V ocular chemical injury
Patients presenting within 3 days of injury
Exclusion criteria:
Patients with impending perforation /perforated cornea
Materials and Methods
20 eyes were randomly assigned
Group 1 (10 eyes) – Received Autologous PRP with standard medical
treatment6
Group 2 (10 eyes) – Received standard medical treatment
All participants underwent comprehensive history taking and
ophthalmologic examination, including best corrected visual acuity
(BCVA), cornea clarity grading , size and area of epithelial
defect(product of two maximum linear dimensions perpendicular to
each other), extent of limbal ischemia, grading of chemical injury
according to Dua classification7, clinical photograph (CP) with and
without fluorescein stain, tear film status evaluation, intraocular
pressure (IOP)
Autologous
PRP was prepared under aseptic precautions and stored at
5
4°C
Follow up was done on day 3, 7, 14, 21 and month 1, 2 and 3
Chi square test for categorical variables and Mann-Whitney tests far
quantitative variables were applied for statistical analysis
Table 1: Demographic data of Participants
AGE(years)*
31.5
39.6
0.12
DURATION BETWEEM EXPOSURE
AND RPC TREATMENT (days)*
2.2
2.1
0.8
CORNEA CLARITY#
2.7
2.4
0.624
LARGEST EPITHELIAL DEFECT
DIMENSION(mm) #
7.65
6.44
0.435
EPITHELIAL DEFECT AREA(mm2) #
54.31
42.06
0.37
LIMBAL ISCHEMIA(clock hours)#
6.8
6.5
0.96
BCVA(log MAR)#
1.06
1.09
0.73
* Independent t test
# Wilcoxon rank-sum (Mann-Whitney) test
No. of participants
P-VALUE
(Mean)
Group 2
(Mean)
Group 1
Graph 1 Nature of chemical
Table 2: Mean epithelial defect diameter (EDD) resolution
D0
D3
D7
D14
D21
M1
M2
M3
Group
1*
7.65±2.29,
7.7(4.5-11)
4.80±2.82,
3.35(1.8-10)
2.69±3.15,
1.4(0.0-8.5)
1.16±1.31,
0.65(0-3.30)
0.53±0.72,
0(0-1.8)
0.34±0.53,0
(0-1.4)
0.08±0.17,0(
0-0.5)
0.0±0
.0
Group
2*
6.44±3.58,
6.25(1.311)
5.25±3.39,
4.15(1.810.5)
5.06±3.64,
3.65(2.5-11)
3.98±3.69,
2.8(0-10.7)
2.98±4.02,
1.5(0-10.8)
1.85±3.53,0
(0-9.8)
0.90±1.91,0
(0- 0.5)
0.0±0
.0
P value
0.44
0.79
0.05
0.03
0.04
0.7
0.82
1
*EDD - Mean±SD, median(range) (mm)
Graph 2: Mean EDD
Mean EDD (mm)
%age decrease in EDD
Graph 3: % decrease in EDD
Time →
Time →
Table 3: Mean epithelial defect area (EDA) progression
D0
D3
D7
D14
D21
M1
M2
M3
Group
1*
54.31±33.21,
51.97(14.40107.08)
25.79±31.74
,8.04(1.2688)
13.79±24.83
,7(0-64.60)
1.69±2.67,
0.21(0-6.93)
0.28±0.41,
0(0-1`.26)
0.09±0.16,
0(0-0.42)
0.21±0.4
,0(00.15)
0-0(0-0)
Group
2*
42.06±44.53,
25.55(.56112)
32.63±39.31
,13.52(1.62100)
35.53±45.16
13.78(5.25111.60)
23.79±39.43,5.
6(0-100.58)
20.82±41.2
3,1.43(0104.76)
13.05±29.
04,0(086.24)
0.08±170
(0-0.50)
0-0(0-0)
P value
0.3
0.8
.02
.02
.01
0.69
0.82
EDA - Mean±SD, median(range) (mm2)
Mean EDA mm2
Graph 4: Mean EDA
Time →
The mean time to complete epithelialisation
was 40±31.57 ,25.5 (7 to 90)days and
47 ±26.15,30.0( 21 to 90) days,
in group 1 and group 2 respectively . The
difference was not statistically significant.
(p=0.29)
For grade 3 injuries mean time to complete
epithelialisation was significantly less
14 ± 7 ,14(7 to 21)days in group 1 compared
to and 28.5 ±3.67,28.5(21 to 30)days in
group 2. p value(0.006)
Table 4: Cornea clarity at presentation
Table 5: Cornea clarity at 3 months
Cornea
clarity
Group 1
Group 2
Total
Cornea
clarity
Group 1
Group 2
Total
1
1
2
3
1
1
4
5
2
4
4
08
2
1
3
4
3
4
4
08
3
3
1
4
4
1
0
1
4
5
2
7
Total
10
10
20
Total
10
10
20
p value 0.625
p value 0.048
At 3 months, 5 out of 10(50 %) patients had corneal clarity of grade 4 in group 1 as compared to 2
out of 10 (20 %) in group 2. The difference was statistically significant. (p- value 0.04)
Table 6: BCVA
BCVA at presentation
BCVA at 3 months
% improvement in BCVA
Group 1
1.06 ±18,1.0(.70-1.30)
0.66 ± .60,40(0.2-2.0)
33.64 ± 55.75,55.49(-80 to 100)
Group 2
1.09 ± 20,1.0(.70-1.30)
0.93 ± 0.35,0.85(0.30-1.30)
37.74 ± 9.66,36.70(-20 to 50)
p
0.73
0.07
.082
[Mean±SD, median (range)]
Table 7: Complications
Group 2
Complications
Group 1
Increased intraocular pressure
3
4
0.9
Infiltrate
1
1
1
perforation
0
0
0
symblepheron
3
5
0.65
Entropion and ectropion
2
2
1
* Fisher exact test
P value*
GROUP 1
GROUP 2
DAY 0
DAY 7
DAY 14
MONTH 1
MONTH
2 and 3
Conclusions
Addition of topical autologous PRP to standard treatment
protocol helps in rapid re-epithelialisation of ocular
surface and achieve better corneal clarity
There is a trend towards achieving better BCVA with
addition of topical autologous PRP at 3 months (though
not statistically significant)
We recommend use of topical autologous PRP therapy
along with standard medical treatment in cases of ocular
chemical injuries of grade3 , grade4 and grade5
Studies with larger sample size and longer follow up
periods are required
References
1. Poon AC et al. Autologous serum eyedrops for dry eyes and epithelial defects: clinical and
in vitro toxicity studies. Br J Ophthalmol. 2001 Oct; 85(10): 1188-97
2. Singh G et al. Epidermal growth factor in alkali burned corneal epithelial wound healing.
Am J Ophthalmol. 1987 June; 103(6): 802-7
3. Alio JL et al. A Symptomatic dry eye treatment with autologous platelet-rich plasma.
Ophthalmic Res. 2007 Mar; 39(3): 124-9
4. Alio JL et al. Use of autologous platelet-rich plasma in the treatment of dormant corneal
ulcers. Ophthalmology. 2007 Jul; 114(7): 1286-1293
5. Alio JL et al. Treatment of ocular surface syndrome after LASIK with autologous plateletrich plasma. J Refract Surg. 2007 Jun; 23(6): 617-9
6. Brodovsky SC et al. Management of alkali burns: 11 year retrospective review.
Ophthalmology. 2000 Oct; 107(10): 1829-35
7. Dua HS et al. A new classification of ocular surface burns. Br J Ophthalmol. 2001 Nov;
85(11): 1379-83
Acknowledgements
Dr. T. Velpandian Associate Professor, Dept. of Ocular Pharmacology,AIIMS
Mr. Pankaj Gupta Dept. of Ocular Pharmacology,AIIMS
Dr. Manik Goel, MD
Dr. Amit Sobti, MD
Dr .Twinkle Parmar, MD