Toxic keratopathy associated with topical abuse of low-concentration anesthetics: A report of two cases
Journal
Indian Journal of Ophthalmology
Journal Volume
68
Journal Issue
5
Pages
903-904
Date Issued
2020
Author(s)
Shen H.-C.
Abstract
Case 1, 69-year-old man complained of stinging pain and progressively blurred vision in both eyes after topical application of artificial tears and oxybuprocaine 0.05% trice per day for 1 month at an eye clinic. He presented with bilateral red eyes with a vision of 20/50 in the right and 20/100 in the left eye. Biomicroscopy revealed pseudodentric epitheliopathy, mild edematous cornea, and Descemet's membrane folds [Fig. 1a-d] in both eyes. Reviewing his history, the actual frequency of oxybuprocaine use was up to every 2 h. Toxic keratitis was suspected and oxybuprocaine was discontinued. Preservative-free artificial tear and autologous serum 20% every 2 h per day were administrated with preservative-free betamethasone 0.1% four times daily. Corneal epithelialization was completed in 1 month. Cornea became clear with the vision of 20/25 in both eyes [Fig. 1e and f]. Case 2, a 66-year-old man had eye pain and was prescribed with artificial tears and oxybuprocaine 0.05%. 3 weeks later, he visited our clinic because of increased pain. Marked punctate keratitis, stromal edema, and linear dendrite presented in both corneas [Fig. 2a-d]. He confessed of using topical oxybuprocaine actually every 2 h. We discontinued oxybuprocaine and treated with the same medications in case 1. 3 weeks later, pseudodendrite and epithelial defect disappeared [Fig. 2e and f]. All four eyes showed a value of less than 5 mm in 5-min Schirmer's test and significant pleomorphism and polymegathism.Figure 1: External eye photography in case 1. Marked conjunctival injection, corneal epithelial defect, corneal edema, and Descemet's membrane folds occurred in both eyes (a and b). Cobalt blue light demonstrated bilateral pseudodendrites with fluorescein staining in both eyes and a nasal-low epithelial defect in the left eye (c and d). Both corneas became clear after treatment with topical steroids and autologous serum (e and f)Figure 2: External eye photography in case 2. Slit-lamp biomicroscopy revealed superficial punctate keratitis and pseudodendrite in the right eye (a) and a 4 × 2 mm epithelial defect in the left eye (b), highlighted with fluorescein staining (c and d). Both corneas became clear after the treatment (e and f)Discussion Topical abuse of lower-concentration anesthetics was rare but may cause pseudodendrites, stromal edema, Descemet's membrane folds, and endothelial cell injury.[123] When patients have bilateral presentations mimicking herpetic keratitis, a physician should take anesthetics abuse into consideration and promptly discontinue it. The steroid can decrease inflammation. Autologous serum-containing several growth factors and substance P can facilitate reepithelialization and neuropathy recovery.[45] Physicians should not prescribe oxybuprocaine 0.05% for long-term use especially in dry-eye patients. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Subjects
Oxybuprocaine; pseudodendrite; topical anesthetic abuse; toxic keratopathy
SDGs
Other Subjects
local anesthetic agent; case report; cornea disease; human; topical drug administration; Administration, Topical; Anesthetics, Local; Corneal Diseases; Humans
Type
short survey