READY TO USE TOPICAL INSULIN FOR A CASE OF REFRACTORY PERSISTENT EPITHELIAL DEFECT AFTER OCULAR SURGERY

To report the case of a patient with a central persistent epithelial defect (PED) after ocular surgery, refractory to standard medical therapy, treated safely and successfully with topical insulin.

Department of Ophthalmology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.

A 78-year-old man presented at the ophthalmology outpatient clinic with blurred vision in the left eye (LE) for two weeks. He reported no ocular discomfort or pain. The patient had a history of an uneventful cataract surgery in the LE one month prior and was under topical antibiotic, non-steroid anti-inflammatory, and corticosteroid therapy. LE best-corrected visual acuity was counting fingers and intraocular pressure was normal. Biomicroscopy of the LE revealed an asymptomatic 5 × 5 mm central epithelial defect with ulceration. Treatment with intensive lubrication, prophylactic topical antibiotic, and a bandage contact lens was initiated, and epitheliotoxic medication was withdrawn. At 2-weeks of follow-up, the patient maintained a central epithelial defect and minimal improvement, despite the optimized medical therapy. A decision was made to initiate off-label ophthalmic insulin eye drops (1IU/mL in a propylene glycol base), applied 4 times daily. Prophylactic topical antibiotic and a bandage contact lens were applied concomitantly. Close follow‐up of the patient was assured with visits every two days in the first week and weekly thereafter. Anterior segment photos were taken in each visit. Central PED resolved 7-days after initiating topical insulin and symptoms improved significantly. Insulin eye drops were slowly tapered, and the bandage contact lens removed, with intact epithelium and no PED recurrence.

Despite the wide range of therapeutic options, PEDs management and treatment often represents a challenge in daily clinical practice. When left untreated or if reepithelization does not occur, severe complications may develop including infection, perforation, and scarring. Topical insulin has been found to aid in corneal wound healing by enhancing proliferation of corneal epithelial cells, being useful in persistant epithelial defects refractory to initial therapy. Additionally, insulin is a relatively inexpensive and widely available drug whose safety has already been established as a topical treatment. In this case report, we demonstrate insulin eye drops therapeutic and cost-effectiveness for refractory PED after ocular surgery treatment in real-world clinical practice.