A patient presents complaining of a sharp ocular pain immediately upon awakening. Examination reveals a fresh corneal defect that stains brightly with sodium fluorescein. Thus begins an ongoing nightmare for both patient and clinician: recurrent corneal erosion (RCE) syndrome.
The good news: A variety of conservative and cutting-edge treatments can help end the nightmare.
We typically think of RCE as a consequence of a poorly healed corneal abrasion, but many RCE cases occur spontaneously. In a retrospective series of 104 RCE patients, only 60% had a history of trauma, and 17% of these had other predisposing factors.1
The most common non-traumatic conditions associated with RCE are the corneal dystrophies: epithelial basement membrane dystrophy (EBMD); Reis-Bcklers dystrophy; stromal dystrophies, particularly lattice and granular dystrophy; and Fuchs endothelial dystrophy.2 Other contributory factors for RCE may include lagophthalmos, bullous keratopathy, keratoconjunctivitis sicca, incisional ocular surgery, LASIK and diabetes.3,4
The underlying pathophysiology of RCE involves a dysfunctional corneal basement membrane, which results in impaired epithelial adhesion. The epithelium regenerates after each attack, but it remains poorly anchored to the underlying stroma and is prone to regular and recurrent sloughing, each time, resulting in painful inflammation.
These recurrences can be quite regular. We recall one patient who experienced RCE episodes coincident with her menstrual cycle.
While diagnosing RCE is fairly straightforward, managing the condition can be quite complex. Treatment should ameliorate pain and inflammation, facilitate re-epithelialization, and prevent secondary corneal infection. These goals are best accomplished with cycloplegia (e.g., homatropine 5% or scopolamine 0.25% b.i.d.); a topical non-steroidal anti-inflammatory agent, such as Acular LS (ketorolac tromethamine 0.4%, Allergan); a prophylactic broad-spectrum antibiotic agent, such as Vigamox (moxifloxacin 0.5%, Alcon) t.i.d.; and copious use of an ophthalmic lubricant every one to two hours.
Bandage contact lenses have been shown to be beneficial in several case series. However, other studies advise caution due to the enhanced risk of microbial infection.5-7
Pressure patching also has been used extensively for many years to treat patients with corneal abrasions and recurrent erosions, and some textbooks still advocate this treatment modality for large epithelial defects.8 But, we forego this practice; several prospective studies have shown that pressure patching is not superior in improving healing time or comfort, and it can create hardship for the now-monocular patient.9,10
Management of RCE should reduce associated corneal edema and promote adhesion between the epithelial layer and basement membrane. The most conservative way to accomplish this is to use topical hypertonic agents, such as sodium chloride 5% solution and ointment. We typically prescribe the ointment to be used at bedtime, because it tends to sting and blur vision temporarily.
Hypertonic agents can be quite effective in the acute management of RCE, but may not totally eliminate the problem. A 1994 study of 117 patients with RCE concluded that 96% were successfully managed with this form of therapy.11 A follow-up study of these same patients conducted four years later, however, found that 59% of those contacted reported persistent symptoms of recurrent erosion.12
A recent addition to our treatment regimen is FreshKote (Focus Laboratories). It boasts a high colloidal osmolality (oncotic pressure) using a proprietary combination of conventional ophthalmic demulcents (polyvinyl pyrrolidone and polyvinyl alcohol), according to Frank J. Holly, Ph.D., who developed the drops. So, this agent may work similarly to hypertonic salt solutions but without the associated stinging upon instillation. Also, FreshKote contains a lipid component that improves overall lubricity, comfort and duration of action. We typically prescribe FreshKote q.i.d. while continuing sodium chloride 5% ointment q.h.s.
Oral tetracycline derivatives may also be beneficial in treating chronic RCE. A retrospective series of seven patients using doxycycline 50mg b.i.d. for two months and topical methylprednisone 1% t.i.d. for two to three weeks showed 100% resolution with no recurrences.13 The authors of this study note that doxycycline is a potent inhibitor of matrix metalloproteinase-9, which purportedly causes degradation of the epithelial attachment complexes following corneal insult.13
More invasive treatment modalities may be employed if conventional measures fail. Anterior stromal puncture (ASP) is one such procedure. ASP is designed to initiate scar formation at the level of the basement membrane, which should facilitate adhesion between the epithelium and stroma. While the patient is under topical anesthesia, the clinician uses a 25-gauge needle to place 0.1mm-deep perforations that breach the anterior limiting lamina (Bowmans membrane) at 0.25mm intervals within the area of erosion. ASP can also be performed using the Nd:YAG laser.
Other surgical options include superficial keratectomy using a diamond burr and excimer laser phototherapeutic keratectomy (PTK).14-16 These two techniques appear to have equivalent efficacy, but diamond burr treatment reportedly has a lesser tendency to induce secondary corneal haze.16 A recent long-term study of PTK for RCE found that fewer than half the patients treated with this technique experience recurrences, and 36% of recurrences happen within the first nine months.17
Alcohol delamination of the corneal epithelium (ADCE) has been proposed as another treatment option for those with recalcitrant RCE. This procedure involves the localized application of 20% alcohol to the corneal epithelium, a process most commonly identified with LASEK (laser assisted sub-epithelial keratomileusis). The alcohol, applied for 30 to 40 seconds, disrupts the bonds between the epithelium and underlying lamina to allow for uncomplicated focal debridement.
A prospective study of 20 patients with persistent RCE showed that ADCE was extremely effective at reducing or eliminating additional recurrences.18 Eighty-three percent of the patients that completed the study demonstrated total resolution and reported cessation of all symptoms.18
Recurrent corneal erosion can be a significant hardship for some patients and an ongoing challenge for those practitioners who treat them. But, most patients respond well to conservative ongoing therapy, and a variety of cutting-edge treatment modalities exist for those with recalcitrant symptoms. By properly educating our patients and addressing their individual needs, we can often help end the nightmare.
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13. Dursun D, Kim MC, Solomon A, et al. Treatment of recalcitrant recurrent corneal erosions with inhibitors of matrix metalloproteinase-9, doxycycline and corticosteroids. Am J Ophthalmol 2001 Jul;132(1):8-13.
14. Soong HK, Farjo Q, Meyer RF, et al. Diamond burr superficial keratectomy for recurrent corneal erosions. Br J Ophthalmol 2002 Mar;86(3):296-8.
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16. Sridhar MS, Rapuano CJ, Cosar CB, et al. Phototherapeutic keratectomy versus diamond burr polishing of Bowman"s membrane in the treatment of recurrent corneal erosions associated with anterior basement membrane dystrophy. Ophthalmology 2002 Apr;109(4):674-9.
17. Baryla J, Pan YI, Hodge WG. Long-term efficacy of phototherapeutic keratectomy on recurrent corneal erosion syndrome. Cornea 2006 Dec;25(10):1150-2.
18. Singh RP, Raj D, Pherwani A, et al. Alcohol Delamination of the corneal epithelium for recalcitrant recurrent corneal erosion syndrome. Br J Ophthalmol 2007 Feb 14; [Epub ahead of print].