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Recurrent Corneal Erosion Treatment & Management

  • Author: Arun Verma, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Aug 04, 2014
 

Medical Care

Management of RCE syndrome is usually aimed at regenerating or repairing the epithelial basement membrane to restore the adhesion between the epithelium and the anterior stroma.

In mild cases, the condition may resolve spontaneously within a few hours. However, more often, treatment is required to promote healing and to relieve the symptoms. The healing rate for an abrasion due to RCE syndrome is generally slower than the healing rate for a similar abrasion due to other factors.

Most patients with recurrent corneal erosions respond to topical lubrication therapy, bandage soft contact lenses, debridement of the epithelium and basement membrane, or anterior stromal micropuncture. An occasional patient will continue to have painful recurrent erosions despite all of these measures.

  • Of first importance for the patient with epithelial basement membrane dystrophy is minimization of the pain associated with recurrent corneal erosion. If the erosion is small, it usually heals spontaneously or with the aid of the following:
    • A pressure patch placed on the eye for 1-2 days
    • An antibiotic ointment, which can be used beneath the patch
    • Sometimes these measures must be followed for several months after resolution of the episode. The literature suggests that patching for longer than 2 days can introduce hypoxia, a lacrimal hyposecretion coefficient, or both that may actually inhibit healing. Use lubricating ointments alone, especially at bedtime, for several weeks to months to control symptoms.
  • In a study by Lopez et al, it was found that in severe dry eye syndromes, the corneal epithelium is compromised with development of punctate erosions and increased permeability. [4]
    • In their study, the ability of artificial tear solutions to promote recovery of the corneal epithelial barrier was determined by measurement of corneal uptake of 5,6-carboxyfluorescein (CF).
    • Corneas of anesthetized rabbits were exposed to 0.01% benzalkonium for 5 minutes to increase epithelial permeability. Then, the cornea was exposed to an artificial tear solution for 1.5 hours, followed by measurement of CF uptake.
    • During exposure to 3 commercial isotonic nonpreserved solutions and a solution preserved with polyquaternium-1, CF uptake decreased significantly but did not return to control. No recovery of the epithelial barrier occurred during exposure of corneas to nonpreserved hypotonic solutions. During exposure to an experimental tear solution with an electrolyte composition similar to human tears, buffered with bicarbonate, CF uptake returned to control levels.
    • Bicarbonate is an essential component of this solution because the same formula buffered with borate or without buffer was ineffective in promoting recovery of the damaged corneal epithelium.
  • In some cases of multiple recurrent erosions, soft contact lenses can be helpful. Bandage lens treatment, if used for this indication, must be continued for up to 8-26 weeks to facilitate repair of the corneal epithelial basement membrane. However, persistent use of soft contact lens increases the risk of infectious corneal disease. In fact, due to the cost of bandage contact lenses and the frequent follow-up visits required, as well as the potential for corneal infections with long-term use, contact lens therapy should be postponed until milder forms of treatment prove to be ineffective. [5]
  • In some cases, the recurrence of very mild corneal erosion may be prevented with the following: sodium chloride drops 2% or 5% several times during the day and sodium chloride ointment 5% at bedtime. Many surgeons believe that sodium chloride ointment is no more effective than a lubricant ointment or an ointment without preservatives. Each patient must be established on a regimen of medication that seems to control the symptoms more effectively. This might involve using a medication only when symptoms recur or, in some instances, daily application for many months after the resolution of an erosion episode to prevent further recurrences.
  • In a study by Hykin et al, 117 patients with a history of recurrent corneal erosion were recruited at initial hospital presentation. [6]
    • Seventy-five cases had a history of shallow corneal injury, 23 cases had epithelial basement membrane dystrophy (EBMD), 8 cases had both, and 11 cases had neither. Mean age at presentation was 38 years and follow-up ranged from 6-16 months (mean, 10.6 mo).
    • Sixty-one patients presented first with acute corneal erosion, 21 patients presented with subsequent acute corneal erosion, and 35 patients presented with chronic symptoms. Patients with EBMD or a trauma-related focal epithelial basement membrane abnormality were more likely to present with chronic recurrent symptoms than trauma-related cases with no abnormality on examination. Both EBMD and trauma-related cases typically recurred in the lower half of the cornea, frequently in the midline (z=7.3, P=0.0001), suggesting an intrinsic or acquired abnormality of the epithelial basement membrane at this site.
    • Only 4 of 82 acute episodes did not resolve by 5 days with simple patching, cycloplegia, and topical antibiotic ointment. In most patients presenting with acute erosion, only simple management measures were required. Of 117 cases started on prophylactic ointment at night, further therapy due to prophylaxis failure was required in only 5 patients.
  • Resistant cases may require the following:
    • Mechanical debridement, with or without chemical cautery, depending on the size of the defect and the amount of ocular irritation
    • Local cycloplegic agents
    • A diamond burr, which is used to "polish" the Bowman layer after mechanical debridement (proven to be effective in preventing recurrences)
  • Delaminating the corneal epithelium using alcohol can improve the symptoms of recurrent corneal erosions in eyes that do not respond to topical lubrication or bandage contact lenses. [7]
    • For the delamination procedure, a 20% alcohol solution is used that is dripped into a circular well placed over the defect and applied for 30-40 seconds.
    • The treated area of the corneal epithelium is then completely debrided using a sponge, and the corneal surface is irrigated with saline before placing a bandage contact lens.
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Surgical Care

Simple superficial debridement for removal of the abnormal epithelium and basement membrane, thereby leaving a smooth substrate of the Bowman layer, can be performed at the slit lamp. The adjacent normal epithelium can resurface in this area, allowing formation of competent attachment complexes and resulting in prompt cessation of erosive symptoms with a reduced frequency of recurrences. This procedure can be used if more conservative measures (eg, lubricants, patching, bandage contact lenses) fail in halting the erosions.

See the image below.

Debriding of the epithelium. Poorly adherent epith Debriding of the epithelium. Poorly adherent epithelium with a second layer of basement membrane.

A small group of patients with epithelial basement membrane dystrophy experience reduction of vision and/or recurrent erosions from the extreme deposition of an abnormal basement membrane and fibrillar collagenous material between the epithelium and the Bowman layer. This material may lead to irregular astigmatism and abnormal tear breakup. Patients complain of monocular visual distortion, diplopia, or ghost images. By performing superficial keratectomy, this abnormal material can be removed readily, leaving behind a smooth substrate of an intact Bowman layer. After reepithelialization, a smooth surface is reestablished with the elimination of irregular astigmatism.

  • Anterior stromal puncture
    • In a study by Marechal et al, anterior stromal puncture has been proposed as a treatment of recurrent corneal erosion.[8] A soft technique with a curved needle minimizes scarring and prevents corneal perforation. An insertion depth of 0.1 mm was sufficient to cause the production of new basement membrane attached to the anterior stroma.
    • When more severe cases of recurrent corneal erosion do not seem to respond to any of the above therapies, the use of anterior stromal puncture has been advocated. This procedure involves making 75-150 small punctures with a Rubenfeld needle through the epithelium and the Bowman layer into anterior stroma. The needle tip is inserted through the loosened epithelium or an epithelial defect, making momentary micropunctures to affect only the anterior stroma.
    • Patients who have had multiple recurrent erosions, unresponsive to debridement alone or debridement with cautery, have shown significant improvement with anterior stromal puncture. Used correctly, the technique is effective in 90% of cases of recalcitrant recurrent erosion with the first application; a few patients may require a second application of anterior stromal puncture.
    • With the advent of anterior stromal puncture and related procedures, many clinicians prefer to treat posttraumatic recurrent corneal erosions with these methods, thereby minimizing the number of such patients requiring therapeutic lenses.
  • Excimer laser phototherapeutic keratectomy
    • Excimer laser phototherapeutic keratectomy (PTK) has generated considerable interest in treating recurrent corneal erosions. With the MEL 50 Aesculap-Meditec 193-nanometer argon-fluoride excimer laser, surgeons have treated individuals, who experienced posttraumatic, therapy-resistant, recurrent corneal epithelial erosions. They used the excimer laser in spot-mode under manual guidance. Only in those eyes where the erosion was covered with loose bullous epithelium did they remove the epithelium mechanically prior to surgery.
    • Gyldenkerne et al in Denmark have observed that recurrent corneal erosions are a troublesome clinical problem.[9] Many patients with erosions do not respond satisfactorily to the standard treatment. In a paper, they presented a study of treatment of 24 patients with recurrent corneal erosions with the excimer laser, where 75% of the patients reported the treatment as a success.[9]
    • In a study by John et al, after PTK, no patient had a recurrence after 18 months follow-up care.[10] Subjectively, all the patients believed that the treated area healed faster than previous abrasions. Vision, refraction, keratometry, and corneal thickness measurements appeared unaffected by the treatment.
  • Nd:YAG laser treatment
    • Katz et al retrospectively studied 8 patients with recurrent corneal erosions treated with the Nd:YAG laser using 0.4- to 0.5-mJ pulses applied to the region of the Bowman layer through an intact epithelium.[11] All 8 patients had resolution of their symptoms after treatment. Mean follow-up time was 21.2 months (range, 12.6-36.6 mo).
    • A patient who was scheduled for diagnostic enucleation for a posterior choroidal mass consented to undergo this laser treatment with varied energy settings 6 days before his enucleation. The patient’s cornea was studied with specular microscopy, light microscopy, and transmission electron microscopy. Light microscopy of the cornea disclosed rare 100-µm defects in the Bowman layer with subjacent compaction of the anterior stromal layer.
  • Superficial phototherapeutic keratectomy
    • Superficial PTK can be curative in some cases of painful recurrent erosions despite conventional treatment, including aggressive anterior stromal micropuncture. The ablated anterior corneal stromal surface appears to be highly supportive of stable reepithelialization.
    • Although completely normal reformation of the basal lamina complex, including normal density of hemidesmosomes and anchoring fibrils, may take months to years, most investigators of photorefractive keratoplasty (PRK) have been impressed with the rapid and stable reepithelialization that occurs after ablation, with absence of punctate keratitis, staining defects, or symptoms of recurrent erosion. In this condition, the objective of PTK is simply to remove enough of the superficial Bowman layer to permit formation of a new basement membrane with adhesion structures. The current technique is to debride the epithelium in the involved area, and, with the use of a large spot size, such as 5 mm, apply 16 pulses. Usually, this maneuver will remove no more than 4 mm of the Bowman layer.
    • Because no optical effect is seen with such a superficial ablation, the treatment may be applied centrally or eccentrically. Because these cases are rare, caution should be exercised in the aggressive application of this technique until adequate experience is gained with the long-term success rate.
  • For spontaneous recurrent erosions and erosions secondary to corneal dystrophies, such as Reis-Bücklers dystrophy, lattice dystrophy, and the superficial variant of granular dystrophy, as well as epithelial basement membrane dystrophy, the following procedures have been used with success:
    • Excimer laser photoablation (PTK) through the basement membrane, just into the Bowman layer, has been performed with some success, although it is more expensive than mechanical debridement.
    • Success has been reported in combining PRK with PTK to treat intractable recurrent erosions in myopic patients; even patients who had frequent recurrent erosions for years were symptom free after this combined photoablative procedures in follow-up periods of 26-42 months.
  • Superficial keratectomy and penetrating and lamellar keratoplasty all have been advocated when intervention in Reis-Bücklers corneal dystrophy is necessary because of diminished visual acuity. In a study by Rogers et al, 11 eyes were treated by PTK with an excimer laser. [12] Two eyes had been treated previously by penetrating keratoplasty. The visual acuity improved in all eyes, from an average of 6/60 (20/200) to 6/9 (20/30) with complete cessation of recurrent erosions.
  • Soong et el used diamond burr superficial keratectomy in the treatment of recurrent corneal erosions. [13] They concluded that diamond burr superficial keratectomy appeared to be a safe and effective method of treating recurrent erosions and a good alternative therapy to needle stromal micropuncture, Nd:YAG laser induced epithelial adhesion, and excimer laser surface ablation.
  • Collagen punctal plugs may help identify individuals who might benefit from punctal occlusion or punctal cautery. See the images below.
    Granular dystrophy before phototherapeutic keratec Granular dystrophy before phototherapeutic keratectomy.
    Granular dystrophy after photorefractive keratecto Granular dystrophy after photorefractive keratectomy.
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Activity

See the list below:

  • Patients should avoid rubbing the eyes and splashing water on open eyes.
  • Patients should use protective glasses.
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Contributor Information and Disclosures
Author

Arun Verma, MD Senior Consultant, Department of Ophthalmology, Dr Daljit Singh Eye Hospital, India

Disclosure: Nothing to disclose.

Coauthor(s)

Michael P Ehrenhaus, MD Director, Department of Cornea, External Disease & Refractive Surgery, Assistant Professor, Department of Ophthalmology, State University of New York Downstate Medical Center

Michael P Ehrenhaus, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, International Society of Refractive Surgery, Cornea Society, Eye Bank Association of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Fernando H Murillo-Lopez, MD Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

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Corneal abrasion.
Recurrent corneal erosion.
Recurrent erosion with fluorescein in an area of staining.
Map-dot-fingerprint dystrophy.
Stromal puncture seen with fluorescein.
Direct view with a slit lamp.
Debriding of the epithelium. Poorly adherent epithelium with a second layer of basement membrane.
Granular dystrophy before phototherapeutic keratectomy.
Granular dystrophy after photorefractive keratectomy.
 
 
 
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