Recurrent Corneal Erosion Treatment & Management

The treatment approach for recurrent corneal lesions at the authors’ center is as follows:

• Mechanical debridement, with or without chemical cautery, depending on the size of the defect and the amount of ocular irritation
• Application of local cycloplegic agents such as atropine or homatropine
• “Polishing” of the Bowman layer with a diamond burr after mechanical debridement
• Delamination of the corneal epithelium using alcohol or silver nitrate, which can improve the symptoms of recurrent corneal erosions in eyes that do not respond to topical lubrication or bandage contact lenses

For the delamination procedure, a 20% alcohol solution 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 a bandage contact lens is placed.

The authors apply cotton bud dipped in silver nitrate on the affected area.

The authors have recently started using plasma energy in the form of Fugo blade. Scratches are made to the affected with the Fugo plasma knife. The tissues ablate away, leaving a smooth surface without scarring.

In a study by Hykin et al, 117 patients with a history of recurrent corneal erosion were recruited at initial hospital presentation. ^[4]

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.

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.

Pain relief

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.

Treatment of dry eye

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. ^[5]

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.

Lens treatment

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. ^[6]

Prevention of mild corneal erosion

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.

Treatment of resistant cases

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)

Delaminatiion of the corneal epithelium

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.

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.

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

More severe cases of recurrent corneal lesions are treated with anterior stromal puncture. Marechal et al described anterior stromal puncture in recurrent corneal erosion with a curved needle, which minimizes scarring and prevents corneal perforation. An insertion depth of 0.1 mm was sufficient to result in the production of new basement membrane attached to the anterior stroma. ^[8]

In 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 with a Fugo blade. The authors of this article perform numerous punctures on the affected sites through the epithelium and the Bowman layer into anterior stroma. The Fugo tip is inserted through the loosened epithelium or an epithelial defect, making momentary micropunctures to affect only the anterior stroma.

Anterior stromal puncture with a Fugo blade has resulted in significant improvement among patients who have had multiple recurrent erosions that are unresponsive to debridement alone or debridement with cautery. This is effective in more than 95% of cases of recalcitrant recurrent erosions.

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.

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.

Treatment of spontaneous recurrent erosions and erosions due to corneal dystrophies

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.

Collagen punctal plugs

Collagen punctal plugs may help identify individuals who might benefit from punctal occlusion or punctal cautery. 

Patients should avoid rubbing the eyes and splashing water on open eyes.

Patients should use protective glasses.

Preventive measures for patients with recurrent corneal erosion are discussed below.

Avoid dry or irritating environments (eg, cigarette smoke).

Drink plenty of fluids to help prevent drying of the eyes. This may also involve limiting alcohol intake in the evenings. Drinking heavily may cause an erosion episode the following morning, sometimes referred to as "drinker's eye."

Avoid sleeping in late, as corneal hydration from lid closure may be a factor affecting epithelial adhesion.

Apply long-lasting eye ointments (eg, Lacri-Lube) at bedtime. Many patients use a lubricating ointment at night for months or even years to prevent a recurrence.

Control the air quality and the humidity of the room while sleeping. Avoid having an overventilated room. Air flowing over the face, even with the eyes closed, can increase eye dryness. Cool, moist, still air is the best environment to prevent unnecessary evaporation of eye moisture.

Limit exposure to viruses (eg, annual flu shot). Viruses, such as the flu (and associated gastrointestinal symptoms like diarrhea), seem to cause the eyes to dry out and can help cause an erosion episode.

Wear protective glasses (eg, sunglasses, prescription glasses, even "fake" glasses), especially when engaging in activities like gardening or playing with children.

Learn to wake with the eyes closed and still.

Keep high-quality artificial tears within reach of the bed; if the eyes feel “stuck shut” upon awakening, insert the bottle tip slightly into the inner corner of the eye and gently squirt in the artificial tears. The artificial tears will seep under the eyelid, often allowing the opening of the eyes without an erosion episode. Several repeated applications of artificial tears may be necessary, but with patience, the eyes will likely become “unstuck” and allow the pain-free opening of the eyes and erosion avoidance.

Another method, after waking with the eyes closed and still, is to use the fingers to gently rub the closed eyelids in a circular motion before attempting to open them.

The friction of the eyelid against the cornea may be enough to rip off a piece of the corneal epithelium. If a recurrent corneal erosion is suspected, the affected eye should be kept firmly closed, and only the unaffected eye should be opened. Looking around will help lubricate the affected eye so that, when it is opened, there is no friction and, thus, no repeat of the abrasion.

Regular follow-up care for many months to even years is required for proper evaluation of the condition.