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Ophthalmic Pearls: Cornea
Treatment of Recurrent Corneal Erosions
Recurrent corneal erosion syndrome (RCES) is a common clinical disorder involving the corneal epithelium and epithelial basement membrane. Characterized by the repeated breakdown of epithelium, RCES can cause moderate to severe eye pain, photophobia, lacrimation, and corneal scarring leading to visual changes. Patients are often debilitated by the resulting pain and visual deficits and frustrated by the condition’s lack of response to treatment.
This review presents a spectrum of treatments for RCES, ranging from simple medical management to complex surgical interventions. The stepladder approach will guide ophthalmologists to individualize treatment, minimize iatrogenic risks, and improve long-term outcomes.
In a study of 104 RCES cases, trauma contributed to 45 percent, epithelial basement membrane dystrophy (EBMD) contributed to 29 percent, and a combination of trauma and EMBD contributed to 17 percent of cases.1
As a category, trauma includes mechanical trauma to the corneal surface. The subsequent inflammation from these injuries can cause disruption in the extracellular adhesion in the corneal epithelium. Matrix metalloproteinases have been implicated in degrading these scaffolding proteins, resulting in erosion.2
Patients with EBMD, a congenital condition, have an anterior epithelium that does not adhere well to the basement membrane due to morphological changes in the epithelial cells or basement membrane matrix.1 This creates a loose epithelial layer prone to shifting and tearing when damaged.
Adhesions between the palpebral conjunctiva of the eyelids and the corneal epithelium in dry eye patients contribute significantly to RCES in many patients. Individuals with ocular rosacea are particularly at risk due to meibomian gland dysfunction and resultant evaporative dry eye.
Owing to the recurrent nature of this condition and its resistance to commonly used therapies, patients often make repeated visits to their ophthalmologists. There are many treatment options for RCES, each of which has varying degrees of efficacy. Patients must be assessed on a case-by-case basis so that treatment regimens are individualized. We have devised a management algorithm for the treatment of RCES (see “Treatment Algorithm for RCES”).
Medical. Medical treatment options should be explored before resorting to more invasive surgical alternatives.
For patients with chronic RCES, we recommend the nighttime application of a prophylactic bland ointment, such as Refresh PM or Lacri-Lube, or hypertonic saline, such as Muro 128. For recovering patients whose epithelium is healing, we recommend bland ointment to prevent surface aggravation.
We also recommend the frequent application of preservative-free artificial tears during the day and bland ointment or hypertonic saline ointment at bedtime to promote recovery, especially in patients with dry eye or ocular rosacea. If this regimen fails, surgery may be considered.
Surgical. Due to the attendant risks, surgery should be reserved for patients who have failed aggressive medical therapies. It should not be performed as an initial form of treatment.
It should be noted that ASP has fallen out of favor as a surgical treatment for RCES in many practices, as it can cause scarring, glare, and blurred vision, and has a high failure rate in preventing further erosions.
We advise that all patients who are treated surgically be monitored postoperatively with a follow-up appointment scheduled two to four weeks after the procedure. If symptoms have improved or are completely eliminated, we recommend prophylactic treatment with lubrication as described above to prevent a recurrence. If symptoms recur, oral doxycycline and topical steroids may be administered twice daily for two to three weeks.
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Several options exist for treating RCES. However, the underlying condition, if overlooked, can result in recurrent erosions and debilitating symptoms. Based on clinical evidence, combination therapy with oral tetracycline, topical corticosteroids, and lubrication is the most effective treatment for RCES. For severe and refractory cases of RCES, superficial keratectomy and PTK may also be effective.
1 Reidy JJ et al. Cornea. 2000;19(6):767-771.
2 Dursun D et al. Am J Ophthalmol. 2001;132(1):8-13.
3 Fraunfelder FW, Cabezas M. Cornea. 2011;30(2):164-166.
4 Das S, Seitz B. Surv Ophthalmol. 2008;53(1):3-15.
5 Maini R, Loughnan MS. Br J Ophthalmol. 2002;86(3):270-272.
Mr. Thakrar is a medical student and Dr. Hemmati is assistant professor of ophthalmology and surgery; both are at the University of Vermont in Burlington. The authors report no related financial interests.