Recurrent corneal erosions are characterized by the sudden onset of eye pain, usually during the night or upon first awakening, accompanied by redness, photophobia, and tearing. Individual episodes may vary in severity and duration. Minor episodes usually last from 30 minutes to several hours; typically, the cornea has an intact epithelial surface at the time of examination. More severe episodes may last for several days and are often associated with greater pain, eyelid edema, decreased vision, and extreme photophobia. Many patients seem to experience ocular discomfort that is out of proportion to the degree of observable pathology. However, slit-lamp examination using retroillumination frequently reveals subtle corneal abnormalities (eg, epithelial cysts). The corneal epithelium is loosely attached to the underlying basement membrane and Bowman layer, both at the time of a recurrent attack and between attacks, when the cornea appears to be entirely healed. During an acute attack, the epithelium in the involved area often appears heaped up and edematous. Although no frank epithelial defect may be present, significant pooling of fluorescein around the affected area is often visible.
A key to distinguishing between posttraumatic erosion and dystrophic erosion in a patient who has no clear-cut history of superficial trauma is careful examination of the contralateral eye following maximal pupillary dilation. Occasionally, subtle areas of loosely adherent corneal epithelium can be identified by applying gentle pressure with a surgical sponge following instillation of topical anesthetic. The presence of basement membrane changes in the unaffected eye implicates a primary basement membrane defect in the pathogenesis, whereas the absence of such findings suggests a posttraumatic etiology. Other clinical conditions with associated abnormalities of the epithelial basement membrane include diabetes mellitus and dystrophies of the stroma and Bowman layer (see also the discussion on corneal dystrophies in Chapter 7).
Traditional therapy for the acute phase of this condition consists of frequent lubrication or patching with antibiotic ointments and cycloplegia, followed by use of non-preserved lubricants or hypertonic saline solution (5% sodium chloride) during the day and ointment at bedtime for at least 6 weeks to facilitate epithelial attachment. Hypertonic agents provide lubrication and may transiently produce an osmotic gradient, drawing fluid from the epithelium and theoretically promoting the adherence of epithelial cells to the underlying tissue. Some patients find hypertonic medications unacceptably irritating, but many others do quite well with this therapy indefinitely. Low-dose oral doxycycline and short-term use of topical corticosteroids have been shown to be very efficacious. The mode of action is thought to be localized inhibition of MMPs.
Although use of a bandage contact lens may be helpful, proper patient education and judicious monitoring are crucial to a successful outcome. The ideal bandage lens fits without excessive movement and has high oxygen transmissibility (Dk). New-generation soft contact lenses with lens-surface treatments that decrease bacterial adherence may offer a better safety profile than older lens designs. Concomitant use of a topical broad-spectrum antibiotic 2–4 times daily may reduce the possibility of secondary infection but increase the risk of toxicity and bacterial resistance over the long term. Some cornea specialists prefer not to prescribe topical antibiotics for a patient using a bandage contact lens.
When consistent conservative management fails to control the symptoms, surgical therapy may be indicated. Surgical management of recurrent corneal erosion includes epithelial debridement and anterior stromal puncture. Some clinicians prefer to use debridement for central erosions or erosions related to corneal dystrophy, and stromal puncture in patients with posttraumatic recurrent erosions. An alternative to these procedures is excimer laser ablation either with phototherapeutic keratectomy (PTK) or photorefractive keratectomy (PRK). See Chapter 13 in this volume and BCSC Section 13, Refractive Surgery, for further discussion.
Ewald M, Hammersmith KM. Review of diagnosis and management of recurrent erosion syndrome. Curr Opin Ophthalmol. 2009;20(4):287–291.
Reidy JJ, Paulus MP, Gona S. Recurrent erosions of the cornea: epidemiology and treatment. Cornea. 2000;19(6):767–771.
Wang L, Tsang H, Coroneo M. Treatment of recurrent corneal erosion syndrome using the combination of oral doxycycline and topical corticosteroid. Clin Experiment Ophthalmol. 2008;36(1):8–12.
Wong VW, Chi SC, Lam DS. Diamond burr polishing for recurrent corneal erosions: results from a prospective randomized controlled trial. Cornea. 2009;28(2):152–156.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.