Recurrent Corneal Erosion
Recurrent Corneal Erosion (RCE) is a chronic relapsing condition caused by a breakdown of the corneal epithelium; this pathology could be mostly neglected among ocular disorders and debilitates the patient with the sudden onset of pain, lacrimation, and photophobia.
Acute episodes could last from hours up to 5 days and after this time prophylaxis should be considered to prevent corneal infection, conservative and surgical treatment is available depending on the severity of the corneal erosion and if it is either an acute or chronic episode.
RCE involves both, the corneal epithelium and the epithelial basement membrane, the most common conditions associated are:
- Corneal Dystrophies
- Mechanical trauma from foreign bodies, fingernails, tree branches, paper cuts, which could be counted up to 45 - 64% of cases according to studies.
- Corneal Dystrophies like anterior basement membrane dystrophy (Cogan dystrophy or map-dot-fingerprint dystrophy) in 19 – 29% of cases.
- Patients with Diabetes, Dry Eye Syndrome and Ocular Rosacea are at potential risk to develop RCE.
Injury to the corneal surface results in an epithelial defect and repair of epithelial defects occurs in three distinct phases characterized by epithelial cell migration, proliferation, and differentiation, resulting in restoration of the stratified structure of the epithelium.
Trauma to the corneal epithelium induces the sliding and migration of the remaining epithelial cells adjacent to the injury site toward the defective area. Changes in cell–cell and cell–matrix (fibronectin–integrin system) interactions and modulation of the extracellular matrix by newly expressed proteolytic enzymes play important roles.
Recurrent erosion occurs since the inflammation from injuries causes disruption of the epithelial basement membrane and debilitates extracellular adhesion at hemidesmosomes. Patients with anterior basement membrane dystrophy show a loose adherence of the epithelium. In vivo confocal microscopy presents deposits in basal epithelial cells, subbasal microfolds and streaks, damaged subbasal nerves and altered morphology of the anterior stroma.
RCE diagnosis is mostly done with slit lamp examination; findings could range from normal or mild irregularity to a large area of loose epithelium, even including a large defect. Fluorescein stain will help to reveal the corneal defect.
In a study done by Hykin, Foss and Pavesio the site and size was recorded by dividing the cornea in 12 sectors and indicating which of them were involved, this allows the pathology to be classified in: small 0-3 sectors, moderate 4-6, large 7-9 and very large 10-12 sectors. According to their results the lower half of the cornea was the more frequent affected location.
Signs and Symptoms
- Mild to severe pain is one of the main symptoms, occurring in a sudden onset and presents particularly upon awakening, the episodes might last from seconds to days. If the epithelium is loose opening of the lids could tear it off.
- Foreign body sensation
- Blurred vision
- Band kerathopathy
- Corneal Ulcers: bacterial, fungical or herpetic
- Corneal Foreign Body
- Corneal Dystrophies: Reis - Buckler, Granular, Fuchs, Lattice
- Chemical and Thermal Burns
- Dry Eye Syndrome
- Floppy Eyelid Syndrome
- Salzmann’s nodular degeneration
RCE treatment depends if it is an acute or chronic episode, it could be either medical or surgical, and it should be individualized for each patient depending on the manifestations shown during slit lamp examination. Treatment algorithms are available in different studies.
- Lubrication: as first line of therapy or preventing corneal erosion, the use of preservative-free artificial tears and ointment is recommended in a frequent application during the day and before bed time to keep the eyes moist, also the use of constant lubrication could prevent future corneal erosions to appear, even though patients with anterior basement membrane dystrophies had an increased risk of prophylactic failure.
- Antibiotics and pain relievers: as a prophylactic treatment for patients with chronic REC to prevent bacterial infection and oral pain relievers as ibuprofen.
- Inhibitors of matrix metalloproteinase-9 (doxycycline), corticoesteroids: based on the increased matrix metalloproteinase activity, it has been reported that doxycycline decreases it’s activity in epithelial cultures and in combination with topical corticosteroids reduces the frequency of recurrent corneal erosion. Recommended dose according studies is doxycycline 50 mg orally two times daily and topical application of corticosteroids (either methylprednisolone 1%, prednisolone acetate 1%, or fluorometholone 0.1%) two or three times a day for 3 weeks.
- Bandage Contact Lens: using Hydrogel soft contact lenses and reviewed after 24 hours, could be left from 2 to 8 weeks always reminding the patient to show at consult as soon as any signs of redness or pain appear, topical antibiotic could be used as prophylaxis during this period.
- Punctal Occlusion: considered for severity level 3 and 4 in Dry Eye Syndrome, temporary occlusion with collagen plugs might be the next approach while dealing with acute corneal erosion, this type of plugs usually dissolve in four to seven days, but if the corneal erosion is chronic, permanent occlusion with silicon plugs is best recommended, it has to be considered that the plug may extrude or migrate over time. Among the advantages of this procedure is that besides of being a safe, quick and reversible method, it will help to increase the contact time of the drops with the cornea.
- Anterior Stromal Micropuncture: is an ambulatory procedure that can be performed with the patient at the slit lamp, anesthetic drops are administered (proparacaine) and a 25 gauge needle with a 1mL syringe is used to create micropunctures less than 1mm apart over the area that felt loose. Using cobalt blue light and fluorescein helps to determine completition of the treatment. Nd:YAG laser micropuncture uses 0.4 – 0.5mJ pulses applied to the region of the Bowman layer through an intact epithelium. After the treatment fibrocytic response and basement membrane production is stimulated, and epithelial adherence is improved by inducing scar tissue between the epithelium and anterior stroma. In the study by Zauberman et al, the technique with a 25 gauge needle demonstrates effectiveness in 62.9% eyes after a single procedure.
- Diamond Burr Polishing: includes debridement with a cellulose sponge of the 7 – 10mm of the central epithelium, afterwards 5.0mm diameter diamond burr was used to polish the Bowman membranes during 10 seconds, a bandage contact lens is used during 4 -5 days and topic antibiotic are instilled 4 times a day.
- Excimer Laser Phototherapeutic Keratectomy (PTK): after removing the central epithelium, treats the cornea uniformly creating a depth ablation of 5 – 6um at 6Hz. In a study presented by Gyldenkerne et al 75% of patients reported the treatment as success. And according to the study presented by John et al, reported no recurrence after 18 months during follow up.
- Corneal haze and scarring
- Infectious keratitis
- Decreased vision
With adequate treatment and prompt diagnosis, prognosis is excellent, the healing process is an important part and it may take years. Patients must be aware of signs and symptoms in order to avoid complications. Prophylaxis in patients with risk factors must be considered.
- American Academy of Ophthalmology. Cornea/External Disease: Recurrent corneal erosion Practicing Ophthalmologists Learning System, 2017 - 2019 San Francisco: American Academy of Ophthalmology, 2017.
- Suri K, Kosker M, Duman F, Rapuano J, Nagra P, Hammersmith K. Demographic Patterns and Treatment Outcomes of Patients With Recurrent Corneal Erosions Related to Trauma and Epithelial and Bowman Layer Disorders. Am J Ophthalmol 2013;156:1082–1087
- Ramamurthi S, Rahman MQ, Dutton GN, Ramaesh K. Pathogenesis, clinical features and management of recurrent corneal erosions. Eye 2006;20(6):635–644.
- Hykin PG, Foss AE, Pavesio C, Dart JK. The natural history and management of recurrent corneal erosion: a prospective randomised trial.Eye 1994; 8(Part 1): 35–40.
- Fraunfelder FW, Cabezas M. Treatment of recurrent corneal erosion by extended-wear bandage contact lens. Cornea 2011;30(2):164–166.
- Thakrar R, Hemmati H. Treatment of Recurrent Corneal Erosions. EyeNet. Available at http://www.aao.org/eyenet/article/treatment-of-recurrent-corneal-erosions
- Findley FM. Recurrent corneal erosions. J Am Optom Assoc 1986;57:392-6.
- Dohlman CN. Healing problems in the corneal epithelium. Jpn J Ophthalmol 198 1 ;25: 13 1-4.
- Rosenberg ME, Tervo TM, Petroll WM, Vesaluoma MH.In vivo confocal microscopy of patients with corneal recurrent erosion syndrome or epithelial basement membrane dystrophy.Ophthalmology 2000;107(3):565–573.
- Sobrin L, Liu Z, Monroy DC, et al. Regulation of MMP-9 activity in human tear fluid and corneal epithelial culture supernatant. Invest Ophthalmol Vis Sci 2000;4:1–7.
- Hope-Ross MW, Chell PB, Kervick GN, McDonnell PJ, Jones HS. Oral tetracycline in the treatment of recurrent corneal erosions. Eye 1994;8:384 –388.
- Dursun D, Kim M, Solomon A, Pflugfelderand S. Treatment of Recalcitrant Recurrent Corneal Erosions With Inhibitors of Matrix Metalloproteinase-9, Doxycycline and Corticosteroids. Am J Ophthalmol 2001;132: 8–13.
- Zauberman N, Artornsombudh P, Elbaz U, Goldich Y, Rootman D, Chan C. Anterior Stromal Puncture for the Treatment of Recurrent Corneal Erosion Syndrome: Patient Clinical Features and Outcomes. Am J Ophthalmol 2014;157:273–279
- Maréchal-Courtois C, Duchesne B. [Recurrent corneal erosion]. Bull Soc Belge Ophtalmol. 1993. 247(1):13-5
- Katz HR, Snyder ME, Green WR, Kaplan HJ, Abrams DA. Nd:YAG laser photo-induced adhesion of the corneal epithelium. Am J Ophthalmol. 1994 Nov 15. 118(5):612-22.
- Gyldenkerne GJ, Ehlers N. [Excimer laser therapy of recurrent corneal erosions]. Ugeskr Laeger. 1994 Sep 12. 156(37):5282-4.
- John ME, Van der Karr MA, Noblitt RL, Boleyn KL. Excimer laser phototherapeutic keratectomy for treatment of recurrent corneal erosion. J Cataract Refract Surg. 1994 Mar. 20(2):179-81.