Recurrent Corneal Erosion

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Corneal erosion affects the cornea, the clear dome covering the front of the eye. The cornea is composed of five layers. The outermost layer is the epithelium. When the epithelium does not stay attached correctly to the corneal tissue below, including the layer called the Bowman’s layer or the basement membrane, this can cause a condition called corneal erosion. If the problem occurs repeatedly, it is called recurrent corneal erosion.

Signs and Symptoms

  • Severe pain (especially after awakening)
  • Blurred vision
  • Foreign body sensation
  • Dryness and irritation
  • Tearing
  • Red eye
  • Light sensitivity

Management of RCE can be frustrating for both the patient and doctor. The patient becomes upset due to the recurrent episodes of pain and decreased vision, and the doctor is discouraged due to his or her inability to cure the patient’s disease.

Who Is At Risk for Corneal Erosion?

Corneal erosion can occur spontaneously and happen to anyone. Certain factors increase your risk for corneal erosion:

  • Having a history of eye injury;
  • Having a corneal disease, such as corneal dystrophy;
  • Having had an eye ulcer, such as from a herpes simplex infection;
  • Wearing contact lenses including lenses that are improperly fitted or not properly cared for.

Of the few trials that have been performed in patients with RCE, the greatest successes have been seen when multiple treatments were used. Listed are several individual treatment strategies that could be combined together to create a treatment plan.

Medical Management

Artificial tears. One of the main goals of medical management is to promote epithelial health and regeneration. Therefore, initial treatment routinely starts with increasing lubrication and optimizing the health of the tear film. This allows a reduction in friction and decreases the adherence of the eyelids to the epithelium. Improving lubrication and moisture is especially critical upon patients’ awakening. FreshKote (Focus Laboratories), now available as an over-the-counter option, is a good option.

Hyperosmotics. Sodium chloride solutions and ointments (Muro 128) create an osmotic gradient that is useful in reducing corneal edema. These hypertonic agents also promote epithelial adherence.

Tetracyclines. The tetracycline family of antibiotics, specifically doxycycline, plays an important role in the management of RCE. Low-dose doxycycline reduces the level of inflammatory enzymes and reduces recurrences. Typically prescribed at 20 to 50 mg twice a day for a minimum of 2 months.

Topical azithromycin. AzaSite (topical azithromycin solution 1%; Akorn), a topical macrolide indicated for the treatment of bacterial conjunctivitis, has also been shown to reduce levels of inflammatory enzymes that contribute to RCE.

Corticosteroids. Topical corticosteroids such as loteprednol etabonate 0.5% (Lotemax; Bausch + Lomb) have been shown to be effective in reducing inflammatory enzymes. As with all corticosteroids, use may delay epithelial healing and should be used with caution.

Cyclosporine ophthalmic emulsion. This topical immunomodulator with antiinflammatory activity has been available topically for 10 years (Restasis; Allergan). It works by reducing inflammation and producing a more stable tear film to help epithelial cells to anchor properly.

Mechanical Management

Bandage contact lens. Bandage contact lenses are a useful adjunct for treatment, especially when coupled with other modalities. Extended use of bandage contact lenses (worn for 3 months, replaced every 2 weeks) offered immediate relief of symptoms and long-term resolution for most of their recalcitrant RCE patients.

Punctal plugs. These may help thicken the tear film and help prevent tear evaporation at night.

Epithelial debridement. Debridement is a means of removing the dystrophic epithelium and basement membrane. The goal is to create a smooth Bowman layer, and a clean, more regular surface for new basement membrane to form with stronger adhesions of the basal epithelial cells to the basement membrane

Anterior stromal puncture. With anterior stromal puncture, a 25-gauge disposable hypodermic needle is used to make multiple punctures through loose epithelium and Bowman layer into the anterior half of the stroma. It is believed that the breaching of the Bowman membrane stimulates a more secure bonding of the epithelium to the underlying basement membrane, Bowman, and stroma.

Surgical Management

Phototherapeutic keratectomy. Phototherapeutic keratectomy involves the use of an excimer laser after the epithelium is removed to help smooth Bowman layer and permit the formation of a new basement membrane with adhesion complexes.

Alcohol delamination. A solution of 20% ethanol placed on the cornea for 30 seconds splits the basement membrane and epithelium from the remaining corneal tissue. This is intended to allows a new anchoring complex to form.

Superficial keratectomy. The benefit with this technique is that the dystrophic epithelium and basement membrane are peeled off in one continuous sheet, leaving an undisturbed Bowman membrane and a clean surface for new basement membrane to form.

Conclusions
The treatment goal in a patient with RCE patient is to restore the normal ocular surface anatomy. With today’s understanding of RCE, and utilizing a combined treatment modality, it is possible to maintain vision and prevent recurrences in the large majority of these patients.

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