Fishman Comments: Recurrent cornea erosions (RCE) can be a tough condition to treat. One particularly frustrating cause is LASIK or PRK. I see a number of patients who have been diagnosed with “dry eye” and/or neuropathic pain syndrome after refractive surgery. However, a careful examination of the cornea in many cases reveals recurrent epithelial erosions. Often RCE can be difficult to detect because by the time the patient is seen in the office, the epithelium can heal. It is therefore extremely important to see the patient as soon as they report symptoms in hope that the corneal erosion can be detected at the slit lamp. While RCE can be a “1 second diagnosis,” and often diagnosed by history alone, it can take persistence to definitively make this diagnosis in some patients.
There are numerous other causes of RCE and as this article reports, “Recurrent corneal erosion (RCE) typically occurs in eyes that have had previous abrading injuries (even years prior), eyes with epithelial basement membrane dystrophy (EBMD), corneal dystrophies such as lattice degeneration, corneal degenerations such as band keratopathy, or prior ocular surgery for refractive errors, cataracts, or corneal transplantation. ”
“Recurrent corneal erosion: a comprehensive review.” Darby D Miller 1, Syed A Hasan 1, Nathaniel L Simmons 2, Michael W Stewart. Clin Ophthalmol . 2019 Feb 11;13:325-335.
Purpose: To comprehensively review the literature regarding recurrent corneal erosion (RCE) and to present treatment options and recommendations for management.
Overview: RCE usually presents with sharp, unilateral pain upon awakening, in an eye with an underlying basement membrane dystrophy, prior ocular trauma, stromal dystrophy or degen- eration, or prior surgery for refractive errors, cataracts, or corneal transplantation. Making the correct diagnosis requires a careful slit-lamp examination of both eyes coupled with a high degree of suspicion. Several treatments are commonly used for RCE but new therapies have been introduced recently. Conservative treatment consists of antibiotic and preservative-free lubricating drops, with topical cycloplegics and oral analgesics to control pain. Patients who are unresponsive to these therapies may benefit from therapeutic bandage contact lenses (BCL). Newer therapies include oral matrix metalloproteinase (MMP) inhibitors, blood-derived eye drops, amniotic membrane graft application, and judicious application of topical corticosteroids. Once the epithelium is healed, a course of hypertonic saline solution and/or ointment can be used. Surgical procedures may be performed in patients who fail conservative therapy. Punctal occlusion with plugs increases the tear film volume. Epithelial debridement with diamond burr polishing (DBP), anterior stromal puncture (ASP), or alcohol delamination should be considered in selected patients. DBP can be used for patients with basement membrane dystrophies and is the preferred treatment overall due to a low recurrence rate. ASP can be used for erosions outside the central visual axis. Excimer laser phototherapeutic keratectomy is an attractive option in eyes with central RCE since it precisely removes tissue while preserving corneal transparency. In patients with RCE who are also candidates for refractive surgery, photorefractive keratectomy can be considered.
Fishman Comments (continued): Another possibly treatment option is to use autologous serum eye drops (ASED) combined with a bandage contact lens. The below article describes some success with this treatment. At FishmanVision, we can provide our patients with a subset of ASED called PRGF.
“Therapeutic outcomes of combined topical autologous serum eye drops with silicone–hydrogel soft contact lenses in the treatment of corneal persistent epithelial defects: A preliminary study.” By Yu-Kuei Lee et al.
To evaluate the efficacy of the combination of topical 20% autologous serum eye drops (ASEs) and silicone–hydrogel soft contact lenses (SCLs) for the treatment of corneal persistent epithelial defects (PEDs), and to compare the recurrence of epithelial breakdown with or without continuous use of ASEs after silicone–hydrogel SCLs removal.
We conducted a prospective interventional study of 21 eyes of 21 patients with PEDs treated with combined ASEs and silicone–hydrogel SCLs from September 2014 to August 2015. SCLs were removed after total re-epithelialization and patients were subsequently randomized divided into two groups: (1) with and (2) without continuous use of ASEs for an additional 2 weeks. PEDs healing rate and epithelial defect recurrence were evaluated.
PEDs healed in all eyes within 3 weeks. Recurrence was noted in five eyes (50%) in patients without continued use of ASEs for 2 weeks after total re-epithelialization and SCLs removal during a 3-month follow-up (odds ratio: 23.0; P < 0.05). Recurrent epithelial defects were successfully treated with secondary SCLs application combined with autologous serum use. No adverse events were noted during the entire treatment period.
The combined use of ASEs and silicone–hydrogel SCLs can successfully treat recalcitrant PEDs. Prolonged use of ASEs after total re-epithelialization can decrease recurrence rates.
Summary: Newly introduced therapies for RCE enable therapy to be individualized and lower the recurrence rate.
Keywords: recurrent corneal erosion, anterior basement membrane dystrophy, map-dot- fingerprint dystrophy, epithelial basement membrane dystrophy, corneal abrasion