Recurrent Corneal Erosion
Recurrent Corneal Erosion (RCE) syndrome is a common, recurrent condition caused by abnormal epithelial adhesion to the underlying basal lamina. The spontaneous breakdown of the corneal epithelium can lead to the sudden onset of ocular pain, blurred vision, tearing, and photophobia, typically upon awakening.
Conservative and surgical treatments are available depending on the severity and duration of the corneal erosions.
Trauma is the most common cause of RCE. Corneal dystrophies such as epithelial basement membrane dystrophy, Reis- Buckler dystrophy, lattice dystrophy, macular dystrophy, granular dystrophy, and Fuchs endothelial corneal dystrophy; previous corneal infections; meibomian gland dysfunction; diabetes mellitus; ocular rosacea; band keratopathy; nocturnal lagophthalmos; and, dry eye syndrome have all been implicated in the pathogenesis of RCE.
- Mechanical trauma from foreign bodies, fingernails, tree branches, paper cuts, accounts for 45-64% of cases according to studies.
- Corneal dystrophies like anterior basement membrane dystrophy (ABMD, aka Cogan dystrophy or map-dot-fingerprint dystrophy) are associated with 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 can result in an epithelial defect. Healing occurs in three distinct phases characterized by epithelial cell migration, proliferation, and differentiation. Trauma to the corneal epithelium induces the 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.
Patients with RCE demonstrate a faulty, loose adherence of the epithelium to the underlying stroma following the initial injury, that can be sheared off upon awakening with the opening of the eyelids. Recurrent erosions occur secondary to inflammation from the inciting insult, which causes disruption of the epithelial basement membrane and proper extracellular adhesions of the hemidesmosomes. In affected patients, in vivo confocal microscopy demonstrates defects of the adhesion complex, deposits in basal epithelial cells, subbasal microfolds and streaks, damaged subbasal nerves, aberrant basement membrane, and altered morphology of the anterior stroma.
Increased levels of toxic free fatty acids, interleukin-1, and matrix metalloproteinases (MMPs) in patients suffering from meibomian gland dysfunction, ocular rosacea, and recurrent erosions is thought to result in faulty adhesion complexes and abnormal basement membrane formation.
RCE is diagnosed with slit lamp examination. Findings range from normal exam to mild irregularities of the cornea (such as epithelial microcysts) to large areas of loose epithelium or epithelial defects, which can be delineated with fluorescein staining. Intrinsic abnormalities of corneal epithelial adhesions such as from corneal dystrophies tend to present bilaterally and symmetrically. In cases of previous trauma, the area of erosion usually corresponds to the location of the previous injury.
In a study done by Hykin et al., the site and size of the erosion was measured by dividing the cornea into twelve sectors and measuring how many sectors were involved. This allowed the corneal erosion to be classified as small (0-3 sectors), moderate (4-6 sectors), large (7-9 sectors), or very large (10-12 sectors). According to their findings, the lower half of the cornea was the most frequently affected location.
Signs and Symptoms
Chandler classified RCE into two forms: (1) Microform erosions tend to be milder in symptoms and shorter in duration, but occur with increased frequency. (2) Macroform erosions can persist for days at a time, and are usually associated with a history of trauma.
- Mild to severe pain, particularly upon awakening
- Foreign body sensation
- Blurred vision
- Band kerathopathy
- Corneal ulcers (bacterial, fungal, or herpetic)
- Neurotrophic keratitis
- Corneal foreign body
- Limbal stem cell deficiency
- Corneal dystrophies (epithelial, stromal, or endothelial)
- Chemical and thermal burns
- Dry eye syndrome
- Floppy eyelid syndrome
- Salzmann’s nodular degeneration
RCE treatment may be either medical or surgical, and should be individualized for each patient dependent on slit lamp findings and clinical history. The primary goal is to facilitate reepithelialization and reestablishment of the basement membrane complex.
- Lubrication: As first line therapy or a mainstay of treatment in the prevention of RCE, the use of preservative-free artificial tears and ointment (hypertonic or paraffin) is recommended frequently during the day and before bedtime to keep the ocular surface moist. However, patients with ABMD have an increased risk of prophylactic failure. Autologous serum tears and cyclosporine 0.05% as second- line therapies in patients who failed lubrication and patching have been shown to be effective in preventing recurrences.
- Patching & cycloplegia: During acute episodes of corneal erosion, instillation of a topical cycloplegia with a temporary patch is effective in promoting healing of the ocular surface.
- Antibiotics and pain relievers: Topical antibiotics are commonly prescribed to prevent bacterial infections in patients with epithelial defects. Oral pain relievers such as ibuprofen may be helpful in reducing ocular discomfort during acute episodes.
- Inhibitors of matrix metalloproteinase-9 (MMP-9) & topical corticoesteroids: It has been reported that doxycycline, a MMP-9 inhibitor, in combination with topical corticosteroids, reduces the frequency of RCE. The recommended dose of doxycycline is 50 mg orally two times daily. Topical corticosteroids (methylprednisolone 1%, prednisolone acetate 1%, or fluorometholone 0.1%) can be used two or three times a day for 3 weeks.
- Bandage Contact Lens: A Hydrogel soft contact lens can be left in place while the epithelium heals and stabilizes. The provider should counsel the patient on the signs and symptoms of infection. Fraunfelder et al. reported that 75% of patients with RCE treated for three months with an extended- wear BCL remained recurrence free at one year. Topical antibiotic should be used as prophylaxis against infection.
- Punctal Occlusion: Punctal occlusion is safe, quick, and reversible, and helps increase retention of eyedrops on the ocular surface. Punctal occlusion can be considered in patients with dry eye syndrome. Temporary occlusion with collagen plugs, which usually dissolves in four to seven days, can be helpful. However, if the corneal erosion is chronic, permanent occlusion with silicon plugs is recommended. The patient should be aware that plugs may extrude or migrate over time.
- Anterior Stromal Micropuncture: Anterior stromal micropuncture is an 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 of loose epithelium. The use of cobalt blue light and fluorescein staining helps visualize the area of treatment. Nd:YAG laser micropuncture using 0.4mJ – 0.5mJ pulses, applied to the region of abnormal Bowman layer through an intact epithelium has also been described. Micropuncture treatment is thought to incite a fibrocytic response, resulting in stimulation of basement membrane production. Epithelial adherence is improved by scar tissue induction between the epithelium and the anterior stroma of the cornea. Zauberman et al. reported that the use of micropuncture with a 25- gauge needle had an effectiveness in 62.9% in eyes with RCE after a single treatment.
- Diamond Burr Polishing: Involves epithelial debridement with a cellulose sponge or blade and diamond burr polishing of Bowmans membrane. A bandage contact lens is then used for 4 -5 days along with a topical antibiotic and steroid.
- Excimer Laser Phototherapeutic Keratectomy (PTK): After removal of the central epithelium, an excimer laser is used to ablate the cornea uniformly, creating a ablation depth of 5–6um. In a study conducted by O'Brart, 73% of patients suffering from RCE reported resolution of their symptoms at their final visit.
- Corneal haze and scarring
- Infectious keratitis particularly in the setting of prolonged use of bandage contact lenses and topical steroids
- Decreased vision
With adequate treatment and prompt diagnosis, prognosis is excellent. Patients should be educated on the signs and symptoms of recurrent erosions so they can seek medical attention when appropriate. Prophylaxis treatment in patients with risk factors should be considered in order to minimize long-term complications.
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