Current Concepts in the Management of Recurrent Corneal Erosions

Renée Solomon, MD · Henry D. Perry, MD · Eric D. Donnenfeld, MD

None of the authors has a proprietary or financial interest in any material or method mentioned.

Etiology and Symptoms

Secondary clinical etiologies include organic mechanical trauma (fingernails, paper), surgery, miscellaneous disorders (diabetes, dermatological diseases) or chronic corneal edema, from pseudophakic bullous keratopathy or Fuchs' dystrophy, in which there is abnormally reduced adhesion of the epithelium to the basement membrane and Bowman's membrane.¹

Refractive surgery including laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) can induce or precipitate symptoms of recurrent corneal erosions.^2-3 Surgeons must minimize epithelial damage to prevent recurrent corneal erosions after LASIK. Adequate irrigation of the corneal surface immediately before the microkeratome pass and careful attention to flap epithelium during flap replacement reduce epithelial damage.²

Symptoms suggestive of mild recurrent erosions after refractive surgery include sharp pains, the sensation of the eyelid's sticking to the eyeball, and soreness of the eyelid to touch, the latter a previously unrecognized symptom of this condition. These symptoms occurred commonly after excimer laser procedures but were significantly more common, more severe, and more prolonged after PRK.³ We believe LASIK should be avoided in patients with epithelial basement membrane dystrophy.

The injury secondary to corneal trauma usually heals quickly without evidence of damage. However, it is well known that injuries associated with carbon-based moieties such as a child's fingernail

Contributing factors to recurrent erosions include dry eyes, blepharitis, external disease, and tear film abnormalities (Slide 3). The pathophysiology of recurrent

Activity of gelatinase (MMP-2 and MMP-9) is upregulated in corneal epithelial specimens of patients with recurrent corneal erosions.^5-6 During wound healing, the epithelial basement membrane is altered by gelatinases, which cleave collagen types IV, V, VII and X.^5,6

Immunolocalization studies suggest that MMP-2 is concentrated in basal epithelial cells where it may play an important role in degradation of the epithelial

Symptoms of recurrent corneal erosions include the acute onset of nocturnal pain, pain on awakening, accompanied by photophobia, lacrimation, and conjunctival injection. Extent and severity vary with the individual episodes. There may be a history of similar episodes in the same eye.

Slit Lamp Examination

During an acute attack, signs on slip lamp examination may show increased areas of epithelium in the involved area. Although no epithelial defect may be present, pooling of fluorescein over the affected area may be noted. In addition, slit lamp examination using retroillumination may demonstrate subtle corneal irregularities.

Careful examination of the contralateral eye may aid in the distinction between post-traumatic erosion and dystrophic erosion in a patient who has no evidence or history of superficial trauma.

Medical and Surgical Management of Recurrent Erosions

Ocular lubricants are the standard treatment for recurrent corneal erosion. Loose flaps of epithelium should be removed before prescribing lubricants. In some dystrophic cases, reduplicated basement membrane can be scraped off before lubricant treatment is resumed. In some patients, pressure patching may decrease the pain. Loose corneal epithelium that impedes healing should be debrided.

After the episode subsides, lubrication such as artificial tears and artificial tear ointment may be applied to prevent mechanical epithelial trauma from the eyelids. Lubrication should be continued for 3 to 6 months after an erosion.

Hypertonic saline (5% sodium chloride) drops or ointment may be applied if a patient has a recurrence while using artificial tears and ointment. Hypertonic agents may transiently produce an osmotic gradient, drawing fluid from the epithelium, and may promote the adherence of epithelial cells to the underlying tissue. Brown and Bron⁹ reported the benefit of using long-term topical 5% NaCl ointment (18 months) for clinical improvement in patients with recurrent erosions.

Where these measures fail, other treatment modalities may be used including application of a therapeutic contact lens, or more invasive procedures such as anterior stromal puncture, diamond burr polishing, superficial scraping with a Bard-Parker blade (Becton Dickinson, AcuteCare, Franklin Lakes, NJ) or a 57 Beaver blade (Becton Dickinson, AcuteCare, Franklin Lakes, NJ), and excimer laser phototherapeutic keratectomy (PTK).¹⁰

The choice of treatment may be affected by:

• Etiology
• Location of disease (axial or off-axis)
• Coexisting ocular diseases
• Individual patient reliability
• Availability of equipment

The therapeutic contact lens has a role in the management of difficult post-traumatic cases in which the lesion is axial. The use of such a lens in dystrophic cases is often not effective, and these cases may be most effectively treated with PTK. If a contact lens is used, then the lens should be fit tight and the physician and patient should be aware of the risk of microbial keratitis. The ideal lens should have a flat base curve and high oxygen transmissibility (Dk).^11-14

In patients with recurrent corneal erosions who were unresponsive to conventional medical therapies, therapy with a combination of medications that inhibit metalloproteinase-9 produced

With corneal erosions recalcitrant to all medical therapies, aggressive intervention may be necessary. Anterior stromal micropuncture may be indicated in patients with recurrent erosions secondary to trauma.¹⁵

The ophthalmologist uses a 25-gauge needle to make superficial puncture wounds in the involved area (Slide 9, Slide 10, Slide 11).¹⁵ These wounds produce a firm adhesion between the epithelium and the underlying stroma.

In patients who have a basement membrane disorder, epithelial debridement is the recommended procedure. After application of topical anesthetic,

After debridement, a patient is prescribed topical antibiotics, cycloplegic drops, and bandage contact lenses until re-epithelialzation has occurred. A large diamond burr can be used to polish Bowman's membrane after debridement. This method cleans Bowman's membrane resulting in a fresh substrate onto which the epithelium can regrow and create attachment complexes.

Excimer laser PTK has been shown to be beneficial for the management of epithelial dystrophies and recurrent erosions.16-18 PTK is

This technique permits the precise removal of adherent abnormal basement membrane and allows new epithelium to adhere on fresh substrate. The minimal ablation depth usually results in an insignificant refractive shift. However, in myopic patients, PTK may be combined with PRK. The rate of recurrence of erosions in epithelial basement membrane disease treated with PTK is low during a 12-month follow-up period¹⁹ and repeat PTK has been shown to be effective for repeat episodes.¹⁹

Evaluation of corneal topography, including the surface regularity index (SRI) and surface asymmetry index (SAI) may aid in choosing the appropriate management of recurrent corneal erosions. The SRI is calculated from a summation of local power fluctuations along 256 equally spaced meridians. The SRI rises with increasing irregular astigmatism and approaches zero for a smooth corneal surface. The SRI shows local fluctuations in corneal power.

The SAI is a centrally weighted summation of differences in corneal power between corresponding points 180° apart on 128 equally spaced meridians. The SAI approaches zero for a perfectly radially symmetrical surface and increases as the corneal shape becomes more asymmetrical.²⁰

Evidence of an irregular topography suggests a corneal scraping so that the epithelium has a chance to grow back and smooth out the surface. Significant improvement in topography and vision may be seen after epithelial scraping. Evidence of a regular topography would be an indication for an anterior stromal puncture rather than a corneal scraping.

Summary

Recurrent corneal erosions may be difficult to treat, recalcitrant, and chronic. Many options for treatment are available ranging from artificial tear lubrication and bandage contact lenses to more aggressive management including anterior stromal puncture and PTK. Further research in this area is necessary to develop prophylaxis against future episodes of recurrent erosions in patients.

References

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