Mornings are painful
enough. Imagine how
surprised and distraught
you’d feel if you woke up
with a severely painful eye accompanied by lacrimation, photophobia and blurred vision.
Your eye was fine the night
before, but as the fog of sleep
lifts, you realize that you’ve had
these symptoms before. Why—
and how— did they come back?
And, how can you get rid of this
problem for good?
This is recurrent corneal erosion (RCE) syndrome, one of
many ocular surface diseases that
can be chronic in nature, often
persisting for months to years.
Fortunately, several treatment
modalities can resolve this recalcitrant condition. This article discusses how RCE occurs and how
to treat it.
Recurrent corneal erosion syndrome is defined as the presence of
an epithelial defect that spontaneously recurs without obvious
cause. However, the condition often
can be traced to some earlier trauma, specifically a shearing-type
abrasion of the anterior corneal surface from a sharp edge of stationery, a tree branch or
a fingernail. Other possible origins include:
- Corneal surgery.
The area adjacent to an
incisional keratotomy or
the margin of a lamellar
flap may experience a
disruption of the basement membrane and
susceptible to infection.
- Anterior corneal
with conditions such as epithelial
basement membrane dystrophy
(EBMD), lattice dystrophy, Reis-Bückler’s dystrophy and granular
dystrophy have a greater risk of
- Diabetes mellitus. Recognized systemically as a basement
membrane disease, diabetes predisposes afflicted individuals to RCE as well.
|Evidence of lattice dystrophy associated with RCE.
The pathophysiology of RCE
suggests that the defect may penetrate the full thickness of the epithelium, including the basal lamina
and perhaps into Bowman’s layer.
The basement membrane then
becomes fragmented, folded, split
and reduplicated, causing the
epithelial cells to attach to loose
layers of basement membrane.
Tiny epithelial inclusion cysts are
then created by “confused” subgroups of basal cells that adhere to
free basement membrane. These
generate new basement membrane,
which curls inward and attaches to
itself. (Obviously, the combination
of ragged-instrument trauma and
an anterior corneal dystrophy is
While re-epithelialization typically occurs rapidly and completely
to protect the cornea from microbial assault, the basement membrane is incapable of such accelerated repair. Without competent
hemidesmosomes and anchoring
fibrils, the recovered epithelium
to repeated erosion.
upon awakening, as
the combination of
edema, the shearing
force of the eyelid,
and a thin pre-ocular tear film is too
great for the compromised adherence
|An eye with corneal stromal dystropy associated with RCE.
Notice the gray, granular leisions.
A small degree of
corneal edema is
typical in about 4%
of the normal population.1 This can
be explained largely by two physiological events. First, the active
transport pump mechanism of the
endothelium slows during sleep,
reducing its impact on maintaining
Second, eye closure during sleep
retards evaporation of the pre-ocular tear film; this can exacerbate the
problem. This effectively decreases
tear film osmolarity, diminishing
the osmotic effect on the semi-permeable epithelium.
Corneal abrasions are typically caused by the presence of a foreiegn body in the eye.
RCE can result if the abrasion does not properly heal.
Other factors in RCE include the
presence of corneal gutatta, Fuchs’
endothelial dystrophy, and more
superficial keratopathy related to
keratitis sicca, corneal exposure or
A history of contact lens use may further alter the corneal deturgescence process. Lens movement, surface quality, pervaporation and
permeability all can affect corneal
integrity. Lens care systems and
their interactions with various contact lens polymers have been implicated in corneal insult.2 Then again,
safe and compliant lens wear actually may enhance the ability of the
cornea to resist edema associated
with the closed eye state.3
All these influences on corneal
physiology explain the varied and
intermittent clinical course of RCE.
|An eye with Reis-Buckler’s dystrophy associated with RCE
before undergoing phototherapeutic keratectomy.
|The same eye following phototherapeutic keratectomy. Note
the less cloudy appearence of the sclera.
The Conservative Approach
A prudent approach to managing
RCE is to explore and exhaust conservative treatment as the initial
course of action. This includes:
- Thorough patient education. Most important, be sure the
patient continues and complies
with therapy for at least eight to
12 weeks, as further insult to the
recovering attachments prolongs
the treatment process.5
- Copious lubrication therapy
(every one to two hours while
awake). Systane LiquiGel (Alcon) is
a good choice because of its
propensity to bind to hydrophobic
corneal regions and adjust viscosity
to the pH of the particular ocular
environment. Other lubricating
agents may prove equally efficacious. This dosing frequency calls for
preservative-free, single-use ampules
to promote epithelial recovery.
- Use of a hyperosmotic ointment, such as Muro 128 5%
(sodium chloride, Bausch & Lomb), at bedtime. If you suspect
the patient has nocturnal lagophthalmos, recommend forced closure
with eye pads or hypoallergenic
tape applied to the lids. The hyperosmotic agent helps offset the
increase in stromal hydration
caused by epithelial compromise.
- Punctal occlusion, when appropriate, to maximize therapeutic efficacy. Occlusion of the lacrimal
passage can normalize the ocular
surface and pre-ocular tear film,
and maximize the efficacy of therapeutic adjuncts.
One precaution: The traumatized
epithelium may recruit cytokines
and other inflammatory mediators,
and occlusion may interfere with
their normal egress through the
canalicular system. This, in turn,
leads to an inflammatory assault on
the ocular surface.6 In short, punctal occlusion is likely to be beneficial in the absence of significant
ocular surface inflammation.
- Cycloplegia to manage ocular
discomfort. While repeated use of
topical anesthetics delays healing,
many patients seek relief from the
chronic discomfort associated with
RCE. The use of a cycloplegic, such
as homatropine 5% b.i.d., may
patients. If more
extensive treatment is necessary, an oral
Roche Pharmaceuticals) 10mg
q.i.d. limited to
five days maximum, is indicated to calm the discomfort.
|Punctal occlusion can assist in tear retention, which may prevent recurrence of RCE.
Corneal Pain and Repair
For most patients, pain is the deciding factor that leads them to seek immediate medical
care. While each of us has experienced pain to some degree, the sensation of pain is still
Recent evidence suggests a possible reason for the apparent disparity among individuals
in sensing pain. Neuroscientists at the University of Michigan have identified a gene that
leads to the production of catechol-O-methyltransferase, or COMT, the enzyme responsible
for metabolizing signal messenger dopamine in the brain.4 The process triggers increased
production of natural painkillers known as endorphins, which limits a person’s sense of pain.
This is of particular importance in the eye, as the corneal epithelium contains more terminal nerve endings than any other tissue in the body. The corneal nerve endings do not
reach the most superficial squamous cells; instead, they terminate in the wing cell layer. This
may explain the frequent lack of pain in very superficial corneal insults.
When evaluating the recovery of the disrupted epithelium, it helps to understand the
mechanism of corneal repair. In response to trauma, the corneal epithelium increases the
synthesis of an extracellular matrix, facilitating a chemotactic response. Epithelial growth
factor (EGF) and transforming growth factor-beta (TGF-ß) direct transient amplifying cells,
which arise from limbal stem cells, to proliferate at the wound margin. Stratification may
increase to a 20- to 50-cell layer thickness as mitosis accelerates, promoting migration
across the depths of the defect in an effort to bridge the erosion.
This process rapidly restores the barrier function of the corneal epithelium, providing protection from edema and microbial infection. Often, this process sufficiently allows the
episode to resolve on its own. Patients may simply tolerate the discomfort, refrain from seeking professional advice and self-medicate with topical non-prescription agents. While some
episodes may prove to be self-limiting, others clearly require attention due to their severity
|Anterior basement membrane dystrophy can often be a
predisposing factor for RCE.
Therapeutic bandage contact
lenses have been used to enhance
the effectiveness of more conservative therapy by controlling hydration, restoring comfort and
establishing a protective barrier to
the shearing forces of the eyelid. To
achieve these benefits, the patient
must follow a continuous-wear
schedule (with silicone hydrogel
contact lenses) for 10 to 12 weeks
My typical approach is to use a
PureVision (balafilcon A, Bausch &
Lomb) or a Focus Night & Day
(lotrafilcon A, CIBA Vision) lens on
a continuous-wear basis, taking
into account any refractive needs. I
have the patient return for re-evaluation and in-office lens replacement
every three to four weeks for a minimum of three cycles.
The proper fit should demonstrate subtle movement to meet
metabolic demands but should not
be so constrictive that it mechanically disrupts cellular repair. Careful inspection must reveal a
hydrated lens that is freely mobile
prior to the exchange.
If the ocular surface is irregular
without a true epithelial defect,
avoid prophylactic antimicrobials
with bandage lens therapy. If frank
defects are present, prescribe a fluoroquinolone-soaked bandage lens,
and instruct the patient to apply
one drop three times daily until the
defect closes. Monitor these individuals more regularly than the aforementioned three- to four-week
interval, perhaps every three to four
days until resolution.
Don’t forget to consider the
potential effect of antibiotics and any preservatives on the rate of
corneal healing. Topical antibiotics
by their very nature are toxic to the
corneal surface and therefore interfere with recovery. Preservative
agents compound this counterproductive effect and provide good reason to limit exposure to these
substances. Use non-preserved medications when possible.
|An example of a therapuetic bandage lens. Bandage leses help to control hyrdation and provide extra protection from the eyelashes.
Take note that the management
outlined above is not universally
accepted. One study found that use
of an NSAID combined with a bandage lens allowed for much quicker
recovery than use of a bandage lens
or NSAID alone.8 Another study,
however, determined that bandage
lens therapy was less effective than
topical medications and yielded a
higher complication rate.9
When treating patients, consider
the medicolegal ramifications of
off-label usage. Careful monitoring
and full patient disclosure are essential.
Other novel approaches have
expanded our management choices
for patients who suffer from RCE.
For many years, we have recognized the antimicrobial benefits of
oral tetracyclines (tetracycline,
doxycycline and minocycline) in the
treatment of ophthalmic chlamydial
infections. Cases of chronic posterior lid disease and meibomian gland
dysfunction respond well to this
class of antibiotics due to its positive effect on fatty acids and meibomian gland sebum.
Oral tetracyclines, along with
steroid therapy, appear to inhibit
matrix metalloproteinase (MMP), a
factor in inflammation.10 MMP facilitates extracellular matrix
deposition and degradation, and
elevated levels of MMP hinder
To investigate this, researchers at
the Ocular Surface and Tear Center
of the Bascom Palmer Eye Institute
in Miami reported on a series of
seven patients with RCE that
proved recalcitrant to conventional
therapy.10 Treatment was aimed at
counteracting MMP and consisted
of 50mg oral doxycycline b.i.d. for
two months along with a topical
steroid t.i.d. in the affected eye for
two to three weeks. All patients
experienced pain relief, and the
epithelial defects resolved within 10
days. There was no recurrence for the duration of the study.
|The Amoils epithelial scrubber is used to remove epithelium prior to
|Phototherapeutic keratectomy is a fairly agressive surgical treatment for RCE. The
procedure was performed on this eye a day earlier.
When more conventional efforts
fail, consider surgical options. Identify the area of involvement by careful
examination, and document with
photos, as available. This analysis
will determine the most appropriate
treatment to maximize the prognosis
for complete remediation.
Surgical treatment options for
- Superficial keratectomy. Epithelial debridement of the involved
area using a patent spatula aims to
remove basement membrane irregularities, necrotic cells and cellular
debris. The goal is to provide a
smooth surface that encourages
adherence of the basal epithelium.
This is accomplished quite effectively with the aid of a biomicroscope.
However, if your licensure does not
permit this procedure, it is wise to
refer the patient to a qualified
Anesthetize the cornea with several drops of proparacaine or tetracaine, and induce cycloplegia with
atropine 1.0% for postoperative
pain management. Position the
patient comfortably and securely
with the fellow eye gaze fixated.
Use a lid speculum to secure the
eyelids away from the treatment
field. Remove epithelium in a centripetal direction to limit treatment
to the compromised area, and remove
any loose or redundant tissue.
Alternatively, some practitioners
advocate phototherapeutic keratectomy (PTK) 5µm to 10µm deep in
the involved area to ensure a
smooth stromal bed and potentially
incite a more aggressive healing
response.11 (Again, access to these
excimer lasers and licensure constraints may require you to refer
Another alternative: One study
reported on the use of the Amoils
epithelial scrubber (AES) (Excimer
Solutions, Inc.) to perform a superficial keratectomy in 26 eyes of 23
patients.12 The AES is an electric
brush designed for removal of the
epithelium prior to photorefractive
keratectomy (PRK). At a mean follow-up of more than 21 months, as
many as 88% of patients were
Whichever variation of keratectomy you choose, you must first
irrigate the ocular surface thoroughly before performing the
procedure. Next, apply a bandage contact lens soaked in a
namely Vigamox (moxifloxicin
0.5%, Alcon) or Zymar (gatifloxacin 0.3%, Allergan). (Note
that Vigamox is preservative-free).
Discharge the patient with instructions to continue antibiotic use
three times daily in the treated eye.
Follow up with the patient in 24 to
48 hours as the defect resolves to
determine the next course of action.
|Anterior stromal micropuncture uses a bent 25-gauge needle to place several
closely spaced micropunctures into Bowman’s membrane.
- Anterior stromal micropuncture. This method employs a bent
25-gauge needle to place several
closely spaced micropunctures into
Bowman’s membrane.13 Reserve
stromal micropuncture for cases
that do not involve the visual axis,
as this procedure typically results in
subepithelial fibrosis that may
Micropunctures create foci of
firm collagenous attachment that
reach from the basement membrane
into the sub-Bowman’s stroma
within the region of poor epithelial
attachment. Think of it as spot
welding the epithelium to the anterior stroma. However, if the basement membrane is diseased, this
technique does nothing to remove it.
Prepare the patient for this procedure as described above. One difference, however: Micropuncture
does not require debridement of the
epithelial layer, but it should extend
slightly beyond the apparent area of
involvement. The treatment must
penetrate 45µm to 50µm into the
epithelium and 15µm to 20µm
through Bowman’s layer into the
Use of an Nd:YAG laser in place
of the 25-gauge needle has demonstrated favorable results.14 The goal
of these treatments is to incite a sufficient healing response that encourages a solid relationship between the
basal epithelium, basal lamina and
Bowman’s membrane and extends
into the anterior stroma.
A Stepwise Approach
- Patient education
- Copious lubrication therapy
- Hyperosmotic agents
- Bandage contact lens therapy
- Mechanical closure of eyelids q.h.s.
Moisture (swim) goggles
- Punctal occlusion
- Cycloplegia for pain management
- Superficial keratectomy
- Stromal micropuncture
- Alcohol delamination
- Alcohol delamination. Researchers in the United Kingdom
recently investigated the safety and
efficacy of alcohol delamination of
the corneal epithelium for recalcitrant RCE.15 They studied 20 eyes
of patients with RCE who remained symptomatic despite topical
lubrication and three months of
using an extended-wear bandage
contact lens. They treated patients
with alcohol delamination and followed up at one week, one month
and 12 months.
Symptoms resolved in 15 eyes
after one month of treatment.
Three eyes had significant reduction
of symptoms that were manageable
with topical lubricants, and two
eyes were lost to follow-up. There
were no failures or intraoperative
complications. The researchers concluded that alcohol delamination of
the corneal epithelium is a safe and
effective method for treating
patients with recalcitrant RCE.
There is some question as to
whether RCE syndrome is a focal
condition or a more diffuse, compromised adherence from limbus
to limbus, extending well beyond
the area apparent from biomicroscopic examination. There may be
logic in performing nearly total
epithelial debridement followed
by excimer ablation, particularly
in cases where subsequent satellite
areas of erosion were documented. This underscores the importance of careful documentation
early in the management process.
A recurrent corneal erosion can
be a painful, troublesome condition
that can create a substantial hardship for affected patients. Resolution of this chronic problem is
extremely gratifying for both the
patient and the doctor, and allows
patients to return to a normal
Dr. Ryan is in group practice in
Rochester, N.Y. He frequently lectures and publishes on anterior segment topics, and actively
participates as an FDA clinical
investigator for many contact lens