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Recurrent Erosion of the Cornea

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Recurrent Erosion of the Cornea Brit. J. Ophthal. (I976) 6o, 84 Br J Ophthalmol: first published as 10.1136/bjo.60.2.84 on 1 February 1976. Downloaded from Recurrent erosion of the cornea NICHOLAS BROWN AND ANTHONY BRON From the Institute of Ophthalmology, Judd Street, London In previous studies of superficial comeal disorders menstrual cycle and use of the contraceptive pill) and (Bron and Brown, 197I) and of superficial lines of details of the examination of both eyes, including lids, the cornea (Brown and Bron, I976), we were tear films, corneae, and anterior chambers. The comeae impressed by the frequency of recurrent erosion were then re-examined after staining with fluorescein In we have set out to and with bengal rose. The comeal signs were recorded of the cornea. this study with the Zeiss photo slit lamp and with the macro examine patients presenting with recurrent erosion camera (Brown, I970) at IO X magnification. of the cornea to establish the type and incidence Each patient was re-examined at least once after of the superficial corneal disorders, and to compare complete healing of the erosion and both corneae were this incidence with that in a control group of inspected for superficial dystrophies. The ocular ten- subjects. Some experience of management of sions were measured at this time. these patients is also reported. Despite the traditional name for the disorder, it is recognized that frank epithelial loss is not required to and methods establish the diagnosis and that focal epithelial oedema Material or bulla formation with or without a breach in the copyright. MATERIAL epithelium, and/or the presence of epithelial cysts, are Patients presenting at the Casualty Department at in keeping with the diagnosis when associated with the Moorfields Eye Hospital with suspected recurrent typical clinical history. The patients were classed as erosion of the cornea were referred by the casualty having either macroform or microform recurrent officers and examined by one of us. The patient was erosion by the criteria of Chandler (I945). Microform admitted to the study if the diagnostic criteria were recurrent erosion was recognized by intraepithelial satisfied. These criteria were: microcysts with a minor break in the epithelium (Fig. i). In macroform recurrent erosion, a large area of epithe- i. A history of initial trauma or abrasion followed by http://bjo.bmj.com/ a recurrence of pain with healing, followed by a lium was separated from the cornea (Fig. 2). clinical recurrence at the time of presentation and associated at some time with the clinical signs of TREATMENT AND FOLLOW-UP recurrent erosion. The initial treatment was decided by the Casualty 2. A typical clinical history of at least two attacks Officer and consisted of either chloramphenicol drops suggestive of recurrent erosion (pain on waking or chloramphenicol ointment with hyoscine 0 5 per or being awakened, difficulty in opening the eye cent drops, and padding for the eye. Patients with large lid, watering, light sensitivity), without a history bags of loose epithelium were treated initially by on September 26, 2021 by guest. Protected of trauma but associated with clinical signs of debridement, the loose corneal epithelium being care- recurrent erosion at some time. fully removed at the slit lamp with a Bard Parker no. I5 For each group, the clinical signs of recurrent erosion blade, using centripetal strokes to avoid stripping off could include not only frank epithelial loss, but also an unnecessarily large area of epithelium. The eye was focal epithelial oedema, epithelial bulla formation, and then treated with drops or ointment and padded as epithelial cyst formation in varying combinations. In above. this way, 8o patients were admitted to the study with Eyes which failed to heal on medical treatment and ages ranging from 24 to 73 years. produced redundant loose epithelium were debrided The control group consisted of 2oo patients aged as above. In those eyes which still failed to heal on this between 2o and 85 years, who had attended clinics at regime, the debridement was repeated and followed by were not Moorfields but complaining of any symptoms carbolization with IOO per cent phenol applied at the referrable to the cornea, and had no history of corneal slit lamp with a small stick to the dried cornea. Care disease. was taken to avoid carbolizing the pupillary area of the cornea, but the phenol was otherwise applied to as METHODS much of the affected area as possible. A proforma was completed for each patient; this con- Once healing was complete the patients were given tained a full clinical history (including details of the sodium chloride 5 per cent ointment to apply each evening immediately before going to bed. This treat- Address for reprints: N. Brown, Institute of Ophthalmology, Judd ment was continued for from 3 to i8 months. Treatment Street, London WCiH gQS of longer duration was given in patients who found that Recurrent erosion of the cornea 85 Br J Ophthalmol: first published as 10.1136/bjo.60.2.84 on 1 February 1976. Downloaded from they suffered relapses if they omitted to apply their ointment. Treatment was eventually withdrawn from all patients still attending at i8 months and the relapse rate was compared with that while on treatment. Results AGE AND SEX DISTRIBUTION (Table I) The age and sex distribution of the patients is shown in Table I, together with the incidence of macroform and microform recurrent erosion; it is common for both forms to occur in the same indi- vidual at different times (3I per cent of patients). Bilateral recurrent erosion is relatively uncommon (io per cent of patients). CAUSES OF INITIAL ABRASION (Table II) The initial abrasion was frequently spontaneous (40 per cent of patients) and the patient was unable to remember any trauma having preceded it. Of the identifiable causes (Table II), the most common a nail, scratches from a was a scratch by finger copyright. baby's finger being particularly prevalent among women. Among men, the causes were also related to their occupations, and metallic objects such as FIG. I Microform recurrent erosion. Macrophotograph screwdrivers were described as causative. Two by retroillumination. Bar gauge 500 [±m cases were seen after the removal of corneal foreign bodies. In the two hereditary cases the patients had no recollection of trauma. The microform type was the most common in http://bjo.bmj.com/ the spontaneous cases (Table II), whereas macro- form and combined macroforrn and microform erosions were more commonly of traumatic origin. In the eight bilateral cases trauma was reported Table I Age and sex distribution of 8o patients* on September 26, 2021 by guest. Protected Age group (years) No. of patients 21-30 13 3 I-40 22 41-50 22 5I-60 i8 6I + 5 At presentation (mean) 42 Percentage of women 48 men 52 Type of recurrent erosion No. Percentage Macroform only IO 13 Microform only 45 56 Both types in same individual 25 3' Bilateral cases 8 Io FIG. 2 Macroform recurrent erosion. Stained with fluorescein to show intraepithelial microcysts. Bar The youngest was 24, the eldest 73 years gauge Ioo .m 86 British Yournal of Ophthalmology Br J Ophthalmol: first published as 10.1136/bjo.60.2.84 on 1 February 1976. Downloaded from Table II Causes of abrasion in 8o patients give a clear history of being awakened by the pain and, in others, the pain occurred after waking. Abrasion No. Percentage An interesting symptom was difficulty in opening the lids; some patients needed to use their fingers Spontaneous 32 40 to open their eye, and this was commonly followed Finger nail I8 22 immediately by a recurrence. Animal claw 3 4 Precipitating factors were sought in the patient's Vegetable matter, for example, history, but none was elicited in 86 per cent. Eye twig I2 15 rubbing was admitted as a cause in io per cent Paper or card 7 9 Metallic object 5 6 and the use of barbiturates was implicated in 3 Corneal foreign body 2 per cent. These patients experienced recurrences Contact lens I whenever they resumed taking barbiturates. Altogether 23 menstruating women were studied, Relation of Percentage Percentage and in only one of these was there a clear history erosion of of of recurrences related to the time of onset of each type to No. traumatic No. spontaneous menstruation. trauma cases cases The general health of the patients appeared to be unrelated; the only finding which was any Macroform in way consistent was that of a history of atopy alone 8 10 2 3 in Microform 5 per cent. A family history suggesting dominant alone 20 25 25 31 inheritance of recurrent erosion was obtained in Combined two patients (3 per cent). form 20 25 5 6 The frequency of recurrence was very variable, ranging from a minor recurrence each morning to major recurrences separated by many months. The copyright. Table III Recurrences in 8o patients frequency of recurrence varied between patients and at different periods in the same individual. Time of recurrence Percentage The recurrences lasted from i to 4 hours in the microform condition, and from i to 2i days in the At about the time of waking 76 macroform condition, which included two cases in Before waking (awakened by pain) 30 which the healing was delayed by a secondary After waking 40 bacterial infection. Difficulty in opening the eye IO http://bjo.bmj.com/ At other times of the day 24 SYMPTOMS (Table IV) Precipitation The symptoms of recurrence (Table IV) are largely as anticipated. Blurring of vision Nil 86 varied Eye rubbing IO from absent or minimal in many eyes with micro- Barbiturates 2-5 form erosion to severe in macroform erosions.
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