Treatment of Recurrent Corneal Erosions

Ophthalmic Pearls

CORNEA

by raj thakrar, ms, and houman d. hemmati, md, phd edited by ingrid u. scott, md, mph, and sharon fekrat, md

ecurrent corneal erosion syndrome (RCES) is a common clinical disorder involving the corneal epithelium and epithelial base- Rment membrane. Characterized by the repeated breakdown of epithelium, RCES can cause moderate to severe eye pain, photophobia, lacrimation, and corneal scarring leading to visual changes. Patients are often debilitated by the resulting pain and visual defi- cits and frustrated by the condition’s lack of response to treatment. This review presents a spectrum of treatments for RCES, ranging CLASSIC PRESENTATION. A patient with recurrent corneal erosion syndrome. Epi- from simple medical management to sodes of corneal erosion arise from detachment of the epithelium from the under- complex surgical interventions. The lying epithelial basement membrane. stepladder approach will guide oph- thalmologists to individualize treat- condition, have an anterior epithelium mologists. There are many treatment ment, minimize iatrogenic risks, and that does not adhere well to the base- options for RCES, each of which has improve long-term outcomes. ment membrane due to morphological varying degrees of efficacy. Patients changes in the epithelial cells or base- must be assessed on a case-by-case ba- Etiology ment membrane matrix.1 This creates a sis so that treatment regimens are indi- In a study of 104 RCES cases, trauma loose epithelial layer prone to shifting vidualized. We have devised a manage- contributed to 45 percent, epithelial and tearing when damaged. ment algorithm for the treatment of basement membrane dystrophy (EBMD) Adhesions between the palpebral RCES (see “Treatment Algorithm for contributed to 29 percent, and a com- conjunctiva of the eyelids and the RCES”). bination of trauma and EMBD con- corneal epithelium in dry eye patients Medical. Medical treatment options tributed to 17 percent of cases.1 contribute significantly to RCES in should be explored before resorting to As a category, trauma includes me- many patients. Individuals with ocular more invasive surgical alternatives. chanical trauma to the corneal surface. rosacea are particularly at risk due to • Lubrication. This is considered The subsequent inflammation from meibomian gland dysfunction and re- first-line therapy, and we recommend these injuries can cause disruption sultant evaporative dry eye. frequent application of preservative- in the extracellular adhesion in the free artificial tears combined with a corneal epithelium. Matrix metallo Treatment Options lubricating ointment at bedtime (or proteinases have been implicated in Owing to the recurrent nature of this more frequently, as needed) to prevent degrading these scaffolding proteins, condition and its resistance to com- the eyelid from adhering to the corneal resulting in erosion.2 monly used therapies, patients often epithelium. For patients needing pain

Houman D. Hemmati, MD, PhD, and the Massachusetts Eye and Ear Infirmary Patients with EBMD, a congenital make repeated visits to their ophthal- relief, these agents may be chilled.

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For patients with chronic RCES, we recommend the nighttime application Treatment Algorithm for RCES of a prophylactic bland ointment, such as Refresh PM or Lacri-Lube, or hypertonic saline, such as Muro 128. For recovering patients whose epithelium is healing, we recommend bland ointment to prevent surface aggravation. • Antibiotics and pain relievers. For patients in the midst of an acute attack with an epithelial defect on examina- tion, we recommend an antibiotic- containing ointment, such as erythro- mycin or bacitracin, to retard bacterial infection, and oral NSAIDs, such as ibuprofen, for pain. Those with severe pain may be prescribed oral narcot- ics such as hydrocodone. Antibiotics and NSAIDs also are appropriate for chronic cases of RCES. • Punctal occlusion. For chronic dry eye patients whose RCES is resistant to lubrication alone, punctal occlusion may be performed. This simple, one-time intervention can promote more rapid healing and prevent further attacks by increasing the ocular surface residence time of both natural and exogenously applied tears. As a trial, especially in patients with mild to moderate dry eye, a dissolvable short- term collagen punctal plug may be used. However, in patients with severe tear film insufficiency, we recommend longer-term silicone punctal plugs. • Bandage soft contact lens. Patients who are unresponsive to lubrication or have large erosions may benefit from an extended-wear bandage soft contact lens (BCL), such as Focus Night & Day or Kontur, in the affected eye for two to eight weeks, with a prophylactic topical antibiotic, such as ofloxacin, applied twice a day.3 This intervention is particularly useful for patients in bination therapy with topical lubrica- period of almost two years. Both doxy- whom meibomian gland dysfunction tion, oral tetracyclines, and a topical cycline and methylprednisolone inhib- and ocular rosacea are not significant corticosteroid. In one retrospective it matrix metalloproteinase-9, which is contributing factors. In a small retro- study, seven patients who took 50 mg implicated in cleaving scaffolding pro- spective study, 75 percent of patients oral doxycycline twice daily and ap- teins in the corneal epithelial basement who underwent BCL placement had no plied a topical steroid such as methyl- membrane.2 This inhibition can aid recurrence of RCES symptoms for one prednisolone 1 percent twice or more the recovery and reattachment of the year after treatment.3 daily for three weeks demonstrated corneal epithelium following RCES. • Combination therapy. An alterna- marked improvement, including a de- We also recommend the frequent tive to BCL placement, particularly crease in pain, improvement in visual application of preservative-free arti- for patients with meibomian gland acuity, and no recurrence of RCES ficial tears during the day and bland dysfunction or ocular rosacea, is com- symptoms during a mean follow-up ointment or hypertonic saline oint-

40 march 2013 Ophthalmic Pearls ment at bedtime to promote recovery, 10 µm of Bowman’s layer after me- especially in patients with dry eye or chanical debridement of the overlying Coming in the next ocular rosacea. If this regimen fails, corneal epithelium. Like superficial surgery may be considered. keratectomy, this allows the cornea to Surgical. Due to the attendant risks, re-epithelialize with stronger adhe- surgery should be reserved for patients sion to the basement membrane. We who have failed aggressive medical recommend placement of a BCL and therapies. It should not be performed administration of topical antibiotics Feature as an initial form of treatment. and corticosteroids, such as fluoro- Clinical Trials: Conquering • Anterior stromal micropuncture. metholone acetate 1 percent, two to the Mountain of Evidence ASP may be considered for lesions out- four times daily after ablation. In a side the visual axis because it is a rapid retrospective study of 76 eyes, PTK was You want to base your treat- procedure that can be performed in used to treat RCES, with a recurrence ment decisions on strong evi- the office. Under a slit lamp, a bent 20- rate of 11 percent.5 dence but may lack the time to 25-gauge hypodermic needle is used We advise that all patients who are to keep up with all the studies. to make several punctures through the treated surgically be monitored post- Here are strategies and tools anterior corneal epithelium and Bow- operatively with a follow-up appoint- for applying research findings man’s layer and into the anterior stro- ment scheduled two to four weeks after ma. These micropunctures elicit a fi- the procedure. If symptoms have im- to clinical practice. brocytic response and rapid basement proved or are completely eliminated, membrane production, which anchor we recommend prophylactic treatment Clinical Update the corneal epithelium in place.4 with lubrication as described above Low Vision Microperimetry in It should be noted that ASP has to prevent a recurrence. If symptoms diagnosis and rehabilitation. fallen out of favor as a surgical treat- recur, oral doxycycline and topical ste- Refractive How to center ment for RCES in many practices, as it roids may be administered twice daily can cause scarring, glare, and blurred for two to three weeks. multifocal IOLs and implants. vision, and has a high failure rate in Retina Update on therapy for preventing further erosions. Conclusion dry AMD from the latest trials. • Debridement and superficial Several options exist for treating keratectomy. For patients with lesions RCES.6 However, the underlying con- Savvy Coder in the visual axis, debridement and dition, if overlooked, can result in Testing services—how MPPR superficial keratectomy may be per- recurrent erosions and debilitating impacts payment. formed with either a number 15 scalpel symptoms. Based on clinical evidence, or diamond burr. Although this is a combination therapy with oral tetra- relatively rapid outpatient procedure, cycline, topical corticosteroids, and Practice Perfect it is more invasive than ASP. Under lubrication is the most effective treat- How to integrate your imaging topical anesthesia, sterile forceps or ment for RCES. For severe and refrac- devices with your EHR. ophthalmic sponges are used to clear tory cases of RCES, superficial keratec- away the loose anterior epithelium. tomy and PTK may also be effective. Blink The surrounding epithelium is then Take a guess at the next debrided, leaving a rim of corneal epi- 1 Reidy JJ et al. Cornea. 2000;19(6):767-771. issue’s mystery image. thelium for re-epithelialization. The 2 Dursun D et al. Am J Ophthalmol. 2001; depth of the keratectomy should reach 132(1):8-13. the anterior portion of Bowman’s 3 Fraunfelder FW, Cabezas M. Cornea. 2011; layer. After surgery, a BCL should be 30(2):164-166. For Your Convenience placed until re-epithelialization has 4 Das S, Seitz B. Surv Ophthalmol. 2008; These stories also will be been achieved, with topical antibiotics 53(1):3-15. available online at applied up to four times daily. 5 Maini R, Loughnan MS. Br J Ophthalmol. www.eyenet.org. • Phototherapeutic keratectomy. 2002;86(3):270-272. This may be considered for patients 6 See treatment summary at www.eyenet.org. for whom all other treatments have FOR ADVERTISING INFORMATION failed. PTK is also indicated in patients Mr. Thakrar is a medical student and Dr. Mark Mrvica or Kelly Miller with macroerosions, which are often Hemmati is assistant professor of ophthalmol- M. J. Mrvica Associates Inc. associated with nondystrophic RCES ogy and surgery; both are at the University of 856-768-9360 following ocular trauma. In PTK, an Vermont in Burlington. The authors report no [email protected] excimer laser is used to ablate 5 to related financial interests.

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