Recurrent Corneal Erosion

Recurrent corneal erosion (RCE) is repeated spontaneous breakdown of the corneal epithelium due to poor adhesion of the basal epithelium to Bowman layer.

• Post-traumatic (about 50 percent): fingernail, branch, paper or other abrasion, with abnormal hemidesmosome formation.
• Dystrophic: epithelial basement membrane (map-dot-fingerprint) dystrophy, Meesmann, Reis-Bucklers, lattice, granular and Fuchs dystrophies.
• Others: diabetes, previous refractive surgery, recurrent herpetic disease, ocular rosacea and meibomian gland dysfunction, dry eye, and exposure.
• Episodes usually come on waking or when opening the eyes in the morning, because the eyelid pulls off the loosely attached epithelium after prolonged closure and reduced overnight tear film.

• Sudden severe pain, foreign body sensation, tearing, photophobia and blepharospasm on waking in the early hours, in an eye that had an abrasion previously (weeks to years earlier).
• Slit lamp: epithelial defect or loosely adherent, irregular, oedematous epithelium, with negative staining areas; between episodes the cornea may be normal or have subtle map-dot-fingerprint changes.
• Resolution within hours to days, with a tendency to recur for months to years.
• Bilateral signs suggest a dystrophy.

• Characteristic history of early morning pain with prior injury; slit lamp with fluorescein during and between attacks (look for loose epithelium, basement membrane changes with retroillumination, and the fellow eye).
• Corneal topography and anterior segment OCT when planning laser.
• Exclude herpetic keratitis (dendrite, reduced sensation), infection, and exposure.
• Dry eye and meibomian gland assessment.

• Acute episode: topical lubricating ointment (paraffin or carbomer) every 2 to 3 hours, cycloplegic (cyclopentolate 1 percent twice daily for 2 to 3 days), topical antibiotic ointment (chloramphenicol 1 percent four times daily or erythromycin 0.5 percent), bandage soft contact lens for 1 to 4 weeks with antibiotic cover (moxifloxacin 0.5 percent four times daily), oral analgesia (paracetamol 1 g, ibuprofen 400 mg), and removal of loose epithelium. No topical anaesthetic for home use.
• Prevention (for at least 3 to 6 months, the epithelium takes 3 to 6 months to strengthen):
  • Lubricant drops during the day and ointment at bedtime, and 5 percent sodium chloride ointment at night.
  • Oral doxycycline 50 mg twice daily (or 100 mg daily) for 6 to 12 weeks with topical steroid (fluorometholone 0.1 percent or loteprednol 0.5 percent four times daily for 2 to 4 weeks, then taper) to inhibit matrix metalloproteinase-9 and promote adhesion.
  • Treat blepharitis and dry eye (warm compresses, lid hygiene, omega-3), and autologous serum for refractory cases.
  • Prolonged extended wear bandage contact lens for 2 to 3 months in recurrent disease.
• Procedural therapy for recurrences after medical treatment:
  • Epithelial debridement with diamond burr polishing of Bowman layer (about 90 percent success).
  • Anterior stromal micropuncture with a 23 to 25 gauge needle, for peripheral lesions (avoid the visual axis).
  • Phototherapeutic keratectomy with excimer laser for central, dystrophic or extensive disease (about 90 to 95 percent success, about 0.25 micrometres per pulse, to a depth of 5 to 10 micrometres, with hyperopic shift risk).
  • Alcohol delamination, superficial keratectomy, and amniotic membrane in selected cases.
• Counsel patients: do not rub the eyes, use lubricants long term, and seek review when symptoms start so treatment can begin early.