April 2020

IN FOCUS

Therapeutic Refractive Corneal Surgery
Recurrent corneal erosion


by Chiles Samaniego Contributing Writer


Hereditary ABMD slit lamp image with map dot fingerprint aggregates
Source: John Sheppard, MD

 

Recurrent corneal erosion is so commonly encountered in the clinic that John Sheppard, MD, whose experience spans 4 decades, said to this day he sees cases daily.
EyeWorld reached out to Dr. Sheppard, Kathryn Hatch, MD, Russell Swan, MD, and Audrey Talley Rostov, MD, to share their experience and expertise on the symptoms, signs, and management of this condition.

Case profiles

All four doctors see recurrent corneal erosion cases, commonly associated with anterior/epithelial basement membrane dystrophy (ABMD or EBMD) and injuries, the latter typically “with organic material such as fingernails, plants or branches, and paper products such as envelopes,” Dr. Talley Rostov said. “The initial injury causes significant disruption on the epithelial and subepithelial layers of the cornea and heals with EBMD-like abnormality that easily sloughs when awakening in the morning and/or in dry conditions.”
She also cited cases of hereditary EBMD and, less commonly, younger patients with Meesmann or lattice corneal dystrophies.
Other situations where Dr. Sheppard said he sees recurrent corneal erosion include postoperative cases, dry eye patients, elderly patients, and swimmers.

Symptoms and signs

In terms of symptoms, patients “most commonly have a history of recurrent pain and light sensitivity upon awakening,” Dr. Swan said. “These episodes can last for a few seconds to several hours, depending on the size of the epithelial defect created.”
Dr. Hatch described the most typical symptom as a “ripping” sensation upon waking. She describes it to patients “like a rug that’s not tacked down to the next layer of the floor, so there’s a gap between the rug and the floor. The epithelium is not ‘tacked down’ to its underlying basement membrane, so when patients are sleeping and their eyes are closed, it’s that interaction between the eyelid and the epithelium.” When patients open their eyes, the eyelid rubs against the epithelium’s “rug” and “strips” it from the basement membrane “floor.” While minor cases will heal during the day, more debilitating cases can leave patients unable to open their eyes due to the pain and seeking consult with a doctor.
To this list of symptoms, Dr. Talley Rostov added epiphora and foreign body sensation that takes anywhere from a few hours to a few days to resolve.
On eye exam “the typical ABMD/EBMD- like changes are usually apparent,” she said.
Dr. Swan cited epithelial breakdown, typically in the interpalpebral zone, as the most common sign in acutely symptomatic patients. “For patients whose epithelial defect has already healed you may see some negative staining with fluorescein in the area of irregular healing epithelium,” he said. “In patients with EBMD, the classic epithelial irregularity and map dot fingerprint patterns of redundant epithelium will likely be visible.”

Nonsurgical treatment

Initial treatment of recurrent corneal erosion is nonsurgical. All the doctors use some combination of ocular surface lubrication with artificial tears or ointments, hypertonic drops, antibiotics, an anti-inflammatory agent, and bandage contact lens. In addition, Dr. Hatch often uses punctal occlusion to support the tear film. Dr. Swan also considers augmentation with punctal occlusion and would add inhibition of matrix metalloproteinase-9 (MMP-9) and environmental modification. Dr. Talley Rostov treats everyone for dry eye disease, using artificial tears and topical cyclosporine during the day and preservative-free ointment at night. She also considers hypertonic drops or ointments but doesn’t find them more helpful than regular tears.
Regarding the use of hypertonic drops, Dr. Sheppard noted that there are no non-preserved drop formulations available, limiting their usefulness for chronic, routine use in sensitive eyes. Muro 128 (sodium chloride hypertonicity ophthalmic solution, Bausch + Lomb) is available in a preservative-free 5% ointment, which many patients tolerate well, especially before bedtime, he said. Hypertonics are, however, “very useful for epithelial basement membrane disease, which produces poor adhesion of the epithelium to the underlying basement membrane,” he said. “When the epithelial cells slough off in that particular scenario, it becomes a suddenly acutely painful situation for the patient unless they are also neurotrophic. We find that hypertonic drops promote osmotic thinning of corneal epithelial cells and therefore the adhesion of these cells to the underlying basement membrane, thereby reducing the risk of epithelial sloughing creating symptoms and delaying healing.”
Dr. Sheppard follows a tiered approach that also guides his surgical management (see sidebar).

Surgical management

Dr. Hatch emphasized that she prefers to not perform a surgical procedure while a patient is suffering an acute attack, waiting until the tissues are not inflamed. Regarding surgical intervention, she does not perform anterior stromal micropuncture. All the doctors cited concern for scarring and limited results with the procedure; Dr. Sheppard called it a temporizing procedure at best.
Instead, Dr. Hatch opts for superficial keratectomy and, for refractory cases, phototherapeutic keratectomy (PTK). These are also Dr. Swan’s preferred surgical approaches, while Dr. Talley Rostov performs PTK for all cases needing surgical therapy. “PTK is 98% successful in my practice for eliminating recurrent corneal erosions,” she said. “It is a quick procedure and resolves the problem nicely.”
However, Dr. Sheppard noted that surgical therapy with PTK in his practice is generally unwarranted unless concomitant to a refractive procedure such as photorefractive keratectomy (PRK). “Removal of the surface epithelium in the office is simple with a spatula or Weck-Cel spear sponge,” he said. “In the ASC, cicatricial epithelial lesions or nodules are readily removed with the 64 Beaver blade. Excimer laser PTK is an expensive superfluous intervention that adds a cost to the overhead. If there are no scars or nodules, a small refractive error can also be corrected with an excimer PRK, which removes not only the central epithelium but the basement membrane and some anterior stroma. The refractive advantage is obvious, but the inability of PRK or PTK to reach all the way to the limbus may leave non-adherent epithelium and therefore a residual nidus for recurrence.”

Postoperative management

Postoperatively, Dr. Hatch said, “it’s important to make sure patients are comfortable.” She will prescribe pain medication as well as antibiotics and steroids. She also said she leaves the bandage contact lens on for about 2 weeks.
Dr. Swan’s short-term management for PTK includes 1 week of a broad-spectrum antibiotic with fluoroquinolone therapy four times a day and topical steroid four times a day for 1 week weaning to two times a day for 1 week. “Careful examination in the postoperative state is required to rule out steroid-induced ocular hypertension and to ensure a patient does not need longer steroid treatment for the cornea,” he said. “I also continue to emphasize to patients the importance of long-term ocular surface disease management to reduce the risk of recurrence.”
Dr. Sheppard also highlighted the importance of ocular surface management, stating that “appropriately aggressive management of concomitant ocular surface disease is warranted, addressing dry eye, allergy, and meibomian gland disease according to standard protocols.”
Dr. Talley Rostov’s postop care is similar to what she employs for PRK, with a bandage contact lens, antibiotics QID until the bandage lens comes off, tapering steroid doses, and NSAID drops. She has patients continue ointment at night when the bandage contact lens is removed and use topical cyclosporine and artificial tears.

Pearls

Dr. Swan thinks it is important to emphasize the chance of recurrence, even after surgical intervention, to patients. They need to know that ongoing monitoring is important, he said.
Dr. Sheppard detailed the importance of environmental control. “Most importantly, direct water into the eyes must be avoided, be it swimming, in the shower, or as a form of self-prescribed treatment,” he said. “The hypotonic water creates boggy epithelium through osmotic gradients, reducing adhesion to the underlying basement membrane, and a much higher likelihood of a new or recurrent erosion.
“Similarly, extremely low-humidity environments should be avoided, like fans, open windows, and fireplaces, especially at night,” he said. “Dust, toxic fumes, the abysmally low-humidity content of airplane air, or the continuous staring accompanying prolonged computer or cell phone use are all to be minimized.”
Dr. Sheppard also instructs patients to roll their globes around under the lids before opening their eyes upon awakening. This helps avoid sudden shear stress on the epithelium with exposure to a dry ambient atmosphere, he said. “So many attacks at night or first thing in the morning can be avoided by this simple self-lubricating maneuver.”
Dr. Hatch reminds doctors to listen to their patients. This is a painful condition, and a lot of patients are suffering, she said. It affects how she approaches these cases in the clinic. For instance, she’ll consider whether checking eye pressure is necessary. While it might be important when patients are on steroids, she won’t routinely applanate them, considering risk of causing a recurrence as well as the patient’s comfort.
“Patients don’t typically lose their vision from this condition, fortunately, but it’s important to take their concerns seriously,” she said.

At a glance

• Recurrent corneal erosion is commonly seen in clinics, associated with anterior/epithelial basement dystrophy and injury.
• Patients typically experience recurrent pain, particularly a “ripping” sensation when opening their eyes upon waking, and light sensitivity. Examination reveals epithelial breakdown, the typical changes of EBMD.
• Nonsurgical management involves ocular surface lubrication, hypertonic drops, anti-inflammatory agents, antibiotics, and a bandage contact lens.
• Removal of the surface epithelium can be done through office debridement. When surgical intervention is warranted, superficial keratectomy and phototherapeutic keratectomy seem to be preferred.
• Ocular surface management and environmental control are essential to prevent recurrence.

About the doctors

Kathryn Hatch, MD

Assistant professor
of ophthalmology
Harvard Medical School
Boston, Massachusetts

John Sheppard, MD
President
Virginia Eye Consultants
Norfolk, Virginia

Russell Swan, MD
Vance Thompson Vision
Bozeman and Billings, Montana

Audrey Talley Rostov, MD
Northwest Eye Surgeons
Seattle, Washington

Relevant disclosures

Hatch
: None
Sheppard: Allergan, AbbVie, Bausch + Lomb, Allysta, Oyster Point, Novartis, Shire, Novaliq, Aldeyra, Johnson & Johnson Vision, Mallinckrodt, Dompe
Swan: None
Talley Rostov: None

Contact

Hatch
: Kathryn_hatch@meei.harvard.edu
Sheppard: docshep@hotmail.com
Swan: Russell.swan@vancethompsonvision.com
Talley Rostov: atalleyrostov@nweyes.com

 

Dr. Sheppard’s three-tiered approach

There are three tiers of therapy for recurrent corneal erosion in Dr. Sheppard’s practice. He said the success rate with this protocol approaches 100% and prepares the patient’s topography for cataract biometry, penetrating keratoplasty, or refractive surgery, when indicated.

Tier 1

Dr. Sheppard starts with conservative, office management, consisting of hypertonic tears (5% sodium chloride) and a therapeutic bandage contact lens. Prior to placing the bandage contact lens, he assesses the epithelium with a dry Weck-Cel spear sponge and topical proparacaine. If the epithelium does not slide over the basement membrane, he doesn’t do any epithelial debridement.
After placing the bandage contact lens, he’ll consider a punctal plug to increase moisture during contact lens use. Dr. Sheppard carefully replaces the contact lens, if needed, on a monthly basis. Many patients resolve under this protocol over 1–3 months, he said.

Tier 2

An obvious epithelial defect requires a debridement, Dr. Sheppard said. He called patient comfort essential and said he will take anxious, blepharospasm, or vagal candidates to a minor procedure room to perform a superficial keratectomy while they are laying down with a lid speculum in place.
He said clinicians may be surprised at how loosely adherent epithelium often extends beyond the lesion all the way to the limbus, and frequently all is removed.
Dr. Sheppard said in addition to bandage contact lenses, cryopreserved, sutureless amniotic membrane (Prokera, BioTissue) can be beneficial. He said he’ll do a temporary tarsorrhaphy when using the amniotic membrane in some patients. He cautioned against using Prokera in patients with glaucoma shunts due to the potential for erosion of the tube from the product’s outer ring but said dried amniotic membrane (Katena) under the bandage contact lens could be used.
In general, while using the bandage contact lens, Dr. Sheppard provides a daily drop of azithromycin for antibiotic support and anti-collagenolytic effects. When the amniotic membrane is removed (5–7 days later), Dr. Sheppard said he keeps the patient in a bandage contact lens until fully healed.

Tier 3

Patients who reoccur or who have significant scarring, elevations, Salzmann’s nodules, fibrosis, or filamentary keratitis require a trip to the ASC, Dr. Sheppard said. He will use sedation and a retrobulbar block with cycloplegia to “enable a nearly pain-free postoperative course following extensive aggressive lamellar keratectomy, which may on not so rare an occasion create a miserable or even combative situation in the office.”
He patches these patients for a day, places a Prokera amniotic membrane in the office, leaves it for a week, and has them in a bandage contact lens (exchanged monthly for 3 months). These patients are on a topical antibiotic course, and rarely require oral analgesia beyond acetaminophen or naproxen.

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