Natural history of recurrent erosion syndrome--a 4 year review of 117 patients

Transepithelial phototherapeutic keratectomy for treatment-resistant recurrent corneal erosion syndrome

BACKGROUND

To evaluate the efficacy and safety of trans-epithelial phototherapeutic keratectomy (TE-PTK) as a treatment for recurrent corneal erosion syndrome (RCES) in patients with symptoms refractory to conventional treatments.

METHODS

All patients who received TE-PTK treatment for RCES had failed 3 or more conventional treatments and were reviewed, and if met criteria, approved by healthcare workers of the British Columbia public health authority (Medical Services Plan (MSP). A retrospective chart review and telephone survey were conducted at the Pacific Laser Eye Centre (PLEC). Exclusion criteria were ocular co-morbidities potentially affecting treatment efficacy.

RESULTS

This study included 593 eyes of 555 patients (46.2% male; 50.9 ± 14.2 years old) who underwent TE-PTK. The leading identified causes of RCES were trauma (45.7%) and anterior basement membrane dystrophy (44.2%). The most common pre-PTK interventions were ocular lubricants (90.9%), hypertonic solutions (77.9%), and bandage contact lenses (50.9%). Thirty-six eyes had undergone surgical interventions such as stromal puncture, epithelial debridement, or diamond burr polishing. Post-PTK, 78% of patients did not require any subsequent therapies and 20% required ongoing drops. Six patients (1.1%) reported no symptom improvement and required repeat TE-PTK for ongoing RCES symptoms after initial TE-PTK. All 6 eyes were successfully retreated with TE-PTK (average time to retreatment was 11.3 ± 14.9 months). There was no significant difference in best corrected visual acuity pre- vs. post-operatively. The mean post-operative follow-up was 60.5 months (range: 5-127 months).

CONCLUSION

TE-PTK has a good efficacy and safety profile for treatment-resistant RCES. The third-party public health-reviewed nature of this study, the low recurrence rate of RCES, and the low PTK retreatment rate suggest that TE-PTK might be considered for wider use in the management of RCES.

The incidence and prevalence of recurrent corneal erosion syndrome in London, UK

BACKGROUND

Recurrent corneal erosion syndrome (RCES) is caused by repeated episodes of corneal epithelial breakdown due to improper adherence of the corneal epithelium to the underlying basement membrane. The most common aetiologies are corneal dystrophy or previous superficial ocular trauma. The incidence and prevalence of the condition is currently unknown. This study aimed to determine the incidence and prevalence of RCES within the London population over a 5-year period in order to better inform clinicians and evaluate how this condition affects ophthalmic service provision.

METHODS

A retrospective cohort study over a 5-year period reviewed 487,690 emergency room patient attendances at Moorfields Eye Hospital (MEH) London between 1 January 2015 and 31 December 2019. MEH caters for a local population comprising of around ten regional clinical commissioning groups (CCGs). The data for this study were collected using OpenEyesTM electronic medical records including demographics and comorbidities. The CCGs encompass 41% (3,689,000) of London's total 8,980,000 inhabitants. Using these data the crude incidence and prevalence rates of disease were estimated with results reported per 100,000 population.

RESULTS

Out of 330,684 patients, 3623 patients were given a new diagnosis of RCES by the emergency ophthalmology services, and from these, 1056 patients attended outpatient follow-up. The crude annual incidence of RCES was estimated at 25.4 per 100,000, with a crude prevalence rate of 0.96%. There was no statistical difference in annual incidence across the 5-year period.

CONCLUSIONS

The period prevalence of 0.96% shows that RCES is not uncommon. There was also a stable annual incidence over the 5-year period, showing no changing trend over the study period. However, identifying the true incidence and period prevalence is a challenging task, as minor cases may heal prior to examination by an ophthalmologist. It is highly likely that RCES is underdiagnosed and therefore underreported.

Safety and Efficacy of the Phototherapeutic Keratectomy for Treatment of Recurrent Corneal Erosions: A Systematic Review and Meta-Analysis

BACKGROUND

Phototherapeutic keratectomy (PTK) has been increasingly used to treat severe recurrent corneal erosion syndrome (RCES) patients who do not respond to other treatments. However, the efficacy and complication of each study are currently uncertain due to varying rates.

OBJECTIVES

The objective of this study was to investigate the safety and efficacy of the PTK for recurrent corneal erosions.

METHODS

This article performed a systematic literature research in Cochrane, Embase, PubMed, Scopus, and the Web of Science for the literature on PTK treatment of RCES until December 20, 2022. The extracted data including recurrence rate and the adverse event rate were used for meta-analysis.

RESULTS

The recurrence rate was 18% (95% CI, 13%-24%) (129/700 eyes). Subgroup analysis showed that the RCE recurrence was 17% (95% CI, 9%-24%) after trauma and 22% (95% CI, 11%-32%) in the corneal dystrophy group. Treatment-related adverse events included subepithelial haze, hyperopic shift, and decrease of the best spectacle-corrected visual acuity. In this study, the incidence of these events was 13% (95% CI, 6%-21%), 20% (95% CI, 11%-28%), and 11% (95% CI, 5%-16%), respectively.

CONCLUSIONS

PTK represented a valuable treatment option for patients with recurrent corneal erosions, especially those with traumatic injuries, which had minimal side effects.

Safety and Efficacy of Hypertonic Sodium Chloride 5% Ointment for Recurrent Corneal Erosion Syndrome

Background In this study, we aimed to assess the safety and efficacy of hypertonic sodium chloride 5% ointment in the treatment of recurrent corneal erosion syndrome (RCES). Methodology A total of 21 eyes from 21 patients with RCES either following trauma or spontaneously due to underlying anterior basement membrane dystrophy (ABMD) were prospectively enrolled over a six-month period. The acute episode was managed with topical sodium chloride 5% ophthalmic ointment applied twice daily for 30 days. Patients were followed up at one month and six months with visual acuity and endothelial cell count (ECC) measurement. Results The mean age was 44.19 years (range = 17-87 years). All patients had unilateral involvement. The etiology was ABMD in 12 cases, while nine cases were post-traumatic. The mean best-corrected visual acuity (BCVA) at presentation was 0.32 logMAR units (SD = 0.18), and the mean ECC before treatment initiation was 2,720 cells/mm² (SD ± 192). At the one-month follow-up, all patients had a full recovery with complete re-epithelization of the defective area and resolution of symptoms. The mean BCVA was 0.05 logMAR units (SD = 0.12), and the mean ECC was 2,703 cells/mm² (SD = 205). At six months, only one recurrence was documented following another episode of trauma. The mean BCVA and ECC at six months were 0.01 logMAR units and 2,714 cells/mm², respectively. Conclusions Sodium chloride 5% ophthalmic ointment applied twice daily for 30 days following the acute event seems to be a safe and effective treatment option for RCES from both traumatic and ABMD etiology.

Equine Umbilical Cord Serum Composition and Its Healing Effects in Equine Corneal Ulceration

Background

Human autologous serum (AS) and umbilical cord serum (UCS) both contain growth and neurotrophic factors that promote corneal healing.

Aim

Our objectives were to compare equine AS and UCS cytokine and growth factor profiles and to assess the safety and clinical feasibility of the therapeutic use of UCS eye drops in cases of spontaneous complex ulcers.

Study Design

Prospective clinical trial.

Methods

Vitamin A insulin growth factor, platelet-derived growth factor-BB, transforming growth factor (TGF)-β1 (enzyme-linked immunosorbent assay), interleukin (IL)-1β, IL-6, interferon-γ, and monocyte chemoattractant protein 1 concentrations were determined in 10 AS collected from different horses and 10 UCS sampled at delivery. Six client-owned horses presenting with complex non-healing corneal defects of >5 mm² were included in a clinical trial and treated with conventional therapy and conditioned UCS drops for 8–15 days. Ulcer surface and time to complete epithelialization were recorded.

Results

Median concentrations of vitamin A, insulin growth factor, and platelet-derived growth factor-BB were not significantly different in AS compared with UCS (respectively, 14.5 vs. 12.05 μg/ml; 107.8 vs. 107.3 pg/ml; and 369.1 vs. 924.2 pg/ml). TGF-β1 median concentration in UCS was significantly higher than in AS (3,245 vs. 2571pg/ml) (p = 0.04). IL-1β, IL-6, interferon-γ, and monocyte chemoattractant protein 1 concentrations were variable in AS and undetectable in UCS. The corneal median ulcerative area was 37.2 mm² (6.28–57.14 mm²) and had a duration of 4–186 days (median 19 days). All lesions healed within 13–42 days (median 17 days). No adverse effects nor recurrences within 1 month were noticed.

Limitations

The sample size was small. Spontaneous corneal epithelial defects presented with variable clinical characteristics. There were no age-matched control horses to assess corneal healing time and rate.

Conclusion and Clinical Significance

Equine UCS may be beneficial, as it contains no pro-inflammatory cytokines and a greater concentration of TGF-β1 compared with AS. Topical UCS appears safe and may potentially be used as adjunctive therapy for equine complex non-healing ulcers.

Phototherapeutic keratectomy versus epithelial debridement combined with anterior stromal puncture or diamond-dusted burr for treatment of recurrent corneal erosions

OBJECTIVE

To compare outcomes of phototherapeutic keratectomy (PTK) versus epithelial debridement combined with anterior stromal puncture (ASP) or diamond burr for the treatment of recurrent corneal erosions (RCES) in a large tertiary centre.

METHODS

Patients with a diagnosis of RCES secondary to trauma or epithelial basement membrane dystrophy who underwent a surgical procedure between 2009 and 2019 were included in the study. The following data were collected: demographics, ocular history, prior medical treatment, ocular surgeries, intervention, complete epithelialization at postoperative week 1, recurrences, and complications. Recurrence was defined as either an objective finding of a corneal epithelial defect or symptoms suggestive of recurrent epithelial erosion on history. Recurrence rate and time to epithelialization were compared between groups.

RESULTS

A total of 97 eyes (73 patients) were included in the study. Mean patient age was 51 ± 16.1 years, and mean follow-up was 474 days. RCES was secondary to epithelial basement membrane dystrophy in 80% (n = 78 of 97), trauma (15%, n = 15 of 97), or idiopathic (4%, n = 4 of 97). Epithelial debridement with ASP was performed in 34 eyes (35%), diamond burr in 33 eyes (33%), and PTK in 30 eyes (31%). Compared with epithelial debridement with ASP (recurrence 29.4%), the recurrence rate was significantly lower for both the diamond burr (9.1%, p = 0.031) and PTK groups (10%, p = 0.048). The diamond burr and PTK groups also had a significantly higher rate of complete epithelialization at 1 week (p < 0.05).

CONCLUSION

Compared with epithelial debridement with ASP, diamond burr and PTK have significantly lower rates of recurrence and time to epithelialization and may be considered first for surgical management of RCES.

Preclinical Studies of a Novel Microfabricated Device to Treat Corneal Epithelial Disease

PURPOSE

Anterior stromal puncture is an inexpensive technique for treating recurrent corneal erosions but is often ineffective and cannot be used in the optical axis because of scarring. These studies tested a novel microfabricated imprinting instrument to assess its potential efficacy for the treatment of corneal epithelial disease in the optical axis.

METHODS

The device is made using glass rods, bundled and drawn through multiple iterative cycles, and then fused under high heat to generate a solid rod comprised of many parallel, aligned, cladded fibers. The rods are sliced into discs and then etched to yield designable spikes based on the borosilicate composition of the glass.

RESULTS

Imprinting the cornea yields a regular pattern of imprints. Histologic studies showed both nonpenetrating stable deformations of Bowman layer, with formation of stable epithelial attachments, and full thickness penetration, with superficial ingrowth of the basal epithelium.

CONCLUSIONS

Microimprinted corneal tissue shows focal subepithelial scarring without evidence of optically evident anterior stromal scarring, and may be an effective way of treating recurrent corneal erosions in the optical axis, which is not currently possible using standard anterior stromal puncture methods.

[Recurrent corneal erosion: modern view of the problem]

Recurrent corneal erosion syndrome (RCES) is a common chronic disease associated with repeated episodes of epithelial disruption and is characterized by sudden onset of sharp pain in the eye, usually at night or upon waking, as well as redness, photophobia and lacrimation. The cause of the disease is considered to be impaired adhesion of the epithelial layer to the stroma, which is a consequence of abnormal regeneration of the basement membrane of corneal epithelium. A number of biological factors, including inflammatory mediators and proteinases in high concentrations, contribute to the destruction of the formed adhesion complexes. The basis of RCES diagnosis is characteristic medical history and biomicroscopy. An area of epithelium absence can be detected under direct illumination - more often in paracentral view - mainly in the lower third of the cornea, where an area of loose and irregular epithelium with microcysts or grayish inclusions can be seen. There may also be a card-like or «fingerprint» pattern. First of all, it is necessary to differentiate RCES from infectious lesions, which require a fundamentally different treatment regimen. It is believed that the first stage of treatment should include lubricants, drugs that promote epithelialization, inhibitors of matrix metalloproteinases and lipases. The «second line» of conservative treatment can include blood derivatives. If conservative therapy is ineffective, it is advised to use phototherapeutic keratectomy (PTK) or perform diamond burr polishing of Bowman's layer. The choice of a method for treating recurrent erosion should be based on the effectiveness of drug therapy, frequency of recurrence, duration of the disease, severity of clinical symptoms, availability of specific ophthalmic equipment and experience with it.

Corneal Sensitivity and Tear Function in Recurrent Corneal Erosion Syndrome

Purpose

To determine the association of corneal sensitivity and tear functions on the prognosis of eyes after posttraumatic recurrent corneal erosion syndrome (RCES).

Methods

Patients were enrolled retrospectively and had unilateral RCES and a history of ocular surface trauma. A corneal sensitivity test and tear function test (tear break-up time and Schirmer test) were performed at three time points (month 1 to month 3, month 3 to month 6, and month 6 to month 12). Depending on the number of recurrences during the follow-up, patients were divided into group A (n > 2) or group B (n = 2). A comparison between diseased and normal fellow eyes in each patient was performed.

Results

A total of 31 patients were enrolled and divided into group A (n = 14) and group B (n = 17). The mean age was 40.3 ± 12.2 years, whereas the mean follow-up was 28.0 ± 3.6 months. During the study period, corneal sensitivity, tear break-up time, and the Schirmer test results were all lower in diseased eyes than in normal fellow eyes in both groups. Compared to the first time point, recovery of corneal sensitivity and the Schirmer test values were observed in diseased eyes in group B at the second and third time points.

Conclusions

Poor corneal sensitivity and tear function are associated with posttraumatic RCES. Recovery of corneal sensitivity and tear function may be associated with a reduction of recurrence in eyes with posttraumatic RCES.

Efficacy of a Topical Heparan Sulfate Mimetic Polymer on Ocular Surface Discomfort in Patients with Cogan's Epithelial Basement Membrane Dystrophy

Purpose: Treatment of persistent ocular discomfort in patients with Cogan's epithelial basement membrane dystrophy (EBMD) is a challenge for ophthalmologists. This study aimed to determine the efficacy of a topical heparan sulfate mimetic polymer (HSMP) in reducing ocular discomfort in EBMD patients. Methods: This retrospective, noninterventional study included 22 consecutive patients in 3 tertiary ophthalmological units with spontaneous, recurrent, acute ocular pain, resistant to various topical lubricants. After EBMD diagnosis, HSMP treatment was initiated while lubricating eye drops were continued. The main study outcome was the change in ocular discomfort assessed using the ocular surface disease index (OSDI) from initiation of treatment to last follow-up visit. Results: The mean OSDI decreased from 46.7 ± 22.3 to 31.6 ± 17.4 (P < 0.001) at first visit and 32.5 ± 17.9 (P < 0.01) at last visit. The rate of patients with severe ocular surface disease (OSDI >33) decreased from 68.2% to 36.4% at first visit and 42.9% at last visit. After a median follow-up of 8.5 months, 7 (31.8%) patients discontinued the HSMP treatment due to a marked improvement in ocular surface comfort and no recurrence of ocular pain, 5 (22.7%) due to lack of efficacy, and 1 (4.5%) due to an ocular adverse event (not treatment related). Eight patients continued treatment after the last visit and 1 patient was lost to follow-up. Globally, HSMP prevented acute painful episodes in 11 (61.1%) of 18 patients followed for ∼4 months. Conclusions: Topical HSMP may be an option for alleviating ocular discomfort in patients with EBMD resistant to standard symptomatic treatments.

Recurrent corneal erosion syndrome

Recurrent corneal erosion syndrome (RCES) is a disorder characterised by a dysfunctional epithelial ecosystem. It often begins after trauma, or in the setting of epithelial basement membrane degeneration or dystrophy. Historically, RCES has been understood as a structural derangement of the anterior corneal architecture. More recently, studies have demonstrated the important role of neuropeptides in corneal homoeostasis. Thus, RCES may also be understood as a disorder of corneal epithelial cell biology. Management of RCES can be challenging, but newer therapies have demonstrated improved efficacy for this condition. This review examines the aetiology and pathogenesis of RCES, and provides an update on current and emerging treatment modalities for the management of this disorder.

Interventions for recurrent corneal erosions

BACKGROUND

Recurrent corneal erosion is a common cause of disabling ocular symptoms and predisposes the cornea to infection. It may follow corneal trauma. Measures to prevent the development of recurrent corneal erosion following corneal trauma have not been firmly established. Once recurrent corneal erosion develops, simple medical therapy (standard treatment) may lead to resolution of the episode. However, some people continue to suffer when such therapy fails and repeated episodes of erosion develop. A number of treatment and prophylactic options are then available but there is no agreement as to the best option. This review version is an update to the original version published in 2007 and a previous update published in 2012.

OBJECTIVES

To assess the effectiveness and adverse effects of regimens for the prophylaxis of further recurrent corneal erosion episodes, the treatment of recurrent corneal erosion and prophylaxis of the development of recurrent corneal erosion following trauma.

SEARCH METHODS

We searched CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; MEDLINE; Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov and the ICTRP. The date of the search was 14 December 2017.

SELECTION CRITERIA

We included randomised and quasi-randomised trials that compared a prophylactic or treatment regimen with another prophylaxis/treatment or no prophylaxis/treatment for people with recurrent corneal erosion.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. Two authors independently screened search results, extracted data and assessed risk of bias in the included studies using the Cochrane tool for assessing risk of bias. We considered the following outcome measures: resolution of symptoms after treatment; recurrence after complete or partial resolution; symptoms (pain); adverse effects (corneal haze, astigmatism). We graded the certainty of the evidence using GRADE for the three most clinically relevant comparisons.

MAIN RESULTS

We included eight randomised and two quasi-randomised controlled trials in the review, encompassing 505 participants. Seven studies were from Europe (Germany, Sweden and the UK), two from East Asia (Hong Kong and Japan) and one from Australia. Nine of the studies examined treatments for episodes of recurrent corneal erosions and one study considered prophylaxis to prevent development of recurrent corneal erosions after injury. Two of the nine treatment studies also enrolled participants in a study of prophylaxis to prevent further episodes of recurrent corneal erosions. The studies were poorly reported; we judged only one study low risk of bias on all domains.Two studies compared therapeutic contact lens with topical lubrication but one of these studies was published over 30 years ago and used a therapeutic contact lens that is no longer in common use. The more recent study was a two-centre UK study with 29 participants. It provided low-certainty evidence on resolution of symptoms after treatment with similar number of participants in both groups experiencing resolution of symptoms at four months (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.62 to 1.53). There was very low-certainty evidence on recurrence after partial or total resolution at seven months' follow-up (RR 1.07, 95% CI 0.07 to 15.54). There was no evidence of an important difference in pain score (score of 3 in the contact lens group and score of 2 in the topical lubrication group, low-certainty evidence) and no adverse effects were reported. The older study, using a contact lens no longer in common use, found an increased risk of pain and complications with the contact lens compared with hypromellose drops and paraffin ointment at night.A single-centre, Australian study, with 33 participants, provided low-certainty evidence of an increased risk of recurrence with phototherapeutic keratectomy compared with alcohol delamination but with wide confidence intervals, compatible with increased or decreased risk (RR 1.27, 95% CI 0.48 to 3.37). Time to recurrence was similar in both groups (6.5 and 6 months, low-certainty evidence). On average people receiving phototherapeutic keratectomy reported less pain but confidence intervals included no difference or greater pain (mean difference (MD) -0.70, 95% CI -2.23 to 0.83, low-certainty evidence). No adverse effects were reported.A 48-participant study in Hong Kong found recurrences were less common in people given diamond burr superficial keratectomy after epithelial debridement compared with sham diamond burr treatment after epithelial debridement (RR 0.07, 95% CI 0.01 to 0.50, moderate-certainty evidence). The study did not report pain scores but adverse effects such as corneal haze (RR 0.92, 95% CI 0.06 to 13.87, low-certainty evidence) and astigmatism (0.88 versus 0.44 dioptres, moderate-certainty evidence) were similar between the groups.A study comparing transepithelial versus subepithelial excimer laser ablation in 100 people found low-certainty evidence of a small increased risk of recurrence of corneal erosion at one-year follow-up in people given the transepithelial compared with subepithelial technique, however, the confidence intervals were wide and compatible with increased or decreased risk (RR 1.20, 95% CI 0.58 to 2.48, low-certainty evidence). Other outcomes were not reported.Other treatment comparisons included in this review were only addressed by studies published two decades or more ago. The results of these studies were inconclusive: excimer laser ablation (after epithelial debridement) versus no excimer laser ablation (after epithelial debridement), epithelial debridement versus anterior stromal puncture, anterior stromal puncture versus therapeutic contact lens, oral oxytetracycline and topical prednisolone (in addition to 'standard therapy') versus oral oxytetracycline (in addition to 'standard therapy') versus 'standard therapy'.

AUTHORS' CONCLUSIONS

Well-designed, masked, randomised controlled trials using standardised methods are needed to establish the benefits of new and existing prophylactic and treatment regimes for recurrent corneal erosion. Studies included in this review have been of insufficient size and quality to provide firm evidence to inform the development of management guidelines. International consensus is also needed to progress research efforts towards evaluation of the major effective treatments for recurrent corneal erosions.

[SEM visualization of corneal epithelium through lanthanoid staining based on Ca/Nd isomorphous substitution in Ca-dependent molecular systems]

Cumulative biomicroscopic evidence is usually sufficient for the diagnosis of recurrent corneal erosion or bullous keratopathy, however, exploration of the disease pathogenesis requires subcellular-level visualization of corneal structure. In the current study, lanthanoid staining and scanning electron microscopy were employed to visualize quite a number of structures responsible for epithelium organization. In particular, the study proves possible the use of Ca/Nd isomorphous substitution at Ca2+ sites of cytoadherence proteins for visualization of corresponding cellular structures.

AIM

To assess the value of information provided by scanning electron microscopy of corneal epithelium that involves lanthanoid staining based on the Ca/Nd isomorphous substitution in Ca-dependent molecular systems.

MATERIAL AND METHODS

Anterior corneal epithelial scrapes were obtained from patients with recurrent corneal erosion or bullous keratopathy and cadaver eyes with no signs of any ophthalmic disease. Samples were then studied under a scanning electron microscope (Zeiss EVO LS10, BSE, EP - 79 Pa, 20-28 kV, Ln-staining with the BioREE assay kit).

RESULTS

In all cases, lanthanoid staining of biopsy material provided high-contrast SEM images with well-recognizable structural and ultrastructural elements associated with Ca2+ sites of cytoadherence proteins.

CONCLUSION

Lanthanoid staining of biopsy material and subsequent SEM enabled detailed visualization of structural features of the corneal epithelium in various pathologies. Due to the Ca/Nd isomorphism we were able to evaluate structural position of the majority of protein molecules engaged in Ca-dependant processes and, consequently, in cytoadherence. Basing on the neodymium distribution within the basal membrane, we have described local effects of different substances on the lamina densa in the projection of basal layer cell borders that occur after unidirectional ultrafiltration. The results confirm the failure of the junctional adhesion complex in recurrent corneal erosion.

Treatment of nonhealing corneal ulcers in 60 horses with diamond burr debridement (2010-2013)

OBJECTIVE

To review the signalment, clinical characteristics, and outcome of horses with nonhealing corneal ulcers treated with diamond burr debridement (DBD); and to evaluate the role of ulcer duration, size and location, and bandage contact lens (BCL) placement on healing.

ANIMALS

From January 2012-April 2013, 60 horses were diagnosed with ulcers classified as nonhealing based on the presence of raised epithelial margins and duration of at least 7 days.

PROCEDURE

Retrospective record review.

RESULTS

Average age of included horses was 14.68 years, SD 8.17 years. There were three times as many males (45) as females (15), (χ12 = 15, P = 0.001). Forty-eight horses (80%) had nonhealing ulcers uncomplicated by associated corneal disease. In the remaining horses, associated corneal disease included esinophilic keratitis (10%), calcific band keratopathy (5%), endothelial decompensation (1.67%), habronemiasis(1.67%), and lid suture abrasion (1.67%). Average corneal ulcer duration prior to diamond burr debridement (DBD) was 29.0 days (n = 56). Ulcers occurred most commonly in the axial cornea (41%). Fifty-five of 60 horses (92%) healed with DBD. Healing time, defined as time to epithelialization following DBD, averaged 15.5 days, SD 9.32 days, and was not correlated with patient age or ulcer duration, location, or size prior to or following DBD. Healing time was significantly longer for eyes in which a BCL had been placed (n = 28, 19.0 days) than for eyes without a BCL (n = 32, 12.9 days), F(1,58) = 5.543, P = 0.02. DBD was considered a failure for five horses (8%).

CONCLUSIONS

DBD may be an effective treatment for nonhealing corneal ulcers in horses.

Anterior stromal puncture for the treatment of recurrent corneal erosion syndrome: patient clinical features and outcomes

PURPOSE

To evaluate the clinical features and outcomes of patients with recurrent corneal erosion syndrome who underwent anterior stromal puncture.

STUDY DESIGN

Retrospective, nonrandomized, consecutive case series.

METHODS

Database search of patients from 2003-2013 who underwent anterior stromal puncture was conducted at a tertiary care hospital cornea clinic. Charts of 30 patients (35 eyes) were reviewed. Outcome measures included demographics, laterality, history of corneal trauma, prior ocular history, frequency and duration of symptoms, failed treatments, signs on examination, degree of symptom resolution, additional treatments needed, and complications.

RESULTS

Mean patient age at presentation was 37 (± 11.5 SD) years, 60% were male. A total of 83.3% of patients had unilateral and 16.7% had bilateral involvement. In all, 62.9% of eyes had prior history of corneal trauma and 2.9% had prior laser-assisted in situ keratomileusis. Ninety-seven percent of eyes had symptoms of pain upon awakening refractory to conservative treatment. In 97% of eyes, there were findings of microcysts, fingerprint lines, loose epithelium, and/or faint scars. Mean follow-up was 14 months (range: 3-120 months). At final follow-up, 62.9% of eyes were symptom free and 37.1% experienced milder episodes. Seventeen percent required additional treatment: 16.6% superficial keratectomy, 66% repeat anterior stromal puncture, and 16.7% phototherapeutic keratectomy. No complications were observed.

CONCLUSION

Anterior stromal puncture using a short (5/8 inch) 25 gauge bent needle is a simple, safe, and cost-effective procedure for symptomatic relief in patients with recurrent corneal erosion syndrome refractive to conservative measures. Repeat treatment may be performed prior to additional surgical intervention.

Demographic patterns and treatment outcomes of patients with recurrent corneal erosions related to trauma and epithelial and bowman layer disorders

PURPOSE

To evaluate demographics and outcomes of patients with recurrent corneal erosions related to trauma and epithelial and Bowman layer disorders.

DESIGN

Retrospective case series.

METHODS

setting: Wills Eye Institute, Philadelphia, Pennsylvania. study population: Two hundred seventy-two eyes (230 patients) presenting between 2008 and 2011 with recurrent corneal erosions related to trauma and epithelial and Bowman layer disorders. procedure: Conservative management, diamond burr polishing, excimer laser phototherapeutic keratectomy (PTK), and epithelial debridement alone. main outcome measure: Recurrence of erosions, more than 6 weeks after commencing treatment.

RESULTS

Mean age was 46.5 ± 14.6 (2-85) years. Female subjects accounted for 53% of patients and 18.3% had bilateral involvement. Etiology included epithelial basement membrane dystrophy in 52.9% (144/272) and trauma in 25.7% (70/272). One hundred sixty-six eyes with more than a single visit were initially managed conservatively, 68 of 166 (40.9%) had diamond burr polishing, 7 of 166 (4.2%) had PTK, and 4 of 166 (2.4%) had epithelial debridement alone. Many eyes had >6 weeks follow-up: 120 of 166 (72.3%) after conservative management, 54 of 68 (79.4%) after diamond burr polishing, 7 of 7 (100%) after PTK, and 4 of 4 (100%) after epithelial debridement. Percentage of eyes with recurrence was 56.7% (68/120) after conservative management, 14.8% (8/54) after diamond burr polishing, and 28.6% (2/7) after PTK. Rate of recurrence (eye-years) was 0.74, 0.19, and 0.23 with conservative management, diamond burr polishing, and PTK, respectively. Mild haze was seen in 22.2% of eyes (12 eyes) after diamond burr polishing and 28.6% (2 eyes) after PTK.

CONCLUSION

Recurrent corneal erosions are most commonly associated with epithelial basement membrane dystrophy. Patients are generally initially managed conservatively, with recurrence in more than half of eyes. Diamond burr polishing is the most common surgical intervention and is effective in a majority of eyes.

Recurrent Corneal Erosion Syndrome

Recurrent corneal erosion syndrome is characterized by repeated episodes of sudden onset of pain usually upon awakening or at night because of detachment of the weakly adhered corneal epithelium. Most of the cases can be attributed to trauma or superficial corneal dystrophies. Because of the variable clinical course, the disease causes much frustration to patients and to the ophthalmologists. Treatment options range from conservative management with lubricants, bandage contact lenses, and matrix metalloproteinase inhibitors to surgical interventions such as epithelial debridement, anterior stromal puncture, alcohol delamination, and excimer laser therapy.

Interventions for recurrent corneal erosions

BACKGROUND

Recurrent corneal erosion is a common cause of disabling ocular symptoms and predisposes the cornea to infection. It may follow corneal trauma. Measures to prevent the development of recurrent corneal erosion following corneal trauma have not been firmly established. Once recurrent corneal erosion develops simple medical therapy (standard treatment) may lead to resolution of the episode. However, some patients continue to suffer when such therapy fails and once resolved further episodes of recurrent erosion may occur. A number of treatment and prophylactic options are then available but there is no agreement as to the best option.

OBJECTIVES

To assess the effectiveness and safety of prophylactic and treatment regimens for recurrent corneal erosion.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (January 1946 to June 2012), EMBASE (January 1980 to June 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to June 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 13 June 2012. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised and quasi-randomised trials that compared a prophylactic or treatment regimen with another prophylaxis/treatment or no prophylaxis/treatment for patients with recurrent corneal erosion.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality. We contacted study authors for additional information.

MAIN RESULTS

Seven randomised and one quasi-randomised controlled trial were included in the review. The trials were heterogenous and of poor quality. Safety data presented were incomplete. For the treatment of recurrent corneal erosion, a single-centre trial in the UK with 30 participants showed that oral tetracycline 250 mg twice daily for 12 weeks or topical prednisolone 0.5% four times daily for one week, or both, in addition to standard treatment, accelerated healing rates and improved symptoms. A single-centre trial in Sweden with 56 participants showed that excimer laser ablation in addition to mechanical debridement may reduce the number of erosions and improve symptoms. Furthermore, in a single-centre trial in Germany with 100 participants, transepithelial technique for excimer laser ablation had the same efficacy as the traditional subepithelial excimer laser technique but caused less pain. In a small study of 24 participants in UK, therapeutic contact lens wear was inferior to lubricant drops and ointment in abolishing the symptoms of recurrent corneal erosion and had a high complication rate, although the contact lenses used were the older generation with low oxygen permeability. A recent study in Hong Kong with 48 participants found diamond burr polishing to reduce episodes of recurrent corneal erosion. For prophylaxis of further episodes of recurrent corneal erosion, there was no difference in the occurrence of objective signs of recurrent erosion between hypertonic saline ointment versus tetracycline ointment or lubricating ointment in a small Japanese study with 26 participants. Also, in a single-centre study in the UK with 117 participants, there was no difference in symptom improvement between hypertonic saline versus paraffin ointment when used for prophylaxis. In a UK study with 42 participants, lubricating ointment at night in addition to standard treatment to prevent recurrence following traumatic corneal abrasion (erosion) caused by fingernail injury led to increased symptoms of recurrent corneal erosion compared to standard therapy alone.

AUTHORS' CONCLUSIONS

Well-designed, masked, randomised controlled trials using standardised methods are needed to establish the benefits of new and existing prophylactic and treatment regimes for recurrent corneal erosion. International consensus is also needed to progress research efforts towards evaluation of the major effective treatments for recurrent corneal erosions.

Recurrent erosion syndrome--the patient's perspective

AIM

The purpose of this study was to investigate the symptomatic effect of bandage contact lens (BCL) wear along with regular lubrication for the treatment of recurrent erosion syndrome (RES) resistant to simple measures alone (lubrication, artificial tears, or ointment). A patient satisfaction questionnaire assessed the longer term impact on RES symptoms and recurrence rate following the period of BCL wear.

METHOD

A retrospective case note review of all patients presenting with RES to a regional Ophthalmology department and referred for therapeutic BCL fitting over a one year period. An audit of 50 clinical records was performed and a patient satisfaction questionnaire survey completed before, during and following treatment.

RESULT

Thirty four patients responded to a satisfaction questionnaire which was sent to the fifty patients identified with RES. These patients were identified over a one-year period and all had been treated with BCLs. The predominant RES symptoms were pain (n=31), photosensitivity (n=5) and reduced vision (n=4). The majority of patients (n=30) felt that RES significantly affected their professional or social life. The average duration of BCL wear for RES was 6 months (range 2-15 months). On completion of treatment 79% (27/34) of patients felt that overall there had been some improvement in their RES symptoms, and 13 of these patients defined this improvement as being "cured".

CONCLUSION

Overall we found that RES patients were satisfied that BCL wear was beneficial in relieving their RES symptoms. The predominant symptom of RES was ocular pain. No patient developed a sight threatening complication secondary to BCL wear.

Long-term follow up of autologous serum treatment for recurrent corneal erosions

PURPOSE

The aim of the study was to evaluate long-term results of autologous serum treatment for recurrent corneal erosions.

METHODS

In this prospective single-centre study, 33 eyes of 33 patients (21 male and 12 female) were treated with autologous serum eye drops for recurrent corneal erosions. Mean age of the patients was 49.3 ± 9.8 standard deviation (range 24-73) years. All subjects had failed to respond to other treatments. Autologous serum drops were administered for a 6-month period: six times daily for the first 3 months and four times daily for the remaining 3 months. Detailed informed consent was obtained from the entire patient group before the study.

RESULTS

The mean follow-up period was 30 ± 6.3 standard deviation (range 12-48) months. None of the patients experienced a recurrence while under treatment. Twenty-eight patients (85%) had complete healing of erosions with no relapses of the disease over the whole follow-up period. Five patients (15%) presented a single recurrence 3-12 months after the end of the treatment. No sight-threatening complications were reported over the follow up. There was no statistically significant difference in the best spectacle-corrected visual acuity values (t(stat) = 2.1, F = 0.096, degree of freedom = 40,166, P < 0.41) or in the intraocular pressure measurements (P < 0.38) between the pre- and post-treatment patient groups.

CONCLUSIONS

Autologous serum drops proved to be a safe and efficient treatment modality for patients with recurrent corneal erosion syndrome as observed through a long-term follow up.

Dystrophia Helsinglandica: a new type of hereditary corneal recurrent erosions with late subepithelial fibrosis

PURPOSE

To describe the phenotype of an autosomal-dominant corneal dystrophy with an early onset of recurrent corneal erosions and development of subepithelial fibrosis in the cornea, and also to exclude genetic linkage to known corneal dystrophies with autosomal-dominant inheritance and clinical resemblance.

METHODS

We describe the medical history and clinical findings in individuals from a seven-generation family with recurrent corneal erosions. A total of 43 individuals were evaluated by ophthalmological examination. Genomic DNA was prepared from peripheral blood and polymorphic microsatellite markers were analysed to study haplotypes surrounding genes causing corneal dystrophies with similar phenotypes.

RESULTS

Erosive symptoms usually lasted for between 1 and 10 days. By the age of 7 almost all of the affected individuals suffered from recurrent corneal erosions. The attacks generally declined in frequency and intensity from the late 20s, but all examined individuals had developed subepithelial fibrosis by the age of 37. The fibrosis generally started in the mid periphery and was followed in some family members by central fibrosis and the development of gelatinous superficial elevations. Only a marginal reduction of visual acuity was seen in a few individuals. The affected individuals did not share haplotypes for genetic microsatellite markers surrounding genes that are known to cause autosomal-dominant corneal dystrophies.

CONCLUSION

We describe a new type of autosomal-dominant corneal disorder with recurrent corneal erosions and subepithelial fibrosis not significantly affecting visual acuity.

A new corneal disease with recurrent erosive episodes and autosomal-dominant inheritance

PURPOSE

The aim of this study was to characterize the phenotype in a large family with autosomal-dominant recurrent corneal erosions, and also to exclude genetic linkage to known autosomal-dominant inherited corneal dystrophies with clinical resemblance.

METHODS

We describe the medical history and clinical findings in patients from a six-generation family with recurrent corneal erosions. A total of 28 individuals were evaluated by ophthalmological examination. Genomic DNA was prepared from peripheral blood and analysed with polymorphic microsatellite markers close to known genes causing autosomal-dominant corneal dystrophies.

RESULTS

The patients had erosive symptoms that usually lasted from 1 to 7 days. The symptoms were described as early as at 8 months of age, and by the age of 5 the majority of the affected individuals suffered from recurrent corneal erosions. The attacks generally declined in frequency and intensity with age, and 52% of the patients developed central keloid-like corneal opacities. Nine patients received corneal grafts, and recurrences were seen in all grafts. The affected patients did not share haplotypes for genetic microsatellite markers surrounding known genes causing autosomal-dominant corneal dystrophies.

CONCLUSION

We describe a new hereditary disease with recurrent corneal erosions. Attacks of symptoms similar to recurrent erosions dominate the phenotype, but half of those affected also developed corneal, keloid-like, central opacities. This disorder was not genetically linked to any clinically resembling corneal dystrophies with autosomal-dominant inheritance.

Expression of matrix metalloproteinase 2 and 9 in experimentally wounded canine corneas and spontaneous chronic corneal epithelial defects

PURPOSE

To determine matrix metalloproteinase (MMP) 2 and MMP 9 expression in acute and chronic experimentally wounded canine corneas and keratectomy samples from canine patients with spontaneous chronic corneal epithelial defects (SCCEDs).

METHODS

Mechanical debridement was performed unilaterally in 25 healthy dogs for the acute wound study. Twenty-four hours (n = 8), 48 hours (n = 5), 72 hours (n = 3), or 1 week (n = 9) after wounding, the dogs were euthanized. Debridement was performed once weekly for 8 weeks for the chronic study (n = 8). Therapeutic superficial keratectomies (n = 16) were performed on SCCED patients. Gelatin zymography and immunohistochemistry were performed.

RESULTS

Acute wounds showed upregulation of MMP 9 at all time points. At 7 days after wounding, values diminished markedly but remained elevated above those of unwounded controls. SCCED and chronic wound samples showed a significant increase in MMP 9 compared with controls but were less than that of acute wounds. There was no significant difference between chronic wounds versus SCCED samples. Fellow control eyes showed significant upregulation of MMP 9 in tandem with wounded eyes. There was no significant difference in values for MMP 2 in wounded corneas or SCCED compared with those of controls. Immunhistochemistry localized MMP 9 to predominantly the epithelium with some staining of keratinocytes and stroma.

CONCLUSIONS

The dog exhibits similar MMP expression during corneal wound healing to that of other species. The lack of significant difference in MMP expression between SCCED and chronic wounds suggest that MMP 2 and 9 are not involved in the pathophysiology of SCCED and are more likely altered secondary to a chronic epithelial defect.

Interventions for recurrent corneal erosions

BACKGROUND

Recurrent corneal erosion is a common cause of disabling ocular symptoms and predisposes the cornea to infection. It may follow corneal trauma. Measures to prevent the development of recurrent corneal erosion following corneal trauma have not been firmly established. Once recurrent corneal erosion develops simple medical therapy (standard treatment) may lead to resolution of the episode. However some patients continue to suffer when such therapy fails and once resolved further episodes of recurrent erosion may occur. A number of treatment and prophylactic options are then available but there is no agreement as to the best option.

OBJECTIVES

To assess the effectiveness and safety of prophylactic and treatment regimens for recurrent corneal erosion.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE and LILACS in June 2007. The NRR was searched in April 2005. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised and quasi-randomised trials that compared a prophylactic or treatment regimen with another prophylaxis/ treatment or no prophylaxis/ treatment for patients with recurrent corneal erosion.

DATA COLLECTION AND ANALYSIS

Both authors independently extracted data and assessed trial quality. We contacted study authors for additional information.

MAIN RESULTS

Five randomised and one quasi-randomised controlled trial were included in the review. The trials were heterogenous and of poor quality. Safety data presented were incomplete. For the treatment of recurrent corneal erosion there was limited evidence that oral tetracycline 250 mg twice daily for 12 weeks or topical prednisolone 0.5% four times daily for one week or both in addition to standard treatment; and excimer laser ablation in addition to mechanical debridement may be effective. Therapeutic contact lens wear was inferior to lubricant drops and ointment in abolishing the symptoms of recurrent corneal erosion and had a high complication rate. For prophylaxis of further episodes of recurrent corneal erosion there was no difference in the occurrence of objective signs of recurrent erosion between hypertonic saline ointment versus tetracycline ointment or lubricating ointment. Lubricating ointment at night in addition to standard treatment following traumatic corneal abrasion (erosion) caused by fingernail injury to prevent recurrence led to increased symptoms of recurrent corneal erosion compared to standard therapy alone.

AUTHORS' CONCLUSIONS

Well-designed masked randomised controlled trials using standardised methods are needed to establish the benefits of new and existing prophylactic and treatment regimes for recurrent corneal erosion.

Spontaneous chronic corneal epithelial defects in dogs: a review

Spontaneous chronic corneal epithelial defects (SCCEDs) in dogs are typically found in middle-aged dogs of all breeds. These epithelial defects may be present for weeks to months, particularly if left untreated or if treated inappropriately. Typical histopathological findings include loss of the corneal epithelial basement membrane and formation of a superficial, acellular, hyalinized zone in the stroma. Together, these histological abnormalities lead to delayed wound healing and poor epithelial adhesion. Epithelial debridement, anterior stromal puncture, grid keratotomy, and superficial keratectomy are the most common treatment options applied to the defects. Procedures that address the stromal changes present generally have a higher success rate than epithelial debridement alone.

Epithelial Basement Membrane Dystrophy

PURPOSE

To describe corneal changes in patients with epithelial basement membrane dystrophy (EBMD) using a new in vivo confocal microscope.

DESIGN

Observational case series.

METHODS

A retrospective chart review of 22 consecutive patients with EBMD at the Quinze-Vingts National Ophthalmology Hospital from April 2004 to March 2005 was conducted. Gender, age, history of painful episodes suggestive of recurrent erosions, best-corrected visual acuity, slit lamp findings, and in vivo confocal microscopy images were analyzed.

RESULTS

There were 8 male (36.4%) and 14 female (63.6%) subjects. Eighteen patients (81.2%) had a history of recurrent erosions in 1 or in both eyes. In 37 eyes of 19 patients (86.4%), map and/or dot and/or fingerprint changes were observed biomicroscopically. In 3 patients (13.6%) with recurrent erosions, the cornea had a normal structure on slit lamp examination and the diagnosis of EBMD was made after in vivo confocal microscopy examination. Four patients (18%), despite basement membrane abnormalities, reported no corneal symptoms suggesting recurrent erosions. In vivo confocal microscopy images showed that all patients had an abnormal epithelial basement membrane protruding into the corneal epithelium, epithelial cell abnormalities, and microcysts. No abnormalities were observed in superficial epithelial cells or the stroma.

CONCLUSION

Epithelial basement membrane dystrophy is characterized by an abnormal basement membrane protruding toward the epithelium and epithelial microcysts. In vivo confocal microscopy using the HRT II Rostock Cornea Module provides better resolution and therefore outlines distinctively in vivo microstructural characteristics of EBMD. It assists in the diagnosis of EBMD in patients suffering from recurrent erosion syndrome, particularly in patients with no corneal change visible biomicroscopically.

Alcohol Delamination of the Corneal Epithelium: An Alternative in the Management of Recurrent Corneal Erosions

PURPOSE

To investigate the efficacy of alcohol delamination in the management of recurrent corneal erosions (RCEs).

DESIGN

Prospective single-center consecutive descriptive case series.

PARTICIPANTS

Twelve patients with RCEs who did not respond to conservative management were treated with alcohol delamination.

METHODS

A consecutive case series of 12 patients with RCEs who did not respond to conservative management were treated by alcohol delamination. A pain score was generated based on a visual analog scale of pain intensity. The duration of pain and frequency were also recorded. Patients were followed up at 1 week, 4 weeks, 3 months, 6 months, and 1 year and then at yearly intervals and monitored for recurrence of symptoms and corneal morphology. The removed epithelial sheet was examined by electron microscopy in 4 patients.

INTERVENTION

The affected area of epithelium was peeled off after an application of 20% alcohol for 40 seconds under topical anesthesia. Eyes of patients were treated with an antibiotic and preservative-free artificial tear medication, and a bandage contact lens was inserted until epithelial healing was complete.

MAIN OUTCOME MEASURES

Frequency of recurrence of erosions and duration and intensity of symptoms after alcohol delamination were studied.

RESULTS

Eleven of the 12 eyes of patients had dramatic relief of symptoms over the follow-up period, ranging from 6 to 40 months. Eight patients were symptom free, and 1 patient had 2 mild symptom episodes in the first posttreatment month before becoming symptom free. The average follow-up period was 23.5 months. There were no residual effects from the application of alcohol noted in any patient. Electron microscopy of removed epithelium showed features of the underlying pathology. The separation of the epithelium occurred at the interface of the subepithelial abnormal deposit and the surface of Bowman's zone.

CONCLUSION

Alcohol delamination appears to be a novel, simple, inexpensive treatment for RCEs. Unlike other methods, the removed epithelium is available as a sheet that may be subjected to further examination, though some of the changes observed may reflect the effect of alcohol on the epithelium.

Combination of transepithelial phototherapeutic keratectomy and autologous serum eyedrops for treatment of recurrent corneal erosions

PURPOSE

To evaluate the clinical outcomes after transepithelial phototherapeutic keratectomy (t-PTK) using an excimer laser and postoperative administration of autologous serum eyedrops.

SETTING

Department of Ophthalmology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany.

METHODS

Twenty-five eyes of 25 patients with 3 to 12 recurrent corneal erosions were treated with t-PTK using the Schwind Keratom broad-beam excimer laser (Schwind). Routine therapy consisted of 2 pulses x 40 pulses (18.82 +/- 2.56 mum ablation). Postoperatively, autologous serum eyedrops were administered 6 times a day for 6 weeks. Postoperative outcomes and rate of recurrent erosions were evaluated.

RESULTS

The median of the follow-up after t-PTK was 15.5 months (range 6 to 20 months), and the mean age of the patients was 40.6 years +/- 12.0 (SD). Twenty of 25 eyes (80%) recovered without further corneal erosion. Five eyes had 1 further erosion, which was treatable in 4 cases with autologous serum eyedrops without additional excimer laser treatment. One patient requested additional t-PTK treatment and recovered without further complications thereafter.

CONCLUSIONS

Transepithelial phototherapeutic keratectomy is a safe and effective therapy for recurrent corneal erosions. Additional treatment with autologous serum eyedrops can support the healing process following corneal erosions and t-PTK and can be given as a long-term artificial tear treatment.

Pathogenesis, clinical features and management of recurrent corneal erosions

Recurrent corneal erosions (RCE) are common. They are characterised by repeated episodes of pain, difficulty in opening the eyes, watering, and photophobia resulting from poor epithelial adhesion. In the majority of patients with RCE, trauma is the initiating factor. Epithelial, stromal, and endothelial corneal dystrophies have all been described in association with RCE. Other causes that may lead to RCE include chemical and thermal injuries, previous herpetic keratitis, meibomian gland dysfunction, ocular rosacea, diabetes mellitus, Salzmann's nodular degeneration, band keratopathy, previous bacterial ulceration, kerato-conjunctivitis sicca, and epidermolysis bullosa. The conditions that are associated with RCE can be either primary or secondary depending on whether the basement membrane complex abnormality is intrinsic or acquired. Primary types tend to be bilateral, symmetrical and develop in multiple corneal locations. The pathogenetic mechanism of this disorder is related to poor adhesion of the corneal epithelium to the underlying stroma. Excessive matrix metalloproteinase (MMP) activity may play a role in the pathogenesis. Although the majority of patients will respond to simple measures such as padding and antibiotic ointment, RCE resistant to simple measures require approaches that are more elaborate. The common goal of these approaches is to encourage proper formation of adhesion complexes between the epithelium and the stroma. The use of long-term contact lenses, autologous serum eye drops, botulinum toxin, induced ptosis, oral MMP inhibitors, diamond burr polishing of Bowman's membrane have been reported with varying degree of success in treating RCE. Anterior stromal puncture with insulin needles or Neodymium : aluminium-yttrium-garnet may enhance the epithelial adhesion to the basement membrane by scar formation and success rates of up to 80% have been reported in the treatment of recalcitrant RCE. Excimer laser photo-therapeutic keratectomy (PTK) is now a well-established treatment modality for RCE and is being used both safely and effectively. Partial ablation of Bowman's layer with PTK gives a smooth surface for the newly generating epithelium to migrate and form adhesion complexes. The pathogenesis, clinical features, and management options of this common disorder are discussed in this review article.

Amoils epithelial scrubber to treat recurrent corneal erosions

PURPOSE

To evaluate the treatment of recalcitrant recurrent corneal erosions (RCE) with superficial keratectomy using the Amoils epithelial scrubber (AES).

SETTING

Muncie Eye Center, Muncie, Indiana, USA.

METHODS

This study was a retrospective consecutive case series comprising 23 patients (26 eyes) who had superficial keratectomy for RCE using the AES between September 1997 and May 2003 at a private tertiary-care center. The preoperative and postoperative best corrected visual acuities (BCVAs), slitlamp findings, and postoperative incidence of RCE were studied.

RESULTS

During a mean telephone survey follow-up of 21.2 months +/- 20.5 (SD) (range 1.4 to 71.3 months), 20 patients (23 eyes, 88%) reported no further RCE symptoms. The BCVA improved or stayed the same in 25 eyes (96%). No significant complications were found.

CONCLUSION

Superficial keratectomy using the AES appears to be safe and effective for treating recalcitrant RCE.

The Effects of LASIK on the Ocular Surface

Laser in situ keratomileusis (LASIK) can affect corneal sensation, aqueous tear production, wound healing, and the incidence of corneal erosions. Virtually all patients experience dry eye at least transiently after LASIK. Because intact corneal sensation drives tear production, denervation associated with the LASIK procedure is the most significant cause of post-LASIK dry eye. To prevent symptomatic postoperative dry eye, it is crucial to identify and treat pre-existing dry eye before surgery. This review addresses the pathophysiology and management of dry eye, as well as the relationship between LASIK and corneal erosions, and suggests intra- and post-operative management techniques to minimize complications and maximize the stability of the ocular surface. Contraindications to LASIK and alternative refractive surgical procedures are discussed.

Severe late-onset recurrent epithelial erosion with diffuse lamellar keratitis after laser in situ keratomileusis

A 39-year-old woman had laser in situ keratomileusis that was complicated by intraoperative epithelial erosion in both eyes. Seven months after surgery, the patient returned, complaining of pain and blurred vision in the left eye. Slitlamp examination revealed corneal epithelial erosion with severe diffuse lamellar keratitis (DLK). Reepithelialization was complete in several days. However, severe inflammation remained until systemic steroids were administered. Recurrent erosions can lead to a serious inflammatory reaction such as DLK because of the presence of the flap-stroma interface.

Treatment of recurrent corneal erosions using autologous serum

PURPOSE

To study the effect of autologous serum in the treatment of recurrent corneal erosions.

METHODS

Eleven eyes of 11 consecutive patients with acute macroform corneal erosions who had suffered several relapses despite receiving different types of treatment were analyzed from November 2000 to February 2002. All patients were treated with autologous serum for 3 months.

RESULTS

Mean follow-up time was 9.4 +/- 3.7 months (range, 4-16). No side effects were noted in any of the treated patients. Treatments prior to the use of autologous serum had failed to avoid recurrences in all the patients, with the mean recurrence rate being 2.2 recurrences per month of follow-up. After the onset of serum treatment, only a single recurrence was recorded in three of the patients (0.028 recurrences per month of follow-up).

CONCLUSION

The use of autologous serum for the treatment of patients with recurrent corneal erosion is effective and safe in reducing the number of recurrences experienced by patients.

Phototherapeutic keratectomy versus diamond burr polishing of Bowman's membrane in the treatment of recurrent corneal erosions associated with anterior basement membrane dystrophy

PURPOSE

To compare the efficacy of phototherapeutic keratectomy (PTK) to epithelial debridement and polishing of Bowman's membrane using a diamond burr (DB) in the treatment of recurrent corneal erosions associated with anterior basement membrane (ABM) dystrophy.

DESIGN

Retrospective nonrandomized comparative trial.

METHODS

Medical records of 39 patients (42 eyes) who underwent a PTK or DB procedure for recurrent corneal erosions associated with ABM dystrophy between March 1992 and June 2000 were reviewed. History of injury, prior treatment received, and the corneal slit-lamp findings were noted in all patients. In both procedures, all loose epithelium was completely removed. In PTK patients, 5 microm of Bowman's membrane was ablated with the excimer laser. In patients who underwent DB treatment, a hand-held battery-driven diamond dusted burr was used to gently and uniformly polish Bowman's membrane in the area of the epithelial defect.

MAIN OUTCOME MEASURES

Symptomatic improvement, recurrence of painful erosions, development of haze, and change in the visual acuity. Statistical analysis was performed for comparison of data between the two groups.

RESULTS

Fifteen eyes of 14 patients underwent PTK, and 27 eyes of 25 patients underwent epithelial debridement and DB treatment. In the PTK group, mild haze was seen in five (35.7%) eyes. Recurrence of painful erosions was seen in four eyes (26.7%). The mean follow-up was 17.6 +/- 5.7 months (range, 0.7-81.9 months). Best-corrected visual acuity was better in five eyes (35.7%) after the procedure and the same in nine eyes (64.3%). In the DB group, mild haze was seen in seven eyes (25.9%). Recurrence of painful erosions was seen in three eyes (11.1%). The mean duration of follow-up was 6.7 months (range, 1-24.2 months). Best-corrected visual acuity was better in 3 eyes (14.3%), the same in 17 eyes (81%), and worse in 1 eye (4.8%) after the procedure. Final visual acuity was not available for one eye in the PTK group and 6 eyes in the DB group. There was no statistically significant difference in haze (Fisher's exact test, P = 0.38), recurrence of erosions (Kaplan-Meier analysis with log rank, P = 0.73), and vision being better or the same (Fisher's exact test, P = 0.6) between the PTK and DB groups.

CONCLUSIONS

Both PTK and DB treatment are effective methods of treating recurrent corneal erosions associated with ABM dystrophy. Diamond burr treatment, being a simpler, less expensive office procedure with a tendency toward lesser incidence of haze and recurrence in this study, seems to have advantages over PTK in the treatment of recurrent corneal erosions. Further prospective studies are required to confirm the long-term efficacy of DB treatment in the management of recurrent corneal erosions associated with ABM dystrophy.

LASIK complications: etiology, management, and prevention

Laser in situ keratomileusis (LASIK) is a rapidly evolving ophthalmic surgical procedure. Several anatomic and refractive complications have been identified. Anatomic complications include corneal flap abnormalities, epithelial ingrowth, and corneal ectasia. Refractive complications include unexpected refractive outcomes, irregular astigmatism, decentration, visual aberrations, and loss of vision. Infectious keratitis, dry eyes, and diffuse lamellar keratitis may also occur following LASIK. By examining the etiology, management, and prevention of these complications, the refractive surgeon may be able to improve visual outcomes and prevent vision-threatening problems. Reporting outcomes and mishaps of LASIK surgery will help refine our approach to the management of emerging complications.