Eyeworld

I THERAPEUTIC REFRACTIVE CORNEAL SURGERY N FOCUS 80 | EYEWORLD | APRIL 2020 R ecurrent corneal erosion is so com- monly encountered in the clinic that John Sheppard, MD, whose experi- ence 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/epi- thelial 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 enve- lopes," Dr. Talley Rostov said. "The initial inju- ry 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 post- operative cases, dry eye patients, elderly patients, and swimmers. Symptoms and signs In terms of symptoms, patients "most com- monly 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 under- lying basement membrane, so when patients are sleeping and their eyes are closed, it's that interaction between the eyelid and the epitheli- um." 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 debil- itating 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 combina- tion of ocular surface lubrication with artificial tears or ointments, hypertonic drops, antibiot- ics, an anti-inflammatory agent, and bandage contact lens. In addition, Dr. Hatch often uses punctal occlusion to support the tear film. Dr. by Chiles Samaniego Contributing Writer Recurrent corneal erosion 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 chang- es of EBMD. • Nonsurgical management involves ocular surface lubrication, hypertonic drops, anti-inflammatory agents, anti- biotics, and a bandage contact lens. • Removal of the surface epi- thelium can be done through office debridement. When sur- gical intervention is warranted, superficial keratectomy and phototherapeutic keratectomy seem to be preferred. • Ocular surface management and environmental control are essential to prevent recur- rence. Hereditary ABMD slit lamp image with map dot fingerprint aggregates Source: John Sheppard, MD

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