Eyeworld

SPRING 2026 | EYEWORLD | 87 C Reference 1. Watson SL, Leung V. Inter- ventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2018;7:CD001861. pattern, and prior treatment response, with some patients requiring repeated or combina- tion therapies to achieve optimal outcomes. Off-center zones of erosions may respond to stromal puncture, while central zones often benefit more from superficial keratectomy with burr or PTK. Dr. Rapuano said he will often use diamond burr polishing, for which he gives the patient numbing drops and uses a blade to remove all the loose epithelium anywhere that looks irreg- ular. "As opposed to those with post-traumatic recurrent erosions, for patients with EBMD, it's usually the entire cornea," he said. Even though they've only had an erosion in one area, it tends to be loose everywhere. Dr. Rapuano will debride the epithelium to the limbus and use a 5-millimeter diameter fine-grit diamond dusted burr, going over the entire cornea for about 5–10 seconds. The idea is that it's remov- ing any kind of residual basement membrane that's abnormal in these EBMD patients, he said. Post-treatment, Dr. Rapuano will use a bandage soft contact lens and antibiotic drops. The other option, he said, is excimer laser PTK, which is an identical treatment except instead of the diamond burr, you use a laser to smooth out the surface. When doing PTK, Dr. Rapuano said you only need to remove 5 or 6 microns of tissue in any particular location. Downsides to the laser are not everyone has one, and it's more expen- sive. Additionally, the laser diameter is usually not the entire cornea, so you have to use multi- ple spots. "You don't want the spots to overlap, so it's a little trickier to do," he said. Stromal puncture, Dr. Rapuano said, is another good treatment, but it's usually not great for patients with EBMD because eyes with EBMD tend to have more diffuse pathology where the entire epithelium is abnormal and loose. It also requires diffuse treatment, includ- ing in the visual axis. "Where ASP works well is in post-traumatic recurrent erosions," he said. "Let's say someone gets poked in the eye. It's just a small abnormal area, where they were poked. The rest of the ep- ithelium is totally normal. All the erosions are in the exact same area. Then I'll do stromal punc- ture, as long as the abnormal area is relatively small and also not in the visual axis." Dr. Rapua- no added that he doesn't like to do punctures in the visual axis because the punctures leave small scars. When doing a stromal puncture, he uses a 25-gauge needle and will treat anywhere from 50 to several hundred spots, as close to- gether as he can. Both PTK and ASP are effective, but each has advantages depending on clinical context, Dr. Chamberlain said. "PTK requires excimer la- ser expertise and access to the laser equipment with associated costs," he said. "It may be better for central lesions than ASP." He added that PTK can shift the refraction in the eye and typically would induce a hyperopic shift, which may not be desirable. "But this might provide an added advantage on slightly myopic patients to reduce refractive error." Meanwhile, he said that ASP is a simpler office-based procedure, requiring only a bent small-gauge needle and slit lamp proficiency. The size of the barb or bend on the needle should be quite small to reduce significant stro- mal scarring, which can induce irregular astig- matism and focal opacities in the cornea, Dr. Chamberlain said, but a higher level of scarring may produce better epithelial adherence. continued on page 88 The elevated epithelial basement membrane dystrophy changes seen here are highlighted with negative staining using fluorescein dye and the cobalt blue light. Source: Christopher J. Rapuano, MD

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