- Doug Cook
Recurrent Corneal Erosion
Recurrent Corneal Erosion can be best described as a healing disorder of the epithelium or the “skin” that covers the cornea of the eye.
The epithelium doesn’t attach to the cornea after an injury. It is loose and easily torn off. Normally the epithelium should attach back to the cornea. When this part of the eye is injured as from a scratch, an abrasion or a foreign body, the epithelium should grow back, seal down to the cornea and heal in a quick manner. The epithelium of the cornea is one of the quickest healing tissues of the body in fact. The presumably healed epithelium may cover the injury site and even appear normal even with a microscopic view.
This condition is considered a dystrophy which means the tissue doesn’t work the way it should. In this case, it doesn’t heal properly.
This can be a very frustrating condition for patients to endure. They will report a sensation that a foreign body must still be present even though it was completely removed earlier. This feeling of pain can be quite intense. Extreme sensitivity to bright light can occur also when this problem is at it’s worst. The patient swears something is still there and will even doubt that the doctor got the foreign body out – suspecting that another must be present or that the doctor must have missed something.
What is happening is that the epithelium moves with each blink. The blink moves the loose epithelium, healed but not attached over the cornea. The epithelium rubs against raw nerve endings giving the sensation of a persistent foreign body with each blink. Doubt about the health care provider’s competency may enter the patient’s mind especially if previous foreign bodies never produced such a problem. “This used to always get better,” or “I’ve had these injuries before and they healed up quite quickly in the past,” are common statements made by some.
Patients with Recurrent Corneal Erosion may often seek several opinions for their condition if they feel their current doctor does not appear to be efficiently healing their problem. They can move from doctor to doctor in frustration.
RCE can be difficult to treat because it recurs. A patient may carefully follow the correct treatment and suddenly lose all their success upon awakening one morning in pain – the epithelium rubbed off because of dryness of the eye causing the upper lid to adhere to the epithelium, ripping it when the eyes are first opened upon awakening. The can occur over weeks – even months.
We find that the treatment needs to be customized to each patient. A strategy for one patient may not necessarily work for another. The treatments we try include:
Artificial tears: Many times a day. Usually more is needed than the patient can attend. One drop even once an hour or more often may be necessary.
Nighttime Ointment: A bland ophthalmic ointment such as Lacrilube or Refresh PM instilled into the eye helps to prevent nighttime drying – which may be the most common reason for recurrence.
Hypertonic saline solution such as Muro 128 5% by Bausch and Lomb is a salt water drop that is 5 times more salty than our natural tears. The extra salt of these drops can draw fluid trapped between the epithelium and the cornea to help the epithelium adhere to the cornea. This drop may be needed several times a day and can sting upon instilling. An hypertonic ointment at night may also be prescribed.
Bandage contact lenses may help by fitting tight against the cornea preventing the epithelium from moving. This can allow the epithelium to stay still long enough to adhere. For some people, a bandage contact lens may not work or seem to worsen the condition. Studies have demonstrated that snug to tight fittting lenses can work best. However a dry eye condition itself can make a lens uncomfortable.
Patching of the eye can be used if a bandage contact lens does not work. Patching for some people however may feel worse in a way similar that the bandage contact lens didn’t work.
Debridement is a procedure that removes the loosened epithelium. A very light scuffing of the cornea may roughen the surface enough to allow the epithelium to grow back attached to the eye.
Anterior stromal puncture accompanied with debridement places a grid of tiny anchor points for the epithelium to attach to the cornea as it grows back.
Ocular comfort drops is a recent development. A formulation of dilute anesthetic was recently discussed at an ocular disease conference. Only 10% the strength of normal anesthetic, it’s weak enough to prevent toxic effects but allow patient comfort until healed. This requires careful follow up to prevent complications and can only be used for a very select few conditions. We have had excellent results with this option.
Restasis and Doxycycline are each considered experimental and off label treatments. Restasis, an eyedrop, is normally used for the treatment of dry eye. Most folks with RCE have this problem anyway but it is theorized that the active ingrediant, (cyclosporine) may inhibit inflammatory factors that are involved in preventing the attachment of the epithelium back to the cornea. Doxycycline, a capsule or tablet taken orally, has been shown to help patients with meibomian gland dysfunction in producing a normal sebaceous gland product. It may also help inhibit the inflammatory factors the prevent efficient and normal tear production.
Amniotic membrane (updated June 2016) is gaining consideration as a treatment option for resistant cases. This is not a stem cell treatment but use of tissue that contains chemical mediators and growth factors that appear to improve healing
Time is a critical component of any treatment of this condition. Days may run into weeks which run into months. Setbacks may occur frequently requiring we begin from the beginning all over again. The good news is that most patients do get the upper hand in successfully managing this condition and achieving a complete healing – although it took longer than they wish.
If you suffer from this condition you have our sincere empathy and understanding. Persistence on your part will pay off in overcoming this often painful and nagging healing problem. We dedicate ourselves to staying with you during thick and thin in helping you achieve a normal life.
#DryEye #foreignbodysensation #healingdisorder #RecurrentCornealErosion