treatment plan

Options for Recurrent Erosion

BY LEO SEMES, OD, FAAO

A 59-year-old female contact lens wearer presented complaining of tearing in her right eye. She said it always occurred when she first awoke and she also experienced increased light sensitivity and pain on blinking. These complaints had occurred since her first experience with a contact lens-related corneal abrasion 30 years ago. We recognized the symptoms as consistent with recurrent erosion (RCE).

At examination her visual acuity was 20/20 in each eye. The lids, lashes, conjunctiva, anterior chamber and iris were unremarkable in each eye. The cornea showed mild superficial punctate staining but no overt area of epithelial erosion or free epithelium. Intraocular pressure and dilated fundus evaluation also were unremarkable.

After discussing her episodes of corneal erosion, I suggested that she try using bland ointment (for example, Lacri-Lube S.O.P, by Allergan, Inc.) in the right eye at bedtime each night for six weeks. I've followed the patient for more than two years without a single recurrence.

While there are many options for managing RCE, I've found that this strategy is effective prophylaxis against RCE in patients who have suffered corneal abrasion. I began offering this more than 25 years ago and have yet to see a case of RCE in any one. While this does not represent a controlled clinical trial, my experience suggests at least efficacy. There are other limitations such as patients who may have suffered erosions and not returned to my care. Also, the literature suggests that this regimen isn't ironclad protection against erosions.

Alternative Treatments

Let's explore some alternative treatments for RCE. A recent review explored many options, but concluded that further controlled trials are necessary to demonstrate superiority of any one methodology over standard treatment (treat the abrasion and recommend tear supplements).

The spectrum currently ranges from lubricating drops and ointments to anterior stromal puncture to standard treatment augmented with oral doxycycline. In between these extremes are such strategies as alcohol delamination of the epithelium and phototherapeutic keratectomy. Each has its adherents.

One method that has been dispelled is the use of hypertonic agents, suggesting that epithelial dehydration plays no significant role in the restoration process.

How Treatment Works

The mechanism for RCE appears to be irregular rearrangement of overlying epithelial cells onto the underlying Bowman's layer. This is attributed to abnormal anchoring of cellular attachments to Bowman's layer.

On the surface, the epithelium shows its normal integrity by clinical observation with slit lamp biomicroscopy, even with the absence of fluorescein staining. The lurking misadhesion underneath the epithelium may become adherent to the palpebral conjunctiva of the lids, potentiated by tear film thinning at night, and torn free upon awakening. This accounts for the well-known symptoms with which patients present. The etiopathology is disruption of the corneal epithelial cells.

Each of the mentioned strategies aims to eliminate or minimize the disparity between the epithelium and Bowman's layer to allow normal apposition.

There are many approaches to treatment. The one that I've used successfully may work by disallowing adhesion between the corneal epithelial surface and palpebral conjunctiva. Alternatively, it may allow healing of the epithelium.

Not Just One Treatment

What we've learned about causes of RCE has spawned many treatment options. Unfortunately, no single choice has emerged as bulletproof. We hope our patients will respond to the treatment choice that we offer. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #146.

Dr. Semes is an associate professor at the University of Alabama at Birmingham School of Optometry.