Recurrent corneal epithelial erosion syndrome

Aetiology

• Recurrent breakdown of corneal epithelium due to defective adhesion to basement membrane
• Prevalence greatest between third and fourth decade
• Initial cause may have been traumatic, but underlying epithelial dystrophy may be present
• Repair of epithelial basement membrane takes around three months if largely undisturbed

Predisposing factors

• History of superficial trauma
• Corneal dystrophy (especially Map-Dot-Fingerprint Dystrophy [Epithelial Basement Membrane or Cogan’s Dystrophy])
• Posterior marginal blepharitis (Meibomian gland dysfunction)
• Diabetes
• Previous refractive surgery (particularly PRK)

Symptoms

• Unilateral sharp pain, typically sudden onset on waking and opening eyes; may also awake patient in middle of night
• Feeling as if eyelid is stuck to eyeball
• Lacrimation
• Photophobia
• Blurred vision
• May recur over weeks, months or years

Signs

• Epithelial erosion (usually inferior cornea)
  • stains with fluorescein
  • ‘loose’ edges, ‘slipped rug’ appearance
• Intra-epithelial microcysts
• Mild stromal oedema
  NB: examine both eyes for signs of corneal dystrophy

Differential diagnosis

• Tear deficiency
• Other corneal dystrophies with epithelial manifestations
• Contact lens-related epithelial conditions

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological

Bandage contact lens (although trials suggest that bandage lenses are equivalent to lubrication alone)

(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)

Pharmacological

Mild cases:
ocular lubricants

• artificial tears (e.g. gutt. hypromellose) frequently during day

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

• unmedicated ointment (e.g. oc Lacrilube) before sleep – should be continued for at least 3 months from date of last recurrence (however, one study showed that the use of unmedicated ointment at night for two months following traumatic corneal abrasions led to increased symptoms of recurrent corneal erosion)

(GRADE*: Level of evidence=low, Strength of recommendation=weak)

• review at monthly intervals for three months. Advise patient to return/seek further help if symptoms persist

More severe cases with large area of epithelial loss:

• cycloplegic agent (e.g. gutt. cyclopentolate 1%) to prevent pupil spasm
• antibiotic ointment (e.g. oc. chloramphenicol)

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

• In cases which fail to respond to conservative measures, consider a 12-week trial of an oral tetracycline

(GRADE*: Level of evidence=moderate, Strength of recommendation=weak)

• Padding the eye has not been shown to enhance the management of simple corneal abrasions

(GRADE*: Level of evidence=high, Strength of recommendation=strong)
 

Management category

B2: alleviation/palliation, normally no referral
If persistent or if defect large and unstable:
B1: possible prescription of drugs; routine referral

Possible management by ophthalmologist

For those not responding to medical therapy:

• débridement of loose epithelium
• excimer laser photo-therapeutic keratectomy
• micropuncture with hypodermic needle or YAG laser
• ‘alcohol delamination’
• diamond burr polishing of Bowman’s membrane

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
 

Sources of evidence

Chan E, Jhanji V, Constantinou M, Amiel H, Snibson GR, Vajpayee RB. A randomised controlled trial of alcohol delamination and phototherapeutic keratectomy for the treatment of recurrent corneal erosion syndrome. Br J Ophthalmol. 2014;98(2):166-71

Diez-Feijóo E, Grau AE, Abusleme EI, Durán JA. Clinical presentation and causes of recurrent corneal erosion syndrome: review of 100 patients. Cornea. 2014;33:571-5

Lim CH, Turner A, Lim BX. Patching for corneal abrasion. Cochrane Database Syst Rev. 2016;7:CD004764

Mencucci R, Favuzza E. Management of recurrent corneal erosions: are we getting better? Br J Ophthalmol. 2014;98:150-1

Watson SL, Lee MH, Barker NH. Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2012;9:CD001861

Lay summary

In this condition the surface skin of the cornea (the clear window of the eye) breaks down, causing sharp pain, watering and sometimes blurred vision. This may happen as the patient wakes after sleep. It may be due to a previous mild injury (corneal abrasion) or to a condition known as a dystrophy in which the surface of the cornea is unusually delicate. The condition may recur over weeks or months. It is treated by reducing friction between the eye and the eyelids, using lubricating drops and/or ointments, to encourage complete healing of the eye surface. Sometimes other measures are needed, for example a special contact lens applied as a bandage, minor surgery or laser therapy.

Recurrent corneal epithelial erosion syndrome
Version 11
Date of search 21.06.17
Date of revision 19.12.17
Date of publication 06.04.18
Date for review 20.06.19
© College of Optometrists 

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