Recurrent corneal epithelial erosion syndrome

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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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 also be present
Repair of epithelial basement membrane and associated epithelial adhesion complex takes around three months if largely undisturbed

Predisposing factors

History of superficial trauma (occurs in approx. one in 150 cases of traumatic corneal abrasion)
Corneal dystrophy (especially Epithelial Basement Membrane Dystrophy [Map-Dot-Fingerprint Dystrophy or Cogan’s Dystrophy])

Posterior marginal blepharitis (Meibomian gland dysfunction)
Dry Eye Disease
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

Herpes simplex keratitis
Exposure keratopathy
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

Non pharmacological

Bandage contact lens (although trials suggest that bandage lenses are equivalent to lubrication alone)
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Pharmacological

Mild cases:
ocular lubricants

  • artificial tears (preferably unpreserved) frequently during day

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

  • unmedicated ointment (e.g. Simple Eye Ointment) 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:

(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 does not 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 a variety of interventions are used although there is poor quality evidence to support their effectiveness:

  • 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

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

Miller DD, Hasan SA, Simmons NL, Stewart MW Recurrent corneal erosion: a comprehensive review. Clin Ophthalmol. 2019;13:325-335

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

Watson SL, Leung V. Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2018;7:CD001861

Plain Language 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 12
Date of search 30.06.19
Date of revision 12.07.19
Date of publication 10.11.20
Date for review 29.06.21
© College of Optometrists 

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