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One of the most common diagnoses I see in my cornea clinic is recurrent corneal erosion syndrome (RCES). I am always shocked at how many patients present with this condition every week.

RCE is characterized by recurrent episodes of spontaneous corneal epithelium breakdown that is often (45% to 64% of cases) caused by mechanical trauma to the eye.¹ This trauma causes disruption of the epithelium and the underlying basement membrane, leading to poor cellular adhesion. Common traumas I have seen in clinic that induce unilateral RCES include a fingernail to the eye, a tree branch or leaf to the eye, and a golf ball to the eye—all injuries that cause an initial corneal abrasion and subsequent erosion syndrome. In 19% to 29% of cases, underlying anterior basement membrane dystrophy (ABMD) can also predispose patients to RCES.¹ Many times, these cases are bilateral if ABMD is present in both eyes. Other risk factors include prior ocular surgery; Reis Bucklers, Thiel-Behnke, lattice or granular corneal dystrophies; stromal dystrophies or macular dystrophy.¹
 
Patients with RCES are usually around ages 30 to 40 and classically present with significant eye pain upon awakening. The erosions likely occur due the frictional forces of the eyelid and the diseased epithelium when the eye is quickly opened after sleeping, leading to abrupt epithelial breakdown. Patients typically experience tearing, photophobia, eye redness and decreased vision. Many patients have told me that they are afraid to open their eyes when they wake up, for fear of inducing an erosion.

On exam, clinicians typically see irregular corneal epithelium along with small cysts, map lines or fingerprint patterns. Sometimes mild scarring can be seen in areas with recurrent epithelial injury. With fluorescein staining (using the fluorescein strip and one drop of balanced salt solution), the negative staining pattern of irregular epithelium can be highlighted, along with frank epithelial defects. Sometimes, subclinical RCES can be detected with a corneal sweep test. By gently rubbing a cotton swab, Weck-Cel sponge or Kim Corneal Sweeper² along the epithelium under the slit lamp, clinicians can see areas of weak epithelium (often characterized by a visible wrinkle or fold) or even frank epithelial sloughing, both of which are characteristic of the diagnosis.

Medical management of RCE includes an aggressive topical regimen of hypertonic saline (drops dosed 4 times daily and ointment at night), preservative-free artificial tears or short courses of topical steroids (typically loteprednol dosed 2 to 4 times daily for 2 to 4 weeks). Other treatments include oral tetracyclines such as 100 mg doxycycline twice daily to downregulate matrix metalloproteinases in the cornea, or punctal occlusion and a therapeutic bandage contact lens that can be used just at night or for extended periods of both daytime and nighttime wear. These measures alone offer symptomatic relief in up to 43% of patients.³ However, with frequent recurrences or poorly controlled symptomatology, procedural interventions can be employed. Procedural options include superficial keratectomy with diamond burr polishing, phototherapeutic keratectomy (PTK) or stromal micropuncture around the recurrent erosions.

Superficial keratectomy with diamond burr polishing prevents recurrent erosions by not only removing abnormal basement membrane to provide a smooth surface for re-epithelialization, but also stimulates reactive fibrosis to allow for stronger adhesion of corneal epithelium.³ Risk of erosion recurrence is higher with epithelial debridement alone (15% to 18%) vs. epithelial debridement with diamond burr polishing (6%).³

Stromal micropuncture improves epithelial adherence to the underlying anterior stroma by inducing scar tissue formation through penetration of Bowman’s membrane with a bent 25-gauge needle at the slit lamp. To avoid the risk of inducing visually significant central corneal scarring, I advise clinicians to avoid performing stromal micropuncture in the central visual axis. Rather, we should only employ it for peripheral corneal pathology. Variable success rates have been noted with stromal micropuncture in the literature (63 to 85%).⁴

Lastly, PTK laser helps remove enough of Bowman’s layer (often 5 μm to 10 μm) to allow for formation of new hemidesmosomes and to strengthen the adhesion of the basal epithelial cells to the underlying tissue via anchoring fibrils. An antimetabolite such as mitomycin-C is often employed with PTK to prevent corneal haze formation. PTK has been successful with low recurrence rates (18% to 22%)⁵; however, if deeper ablations are performed, patients should be made aware that a significant hyperopic refractive error change can occur.

References

1. Miller DD, Hasan SA, Simmons NL, Stewart MW. Recurrent corneal erosion: a comprehensive review. Clin Ophthalmol. 2019 Feb;13:325–335. doi: 10.2147/OPTH.S157430
2. Stodola E. Corneal sweep test for recurrent corneal erosion. ASCRS Eyeworld. June 2022. Accessed August 29, 2024. https://www.eyeworld.org/2022/corneal-sweep-test-for-recurrent-corneal-erosion/
3. Ewald M, Hammersmith KM. Review of diagnosis and management of recurrent erosion syndrome. Curr Opin Ophthalmol. 2009 Jul;20(4):287-291. doi:10.1097/ICU.0b013e32832c9716
4. Avni Zauberman N, Artornsombudh P, Elbaz U, Goldich Y, Rootman DS, Chan CC. Anterior stromal puncture for the treatment of recurrent corneal erosion syndrome: patient clinical features and outcomes. Am J Ophthalmol. 2014 Feb;157(2):273-279.e1. doi:10.1016/j.ajo.2013.10.005
5. Chen S, Chu X, Zhang C, et al. Safety and efficacy of the phototherapeutic keratectomy for treatment of recurrent corneal erosions: a systematic review and meta-analysis. Ophthalmic Res. 2023;66(1):1114-1127. doi: 10.1159/000533160

Nandini Venkateswaran, MD practices at Massachusetts Eye and Ear Harvard Medical School Department of Ophthalmology, where she is also an instructor. Her specialties are complex and premium cataract surgery, cornea and external diseases, corneal crosslinking, and refractive surgery. She is a consultant for CorneaGen.