EyeWorld India June 2020 Issue

CORNEA EWAP JUNE 2020 45 R ecurrent corneal erosion is so commonly encountered in the clinic that John Sheppard, MD, whose experience spans 4 decades, said to this day he sees cases daily. EyeWorld reached out to Dr. Sheppard, Kathryn Hatch, MD, Russell Swan, MD, and Audrey Talley Rostov, MD, to share their experience and expertise on the symptoms, signs, and management of this condition. %CUG RTQƂNGU All four doctors see recurrent corneal erosion cases, commonly associated with anterior/epithelial basement membrane dystrophy (ABMD or EBMD) and injuries, the latter typically “with organic “>ÌiÀˆ> ÃÕV…>à w˜}iÀ˜>ˆÃ] plants or branches, and paper products such as envelopes,” Dr. Talley Rostov said. “The ˆ˜ˆÌˆ> ˆ˜ÕÀÞ V>ÕÃià È}˜ˆwV>˜Ì disruption on the epithelial and subepithelial layers of the cornea and heals with EBMD- like abnormality that easily sloughs when awakening in the morning and/or in dry conditions.” She also cited cases of hereditary EBMD and, less commonly, younger patients with Meesmann or lattice corneal dystrophies. Other situations where Dr. Sheppard said he sees recurrent corneal erosion include postoperative cases, dry eye patients, elderly patients, and swimmers. Symptoms and signs In terms of symptoms, patients “most commonly have a history of recurrent pain and light sensitivity upon awakening,” Dr. Swan said. “These episodes can last for a few seconds to several hours, depending on the size of the epithelial defect created.” Dr. Hatch described the most typical symptom as a “ripping” sensation upon waking. She describes it to patients “like a rug that’s not tacked down ̜ ̅i ˜iÝÌ >ÞiÀ œv ̅i yœœÀ] so there’s a gap between ̅i ÀÕ} >˜` ̅i yœœÀ° /…i epithelium is not ‘tacked down’ to its underlying basement membrane, so when patients are sleeping and their eyes are closed, it’s that interaction between the eyelid and the epithelium.” When patients open their eyes, the eyelid rubs against the epithelium’s “rug” and “strips” it from the L>Ãi“i˜Ì “i“LÀ>˜i ºyœœÀ°» While minor cases will heal during the day, more debilitating cases can leave patients unable to open their eyes due to the pain and seeking consult with a doctor. To this list of symptoms, Dr. Talley Rostov added epiphora and foreign body sensation that takes anywhere from a few hours to a few days to resolve. On eye exam “the typical ABMD/EBMD-like changes are usually apparent,” she said. Dr. Swan cited epithelial breakdown, typically in the interpalpebral zone, as the most common sign in acutely symptomatic patients. “For patients whose epithelial defect has already healed you may see some negative staining ܈̅y՜ÀiÃViˆ˜ ˆ˜ ̅i >Ài> œv irregular healing epithelium,” he said. “In patients with EBMD, the classic epithelial irregularity >˜` “>« `œÌ w˜}iÀ«Àˆ˜Ì «>ÌÌiÀ˜Ã of redundant epithelium will likely be visible.” Nonsurgical treatment Initial treatment of recurrent corneal erosion is nonsurgical. All the doctors use some combination of ocular surface ÕLÀˆV>̈œ˜ ܈̅>À̈wVˆ> Ìi>Àà or ointments, hypertonic drops, >˜ÌˆLˆœÌˆVÃ] >˜ >˜Ìˆ‡ˆ˜y>““>̜ÀÞ agent, and bandage contact lens. In addition, Dr. Hatch often uses punctal occlusion to ÃÕ««œÀÌ Ì…i Ìi>À w“° À° -Ü>˜ also considers augmentation with punctal occlusion and would add inhibition of matrix metalloproteinase-9 (MMP-9) >˜` i˜ÛˆÀœ˜“i˜Ì> “œ`ˆwV>̈œ˜° Dr. Talley Rostov treats everyone for dry eye disease, using >À̈wVˆ> Ìi>Àà >˜` ̜«ˆV> cyclosporine during the day and preservative-free ointment at night. She also considers hypertonic drops or ointments LÕÌ `œiØ½Ì w˜` ̅i“ “œÀi helpful than regular tears. Regarding the use of hypertonic drops, Dr. Sheppard noted that there are no non- AT A GLANCE • Recurrent corneal erosion is commonly seen in clinics, associated with anterior/ epithelial basement dystrophy and injury. • Patients typically experience recurrent pain, particularly a “ripping” sensation when opening their eyes upon waking, and light sensitivity. Examination reveals epithelial breakdown, the typical changes of EBMD. • Nonsurgical management involves ocular surface lubrication, hypertonic drops, >˜Ìˆ‡ˆ˜y>““>̜ÀÞ >}i˜ÌÃ] antibiotics, and a bandage contact lens. • Removal of the surface epithelium can be done ̅ÀœÕ}…œvwVi `iLÀˆ`i“i˜Ì° When surgical intervention ˆÃ Ü>ÀÀ>˜Ìi`] ÃÕ«iÀwVˆ> keratectomy and phototherapeutic keratectomy seem to be preferred. • Ocular surface management and environmental control are essential to prevent recurrence. Contact information Hatch: Kathryn_hatch@meei.harvard.edu Sheppard: docshep@hotmail.com Swan: Russell.swan@vancethompsonvision.com Talley Rostov: atalleyrostov@nweyes.com by Chiles Samaniego Þi7œÀ` čÈ>‡*>VˆwV Senior Staff Writer Recurrent corneal erosion This article originally appeared in the April 2020 issue of EyeWorld . It has been UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ permission from the ASCRS Ophthalmic Services Corp.