Recurrent corneal erosion is a disorder of the eyes characterized by the failure of the cornea's outermost layer of epithelial cells to attach to the underlying basement membrane (Bowman's layer). The condition is excruciatingly painful because the loss of these cells results in the exposure of sensitive corneal nerves. This condition can often leave patients with temporary blindness due to extreme light sensitivity (photophobia).
Symptoms include recurring attacks of severe acute ocular pain, foreign-body sensation, photophobia (i.e. sensitivity to bright lights), and tearing often at the time of awakening or during sleep when the eyelids are rubbed or opened. Signs of the condition include corneal abrasion or localized roughening of the corneal epithelium, sometimes with map-like lines, epithelial dots or microcysts, or fingerprint patterns. An epithelial defect may be present, usually in the inferior interpalpebral zone.[citation needed]
The erosion may be seen by an eye doctor using the magnification of a biomicroscope or slit lamp. Usually fluorescein stain must be applied first and a cobalt blue-light used, but may not be necessary if the area of the epithelial defect is large. Optometrists and ophthalmologists have access to the slit lamp microscopes that allow for this more-thorough evaluation under the higher magnification. Mis-diagnosis of a scratched cornea is fairly common, especially in younger patients.[citation needed]
Prevention
Given that episodes tend to occur on awakening and managed by use of good 'wetting agents', approaches to be taken to help prevent episodes include:
Environmental
ensuring that the air is humidified rather than dry, not overheated and without excessive airflow over the face. Also avoiding irritants such as cigarette smoke.[5]
use of protective glasses especially when gardening or playing with children.[5]
General personal measures
maintaining general hydration levels with adequate fluid intake.[5]
not sleeping-in late as the cornea tends to dry out the longer the eyelids are closed.[5]
Pre-bed routine
routine use of long-lasting eye ointments applied before going to bed.[5]
occasional use of the anti-inflammatory eyedrop FML (prescribed by an ophthalmologist or optometrist) before going to bed if the affected eye feels inflamed, dry or gritty
use of a hyperosmotic (hypertonic) ointment before bed reduces the amount of water in the epithelium, strengthening its structure[citation needed]
use surgical tape to keep the eye closed (if Nocturnal Lagophthalmos is a factor)
Waking options
learn to wake with eyes closed and still and keeping artificial tear drops within reach so that they may be squirted under the inner corner of the eyelids if the eyes feel uncomfortable upon waking.[5]
It has also been suggested that the eyelids should be rubbed gently, or pulled slowly open with your fingers, before trying to open them, or keeping the affected eye closed while "looking" left and right to help spread lubricating tears. If the patient's eyelids feel stuck to the cornea on waking and no intense pain is present, use a fingertip to press firmly on the eyelid to push the eye's natural lubricants onto the affected area. This procedure frees the eyelid from the cornea and prevents tearing of the cornea.[5]
Treatment
With the eye generally profusely watering, the type of tears being produced have little adhesive property. Water or saline eye drops tend therefore to be ineffective. Rather a 'better quality' of tear is required with higher 'wetting ability' (i.e. greater amount of glycoproteins) and so artificial tears (e.g. viscotears) are applied frequently.[citation needed]
Nocturnal Lagophthalmos (where the eyelids do not close enough to cover the eye completely during sleep) may be an exacerbating factor, in which case using surgical tape to keep the eye closed at night can help.[citation needed]
Whilst individual episodes may settle within a few hours or days, additional episodes (as the name suggests) will recur at intervals.
Where episodes frequently occur, or there is an underlying disorder, one medical,[6] or three types of surgical curative procedures may be attempted:[7] use of therapeutic contact lens, controlled puncturing of the surface layer of the eye (Anterior Stromal Puncture) and laser phototherapeutic keratectomy (PTK). These all essentially try to allow the surface epithelium to reestablish with normal binding to the underlying basement membrane, the method chosen depends upon the location and size of the erosion.
Surgical
A punctal plug may be inserted into the tear duct by an optometrist or ophthalmologist, decreasing the removal of natural tears from the affected eye.[8]
The use of contact lenses may help prevent the abrasion during blinking lifting off the surface layer and uses thin lenses that are gas permeable to minimise reduced oxygenation. However they need to be used for between 8–26 weeks and such persistent use both incurs frequent follow-up visits and may increase the risk of infections.[5]
Alternatively, under local anaesthetic, the corneal layer may be gently removed with a fine needle, cauterised (heat or laser) or 'spot welding' attempted (again with lasers). The procedures are not guaranteed to work, and in a minority may exacerbate the problem.
Anterior Stromal Puncture with a 20-25 gauge needle is an effective and simple treatment.[citation needed]
An option for minimally invasive and long-term effective therapy[9] is laser phototherapeutic keratectomy. Laser PTK involves the surgical laser treatment of the cornea to selectively ablate cells on the surface layer of the cornea. It is thought that the natural regrowth of cells in the following days are better able to attach to the basement membrane to prevent recurrence of the condition. Laser PTK has been found to be most effective after epithelial debridement for the partial ablation of Bowman's lamella,[10] which performed prior to PTK in the surgical procedure. This is meant to smoothen out the corneal area that the laser PTK will then treat. In some cases, small-spot PTK,[11] which only treats certain areas of the cornea may also be an acceptable alternative.
Amniotic membrane tissue corneal bandages such as Prokera have been shown to be effective in alleviating RCE.[12] These bandages aid in ocular surface regeneration while simultaneously protecting the cornea from further irritation.
There is a lack of good quality evidence to guide treatment choices. A recently updated Cochrane Review[16] concluded that "Studies included in this review have been of insufficient size and quality to provide firm evidence to inform the development of management guidelines."
1 2 Wang L, Tsang H, Coroneo M (2008). "Treatment of recurrent corneal erosion syndrome using the combination of oral doxycycline and topical corticosteroid". Clin. Experiment. Ophthalmol. 36 (1): 8–12. doi:10.1111/j.1442-9071.2007.01648.x. PMID18290949. S2CID205492163.
↑ Liu C, Buckley R (January 1996). "The role of the therapeutic contact lens in the management of recurrent corneal erosions: a review of treatment strategies". CLAO J. 22 (1): 79–82. PMID8835075.
↑ Dursun D, Kim M, Solomon A, Pflugfelder S (2001). "Treatment of recalcitrant recurrent corneal erosions with inhibitors of matrix metalloproteinase-9, doxycycline and corticosteroids". Am J Ophthalmol. 132 (1): 8–13. doi:10.1016/S0002-9394(01)00913-8. PMID11438047.
The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical power. In humans, the refractive power of the cornea is approximately 43 dioptres. The cornea can be reshaped by surgical procedures such as LASIK.
LASIK or Lasik, commonly referred to as laser eye surgery or laser vision correction, is a type of refractive surgery for the correction of myopia, hyperopia, and an actual cure for astigmatism, since it is in the cornea. LASIK surgery is performed by an ophthalmologist who uses a laser or microkeratome to reshape the eye's cornea in order to improve visual acuity. For most people, LASIK provides a long-lasting alternative to eyeglasses or contact lenses.
Photorefractive keratectomy (PRK) and laser-assisted sub-epithelial keratectomy (LASEK) are laser eye surgery procedures intended to correct a person's vision, reducing dependency on glasses or contact lenses. LASEK and PRK permanently change the shape of the anterior central cornea using an excimer laser to ablate a small amount of tissue from the corneal stroma at the front of the eye, just under the corneal epithelium. The outer layer of the cornea is removed prior to the ablation.
Eye surgery, also known as ophthalmic or ocular surgery, is surgery performed on the eye or its adnexa, by an ophthalmologist or sometimes, an optometrist. Eye surgery is synonymous with ophthalmology. The eye is a very fragile organ, and requires extreme care before, during, and after a surgical procedure to minimize or prevent further damage. An expert eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. Today it continues to be a widely practiced type of surgery, with various techniques having been developed for treating eye problems.
The Bowman layer is a smooth, acellular, nonregenerating layer, located between the superficial epithelium and the stroma in the cornea of the eye. It is composed of strong, randomly oriented collagen fibrils in which the smooth anterior surface faces the epithelial basement membrane and the posterior surface merges with the collagen lamellae of the corneal stroma proper.
The corneal endothelium is a single layer of endothelial cells on the inner surface of the cornea. It faces the chamber formed between the cornea and the iris.
Corneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue. When the entire cornea is replaced it is known as penetrating keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty. Keratoplasty simply means surgery to the cornea. The graft is taken from a recently deceased individual with no known diseases or other factors that may affect the chance of survival of the donated tissue or the health of the recipient.
Corneal abrasion is a scratch to the surface of the cornea of the eye. Symptoms include pain, redness, light sensitivity, and a feeling like a foreign body is in the eye. Most people recover completely within three days.
A corneal ulcer, or ulcerative keratitis, is an inflammatory condition of the cornea involving loss of its outer layer. It is very common in dogs and is sometimes seen in cats. In veterinary medicine, the term corneal ulcer is a generic name for any condition involving the loss of the outer layer of the cornea, and as such is used to describe conditions with both inflammatory and traumatic causes.
Corneal dystrophy is a group of rare hereditary disorders characterised by bilateral abnormal deposition of substances in the transparent front part of the eye called the cornea.
Vernal keratoconjunctivitis is a recurrent, bilateral, and self-limiting type of conjunctivitis having a periodic seasonal incidence.
Phototherapeutic keratectomy (PTK) is a type of eye surgery that uses a laser to treat various ocular disorders by removing tissue from the cornea. PTK allows the removal of superficial corneal opacities and surface irregularities. It is similar to photorefractive keratectomy, which is used for the treatment of refractive conditions. The common indications for PTK are corneal dystrophies, scars, opacities, and bullous keratopathy.
Corneal ulcer is an inflammatory or, more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and the agrarian societies. In developing countries, children afflicted by Vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes, which may persist lifelong. In ophthalmology, a corneal ulcer usually refers to having an infectious cause while the term corneal abrasion refers more to physical abrasions.
Meesmann corneal dystrophy (MECD) is a rare hereditary autosomal dominant disease that is characterized as a type of corneal dystrophy and a keratin disease. MECD is characterized by the formation of microcysts in the outermost layer of the cornea, known as the anterior corneal epithelium. The anterior corneal epithelium also becomes fragile. This usually affects both eyes rather than a single eye and worsens over time. There are two phenotypes, Meesmann corneal dystrophy 1 (MECD1) and Meesmann corneal dystrophy 2 (MECD2), which affect the genes KRT3 and KRT12, respectively. A heterozygous mutation in either of these genes will lead to a single phenotype. Many with Meesmann corneal dystrophy are asymptomatic or experience mild symptoms.
Reis-Bücklers corneal dystrophy is a rare, corneal dystrophy of unknown cause, in which the Bowman's layer of the cornea undergoes disintegration. The disorder is inherited in an autosomal dominant fashion, and is associated with mutations in the gene TGFB1.
Epithelial basement membrane dystrophy (EBMD) is a disorder of the eye that can cause pain and dryness.
Lattice corneal dystrophy type is a rare form of corneal dystrophy. It has no systemic manifestations, unlike the other type of the dystrophy, Lattice corneal dystrophy type II. Lattice corneal dystrophy was first described by Swiss ophthalmologist Hugo Biber in 1890.
Peter S. Hersh is an American ophthalmologist and specialist in LASIK eye surgery, keratoconus, and diseases of the cornea. He co-authored the article in the journal Ophthalmology that presented the results of the study that led to the first approval by the U.S. Food and Drug Administration (FDA) of the excimer laser for the correction of nearsightedness in the United States. Hersh was also medical monitor of the study that led to approval of corneal collagen crosslinking for the treatment of keratoconus.
Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.
The human cornea is a transparent membrane which allows light to pass through it. The word corneal opacification literally means loss of normal transparency of cornea. The term corneal opacity is used particularly for the loss of transparency of cornea due to scarring. Transparency of the cornea is dependent on the uniform diameter and the regular spacing and arrangement of the collagen fibrils within the stroma. Alterations in the spacing of collagen fibrils in a variety of conditions including corneal edema, scars, and macular corneal dystrophy is clinically manifested as corneal opacity. The term corneal blindness is commonly used to describe blindness due to corneal opacity.
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