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Recognition key to managing recurrent corneal erosions
Surgical management may be necessary if medical management fails.
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Recurrent erosions can be successfully treated with medical therapy or surgery, according to a physician, but first the condition needs to be recognized.
Even patients with normal slit lamp examinations can have classic, recurrent erosion syndrome, Christopher J. Rapuano, MD, said at Hawaiian Eye 2013.
“Recognition of the condition is really the first critical step in the management,” he said. “You cannot ignore the diagnosis of recurrent erosion in those patients because they may have a normal exam and still have recurrent erosions.”
There may be subtle “negative staining” in some patients, he said. In some patients, the dendritiform pattern of a recently healed epithelial defect seen at slit lamp examination may result in diagnosis and treatment of herpes simplex keratitis when, in fact, the patient has recurrent erosions.
Christopher J. Rapuano
“If they don’t have herpes and they have recurrent erosions, that is not a very good treatment,” Rapuano said.
Medical treatment
“The medical treatment for recurrent erosions is lubrication,” Rapuano said, particularly thick-drop artificial tears during the day and ointment every night, plus antibiotics if there is an epithelial defect. Occasionally a topical steroid may be used short term. To prevent recurrence, daytime drops and nighttime ointment are continued for up to 6 months.
If medical treatment fails, a possible next step is bandage contact lenses. This is a long-term treatment, with contact lenses needing to be changed every 2 to 4 weeks for 3 to 6 months, Rapuano said.
Surgical treatment
“It’s very important to proceed with a surgical treatment if medical treatment is not working,” Rapuano said.
Anterior stromal puncture is effective in post-traumatic erosions that are generally small and localized.
For this treatment, Rapuano makes 50 to 200 punctures, depending on the size of the erosion, to 10% to 20% stromal depth through intact, often loose epithelium or directly into stroma.
“Treat 1 mm into normal epithelium outside the area of the erosion,” he said. “I personally stay out of the visual axis.”
Additional surgical options are diamond burr polishing and phototherapeutic keratectomy (PTK) in cases of epithelial basement membrane dystrophy or lesions within the visual axis.
Rapuano said a prospective study by Wong showed diamond burr polishing had fewer recurrences and repeat surgeries and less postoperative astigmatism than just epithelial debridement for recurrent erosions.
“I remove all of the loose epithelium and smooth Bowman’s membrane with a large 5-mm diameter diamond burr,” he said. “I apply the burr uniformly for 5 to 10 seconds over the entire cornea, going from limbus to limbus and back. It usually does not induce much refractive error or haze.”
Excimer laser PTK is approved by the U.S. Food and Drug Administration for epithelial basement membrane dystrophy but not specifically for recurrent erosions, he said.
Rapuano said that the key to successful excimer laser PTK is to ablate only 5 µm to 6 µm, which also tends not to induce much refractive error or haze.
The success rate for anterior stromal puncture, diamond burr polishing and PTK is approximately 90% each, with possible mild erosion symptoms resulting in the first few weeks postoperatively but minimal long-term problems. – by Christi Fox