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Practitioners may need to resort to stromal puncture with unresponsive RCE
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Joseph P. Shovlin, OD, FAAO, a member of the Primary care Optometry News Editorial Board, is in provate practice in Scranton, Pa.
Christopher J. Rapuano, MD, is an associate proffessor with Jefferson Medical College of Thomas Jefferson University and is co-director, refractive surgery department, Cornea Service, Wills Eye Hospital, Philadelphia.
Louis Catania, OD, a member of the Primary Care Optometry News Editorial Board, is senior vice president for professional and clinical affairs, ClearVision Laser Centers.Use a surgical step-up therapy
Joseph P. Shovlin, OD, FAAO: First, taking a look at why this phenomenon occurs from a pathophysiology standpoint may be helpful. Erosive disorders secondary to basal epithelial basement membrane misdirection result in thickened basement membrane, reduplicated basement membrane, intraepithelial pseudocysts and lack of hemidesmosomes and tonofilaments. In addition, one must also carefully consider any associated diseases with careful scrutiny of the precorneal tear film and lids.
Treat conditions such as blepharitis, poor lid position and keratitis sicca that cause or exacerbate faulty healing processes. Vigilance in patients with diabetes, autoimmune diseases, multiple sclerosis and dermatological disorders may also result in poor results from initial therapy. Consider difficulties encountered in secondary erosive disorders, rosacea, chemical burns and neuropathies that further complicate the healing process.
When standard, conventionally employed therapies fail, a surgical step-up therapy is generally required. Although bandage lenses can be used, and drugs such as doxycycline — used for metabolic regulation — have been suggested, most often, the surgical alternatives provide for a much higher yield in complete resolution. Surgical remedies include the following:
- epithelial mechanical débridement with chalazion curette or 57 Beaver blade,
- diamond burr débridement,
- YAG laser micropuncture,
- anterior stromal puncture with a 23- or 25-ga needle or
- excimer laser phototherapeutic keratectomy (PTK).
The surgical options we employ most often are diamond burr débridement, anterior stromal puncture and PTK.
Diamond burr débridement is ideal for “leaky” epithelium or when a lot of dead epithelium is retained. It removes basement membrane complexes on Bowman’s, especially when there’s significant basement membrane dystrophy (too much basement membrane). Simply employ this instrument to remove epithelium and polish.
On the other side, anterior stromal puncture works exceedingly well for traumatic recurrent erosive disorders of the lower third of the cornea (often resulting when not enough basement membrane is present). Make 75 to 150 micropunctures in an area of erosion for 1.0 to 1.5 mm around and into the superficial cornea.
A bent needle at the tip and shaft may be helpful for standardized penetration depth and to minimize scarring. This procedure can be performed with caution in the visual axis (LOOK needle).
PTK is a good alternative to both of the procedures listed above. Laser availability and cost are considerations. Treatment goals are to provide stable re-epithelialization and reformation of hemidesmosomes and tonofilaments.
Safety and efficacy have been clearly demonstrated by Ohman and Fagerholm in traumatic recurrent erosion and epithelial basement membrane dystrophy. Remove the epithelium with a laser scrape or manually. Smooth the underlying Bowman’s layer with a tilted, clean blade.
The laser is set for 5-µm depth if off visual axis and up to 10 µm if over the visual axis. Treatment is applied to the entire area of débridement. (To avoid inducing irregular astigmatism, do not end by splitting the visual axis.)
- Joseph P. Shovlin, OD, FAAO can be reached at 200 Mifflin Ave., Scranton, PA 18503; (570) 342-3145; fax: (570) 344-1309; e-mail: jshovlin@aol.com.
Depends on location, cause
Christopher J. Rapuano, MD: My management depends on the exact location and cause of the recurrent erosion problem. If the erosion is relatively small, outside the visual axis and due to trauma, I would proceed with anterior stromal micropuncture. I perform this procedure with a 25-ga needle (ideally with a bent tip) at the slit lamp. I place numerous punctures, into about 20% stroma, through the loose epithelium or in the area of the epithelial defect. I extend the treatment area about 1 mm into normal epithelium. It is key to make certain the patient’s head is against the headband at all times, otherwise there is a risk of corneal perforation.
If the erosion is large or central or is due to anterior basement membrane dystrophy (as many large central erosions are), I prefer either diamond burr polishing of Bowman’s membrane or excimer laser PTK. For both of these procedures, I debride all loose epithelium (which is typically a much larger area than predicted). I then gently and uniformly treat the area of epithelial defect with diamond dusted burr (5-mm diameter) for 5 to 10 seconds at the slit lamp.
Alternatively, I use PTK to treat the area of epithelial defect for just 8 µm. As many excimer lasers have a maximum ablation zone size of 6 to 6.5 mm, and many erosions are larger than this size, the practitioner must be careful to not double or triple treat certain areas of the cornea with the laser.
After all of these procedures, I treat it as a large epithelial defect and follow patients every 1 to 2 days until the defect has healed. After diamond burr and PTK, there is occasionally some mild anterior stromal haze. This haze typically disappears on its own over several weeks to months but can also be treated with a mild topical steroid (e.g., fluorometholone). Afterwards, patients still need lubricating ointment every night for at least 3 months. My success rate is in the 75% to 90% range for these procedures.
- Christopher J. Rapuano, MD, can be reached at Cornea Service, Wills Eye Hospital, Philadelphia, PA 19107; (215) 928-3180; fax: (215) 928-3854; e-mail: cjrapuano@hslc.org.
Follow a series of therapeutic steps
Louis Catania, OD: Recurrent corneal erosion (RCE) seems to become more common as the years go by. Perhaps, it is due to better recognition of the signs and symptoms, because I cannot come up with any epidemiological reason why such a condition would be increasing in prevalence, though clinically it seems so. Sadly, whether the incidence of RCE is or is not increasing, many of these patients continue to suffer anything from minor to dreadfully severe symptoms without us being able to help, despite the rational and newer methods of treatment that we have available.
The case presented is not an uncommon management dilemma. We can list the clinical treatment steps available sequentially (in order of mild to severe and lesser to greater therapies), but no one can really say which patients will respond (and when) to which therapies and what the best sequence of the varying therapies might be for an individual patient. The more advanced the presenting condition might be, the more chronic the signs and symptoms might be. The more resistant to initial therapies the condition is will give you some indication of the prognosis of the condition and your management efforts.
A simple listing of the therapeutic steps for recurrent corneal erosion (RCE) in a relative sequence from least aggressive to most aggressive (again, with no assurance of how and when the patient might show a positive response to any one level of treatment) would include individually or in combination:
- Lubrication therapy
- Hypertonic (hyperosmotic) saline drops and ointments (5%)
- Pressure patching (unilateral or bilateral — bilateral reducing yoke movements and potential for epithelial aggravation of the affected eye)
- Bandage contact lenses
- “Roughing up” the basement membrane in the area of maximal erosion with a diamond burr
- Débridement (especially in the presence of “brawny edema”)
- Stromal puncture
- PTK
Each of the above therapeutic steps has been reported in the literature as effective in RCE. The reality, however, is that the effectiveness of each of these steps will vary considerably from patient to patient. My experience indicates that some milder-appearing cases wind up needing more advanced therapeutic steps, while other more severe looking corneas respond to the lesser treatment regimens.
Thus, the clinician must follow some degree of protocol in the therapeutic care of RCE, but also must be prepared to move more or less aggressively based on clinical response of the individual patient.
Therefore, in the case in question (assuming the dosage regimens of the hyperosmotics have been at maximal levels, i.e., every hour to every 2 hours), I probably would consider the following steps in the order listed, moving to the next step if there is no response in 3 to 5 days:
- Bilateral patching
- Diamond burr procedure
- Débridement
- Stromal puncture
- PTK
- Louis Catania, OD, can be reached at 2279 Seminole Rd. #4, Atlantic Beach, FL 32233, (904) 246-3900; fax: (904) 247-8934; e-mail: lcatania@aol.com.