Recurrent corneal erosion syndrome

Recurrent corneal erosion syndrome is a chronic relapsing disease of the corneal epithelium characterized by repeated episodes of sudden onset of pain usually at night or upon first awakening, accompanied by redness, photophobia, and watering of the eyes. Individual episodes may vary in severity and duration. These symptoms are related to corneal deepithelialization in an area in which the epithelium is weakly adhered. It is a frustrating disorder for both the patient and the physician. In the majority of cases, the acute episode is managed by patching, and cycloplegic and topical antibiotic ointment, with prophylactic application of gels during daytime and ointment at night to prevent further erosion. In a minority of cases these measures are insufficient and may need alternative treatment modalities including therapeutic contact lens wear, anterior stromal puncture, superficial keratectomy, Nd:YAG, and most effectively, excimer laser therapy (phototherapeutic keratectomy).     

Recurrent erosion of the cornea.

Altogether, 80 patients aged between 24 and 73 years with recurrent erosion of the cornea have been studied and compared with a control group of 200. The patients' erosions were divisible into macroform and microform types. The macroform occurred in 10%, the microform in 56%, and both types in the same patients in 31%. The macroform was more commonly related to trauma than the microform. However, many (40%) were spontaneous in origin. The most common cause of the initial trauma was a finger nail. The recurrences occurred at around the time of waking, either just before or just after. Difficulty in opening the eye occurred in 10%. There was little evidence of precipitating factors, but eye rubbing was admitted by 10% and barbiturates were implicated in 3%. The corneae were examined in the healed state, when a high incidence (59%) were found to have superficial corneal dystrophies of the fingerprint lines, bleb, and Bietti's lacunar (map-like) types. These are considered individually, particular attention being paid to the distinction between the various types of line resembling the fingerprint line. Epithelial microcysts were also a common finding (59%) and were sometimes of the Cogan type. In only 11% of patients were there no corneal signs in the healed state. The need for careful examination of the cornea by retroillumination, using both the iris and the fundus, is stressed. The control group, in contrast, showed a very low incidence of dystrophies and cysts. Treatment was given initially with either drops or ointment and no differences in healing were found. Debridement was performed in 12 eyes as an initial treatment and also in four eyes which were not healing on medical treatment. Debridement assisted healing, but did not prevent recurrence. One eye was treated with debridement and scarification and seven with carbolization. These procedures appeared to reduce the recurrence rate. Sodium chloride ointment 5% was found useful as a prophylactic taken at bedtime, and the recurrence rate increased when it was withdrawn.     

Recurrent erosion. Treatment by anterior stromal puncture

The majority of patients with recurrent corneal erosion respond to conventional forms of therapy such as topical lubricants, patching, debridement, or bandage soft contact lenses. However, there remain a small number who do not. For the small number of patients who do not respond to this type of treatment, this report describes a procedure: multiple anterior stromal punctures are created that presumably stimulate more secure epithelial adhesion to the underlying stroma. Of 21 eyes in 18 patients treated in this manner, three eyes required retreatment of adjacent areas; otherwise, there were no recurrences in follow-up periods ranging from 5 months to 12 years. This procedure is a simple and effective method for safe office treatment of patients with recalcitrant recurrent erosion.     

Recurrent corneal erosion after laser in situ keratomileusis

PURPOSE: To describe how laser-assisted in situ keratomileusis (LASIK) may induce recurrent corneal erosion (RCE) syndrome and the preventive measures for avoiding this complication. METHODS. A case series was used. RESULTS: We report the development of RCE syndrome in eight eyes of six patients after LASIK. In five cases, the RCE was triggered by epithelial trauma at the time of the LASIK procedure, as evidenced by the observation of RCE occurring at the same site as the initial epithelial disturbance. In case 6, RCE occurred with undiagnosed basement membrane dystrophy. The patients responded to treatment with ocular lubricants with one patient undergoing penetrating keratoplasty for RCE after LASIK. CONCLUSION: LASIK can induce or precipitate RCE, and RCE should perhaps be included as a potential complication in the informed consent process. It is important to minimize epithelial damage to prevent RCE after LASIK, and measures to reduce this include adequate irrigation of the corneal surface immediately before the microkeratome pass and careful attention to flap epithelium during flap replacement. Cases in which loose epithelium is noted after LASIK should be identified as potential RCE cases, and extra care should be taken for subsequent enhancement procedures or LASIK of the second eye.     

Recurrent herpetic corneal erosion: diagnosis and treatment

Recurrent corneal erosion (CE) is a common anterior eye disease, which usually occurs after injury, substantially limits a patient's ability to work, and is intractable. The authors single out an individual form of CE herpetic CE (HCE) on the basis of immunofluorescence assay of a conjunctival scrape, which shows the high concentration of herpes simplex virus antigen in 53% of CE cases. Confocal microscopy revealed epithelocyte polymorphism and basement membrane defects. The treatment of patients with HCE involved 2 steps: 1) relief of acute signs of the disease via drug therapy, rapid local autocyte cinotherapy (RLACCT), or phototherapeutic keratectomy (PTK) and 2) prevention of recurrences. For this the authors developed a method based on the systemic use of a new composition of the intradermal herpes vaccine Vitaherpavac in combination with the subcutaneous interferon inducer Poludan. RLACCT was found to be the most effective medical treatment for CE and PTK was the most effective surgical one. Vaccination with the concurrent subcutaneous injection of Poludan is an effective method in preventing recurrent HCE. During a follow-up of 2 years or more, 81% of the patients achieved clinical resolution; there was a decrease in recurrence rates and severity in 15.1% and no effect in 3.8%.     

Recurrent corneal erosion: pathology of corneal puncture

Recurrent corneal erosion is a difficult disorder to treat. Despite conventional therapy, some patients continue to have episodes of erosion. Recent literature suggests the efficacy of corneal puncture, which is thought to induce adherence of the epithelium and basement membrane to the anterior stroma. We performed multiple corneal punctures with 23-, 25-, 27-, and 30-gauge needles on one patient who underwent penetrating keratoplasty 7 weeks later. We found that an insertion depth of 0.1 mm was sufficient to cause the production of new basement membrane and fibrocytic reaction in the anterior stroma. Analysis of the pathologic specimen supports the use of the larger 23- and 25-gauge needles, and cautions against the use of small gauge needles, especially 30-gauge, for this procedure.     

Recurrent dystrophic erosion of the corneal epithelium]

In the majority of cases there exists, at the beginning of the recurrent dystrophic erosion of the corneal epithelium, a slight superficial trauma. There are, neverthless, also spontaneous forms, which are more often bilateral, hereditary forms and secondary forms with more generalized corneal dystrophies. (2) Between the trauma and the appearance of the recurrent erosion there is always a latency period of variable duration. (3) Women are more often affected than men. The condition usually is observed between 25 and 40 years of age. (4) The epithelial erosions reoccur at irregular intervals nearly always in the morning when the eyes are opened. They are always localized below the pupillary area and not necessarily at the site of the trauma. (5) Between two recurrences, there persists a latent epithelial dystrophy, which is characterized by subjective symptoms (pricking pain in the morning at the opening of the eyes) and by objective signs (grey epithelial spots or epithelial microbullae below the pupillary area near the vertical meridian). (6) At the light and electron microscope one sees alterations of the basal epithelial cells, intra epithelial cysts, ruptures of the basement membrane and disappearance of the hemidesmosomes. (7) The disorder is a true epithelial dystrophy, the traumatism being only an occasional cause. (8) The treatment is discussed.     

Recurrent corneal erosion after trauma: a statistical study

Office records of 377 consecutive traumatic corneal abrasions were examined. Twenty-nine cases experienced at least one episode of recurrent corneal erosion (7.69%). There were no recurrences in patients under 20 years of age (P less than .01). The size of the original abrasion could not be correlated with recurrence rate. Injuries with paper, fingernails, or bushes and branches were 4.9 times more likely to recur than injuries from all other materials (P less than .001).     

Recurrent corneal erosion, microcystic epithelial dystrophy, map configurations and fingerprint lines in the cornea

A 45-year-old lady presented with a recurrent corneal erosion. On closer examination, she was found to have epithelial microcysts and fingerprint dystrophy. Pathologic material from the affected cornea showed microcysts, protrusions of basement membrane and evidence of poor adhesion between the basement membrane and the epithelial cells, as well as between the epithelial cells themselves. The case demonstrated the clinical and pathologic features of recurrent corneal erosion, microcystic disease and fingerprint dystrophy of the cornea, together with the pathologic findings of map dystrophy. The authors suggest that these four diseases are various expressions of a clinicopathologic entity, epithelial basement membrane corneal dystrophy. A pathologic explanation for recurrent corneal erosion is apparent.     

Recurrent corneal erosion (RCE) secondary to lattice dystrophy in a patient with acquired immune deficiency syndrome (AIDS).

BACKGROUND: We present a case of an Acquired Immune Deficiency Syndrome (AIDS) patient with recurrent erosion (RCE) secondary to lattice corneal dystrophy. As a human immunodeficiency virus (HIV)-infected patient becomes more immunocompromised, the ocular surface defense mechanisms may be compromised. Lattice dystrophy, RCE, and modifying approaches to the management of RCE in an HIV-positive or AIDS patient are reviewed. CASE REPORT: A 49-year-old man presented with RCE. His ocular history included lattice corneal dystrophy OU, recurrent corneal erosion O.S., and herpes simplex virus keratitis O.S. Systemic history included hepatitis C and HIV infection with a diagnosis of AIDS with secondary Pneumocystis carinii pneumonia. Viral load was 35533 HIV-RNA (ribonucleic acid) molecules/ml of plasma and CD4 lymphocyte count 99 cells/mm3. Acuities were O.D. 20/80 and O.S. 20/50. The abrasion was treated with cycloplegia and bacitracin/polymyxin B ointment q.i.d. O.S. and it resolved in 3 days. CONCLUSION: Management of lattice dystrophy with secondary RCE in an AIDS patient requires that the clinician be familiar with the patient's immune status. As the CD4 count declines and the viral load increases, the patient is at higher risk for opportunistic anterior segment infections. Clinicians need to monitor these patients closely for potential complicating ocular sequelae of AIDS such as herpes zoster ophthalmicus, herpes simplex keratitis, fungal/bacterial keratitis, and keratoconjunctivitis sicca. Our patient responded well to antibiotic therapy and cycloplegia. The importance of daily monitoring of immunocompromised patients is emphasized.     

Recurrent bleb infections

AIM—To report the patient characteristics, causative organisms, and clinical outcomes in patients with recurrent bleb related ocular infections.
METHODS—The medical records of all patients diagnosed with bleb related ocular infection at the New York Eye and Ear Infirmary over a 10 year period were reviewed. Recurrent bleb infection was defined as at least two episodes of bleb purulence with or without associated intraocular inflammation separated by a quiescent period of at least 3 months.
RESULTS—Recurrent bleb infections developed in 12 eyes of 12 patients (10 men, two women) a mean of 16.3 (SD 17.9) months (range 3-51 months) after the initial infection. Two patients developed a third episode 3 and 20 months, respectively, after the second infection, yielding a total of 14 recurrent infection episodes. Recurrent infection developed after trabeculectomy in 11 eyes (adjunctive 5-fluorouracil, nine eyes; mitomycin C, one eye; no antifibrosis agent, one eye) and following cataract extraction with inadvertent bleb formation in one eye. Four (36.4%) of the filtered eyes had undergone trabeculectomy at the inferior limbus. The mean follow up time from filtering surgery to the first bleb related infection was 28 months for the nine patients treated with 5-fluorouracil and 14 months for the single patient treated with mitomycin C. 11 (78.6%) cases had a documented bleb leak in the 4 week period before or at the time of recurrent infection. Topical, prophylactic antibiotics had been used in 7/14 (50%) cases. The same organism was cultured from the initial and recurrent infections in 2/14 (14.3%) cases.
CONCLUSION—Eyes that have been successfully treated for bleb related infection remain at risk for recurrent infection. No apparent correlation exists between organisms responsible for the initial and recurrent infections. The increased rate of recurrent bleb related infection in patients receiving adjunctive 5-fluorouracil compared to mitomycin C may have been related to the longer follow up of the 5-fluorouracil eyes.

Keywords: blebs; ocular infections; 5-fluorouracil; mitomycin C     

Recurrent multifocal choroiditis

The authors examined 11 young adult, moderately myopic female patients who presented with visual loss secondary to a newly described disorder consisting of multiple small discrete lesions at the level of the retinal pigment epithelium and choriocapillaris. The condition appears to be inflammatory and occurs primarily in the macula and posterior pole. Disc edema and a mild vitritis may be present. The condition was bilateral in five patients, although the fellow eye was asymptomatic in each case. Multiple recurrences are common, with new sites developing adjacent to old ones. Four of the 11 patients had subretinal neovascularization develop from parafoveal lesions. The inflammatory lesions, as well as the subretinal neovascularization, regressed with corticosteroid treatment, and most patients recovered excellent visual acuity. Systemic laboratory studies were noncontributory.