Treatment Options for RCE

Recurrent corneal erosion (RCE) is a disorder of the cornea characterized by repeat episodes of abnormal adherence of the epithelium to the basement membrane. Symptoms include ocular pain, ocular redness, tearing, and photophobia, and are more common in the morning, when the eye is open after sleep, causing friction against loose epithelial cells.¹

RCE is typically caused by trauma to the cornea^1-4 and may be associated with epithelial, stromal, and/or endothelial corneal dystrophies. Other risk factors include diabetes mellitus, dry eye disease, and ocular rosacea.^5,6

Although there are no reliable estimates on incidence, prevalence, or annual cases of RCE, the incidence of RCE following traumatic abrasion has been reported at approximately 1:150 cases.² Additionally, RCE primarily affects adults older than 30 years of age, with the highest prevalence occurring in those between 30 and 40 years of age.^5,7-11

MAKING THE ID

Diagnosis of RCE usually begins with taking an accurate history to determine any record of ocular trauma or epithelial basement membrane dystrophy. Physical examination, including fluorescein staining, can also aid in diagnosis to highlight any epithelial erosion. Irregular staining typically appears in the inferior cornea. Any presence of intra-epithelial microcysts or stromal edema can also be identified via slit-lamp examination or using the Kim Corneal Sweep Spatula (Katena).

Unlikely to self-resolve, RCE can lead to increased or persistent eye pain, redness, photophobia, and blurred vision, and eventually lead to persistent epithelial defects, haze, or scarring. Early management is warranted.

TREATMENT OPTIONS

Early Treatment

Initial treatment of RCE usually begins with patching and a course of topical antibiotics.^3-5,12 Use of topical NSAIDs to relieve ocular pain is also common, although NSAIDs may delay epithelial healing.¹³ Topical lubricants, hypertonic agents, and soft bandage contact lenses are also frequently prescribed to prevent further recurrence.^3-5,9,12,14 The literature suggests that these conservative modalities help address symptoms in most cases, although more accurate estimates are lacking.^3-5,12 Although these treatments may help initial healing and reduce pain, they may not be effective in preventing further recurrence and may actually worsen a patient’s prognosis in some cases.^5,9,15 As with relief of symptoms, recurrence rates following conservative treatments is lacking in literature.

For recalcitrant cases, further nonsurgical intervention may include long-term use of bandage contact lenses, autologous serum drops, matrix metalloproteinases inhibitors (such as tetracycline and doxycycline), and addressing underlying lid pathologies (usually meibomian gland disease). Some cases ultimately require surgical intervention to achieve long-term resolution.

Additional Intervention

The most popular interventions involve removal of loose epithelium from the healthy edge or edges to promote healing. Debridement may be performed using sharp blades or via more advanced techniques, such as phototherapeutic keratectomy (PTK) or diamond burr superficial keratectomy (DBSK). Note that although sharp debridement, PTK, and DBSK all debride loose epithelial tissue, the literature makes clear distinctions between the techniques. Literature-reported success (recurrence-free) rates for PTK and DBSK range from 60% to 100% and 94% to 96%, respectively.^11,16,17

Anterior stromal puncture (ASP) has been reported to enhance the epithelial adhesion to the basement membrane via scar formation.¹⁸ ASP involves multiple superficial punctures into the affected area and extends at least 1 mm into the normal epithelial border. Immediately after surgery, a bandage contact lens is placed on the eye and antibiotics are instilled for 1 week.⁹ ASP may be performed with a short-pulsed Nd:YAG laser for improved results. Note that ASP may result in subepithelial scars and should not be performed if the RCE encroaches upon the visual axis.⁵ Literature reports up to 80% success for treatment of RCE with ASP.¹⁹

The persistence or recurrence of RCE after these treatments may be due to dysfunctional corneal basement membrane or impaired epithelial adhesion. For example, after debridement, the epithelial cells proliferate within the defect to heal the wound, but they have poor attachment to the underlying basement membrane or stroma and are prone to inflammation and sloughing.

Amniotic Membranes

Several amniotic membranes are available (see Brush Up on Amniotic Membranes), and they fall into one of two categories: cryopreserved or dehydrated. Prokera (BioTissue) is a self-retained cryopreserved amniotic membrane product and is the only FDA-cleared medical device indicated for use in eyes in which the ocular surface cells have been damaged or the underlying stroma is inflamed and scarred. The product is generally easy to apply in-office for the treatment of RCE. Topical anesthetic is applied to the affected eye, debridement of the abnormal epithelium and basement membrane is performed, the upper eyelid is held, and the patient is asked to look down. The self-retained amniotic membrane is then applied in the superior fornix and slid into the lower fornix.

Brush Up on Amniotic Membranes

Learn more about amniotic membranes.

Amniotic Membranes: What They Are and How to Use Them

Wax On, Wax Off: Placing and Removing Amniotic Membranes

Meet Code 65778 and Hone Your Amniotic Fitting Process

Once the amniotic membrane is placed, it should be checked for proper centration over the cornea and tape-tarsorrhaphy applied over the eyelid crease, if needed, to aid centration. This procedure is generally covered by insurance for medically necessary cases (CPT code 65778, placement of amniotic membrane on the ocular surface; without sutures). The amniotic membrane can be left in place for 3 to 5 days to facilitate epithelialization followed by bandage contact lens placement to ensure fixation over 2 to 6 weeks.

Huang et al found that placement of the self-retained cryopreserved amniotic membrane following debridement successfully treated RCEs in 10 of 11 eyes (90.9%), with one eye requiring a repeated amniotic membrane placement with eventual resolution.²⁰ Use of amniotic membrane for RCE has also been reported in some case studies or series.^21,22 One study reported the recurrence rates of RCE in patients treated with bandage contact lens alone, epithelial debridement with a bandage contact lens, and epithelial debridement with amniotic membrane that had at least 6 months of follow-up. The results showed the bandage contact lens group had a recurrence rate of 66.7% (4/6), debridement with a bandage contact lens had a recurrence rate of 50% (3/6), and debridement with amniotic membrane had a 14.3% (1/7) recurrence rate. Based on their findings, the authors proposed the following treatment algorithm for patients with RCE: The first occurrence of RCE should be treated with lubricants, hyperosmotic solutions, and a bandage contact lens. A secondary occurrence should involve possible debridement, followed by amniotic membrane placement.²³

Dehydrated amniotic membranes options include BioDOptix (Integra LifeSciences), AmbioDisk (IOP Ophthalmics), Opticyte (Merakris), Aril (Seed Biotech), and Apollo (Atlas Ocular). To read more about amniotic membranes in general, check out “Amniotic Membranes to the Rescue” by Rebecca Miller, OD, from a past issue of Modern Optometry (bit.ly/RM21AM).

CHOOSE YOUR TREATMENT ACCORDINGLY

Conservative treatment modalities (eg, patching, topical antibiotics and lubricants, hypertonic agents, and soft bandage contact lenses) may be prescribed to help address symptoms of RCE and prevent further recurrence, but recalcitrant cases may require long-term use of bandage contact lenses, autologous serum drops, matrix metalloproteinases inhibitors, and addressing underlying lid pathologies.

The benefit of using an amniotic membrane for the treatment of RCE may be its ability to act as both a mechanical barrier and a biologic mediator. Amniotic membranes are known to have antiinflammatory and anti-scarring (anti-fibrotic) properties in vitro and may serve as a potent mediator in the regenerative healing of the cornea. Specifically, amniotic membranes have been shown to promote antiinflammatory mediator IL-10, while directly suppressing the pr-scarring TGF-Β pathway that is involved in fibrosis.²⁴ Additionally, amniotic membranes have been shown to promote corneal epithelial adhesion in vitro.^25,26

As with all categories of drugs, devices, etc, all options are not the same, and this is no different for amniotic membranes. The literature demonstrates that cryopreserved amniotic membranes preserve significantly more HC-HA/PTX3 complex than dehydrated amniotic membranes.²⁷ (HC-HA/PTX3 has been shown to be a key biologic complex of amniotic membrane responsible for its therapeutic properties, including promoting apoptosis of proinflammatory macrophages in vitro.^28,29) By reducing inflammation and promoting adhesion of epithelial cells, cryopreserved amniotic membrane acts as an optimal treatment modality for patients with RCE post-debridement.