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Recurrent Corneal Erosion

May 16th, 2009 · 67 Comments · Ocular Disease

Recurrent Corneal Erosion can be best described as a healing disorder of the epithelium or the “skin” that covers the cornea of the eye.

The epithelium doesn’t attach to the cornea after an injury.  It is loose and easily torn off.  Normally the epithelium should attach back to the cornea.  When this part of the eye is injured as from a scratch, an abrasion or a foreign body, the epithelium should grow back, seal down to the cornea and heal in a quick manner.  The epithelium of the cornea is one of the quickest healing tissues of the body in fact.  The presumably healed epithelium may cover the injury site and even appear normal  even with a microscopic view.

This condition is considered a dystrophy which means the tissue doesn’t work the way it should.  In this case, it doesn’t heal properly.

This can be a very frustrating condition for patients to endure.  They will report a sensation that a foreign body must still be present even though it was completely removed earlier.  This feeling of pain can be quite intense.  Extreme sensitivity to bright light can occur also when this problem is at it’s worst.  The patient swears something is still there and will even doubt that the doctor got the foreign body out – suspecting that another must be present or that the doctor must have missed something.

What is happening is that the epithelium moves with each blink.  The blink moves the loose epithelium, healed but not attached over the cornea. The epithelium rubs against raw nerve endings giving the sensation of a persistent foreign body with each blink.  Doubt about the health care provider’s competency may enter the patient’s mind especially if previous foreign bodies never produced such a problem.  “This used to always get better,” or “I’ve had these injuries before and they healed up quite quickly in the past,” are common statements made by some.

Patients with Recurrent Corneal Erosion may often seek several opinions for their condition if they feel their current doctor does not appear to be efficiently healing their problem.  They can move from doctor to doctor in frustration.

RCE can be difficult to treat because it recurs.  A patient may carefully follow the correct treatment and suddenly lose all their success upon awakening one morning in pain – the epithelium rubbed off because of dryness of the eye causing the upper lid to adhere to the epithelium, ripping it when the eyes are first opened upon awakening.  The can occur over weeks – even months.

We find that the treatment needs to be customized to each patient.  A strategy for one patient may not necessarily work for another.  The treatments we try include:

Artificial tears: Many times a day.  Usually more is needed than the patient can attend.  One drop even once an hour or more often may be necessary.

Nighttime Ointment:  A bland ophthalmic ointment such as Lacrilube or Refresh PM instilled into the eye helps to prevent nighttime drying – which may be the most common reason for recurrence.

Hypertonic saline solution such as Muro 128 5% by Bausch and Lomb is a salt water drop that is 5 times more salty than our natural tears.  The extra salt of these drops can draw fluid trapped between the epithelium and the cornea to help the epithelium adhere to the cornea.  This drop may be needed several times a day and can sting upon instilling.  An hypertonic ointment at night may also be prescribed.

Bandage contact lenses may help by fitting tight against the cornea preventing the epithelium from moving.  This can allow the epithelium to stay still long enough to adhere.  For some people, a bandage contact lens may not work or seem to worsen the condition.  Studies have demonstrated that snug to tight fittting lenses can work best.  However a dry eye condition itself can make a lens uncomfortable.

Patching of the eye can be used if a bandage contact lens does not work.  Patching for some people  however may feel worse in a way similar that the bandage contact lens didn’t work.

Debridement is a procedure that removes the loosened epithelium.  A very light scuffing of the cornea may roughen the surface enough to allow the epithelium to grow back attached to the eye.

Anterior stromal puncture accompanied with debridement places a grid of tiny anchor points for the epithelium to attach to the cornea as it grows back.

Ocular comfort drops is a recent development.  A formulation of dilute anesthetic was recently discussed at an ocular disease conference.  Only 10% the strength of normal anesthetic, it’s weak enough to prevent toxic effects but allow patient comfort until healed.  This requires careful follow up to prevent complications and can only be used for a very select few conditions.  We have had excellent results with this option.

Restasis and Doxycycline are each considered experimental and off label treatments.  Restasis, an eyedrop,  is normally used for the treatment of dry eye.  Most folks with RCE have this problem anyway but it is theorized that the active ingrediant, (cyclosporine) may inhibit inflammatory factors that are involved in preventing the attachment of the epithelium back to the cornea.  Doxycycline, a capsule or tablet taken orally, has been shown to help patients with meibomian gland dysfunction in producing a normal sebaceous gland product.  It may also help inhibit the inflammatory factors the prevent efficient and normal tear production.

Amniotic membrane (updated June 2016)  is gaining consideration as a treatment option for resistant cases.    This is not a stem cell treatment but use of tissue that contains chemical mediators and growth factors that appear to improve healing

Time is a critical component of any treatment of this condition.  Days may run into weeks which run into months.  Setbacks may occur frequently requiring we begin from the beginning all over again.  The good news is that most patients do get the upper hand in successfully managing this condition and achieving a complete healing – although it took longer than they wish.

If you suffer from this condition you have our sincere empathy and understanding.  Persistence on your part will pay off in overcoming this often painful and nagging healing problem.  We dedicate ourselves to staying with you during thick and thin in helping you achieve a normal life.

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67 Comments so far ↓

  • SusanNo Gravatar

    Thank YOU! This is the best explanation I have had so far ! Will try to use visc tears as often as possible and remain positive.

  • shannon hoadleyNo Gravatar

    Is there a sign up for the Amniotic membrane study. I’ve been suffering with REC for a little over 2 years. I gave up on going to Doctors due to the fact that it was the same thing over and over again with same results (contact bandage and drops). Since doing the same thing over and over again and expecting different results is the definition of insanity I looked into other treatments. A specialist told me about debridement but said more than likely in 6 months I would be right back where I started. To me paying for something that is not a a solution is not an option. The last doctors were worried due to the fact that the healing process of my eye seems to be quite a bit slower than normal. With that in mind I don’t know if acupuncture would be a wise option and again the permanency of it worries me.

  • Dr Doug CookNo Gravatar

    I recommend searching for “corneal specialist” locally. There ought to be an ophthalmologist or optometrist that offers this service.
    Study enrollment will be difficult to find locally – this treatment is offered in private practice and may be an FDA “off label” indication in the consents you sign. Medicare covers this procedure but other insurance coverage will need to be reviewed as policies can vary on coverage.

  • AndyNo Gravatar

    Hi, this is a great description of the condition and good to read others experiences. I’ve been suffering with RCE for 3 years now and unsure where to turn next. I’ve been through the motions: ointments, doxy, bandage lens, alcohol delamintaion surgery TWICE! Etc. With no success often having to wait months in between to get answers on what they plan to do next but after seeing another specialist yesterday, I’m not to confident they know what to do next as the best advice they could give where things I’ve already tried which she didn’t even appear to be aware that I’d been coming and going for the last two years (are they not reading my file before seeing me?) anyway, apologies I’m sure if u have this condition you will understand my frustration. So I’ve got to wait for two months now just to see the surgeon to discuss next option. Question, has anyone had any success with stromal punctured?

  • Jane HayesNo Gravatar

    Hi, I suffer from RCE & have done for 3 years. It started with a tear in my left eye. This was treated with antibiotics etc. I then had micro puncture, debridement, bandage lens- nothing worked. I carried on with HyloForte throughout the day and Lacrilube at night time (literally caking my eyes in gel). I found the thickness of the lubricant also tore my epithelium when I opened my eye. I was finally referred to an amazing specialist after seeing many many not so amazing ones. He diagnosed Basement Membrane Dystrophy. I went through alcohol delamination 2 years ago and have had circa 4 reoccurrences in my left eye. I am now 37 weeks pregnant & unfortunately the symptoms have started in my right eye, I have had 25 reoccurrences in the last 8 months. Very worrying as I have had to avoid antibiotics. I have managed so far to avoid infection but it is risky. I now have a bandage lens in and have for 3 weeks without occurrence however last night an erosion formed under the lens. No redness, just irritating so hopefully will heal soon. I am using HyloForte in the right eye with the lens now and continue to use lubricant in the left eye, I have changed to Vita Pos as this has been much better than Lacrilube and has Vitamin A in.
    I will have the alcohol delamimation after I have the baby in the right eye. If that doesn’t work I will keep referring back to this forum hopefully.
    It has been great to read some of the comments on here & advice. It can be such a debilitating condition & is so frustrating. I also have a young child and trying to explain to him why my eye isnt working is a task in itself!
    Staying positive is the key I think!

  • SavannahNo Gravatar

    Hi Andy,
    I just had a stromal puncture last week. It was pretty instense. The pain after was comparable to a pretty bad RCE flare up. Stinging, burning, my eye just drained tears for hours. I ended up putting a bandage contact in and immediately felt relief. Itso been exactly a week and I had my follow up appt. Dr. said it’s healing really well and is pretty confident I shouldn’t have anymore flare ups. She said there are few puncture sites that are not totally healed (which are causing some discomfort without the contact.) But other than that she said the site looks nice and tight. I guess only time will tell…

  • LisaNo Gravatar

    Hi. I suffered an injury to the cornea in my left eye in 2011 and saw specialists at the time who told me to self manage with lacrilube and refresh drop daily and nightly. I too am unable to use lacrilube for the same reasons as yourself. I was told that the epithelium should be back to normal and the eye fully healed within 2 year time frame. I had my daughter in 2015 and when she was 6 months scratched my right eye cornea so I now suffer RCES in both eyes. It’s been almost 6 years since the first injury and I don’t sleep much, I am constantly having to apply refresh tears and I have a minor eruption once a week which requires me lying still for 2 hours with copious amounts of eye drops to temp seal the epithelium.
    I was wondering if you can give me some advise from your experience and if you’re able to recommend anyone. The condition is exhausting me, my nerves and takes over my life at night.
    Kindest regards, lisa

  • Dr Doug CookNo Gravatar

    Lubrication at night is critical at preventing recurrences. In the USA, Refresh PM, Lacrilube, or Systane Gel are OTC products I treat. I can’t over-emphasize this is really important.

    So if you aren’t using them and your current eyecare provider isn’t working, seek a second opinion. Look for a corneal subspecialist – these often are at tertiary referral centers and your current eyecare provider may recommend one.

    – A thorough medication review (both Rx and over-the-counter, including supplements)
    – metabolic review (conditions known and potential testing for suspected conditions)

    There is more than what I’m covering here. We have had success in trials of oral doxycycline in about 50% of chronic cases. More literature is supporting this in addition to other information presented.

    https://www.aao.org/eyenet/article/treatment-of-recurrent-corneal-erosions

  • FionaNo Gravatar

    I have had recurrent corneal erosions for over a year and in the midst of a really bad episode. It has stopped me from being the spontaneous person I used to be and has taken over my life. Is PTK surgery successful for this condition? Thanks

  • Jane HayesNo Gravatar

    Hi, where abouts are you based? I can recommend a Doctor who I use. Also the goggles worked for me for a while at night time.
    http://www.butterflies-eyecare.co.uk/
    I still have a bandage lens in, getting it changed every 4 weeks till I have the operation-alcohol Delamination.

  • Dr Doug CookNo Gravatar

    USA so I would be unfamiliar with a referral near you

  • LibbyNo Gravatar

    I had Lasik 17 years ago. I have RCE at the flap site, which started 18 mos ago when I turned 41.
    I tend to tear within the first 90minutes of waking up. Some days I even have put tear gel in right after waking and still torn 45 minutes later.
    After reading this, I will up all my daytime lubrications. I am so tired of the pain, and the contact lens to relieve the pain is also quite uncomfortable. I think I must have really dry eyes.
    My optometrist has been quite reluctant to refer me to an ophthalmologist/corneal specialist.

  • AlfredNo Gravatar

    Doctor – this post and this blog is amazing, thank you so much!

    I’ve been having RCE since I got an infection due to a big abrasion caused by my inward lashes. I had surgery to fix the inward lashes but my RCE comes back.

    After being on muro at night for 4 months, I was RCE free for about a year on my left eye when suddenly I felt it come back. Over the next month it came back again much more strong.

    How is it possible? I thought 1 year was enough for the epithelium layer to be fully healed – do you recommend anything else other than going back to muro for 3 months?

    Also, why is it that doctors recommend anti-bacteria (erythromycin + oxfloxacin) after an abrasion but not so after an erosion attack in the morning? Isn’t the risk for infection the same? (I am deathly afraid of another infection).

  • Dr Doug CookNo Gravatar

    Most authorities consider recurrent corneal erosion a dystrophy – a condition where the function of a tissue does not work as intended. In the case of a corneal erosion, it is a faulty or fragile healing process.
    All it takes is one night of dry eye while sleeping for the whole cycle to begin again. Nightly ointment lubrication would be recommended in cases where a recurrence has developed after such a long symptom-free time.
    Muro 128 is hypertonic, Refresh PM or Lacrilube are more neutral for ointment choices.

    Abrasions caused by foreign bodies are felt to have higher risks of introducing bacteria as opposed to the normal flora of the tearfilm when a RCE recurs. Doxycycline (oral tablets or capsules – not an ointment) is being used in RCE as it is theorized to help with inflammatory / rebuilding troubles seen in this condition. Your tearfilm also contains an enzyme called lysozyme which is a natural anti-infective.

  • Gregory SeatonNo Gravatar

    Lisa, I had RCE a little over a year. My second doctor recommended Miro 128 Ointment. It worked for me. It is over the counter medicine. I used it 3 times a day for 1 month.

  • NirNo Gravatar

    I had PTK on an injury related RCE which completely fixed the issue.(Clear for more the 3 years).

    PTK really works. It’s jut important to find a doctor who does PTK on the entire surface of the cornea.

  • MargNo Gravatar

    Wow justcame across this site.am currently into day 3 of erosion after a break of 2 years since last one.
    It happens just out of the blue and i got lazy with lacrilube.
    Am being assessed tomorrow to see what progress ive made. Night time is worst.can i use lacrilube during an episode of erosion healing
    Thanks s much everyone for your helpful support and thanks Doc .ps im in Australia and summer sun is worst time for me.

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