Corneal erosions, a common and often painful condition, pose a significant challenge in optometric practice. As the first line of eyecare providers, optometrists play a crucial role in the timely diagnosis, effective treatment, and appropriate management of recurrent corneal erosions.
The ability to navigate the complexities of this condition is essential for ensuring optimal patient outcomes and preventing long-term complications. A comprehensive understanding of the underlying pathophysiology, risk factors, and available treatment modalities empowers optometrists to provide comprehensive care and alleviate patient discomfort.
This article aims to provide a comprehensive overview of recurrent corneal erosions (RCEs), offering guidance on accurate diagnosis, evidence-based treatment strategies, personalized management plans, and a glimpse into promising new therapies on the horizon.
By staying informed of the latest advancements in this field, optometrists can continue to enhance their clinical expertise and deliver the highest standard of care to their patients.
Overview of recurrent corneal erosions
RCEs are a prevalent and often debilitating ophthalmic condition characterized by the repeated breakdown or detachment of the corneal epithelium from the underlying basement membrane.
This condition has multiple etiologies and is characterized by defective epithelial adherence to the underlying basement membrane and stroma of the cornea.1,2 These poorly formed attachments are prone to acute episodic de-adhesion that results in painful corneal epithelial defects.1
A look back at the history of RCEs
The condition has been well documented over time, dating back to 1872 when it was first termed “intermittent neuralgic vesicular keratitis” by Hansen,3 and 2 years later, a researcher named Von Arlt described a similar condition with a traumatic etiology.4 Interestingly, both men unanimously linked the condition with prior superficial corneal trauma.4
Hungarian ophthalmologist Adolf Szili in 1900 reported on the presence of gray dots and epithelial irregularities associated with RCEs.5 In 1901, after studying corneal wound healing, German ophthalmologist Ueber Stood proposed that trauma to the corneal epithelium and anterior stroma incapacitates new epithelium from forming normal attachments to the injured Bowman’s layer.6
Later, in 1921, Swiss ophthalmologist Alfred Vogt expanded on Adolf Szili’s work. By utilizing sodium fluorescein and a slit lamp, he was able to discern areas of localized edema within the irregular epithelial surface. This finding led to the discovery that the corneal epithelium can alter its thickness to re-establish a smoother surface in the presence of an irregular stromal surface.4-7
Risk factors for RCE
This condition has a predilection for eyes with a history of corneal abrasions, corneal dystrophies such as epithelial basement membrane dystrophy (EBMD), and corneal degenerations such as lattice dystrophy. Additionally, eyes with prior ocular surgery, such as cataract surgery, corneal transplants, and refractive surgery, are at much higher risk for the development of RCEs.8
RCEs can be triggered by a variety of factors, including previous corneal trauma, such as abrasions or foreign bodies, as well as underlying systemic conditions like diabetes mellitus, dry eye syndrome, and certain corneal dystrophies.
Other risk factors for RCEs include contact lens wear, EBMD, ophthalmic surgical history (especially involving the cornea), and certain medications, notably topical medications such as glaucoma drops, antiviral drugs, and some antibiotics, which can disrupt the epithelial healing process and contribute to the development of recurrent erosions.
The recurrent nature of RCEs often results in significant pain, discomfort, and visual impairment, necessitating prompt diagnosis and effective management to prevent long-term complications and improve patient quality of life.
📚
Treatments for Recurrent Corneal Erosions
Use this cheat sheet for quick reference when treating patients with recurrent corneal erosions to improve patient education and care.
Epidemiology and etiology of recurrent corneal erosions
Due to a mixed group of etiologies, RCEs have demonstrated a capacity to affect any age, sex, or race. In a cohort study by Heyworth et al., the mean age of occurrence was 44 years with a male association.9 More recent studies have suggested a slight female predilection, with the average age of onset being in the mid-fifth decade.10,11
RCE syndrome can be divided into two categories, microform or macroform, based on the size of the erosion.8,9,12 Microform erosions are smaller, spontaneous, recurrent, and associated with an underlying basement membrane dystrophy, such as EBMD. Macroform erosions are larger with more sloughed-off epithelium; they tend to occur secondary to trauma and recurrence is significantly less frequent.9
Most corneal erosions secondary to traumatic abrasions won’t have recurrence. The incidence of which has been reported with a range from 5 to 25%, or 1:150 cases.2,8,9,13 The condition can be further classed as primary or secondary depending on whether the defect in the basement membrane is intrinsic or acquired.8
Primary vs. secondary RCEs
Primary or intrinsic RCEs occur due to genetically related basement membrane dystrophies. Meanwhile secondary or acquired RCEs typically occur due to mechanical trauma to the corneal epithelium or from various ocular surface diseases that lead to the weakening of the underlying adherence to the epithelial basement membrane.
In a study conducted by Hope-Ross and Chell, 30 patients with RCEs were studied for underlying etiology, in which 100% of the patients had concurrent meibomian gland dysfunction (MGD).14 While there is a myriad of causes of RCEs, the prior corneal trauma etiology is the most common among them.2,9,10,11
In a study evaluating the epidemiological characteristics of a sample size of 104 patients with RCEs, it was found that 45% were due to trauma, 29% were secondary to EBMD, and 17% of cases were due to a combination of trauma and EBMD.11
Corneal epithelial regeneration
Composed of five to seven layers of stratified squamous epithelial cells, the corneal epithelium is approximately 50μm thick.15 The major roles are to act as an optical interface, maintain stromal hydration, and to act as a protective barrier.16
If its structure becomes compromised, the underlying stroma and other tissues become susceptible to pathogenic and cicatricial threats. The basal epithelial cells are responsible for secreting the basement membrane, which plays a crucial role in corneal wound healing.16,17
Hemidesmosomes are responsible for the adherence of the epithelial basement membrane to the underlying Bowman’s layer. Fine anchoring fibrils of collagen pass through these connections, where they anastomose with the anchoring plaques of the extracellular matrix within the stroma.15 A RCE results when these intricate connections within this transparent and thin tissue are either intrinsically faulty or extrinsically damaged.
The regeneration of the corneal epithelium after a surface disruption normally occurs in four overlapping stages.15,16 The first is the latent phase where mitosis stops, and reorganization of cell structure begins. The migration phase then begins and is characterized by the movement of adjacent cells to surround and cover the denuded surface.16 The proliferation stage follows and mitosis resumes, restoring the epithelium’s original cell density and structure.
The final stage of attachment involves the formation of new hemidesmosome connections to the underlying basement membrane. Due to corneal regeneration being a quick process, most minor abrasions heal within hours, while larger ones typically heal overnight. The total time it takes for the entire corneal epithelium to regenerate is approximately 7 days. When the basement membrane is damaged, healing can extend over several months and could lead to permanent scarring.15,16
Understanding the pathophysiology of RCE
A corneal erosion may be due to poor epithelial attachment to the basement membrane or between the basement membrane and the underlying stroma. The epithelial basement membrane complex is comprised of the hemidesmosomes of the basal epithelial cell basement membrane, the adjacent extracellular collagenous basement membrane of the stroma, and its attendant anchoring fibrils.2,17
This complex is responsible for the tight adherence of the corneal epithelium to the underlying stroma. Any traumatic, dystrophic, or degenerative process involving the basement membrane can compromise the integrity of this anchoring system.
This leads to faulty epithelial adherence and repetitive breakdown of the epithelial cell layer.2,17 The corneal epithelium continually secretes the basement membrane throughout life, and once the thickness of the membrane exceeds the length of the anchoring fibrils, sloughing of epithelial layers occurs.15,16,17
The extent of basement membrane involvement at the time of the injury influences the outcome of epithelial regeneration. Animal studies show evidence of delayed epithelial cell migration and decelerated adhesion complex reformation in epithelial injuries that involve the removal of basement membranes.8
Consequently, it may take weeks to months to become fully adherent to the underlying stroma. Trauma to the epithelium can lead to defective junctional complexes because of the delayed adhesion of epithelial cells. The subsequent faulty reattachment of the corneal epithelium leads to RCE formation.17
The role of MMPs in RCEs
The onset of a recurrent corneal erosion is said to occur either during sleep or upon waking from sleep. Chandler postulated that during sleep, the separation of epithelial cells is at its greatest due to hypoxia-induced superficial epithelial edema.8,12
The surface tension of the tears during lid closure can cause adherence between the epithelium and the lids. The shearing force from opening the eye or from small rapid eye movements during REM sleep can cause epithelial avulsion and subsequent erosion.12
Corneal epithelial cells and fibroblasts release matrix metalloproteinases (MMPs), which are degradative enzymes that mediate corneal stromal remodeling. During corneal wound healing, MMP-9 actively breaks down damaged extracellular matrix until re-epithelialization is complete. Once complete, it is then responsible for stromal remodeling.
Several factors can trigger excessive MMP production, including inflammatory cytokines, mechanical stress, and persistent inflammation.8,17 When present at higher than required levels, these dysregulated MMPs begin to break down the adherence of the newly forming basement membrane. This malformed basement membrane will have poor adhesion to the overlying epithelium, ultimately forming an RCE.
Criteria for RCE diagnosis
RCEs consist of a classic array of symptoms that include extreme pain, blurred vision, redness, photophobia, and tearing, typically upon waking.18 The timing is due to the initial shearing forces exerted by the lids on the already compromised cornea when opening upon waking. This combined with other factors such as ocular surface dryness leads to this painful attack occurring frequently and unexpectedly.
The timing between the initial insult of a traumatic corneal abrasion and the subsequent first RCE may be days to years later.4 Clinically, an RCE will present unilaterally, however, bilateral RCEs can occur at a far less frequent rate, and are more indicative of an underlying EBMD.8,19,20
The symptomology of the patient will depend greatly upon the extent of the erosion. The size of the erosion is directly proportional to the severity and duration of the symptoms. Making the diagnosis of RCE requires good investigative work by the clinician, as well as reliable patient history.
Slit-lamp examination
Under slit-lamp examination, localized elevation/roughening of the corneal epithelium with or without a corneal abrasion can be seen. The use of sodium fluorescein dye can help enhance the visualization of any epithelial changes, causing a negative staining pattern.
The pre-operative corneal photograph in Image 1 was taken prior to superficial keratectomy (SK) and reveals the classic sodium fluorescein staining pattern associated with EBMD. The distinctive staining highlights irregular epithelial contours, confirming the presence of diseased areas targeted for subsequent treatment.
Figure 1: Negative NaFl staining demonstrates surrounding RCEs (left). The same eye, with a Wratten filter applied, provides enhanced views of epitheliopathy (right).
Figure 1: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Figure 2: A pre-operative corneal photograph taken prior to superficial keratectomy (SK) reveals the classic sodium fluorescein staining pattern associated with EBMD. The distinctive staining highlights irregular epithelial contours, confirming the presence of diseased areas targeted for subsequent treatment.
Figure 2: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Tools for confirming an RCE diagnosis
Furthermore, epithelial microcysts taking the form of bubbles can be seen in areas of poor basement membrane adherence. In cases of EBMD, the characteristic pattern of fingerprint/map-dot lines can be appreciated in greater detail with retro-illumination on a dilated pupil.18
Wek-Cel sponge
Due to the quick nature of epithelial regeneration, the epithelial defect might be difficult to find or completely absent. These “occult corneal erosions” go undetected and are commonly missed by standard diagnostic techniques.
In such cases, a sterile surgical cellulose sponge (Weck-Cel) can be used to gently manipulate the epithelial tissue. If the epithelium in question is easily moveable, this is a positive adherence test indicating faulty epithelial-stromal adhesion.20
Video 1: A Weck-Cel sponge is used to remove debrided epithelial strands from the denuded corneal surface, leaving a smooth basement membrane for re-epithelialization.
Video 1: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Kim Corneal Sweeper
Alternatively, a Kim Corneal Sweeper can be utilized to test the corneal epithelial integrity without disrupting healthy epithelium. The Kim Corneal Sweeper is a handheld instrument resembling a miniature spatula.
It features a straight handle for easy manipulation and a smooth, rounded tip designed to minimize trauma to the delicate corneal surface. The tip is intentionally blunt, with one side being slightly flatter than the other, allowing for efficient sweeping and indentation of the cornea.
The instrument's slender profile ensures an unobstructed view of the cornea during examination, facilitating accurate assessment of any epithelial defects. This atraumatic instrument will readily identify areas of loose, irregular, and diseased epithelial tissue while leaving healthy epithelial tissue undisturbed.21
Video 2: A Kim Corneal Sweeper is used to identify and lift diseased loose epithelium prior to performing a superficial keratectomy for EBMD.
Video 2: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Treatment and management of recurrent corneal erosions
Due to the recurrent nature of this condition, multiple treatment modalities may be used, requiring the clinician to tailor their treatment plans to their patients on a case-by-case basis.
There are numerous treatment options for this condition, thus utilizing a stepwise approach to therapy is generally recommended. The treatment of an RCE can be divided into two stages based on the timing of presentation: the acute phase and the recurrent phase.1,18,20
Antibiotics
The acute phase of an RCE will present with an epithelial defect that is prone to bacterial infection. Due to this, a broad-spectrum antibiotic should be prescribed for prophylactic measures. In a recent study looking at the types of microbial contamination on bandage contact lenses (BCLs) used to treat RCEs, it was discovered that over 70% did not show bacterial growth, and when there was, Staphylococcus epidermidis was isolated 29.98% of the time.22
These results are also supported by another study establishing the efficacy of prophylactic antibiotics on BCLs used for the treatment of RCEs. This study also found that Staphylococcus epidermidis was the most commonly isolated microorganism from the BCLs, with 22.5% positive cultures.22
A study evaluating the normal flora of the conjunctiva and lid margin also had results showing that coagulase-negative Staphylococcus was the most common bacteria isolated from both the conjunctiva (30%) and lid margin (58.33%).23
Staphylococcus epidermidis is the most prevalent species out of the coagulase-negative staphylococcus (CoNS), attributing to 60 to 70% of all CoNS found on the skin.25 The cultured bacteria from the BCLs investigated in the aforementioned studies were all shown to have sensitivity and susceptibility to topical aminoglycosides, as well as topical fluoroquinolones.22-26
Furthermore, in a head-to-head study in treating a bacterial ulcer, it was found that topical 0.3% ofloxacin was comparable to fortified tobramycin plus cefazolin. The study suggested that monotherapy with ofloxacin is preferred due to easy availability and cost-effectiveness.26
Debridement
Debridement of the loosely adhered epithelium allows for a smooth basement membrane for proper re-adherence.2,11,19,20,27-29 The larger macroform lesions can have heaped areas of redundant epithelium with irregular borders. Common instruments used for corneal debridement include Weck-Cel sponges, Desmarres corneal knives (“hockey sticks”), jeweler forceps, and disposable Beaver blades.
Debridement may also be appropriately performed at the time of initial evaluation if extensive sheets of devitalized and sloughed epithelium are evident. Having margins that are neatly dissected and free of any old epithelial fragments allows for more efficient corneal wound healing.2,27
Video 3: A Desmarres Corneal Dissector is used to incise, debride, and remove diseased epithelial tissue.
Video 3: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Topical cycloplegics and oral NSAIDs
Topical cycloplegics and oral non-steroidal anti-inflammatory drugs (NSAIDs) can also be used in the acute phase of treatment to increase patient comfort.4,11,18,20
Bandage contact lens
A bandage contact lens is used to protect the regenerating epithelium from the shearing forces of the lids upon blinking, as well as from adhesion during sleep. The BCL also minimizes pain while promoting proper healing.
Emphasis should be on selecting a lens with a higher DK when using it for therapeutic purposes. Lenses with high DK will have increased oxygen permeability, allowing for enhanced healing while preventing secondary hypoxia and infectious keratitis.30
Figure 3: A substantial epithelial defect is visible following SK and diamond burr polishing. Note the excellent BCL fit, which helps minimize lid interaction on the healing epithelium and enhances patient comfort.
Figure 3: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Once the epithelium has completely healed, the BCL may be removed and the focus of treatment should be on preventing recurrence. This recurrent phase of treatment can be divided into a medical approach and a surgical approach. The FDA currently has approved three lenses for therapeutic use which are listed below.
Table 1: List of FDA-approved BCLs with basic parameters.
| Lens | Dk | Base Curve and Diameter | Replacement | Manufacturer |
|---|---|---|---|---|
| Air Optix Night & Day | 140 | 8.4/8.6 and 13.8 | EW 30 days | Alcon Laboratories, Division of Novartis, Fort Worth, TX |
| Acuvue Oasys with Hydraclear Plus | 103 | 8.4/8.8 and 14.0 | EW 7 days | Vistakon, Division of Johnson & Johnson Vision Care Inc, Jacksonville, FL |
| PureVision | 99 | 8.3/8.6 and 14.0 | EW 30 days | Bausch & Lomb, Bridgewater, NJ |
Table 1: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Management using a medical approach
The majority of RCE cases can be effectively managed with a conservative medical approach.20 This typically involves a multi-faceted strategy aimed at maintaining a healthy ocular surface and minimizing inflammation, key factors in promoting epithelial healing and preventing future erosions.7,8,14,18,20
Lubrication
Frequent application of preservative-free artificial tears or lubricant gels throughout the day, often supplemented with ointment at bedtime, is essential. Lubrication helps prevent the eyelid from adhering to the healing epithelium, reducing the risk of mechanical disruption and promoting a smooth ocular surface.11-13,18,20,28
Punctal occlusion can further enhance these protective effects by prolonging tear film retention and reducing mechanical shear forces between the lid and corneal surface during blinking. This can be achieved through temporary dissolvable collagen plugs, permanent silicone plugs, or thermal cautery of the puncta to induce permanent closure through scarring.
Additionally, hypertonic saline solution can be used to further enhance healing by drawing out excess fluid from the cornea.18,20 This is particularly beneficial at bedtime due to the increased corneal hypoxia that occurs during sleep.20,30
MMP-9 inhibitors
Research suggests that elevated levels of MMP-9, an enzyme involved in tissue remodeling, can hinder corneal healing in RCEs.8,20,31,32 Therefore, medications that inhibit MMP-9 are often incorporated in the treatment plans.20,31,32
MMP-9 inhibitors that can be prescribed for patients with RCEs include:
- Doxycycline: 25 to 50mg BID for 8 to 12 wks
- Oral azithromycin: 500mg po QD day 1, 250mg po QD days 2 to 5
- Topical azithromycin 1%: 1 gtt BID x 1 month
- Topical cyclosporin-A: 1 gtt BID
- Topical lifitegrast: 1 gtt BID
Corticosteroids
While effective in reducing inflammation and promoting comfort, corticosteroids should be used judiciously and under close supervision due to their potential for side effects, such as elevated intraocular pressure (IOP) and delayed wound healing.1,2,33 Short-term courses of topical corticosteroids may be prescribed to manage acute episodes or when inflammation is a significant factor.1,2,20,30-33
First-line corticosteroids include:
- Prednisolone acetate 1% (Pred Forte, Omnipred): QID for 7 days, then taper to BID for 7 days
- Fluorometholone 0.1% (FML, Flarex): QID for 7 to 14 days; preferred in steroid responders
- Loteprednol etabonate 0.5% (Lotemax): QID for 7 days, then BID for 7 days; good safety profile
Total treatment duration typically should not exceed 2 to 4 weeks. IOP monitoring is essential if treatment extends beyond 2 weeks, particularly with more potent steroids like prednisolone and dexamethasone.33
Amniotic membranes
Amniotic membranes, derived from the innermost layer of the placenta, have emerged as a promising treatment option for RCEs.20,34 These membranes possess anti-inflammatory and anti-scarring properties, and they contain growth factors that promote epithelial healing.34
Amniotic membranes can be applied directly to the cornea, providing a protective barrier and facilitating healing. They are available in various forms, including cryopreserved or dehydrated membranes, and can be utilized in post-operative care following surgical intervention for RCEs.20,34
Figure 4: Coalesced superficial punctate keratitis with punctate epithelial erosions (top left); same-day s/p SK and diamond burr polish (top right); same-day dry amniotic membrane placement (bottom left) and 1 week later after BCL removal and complete membrane absorption (bottom right).
Figure 4: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Autologous serum tears
For cases where conventional treatments fail, autologous serum tears can be a valuable option. These custom-made eye drops, derived from the patient's own blood serum, contain various growth factors and nutrients that promote epithelial healing and reduce inflammation.20,35-37
However, it's important to note that this form of therapy is not typically covered by medical insurance, and its expense can be a barrier for some patients. The specific combination and duration of these treatments will vary depending on the severity and frequency of RCEs, as well as individual patient factors.
Regular follow-up visits are crucial to monitor progress, adjust treatment as needed, and ensure optimal outcomes. While most RCEs respond well to medical management, surgical intervention may be considered for refractory cases.
Check out the Treatments for RCEs Cheat Sheet!
Surgical approaches to managing RCEs
Epithelial debridement (ED)
Epithelial debridement promotes short-term healing of an erosion, as well as an initial treatment option for corneal abrasions that have extensive areas of heaped and uneven epithelium.2,27 However, when ED is performed as a standalone procedure, it often has high recurrence rates.20,27
The healing is often slower and the healed cornea is rougher due to not addressing the underlying basement membrane.27 SK and ASP have both been shown to produce better long-term results than ED as a monotherapy.8,20,27,29
Superficial keratectomy (SK)
Superficial keratectomy involves the mechanical removal of the epithelium, Bowman's membrane, and superficial stroma with a sharp blade or a rotating diamond burr. By removing the abnormal epithelial basement membrane and creating a smoother surface, the process of re-epithelialization is facilitated, promoting both the proper regeneration of hemidesmosomal attachments and reactive fibrosis.
This leads to stronger epithelial adhesions to the underlying membranes, effectively preventing recurrence and promoting long-term healing.20,27,29,37 The higher incidence of post-operative corneal haze and patient discomfort from SK can be mitigated with the use of post-operative topical corticosteroids and cycloplegics, respectively.
The use of topical corticosteroids has been shown to drop the incidence of corneal haze from 40 to 4%, making this technique warranted for the majority of central macroform erosions.27,37
Alcohol delamination (AD)
Alcohol delamination encompasses the use of small amounts of dilute 20% alcohol to loosen the epithelium, and ultimately expose a smooth Bowman’s layer. AD only removes the epithelium and results are claimed to be better than ED alone.38,39
A unique advantage of this procedure is that AD does not penetrate or disrupt Bowman’s layer, resulting in a far lower incidence of corneal haze.20,38,39 AD has its limitations as it has yet to be proven to be effective with more severe cases of RCE.39 The procedure also carries a risk of toxicity and requires the use of a surgical microscope.
Due to its less invasive nature, AD may not be suitable for large erosions or cases with significant basement membrane dystrophy, making traditional approaches such as ASP and SK usually recommended because they are more likely to resolve recalcitrant and severe cases of RCE.20,38-40
Phototherapeutic keratectomy (PTK)
Phototherapeutic keratectomy encompasses the use of an excimer laser to smooth the basement membrane underlying an RCE. After the corneal epithelium is removed, the excimer laser ablates Bowman’s layer, as well as a small increment of the anterior stroma.20,41,42 By denuding the epithelium and ablating the underlying tissue, the resultant tissue is free from trauma and/or dystrophies.
As a result, reepithelialization can occur with stronger adherence to the underlying stroma.20.41,42 It has been reported that the generation of new basement membrane and hemidesmosomes occurs within 2 weeks post-PTK.4,8,11,20,41,42
While effective, this procedure has its downfalls including the cost, requirement of a surgical suite, and risk of increasing corneal astigmatism. Since SK is just as effective and far more cost-effective for the patient, it’s recommended more frequently.19,20,41
Anterior stromal puncture
Anterior stromal puncture (ASP) improves epithelial adherence by inducing fibrotic scaffolding to the anterior stroma.8,42-47 It is a relatively simple procedure that can be done in the office behind the slit lamp, does not require expensive instrumentation, and is repeatable. It is an effective procedure with a reported success rate of 85%.8,42-47
Video 4: An anterior stromal puncture was performed on three peripheral corneal erosions, creating micro-injuries in the anterior stroma to promote stronger epithelial adhesion and reduce recurrence. The erosions were thoroughly debrided beforehand, removing diseased epithelial tissue and ensuring a cleaner surface for optimal healing post-puncture.
Video 4: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
ASP can be performed with a pre-packaged manufactured needle that comes pre-bent at the tip to prevent perforation by limiting the depth of insertion to 0.1mm. The size of the needle is 25 gauge, which is large enough to allow for visualization of corneal indention when performing the procedure, and its indentation depth is enough to elicit fibrotic connections to be made within the stroma.40
Larger gauged needles (20-gauge) carry with them an increased chance of residual scarring.44,47 Alternatively, a 25-, 27-, or 30-gauge hypodermic needle can be bent into a "Z" shape to provide similar results with an equivalent safety profile.8,44,47
It is important to extend the treatment at least 1mm into the surrounding healthy adherent epithelium.8,42-47 This will help ensure that the loosely adhered epithelium has a healthy anchoring site.8,11,42-47
Figure 5: Pre ASP (left), same day s/p ASP (center), and 1 day s/p ASP (right).
Figure 5: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Figure 6: 1 week s/p APS (left) and 1 month s/p ASP (right).
Figure 6: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Figure 7: At 1 week post–anterior stromal puncture, the cornea exhibits complete resolution of epithelial defects, with no signs of haze or scarring. The uniform, clear epithelium suggests successful healing, indicating stable adhesion and minimal inflammatory response—key indicators of a favorable post-procedural outcome.
Figure 7: Courtesy of Bradley A. Daniel, OD, FAAO, Dipl. ABO.
Conclusion
RCEs can be a very challenging condition to manage due to the mixed etiology and insidious nature of recurrence. While conservative therapies such as artificial tears, BCL, and hypertonic saline solution are proven first-line therapies, a more aggressive surgical approach may be indicated for larger macroform erosions. When deciding the best surgical option, factors including exam findings, efficacy, safety, cost, and convenience should be considered.
For trauma-induced erosions involving the peripheral cornea, ASP should be heavily considered. This safe, effective, repeatable, and low-cost procedure can be performed in the office behind the slit lamp. For erosions involving the visual axis, SK with diamond burr polish of Bowman’s membrane has established itself as a mainstay treatment with exceptional results.
While all surgical options have their pros and cons, the choice of treatment should be tailored to each patient. By doing so, long-term relief of recurrence can be achieved.
