Recurrent Corneal Erosion

I just realized today I've never blogged about this before, and it's so common I feel I need to. RCE is a condition where a patient has an eye injury that causes a corneal abrasion, HEALS completely from it...then later (weeks, months, years) that area of "healed" cornea just spontaneously falls off again, basically just like the initial "abrasion" w/o the associated eye INJURY. What happens is...in some people when they re-grow their top layer (corneal epithelium) from an abrasion, the new epithelial cells don't anchor themselves very well to the layer below them (Bowman's membrane). Consequently that area is forevermore "fragile" and easily comes off, which is painful. Again this is not EVERY ABRASION. Only SOME people are unlucky enough to have RCE. Most people heal fine from a corneal abrasion and never have another problem ever again. The hallmark symptom of RCE is WAKING UP with pain and excessive tearing in an eye that has a previous history of a pretty severe corneal abrasion in the PAST. Of course if you go to the doctor and you show them your eye, they may diagnose "corneal abrasion", which is technically not incorrect. EXCEPT THAT people with a corneal abrasion REMEMBER the injury that caused the abrasion! It's not a mystery. They got poked in the eye and it hurt and they showed up to the doc complaining of eye pain. That's an abrasion. An EROSION happens when the patient WOKE UP with eye pain. They don't remember an eye injury immediately preceding the pain (but they had an OLD abrasion in that eye that they healed from). Those are different. One has an obvious, immediate cause, one does not. Short term treatment of RCE is the same as that of an abrasion: bandage contact lens and a short course of prophylactic antibiotic eye drops. "Pressure patching" has not been recommended by the American Optometric Association since the year 2000, so if someone is taping a patch to your eye...well that's a bit old school. The problem with treating RCE, of course, is that they're RECURRENT! Although the condition is generally not sight-threatening, it can sure be annoying to wake up every 6 weeks in excruciating eye pain! There have been many attempts in the past to try and "prevent" an RCE from recurring...here are a few terrible/stupid ones that don't work (from Wikipedia): sleeping with a humidifier (worthless), wearing glasses (what?), drinking plenty of fluids (worthless), "not sleeping late" (ha!), steroids (no), "learn to wake up with your eyes closed" (what?), "rubbing" your eyes before waking (getting stupider here), punctal plugs (treats dryness, but is this a dryness problem?)...none of those will work. Using eye ointments at night probably helps some IMO. Using "hyperosmotics" (Muro, etc) might help but has not been proven I don't think. Some surgeons used to recommend Anterior Stromal Puncture, a procedure where a needle is used to punch a bunch of holes in the Bowman's layer, the idea being to create places where epithelial cells can anchor. It's not being used much anymore...I don't think it ever really caught on b/c I don't think it ever really worked great. Some surgeons recommend PTK or phototherapeutic keratectomy, a laser procedure to remove corneal epithelial cells and hope they regenerate properly. In the last TWO of these cases of RCE that I had, I treated them with LONGER TERM extended contact lens wear. These 2 were patients who were in here literally every 4-6 weeks with a new, fresh RCE and they were miserable. On the advice of another O.D. (heard this at a conference in San Antonio in 2012, wish I could remember who said it, sorry) I placed these patients on TWO MONTHS of extended bandage contact lens wear. Basically I put an Alcon Night & Day lens on their eye (even if they didn't wear contacts) and told them not to remove it for EIGHT WEEKS. That's a long time. Neither of them had a problem during the 8 weeks (that's not an endorsement for wearing contacts that long, BTW)...and to date NEITHER of them have had an RCE since we did that. Now is that a "cure?" Who knows? but anecdotally I'm 2-for-2 with this cheap, easy method. I will be treating all of my known RCE's this way for the foreseeable future until I have one that recurs. I'll skip telling them to use a humidifier and never sleep in.

Comments

  1. Hi Doctor,

    My name is Lucy and I am a medical student who recently underwent surgery. My CRNA gave me a scopolamine transderm patch, and, sadly, it got into my eyes and caused near-sighted blurred vision and dizziness. The dizziness is gone but the blurred vision is still there, despite the fact that I had removed the patch and have waited about 1 day already afterward. I understand it can take up to 1 week for symptoms to subside. Is there any way I can speed up the timing, e.g. by flushing out my eyes or something?

    Please help me if you possibly can! I am going back to school on Monday and have to be able to see.

    Thank you so much!

    Best,
    Lucy

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  2. alas there is no home remedy for reducing the cycloplegic effect of scopolamine. just have to wait it out. flushing your eyes won't work b/c it's already inside your eye acting on the ciliary muscle. Rev-Eyes (dapiprazole - an alpha blocker) would probably work, but it's for use by eye docs in-office only and is hard to find. you're probably better off just waiting it out. while it technically *could* take up to a week to wear off, that would be surprising. the vast majority of these cases are fine in 2-3 days. I'd be shocked if it were still there Mon (today being Fri)...although if it is, there's still not much you can do about it. good luck!

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  3. Your going to give them an infectious corneal ulcer by letting them wear a 30 day lens for 60. Treating one thing, but causing another. Why not just do 4 weeks, why does it have to be 8 weeks.

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  4. No I'm not going to give them an "infectious corneal ulcer". Don't be a wuss. 8 weeks...bc 4 weeks is not long enough IMO. Actually the speaker at the San Antonio CE who presented this idea recommended TEN weeks. They're not unsupervised. I don't just stuff a lens on there and say "see you in 2 months".

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  5. I'm 3-for-3 now with this method, as of last week. and no "infectious corneal ulcer", either.

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  6. Are you aware of other professionals in the U.S. versed in this method? I've suffered with RCE for a long time and every episode is met with the same tube of cream, no matter how many offices I go to. I'm tired of waiting 3-5 weeks for any relief! I'm in Missouri, if that's helpful.

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  7. no I don't know anyone in Missouri, sorry! it should be easy enough. tell them you want a bandage contact lens.

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  8. There's a new study on this - http://www.ncbi.nlm.nih.gov/pubmed/23974885

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  9. THANK YOU, Lindsey! Great post and good info! here it is pasted below:

    Randomized Controlled Study of Ocular Lubrication Versus Bandage Contact Lens in the Primary Treatment of Recurrent Corneal Erosion Syndrome.
    Ahad MA, Anandan M, Tah V, Dhingra S, Leyland M.
    Source
    *Oxford Eye Hospital, Oxford, United Kingdom; and †Department of Ophthalmology, Royal Berkshire Hospital, Reading, United Kingdom.
    Abstract
    PURPOSE::
    To investigate the efficacy of bandage contact lenses (BCLs) in comparison with that of ocular lubricants (OLs) in the initial management of recurrent corneal erosion syndrome.
    METHODS::
    A randomized controlled trial of 29 patients with recurrent corneal erosion syndrome presenting to the ophthalmology departments of the Oxford Eye Hospital and the Royal Berkshire Hospital, United Kingdom. The patients were randomized to wear either BCLs (for a 3-month duration, replaced every 30 days) or use OLs (4 times a day, with Lacri-Lube ointment at night for 3 months). The patients were assessed monthly for 4 months, and their symptoms were graded by visual analog scores. The main outcome measure was the complete resolution of symptoms with no noticeable corneal surface abnormality. Patients with a complete resolution were followed up for another 3 months to check for recurrence.
    RESULTS::
    Fourteen patients were randomized to the BCL arm, and 15 were randomized to the OL arm. After 3 months, a complete resolution was achieved in 71% of the patients (10/14) with BCLs compared with that achieved in 73% of the patients (11/15) on OLs (P > 0.05). Partial resolution was noted in 7% of the patients with BCLs versus 13% of the patients on OLs. Twenty-one percent of the patients in the BCL group and 13% of the patients in the OL group failed to respond to the treatment. Patients on BCLs had earlier resolution of symptoms, with a mean time of 5 weeks compared with 9 weeks for OLs (P = 0.02). None of the patients with BCLs developed adverse side effects.
    CONCLUSIONS::
    BCLs do not increase the likelihood of complete resolution when compared with OLs in the initial management of RCES. However, BCL treatment seems safe, and some patients experience earlier relief from symptoms.

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  10. I want to thank you for addressing this, as a professional. I really don't feel like going to the eye doctor AGAIN over this but I know something has to be done. I've tried the eye lubricants at night and they don't work. I would imagine there is something to the humidifier (which I know sounds stupid as you point out) but my waking up episodes have gone from being once every few weeks or longer to several times a night (last night). The night waking episodes have increased right along with how much the heat is blowing at night as winter began and gets colder so I know that's what it is. My throat, lips, nose and eyes are all dryer. I don't think it's that's crazy to think that the heat is drying me out and contributing to this problem. Of course, that doesn't follow a guarantee that a humidifier would work, but I think it's a reasonable thought. I'll be skipping that and going with one of the two methods described in the link that posted. I'm leaning toward the contacts though, but replacing them after 30 days. I'm not a contact wearer. Is this something I can buy over the counter or will I need to go to the doctor again. Thanks in advance and again, thanks for shedding some light on this issue in a serious way so I wouldn't have to Google Yahoo answers for the rest of my morning.

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  11. another quick question, I just wrote a few minutes ago:
    We're to understand that the healing can occur under the contact badge lens but the abrasion will not stick to the lens as it does the eyelid when one's sleeping?
    I ask just to ease my nerves. I have this image of taking out the contact only to create further damage.

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  12. it could stick. it's a risk. however, the lenses we use for this are generally silicone so they're pretty slick. more slick than the backside of your eye lid.

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  13. Would you recommend not to "do it yourself?" and how crucial is it to use the anti-biotic eyedrops over the 8 week period?

    I feel like I'm running out of non-surgical treatment options. My next appointment with my ophthalmologist isn't for another 6 weeks (he recommended Muro at night for 8-12 weeks) but continue to have very slight abrasions (nothing excruciating) in my right eye.

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  14. I cannot in good conscience recommend doing this yourself unsupervised. However, muro is for corneal edema, not healing epithelium.

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  15. Hi doctor, Is this method still available ? Have it shown high percentage of succeed till now i wonder.. I am so miserable i wanna know any method to treat this. Is it really not possible to cure this completely? another question.. can i ask why ASP is not recommended.. Thank you.

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  16. every method discussed in this post is still available. there is no real "cure" that works every time for this, obviously, or we would already be doing it for everyone who has this problem. as for why "ASP" (anterior stromal puncture) is not recommended...it has been shown that ASP is statistically no better at fixing this than anything else, inlcuding no treatment.

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  17. I've been an RCE sufferer for over 30 years with varying frequency of episodes. It took 3 Ophthalmologists to figure out that it wasn’t an infection and actually RCE. There are a few things which TEND to bring about my episodes: dehydration, staring at things too much where I may not be blinking enough (such as video games), and dry air blow at my eyes. I thought a more humid climate may help but seems to have not made much difference. I don’t have concrete evidence but it does seem air conditioned (dry) climates make it worse.

    Usually I can tie recurrences to the previous day’s activities. That said; I am completely baffled as to what causes 10 to 20% of my major episodes.

    I try to regularly use Refresh Tears and use Muro 128 when I get an episode or sense one building. It doesn’t cure it but seems to help noticeably. Both were recommended by Ophthalmologists. During severe episodes where I just had to get to work I’ve had an Optometrist give me contact lenses that lasted many days. My eyes got quite gummed up after a while but it was a wave of pain relief when he put them in. Unfortunately, I am incapable of taking the lenses out and I can only get them in on very rare occasions. Now I’m over 2000 miles from this Optometrist.

    I'm coming to this blog a bit late in the game but would love to hear an update as to the statistics on your patients using the long-term contact lenses. How are they doing? How often do these patients check in with you while under treatment?

    Are there any medical practitioners in Houston area who are using this type of treatment whom you would recommend?

    On a different note, are you aware of any other treatments that may help the body more effectively grow and maintain the epithelial bond? For example, some suggest nutritional changes such as adding or eliminating things from their diet.

    Thanks so much.

    Charles

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    Replies
    1. no I changed practices in May of 2016 to a heavy younger practice (away from an aging population and ocular disease practice). I have seen exactly one RCE patient since I got to the new practice, and I don't have any real contact with the patients of the old practice so I really have no real news for you, sorry! Also - nothing is happening in the profession as far as research for RCE. Nothing new under the sun. No one knows why some people have this problem and no one knows how to help them (diet, etc). It's just not great news, is it?

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    2. I am a 37 year old female from MissourI. I have never had eye problems and recentry stared getting filaments on my right eye, and discovered the outer layer of the cornea is loose. Maybe erosion. My Optimologist put me on antibiotic drops/ steroids for 2 weeks. 2 filaments came off but actually got a bigger one while on medicine. She removed it. While doing so noticed layer was loose. She put the lens bandage on my but just for 2 days. Said things seemed to be healing fine and left bandage off. A weak later had to go back in alt of pain. My eye didn't heal right. It healed up and curled instead of flat and smooth. So she fixed it then put another bandage on. I go back tomorrow she put it on Thursday.

      My biggest question is I'm also had started taking phentermine a few weeks before symptoms started. My Optimologist keeps telling me there is probably no way the phentermine caused this. I changed my diet and such too and the phentermine has been helping loose weight along with the diet and exercise. Do you agree or do you think there is any chance the phentermine is the problem?


      Thank you
      Lisa

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    3. as far as we know, no drug causes or exacerbates this problem. it is strictly genetic/physiologic and has to do with the way your body grows cells. when new epithelium forms, people with RCE don't grow the epithelial "roots" deep enough and they don't anchor strong enough. that's it. it's not dietary or related to any medication that we know of. sorry! good luck! the good news is: RCE is not dangerous (no permanent blindness, etc) and most people eventually get over it and stop having recurrences

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  18. Thoughts of rce in children ? Muro?

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    Replies
    1. rce is rare in children. is that what the official diagnosis is?

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