Management of Recurrent Corneal Erosion

Michael DePaolis, OD (Pennsylvania College of Optometry), FAAO
Professor & Associate Dean of Basic Sciences, University of California, Berkeley

Dr. DePaolis received a B.Sc. in Physiological Optics and a Doctorate of Optometry from the Pennsylvania College of Optometry. Dr. DePaolis is in private practice in Rochester, N.Y. He is Chief Optometric Editor of Primary Care Optometry News; Adjunct Clinical Professor of Optometry, Pennsylvania College of Optometry; and Adjunct Clinical Associate, Department of Ophthalmology, University of Rochester School of Medicine. His research has been published in the International Contact Lens Clinic Journal, Journal of the American Optometric Association, Ophthalmic Surgery, Review of Optometry, Optometric Management, and Contact Lens Spectrum, among others. Dr. DePaolis' work has also been presented at numerous scientific meetings, journal panel discussions and symposia. His expertise is in contact lenses & anterior segment disease. He is a member of the New York State Optometric Association and the American Optometric Association, and a fellow of the American Academy of Optometry.

Nancy Keir - BSc OD Centre for Contact Lens Research, University of Waterloo

Nancy Keir is currently a Research Associate at the Centre for Contact Lens Research at the University of Waterloo in Ontario, Canada, where she is responsible for conducting clinical research in the areas of contact lenses and refractive surgery. She graduated with honours in Optometry from the University of Waterloo and is currently working towards her PhD Degree in Vision Science on a part-time basis.

Introduction

Therapeutic contact lenses, also known as ‘bandage’ contact lenses, can be extremely beneficial under many circumstances. They can be used as a mechanical barrier to protect the cornea or as a vehicle for drug delivery to the ocular surface. A bandage contact lens can also improve comfort when corneal nerve endings are exposed and can aid healing and recovery when the corneal epithelium has been compromised. In fact, in the case presented below and in many others, it’s hard to imagine life without the availability of bandage contact lenses to provide the most comprehensive eye care to our patients.

A fifty-one year old male presented with pain, redness, photophobia and blurred vision OD, for which he had been using lubricating drops without much relief. History was negative for a recent upper respiratory tract infection or trauma to that eye. Systemic history was positive for hypertension and Gastroesophageal Reflux Disease, for which he was taking metroprolol, hydrochlorothiazide, and esomeprazole. He has no known drug allergies and ocular history revealed two similar episodes within the past year.

The ocular examination revealed equal, round pupils that were reactive to light. There was no ipsilateral adenopathy. Corrected visual acuities were 20/20 - OD and 20/20 OS. Slit lamp examination of the right eye revealed flat eyelids, grade 1 conjunctival injection, diffuse epithelial basement membrane disease (EBMD) with recurrent corneal erosion and a dark and quiet anterior chamber. The left eye was normal, with the exception of trace EBMD.

The above findings suggested EBMD in both eyes with recurrent corneal erosion in the right. The treatment plan included 1 drop of lubricant eye drops (Refresh Tears^® ) in both eyes four times per day and a drop of hypertonic sodium chloride (Muro^® 128.5%) OU prior to sleep each night. A follow-up appointment was scheduled for one week or sooner if symptoms intensified.

The patient presented five days later, reporting that he awoke at 5a.m. with intensified symptoms. He had been using a drop of hypertonic sodium chloride prior to sleep every night and lubricant eye drops every three hours OU. Vision at this examination was 20/25 OD and 20/20 OS. A slit lamp examination once again revealed recurrent corneal erosion OD and the impression at this time was recalcitrant recurrent corneal erosion OD. The plan was to discontinue the hypertonic sodium chloride drops and use a high Dk silicone hydrogel 8.6/-0.50D contact lens as a bandage and ciprofloxacin four times per day OD. A follow-up visit one week later was recommended, or sooner if symptoms intensified.

Four days later the patient returned wearing the bandage lens reporting that it worked well for the first 3 days but was painful that morning. Corrected visual acuities were 20/25 - OD and 20/20 OS. A slit lamp examination revealed a tight bandage lens OD. The impression remained as recalcitrant recurrent corneal erosion OD and the plan was to continue with the bandage lens; however, the patient was instructed to wear the lens only at night and to remove the lens every morning. Hypertonic sodium chloride drops were also to be started again, one drop OD four times per day. A follow-up visit one week later was recommended, or sooner if symptoms intensified.

At a four-month follow-up visit, the patient said he was “doing great” and that he hadn’t had another episode. He was wearing the high-Dk silicone hydrogel 8.6/-0.50 lens during the night, removing it each morning, and was using the hypertonic sodium chloride drop three times per day. Corrected visual acuities were 20/20 OU and the slit lamp examination revealed resolution of the recurrent corneal erosion. The plan was to discontinue the bandage contact lens and use a lubricant eye ointment (GenTeal^® ) at night and lubricant drops OU as needed during the day. At one year, the patient was using the lubricant ointment at night and was still doing well.

This case is an excellent example of the benefit of using a silicone hydrogel contact lens as a bandage lens for EBMD with recurrent corneal erosion. Even if the lens is not tolerated on a continuous wear basis and is worn only at night, it can serve to promote healing by protecting migrated and/or newly formed cells from the shearing force of the eyelids upon awakening.