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CLINICAL MANAGEMENT GUIDELINES Recurrent corneal epithelial erosion syndrome Aetiology Recurrent breakdown of corneal epithelium due to defective adhesion to basement membrane Prevalence greatest between third and fourth decade Initial cause may have been traumatic, but underlying epithelial dystrophy may be present Repair of epithelial basement membrane takes around three months if largely undisturbed Predisposing factors History of superficial trauma Corneal dystrophy (especially Map-Dot-Fingerprint Dystrophy [Epithelial Basement Membrane or Cogan’s Dystrophy]) Posterior marginal blepharitis (Meibomian gland dysfunction) Diabetes Previous refractive surgery (particularly PRK) Symptoms Unilateral sharp pain, typically sudden onset on waking and opening eyes; may also awake patient in middle of night Feeling as if eyelid is stuck to eyeball Lacrimation Photophobia Blurred vision May recur over weeks, months or years Signs Epithelial erosion (usually inferior cornea) stains with fluorescein ‘loose’ edges, ‘slipped rug’ appearance Intra-epithelial microcysts Mild stromal oedema NB: examine both eyes for signs of corneal dystrophy Differential diagnosis Tear deficiency Other corneal dystrophies with epithelial manifestations Contact lens-related epithelial conditions Management by Optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere Non pharmacological Bandage contact lens (although trials suggest that bandage lenses are equivalent to lubrication alone) (GRADE*: Level of evidence=moderate, Strength of recommendation=weak) Pharmacological Mild cases: ocular lubricants artificial tears (e.g. gutt. hypromellose) frequently during day unmedicated ointment (e.g. oc Lacrilube) before sleep – should be continued for at least 3 months from date of last recurrence (however, one study showed that the use of unmedicated ointment at night for two months following traumatic corneal abrasions led to increased symptoms of recurrent corneal erosion) review at monthly intervals for three months. Advise patient to return/seek further help if symptoms persist (GRADE*: Level of evidence=low, Strength of recommendation=strong) More severe cases with large area of epithelial loss: cycloplegic agent (e.g. gutt. cyclopentolate 1%) to prevent pupil spasm antibiotic ointment (e.g. oc. chloramphenicol) Recurrent corneal epithelial erosion syndrome Version 10, Page 1 of 2 Date of search 24.04.15; Date of revision 27.05.15; Date of publication 20.10.15; Date for review 23.04.17 © College of Optometrists CLINICAL MANAGEMENT GUIDELINES Recurrent corneal epithelial erosion syndrome (GRADE*: Level of evidence=low, Strength of recommendation=strong) Padding the eye has not been shown to enhance the management of simple corneal abrasions (GRADE*: Level of evidence=high, Strength of recommendation=strong) B2: alleviation/palliation, normally no referral If persistent or if defect large and unstable: B1: possible prescription of drugs; routine referral Possible management by Ophthalmologist For those not responding to medical therapy: débridement of loose epithelium excimer laser photo-therapeutic keratectomy micropuncture with hypodermic needle or YAG laser ‘alcohol delamination’ diamond burr polishing of Bowman’s membrane Evidence base *GRADE: Grading of Recommendations Assessment, Development and Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm) Management Category Sources of evidence Diez-Feijóo E, Grau AE, Abusleme EI, Durán JA. Clinical presentation and causes of recurrent corneal erosion syndrome: review of 100 patients. Cornea. 2014;33:571-5 Mencucci R, Favuzza E. Management of recurrent corneal erosions: are we getting better? Br J Ophthalmol. 2014;98:150-1 Watson SL, Lee MH, Barker NH. Interventions for recurrent corneal erosions. Cochrane Database Syst Rev. 2012;9:CD001861 LAY SUMMARY In this condition the surface skin of the cornea (the clear window of the eye) breaks down, causing sharp pain, watering and sometimes blurred vision. This may happen as the patient wakes after sleep. It may be due to a previous mild injury (corneal abrasion) or to a condition known as a dystrophy in which the surface of the cornea is unusually delicate. The condition may recur over weeks or months. It is treated by reducing friction between the eye and the eyelids, using lubricating drops and/or ointments, to encourage complete healing of the eye surface. Sometimes other measures are needed, for example a special contact lens applied as a bandage, minor surgery or laser therapy. Recurrent corneal epithelial erosion syndrome Version 10, Page 2 of 2 Date of search 24.04.15; Date of revision 27.05.15; Date of publication 20.10.15; Date for review 23.04.17 © College of Optometrists