Recurrent Corneal Erosion (RCE) is an eye condition characterized by the repeated breakdown of the cornea’s outermost layer, the epithelium. RCE occurs when the epithelial cells fail to anchor securely to the underlying basement membrane and Bowman’s layer. This structural failure results in sudden, intense pain, often described as a sharp, foreign-body sensation, typically upon waking or when the eye is rubbed. RCE frequently originates from a past trauma, such as a scratch, or it may be linked to inherited conditions like epithelial basement membrane dystrophy. Successful treatment involves a progression of methods aimed at stabilizing the corneal surface and promoting lasting adhesion between the tissue layers.
Initial and Conservative Treatment Strategies
The initial approach to managing RCE focuses on reducing friction, supporting the healing of the epithelial layer, and controlling inflammation. Liberal use of preservative-free artificial tears throughout the day helps to maintain a smooth, lubricated surface, which minimizes the mechanical stress placed on the fragile epithelium during blinking. At night, a thicker ophthalmic ointment is often used to create a barrier that prevents the eyelid from dragging and ripping the loosely attached epithelial cells when the eye opens in the morning.
Hypertonic saline, typically 5% sodium chloride, is available as a drop or ointment. This treatment works through osmotic action, where the high salt concentration draws excess fluid (edema) out of the corneal tissue. Reducing this fluid accumulation helps improve the adherence of the epithelial layer to the underlying basement membrane. The ointment is recommended for nighttime use, as it can cause temporary blurring of vision.
For the acute erosion event, a therapeutic bandage contact lens (BCL) can be applied to the eye, acting as a physical shield over the exposed area. This protective layer stabilizes the loose epithelium, significantly reduces pain by covering the exposed nerve endings, and allows the new epithelial cells to migrate and heal underneath without interruption. In cases of persistent RCE, pharmacological support may be introduced, sometimes involving oral antibiotics like doxycycline combined with a topical steroid drop. This combination therapy is used to inhibit the activity of matrix metalloproteinase (MMP) enzymes, which break down the collagen structures responsible for epithelial adhesion.
Targeted Clinical Procedures
When conservative measures fail to prevent recurrence, the next step involves in-office procedures designed to physically or mechanically stimulate better epithelial attachment. One technique is epithelial debridement, where the poorly adhering, damaged epithelial tissue is gently removed using a sterile instrument. The goal is to clear the unhealthy tissue, allowing a fresh, healthy sheet of epithelial cells to regrow and form stronger bonds with the underlying corneal surface.
A more targeted procedure is Anterior Stromal Puncture (ASP), typically reserved for erosions outside the central visual axis to mitigate the risk of visual disturbance. In this technique, a fine needle is used to create multiple microscopic punctures that penetrate the basement membrane into the anterior stroma. These tiny punctures incite a localized healing response, resulting in the formation of micro-scars. These scars act as new, durable anchors, effectively stapling the regrowing epithelial cells to the underlying tissue.
Needle abrasion, a variation of this mechanical approach, creates microscopic trauma to the corneal surface to encourage robust adhesion during re-epithelialization. Following these procedures, a bandage contact lens is placed on the eye to protect the treated area and facilitate undisturbed healing. Patients are routinely prescribed topical antibiotics to prevent infection and non-steroidal anti-inflammatory drugs (NSAIDs) to manage post-procedure discomfort.
Advanced Surgical and Laser Interventions
For severe, widespread, or persistent RCE that has not responded to conservative care or initial clinical procedures, definitive long-term solutions are available. Phototherapeutic Keratectomy (PTK) is considered the gold standard for refractory RCE, employing an excimer laser to reshape and prepare the corneal surface. The procedure involves first removing the abnormal epithelium, then using the laser to precisely ablate the superficial corneal layer, including the abnormal Bowman’s layer and a few microns of the underlying stroma.
The laser ablation removes the damaged, weak adhesion complex and creates a smooth, clean surface free of residual debris. This newly exposed surface provides an optimal foundation for new epithelial cells to grow and form strong, healthy hemidesmosomal attachments, which prevent recurrence. PTK has proven to be an effective treatment, particularly in cases stemming from trauma.
An alternative mechanical procedure is Diamond Burr Polishing (DBP). This technique is often performed in an office setting and involves mechanically smoothing the corneal surface after the epithelium has been removed. A rapidly rotating diamond-dusted burr polishes Bowman’s layer, removing irregularities or abnormal basement membrane material. DBP creates a uniform surface that promotes the secure adhesion of the new epithelium. Both PTK and DBP require careful post-operative management, including the use of a BCL and medications.