Recurrent Corneal Erosion (RCE) is a disorder where the corneal epithelium, the outermost layer of the eye’s surface, repeatedly detaches from the underlying basement membrane. This breakdown causes sudden, sharp eye pain, often upon waking or opening the eyes, along with light sensitivity and excessive tearing. RCE typically arises after a superficial injury to the cornea, such as a scratch, which disrupts the anchoring structures holding the epithelium in place. It can also occur spontaneously in people with underlying corneal disorders, most notably Epithelial Basement Membrane Dystrophy. Management focuses on resolving the immediate, painful event and implementing long-term strategies to prevent future recurrences.
Managing the Acute Erosion Event
The first priority when an erosion occurs is to promote rapid healing and manage the intense pain. The pain results from the exposure of sensitive corneal nerves and constant friction from the eyelid. Immediate care often involves placing a temporary therapeutic contact lens, known as a bandage contact lens.
This specialized soft contact lens acts as a physical shield, providing a smooth surface to reduce eyelid friction. This allows new epithelial cells to migrate and heal underneath without interruption. To prevent secondary infection, a topical antibiotic drop or ointment is typically prescribed for a short course. Preservative-free artificial tears are also encouraged to maintain a moist healing environment.
Pain control methods include oral non-steroidal anti-inflammatory drugs (NSAIDs). In more severe cases, a cycloplegic agent—an eye drop that temporarily paralyzes the ciliary muscle—may be used to reduce muscle spasms that cause deep eye pain. For extensive or persistent erosions, the eyelid may be taped shut temporarily to immobilize the lid over the cornea. This minimizes mechanical disruption until the surface has fully closed, paving the way for long-term preventative care.
Long-Term Strategies to Prevent Recurrence
Once the acute erosion has healed, the focus shifts to strengthening the epithelial attachment to prevent recurrence. The foundation of long-term management is lubrication, especially nocturnal lubrication, to reduce the shearing force created when the eyelid separates from the cornea during sleep. Patients should apply a thick lubricating ointment every night for several months, which physically buffers the corneal surface.
A common strategy involves using hypertonic saline solutions, typically 5% sodium chloride (NaCl), available as drops for daytime use and an ointment for nighttime application. Hypertonic saline works by creating an osmotic gradient, drawing excess fluid out of the corneal surface cells. This dehydration encourages the epithelium to flatten and adhere more tightly to the underlying Bowman’s layer, reinforcing the weak bond. This regimen is often continued for six to twelve months.
For cases refractory to simple lubrication and hypertonic agents, a specialized medical regimen targeting biological instability is introduced. This includes an oral tetracycline antibiotic, such as doxycycline, combined with a course of a topical corticosteroid. This combination is prescribed for its ability to inhibit Matrix Metalloproteinase-9 (MMP-9) enzymes, not just for antimicrobial or anti-inflammatory effects. Elevated MMP-9 levels degrade the collagen and anchoring complexes that secure the epithelium. Inhibiting MMP-9 stabilizes the corneal surface, allowing for the formation of a stronger epithelial bond.
In-Office Interventions for Refractory Cases
When conservative medical management fails, minimally invasive, in-office procedures are considered before resorting to laser surgery. These interventions stimulate the formation of new, strong adhesion complexes between the epithelium and the underlying tissue. The choice of procedure often depends on the erosion’s location relative to the central visual axis.
Anterior Stromal Puncture (ASP)
ASP is typically reserved for erosions located in the peripheral cornea, away from the center. This procedure involves using a fine, bent needle to create numerous microscopic punctures through the non-adherent epithelium and Bowman’s layer into the anterior stroma. These tiny punctures induce a controlled, localized scarring response that acts as a spot-weld. This creates stronger physical anchors for the new epithelial cells to attach.
Diamond Burr Polishing (DBP)
DBP can be used for both central and peripheral erosions. After the loose or abnormal epithelium is gently removed, a small, motorized diamond-tipped burr polishes the surface of Bowman’s layer. This polishing removes residual abnormal basement membrane material and creates a smooth, finely abraded surface. The polished surface provides a uniform, clean substrate that encourages migrating epithelial cells to lay down a new basement membrane with strong adhesion complexes.
Phototherapeutic Keratectomy (PTK)
Phototherapeutic Keratectomy (PTK) is the definitive, laser-based surgical option for RCE cases that have failed all other treatments. This procedure uses an excimer laser, the same type used in vision correction surgeries, to precisely reshape the superficial cornea. The goal is not to change refractive power, but to create a new, smooth foundation for the epithelium to reattach.
The procedure begins with the mechanical removal of the damaged epithelial layer. The excimer laser then delivers a controlled, shallow ablation—usually less than 10 micrometers—to the exposed Bowman’s layer and anterior stroma. This process removes the source of the adhesion problem, whether it is an abnormal basement membrane or damaged tissue. The laser simultaneously creates a microscopically textured surface that stimulates a controlled fibrotic response.
This response encourages the formation of a superior, robust attachment complex as the new epithelium grows back. PTK has a high success rate, often achieving long-term resolution of recurrent episodes. Potential side effects include temporary blurring, subepithelial haze during healing, and a minor hyperopic shift (a slight change toward farsightedness) due to the central flattening of the cornea.