Mx Exam Anterior revision

Question 1

List 5 causes of recurrent corneal erosion

Answer 1

previous abrasions (even years prior)
EBMD or Other corneal dystrophies
Band keratopathy
Prior ocular/corneal surgery
Dry eye disease

Question 2

What is the most common cause of recurrent corneal erosion?

Answer 2

Mechanical trauma/abrasions [45-65%]. These are typically shallow corneal abrasions like fingernail scratch.

Question 3

What is the second most common cause of recurrent corneal erosion?

Answer 3

EBMD [19-29%]

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376883/]

Question 4

Explain the basic pathophysiology behind recurrent corneal erosion.

Answer 4

Weakened adherence of the corneal epithelium to the basement membrane.

Question 5

Explain the pathophysiology behind why symptoms of recurrent corneal erosion are greatest on waking

Answer 5

The nocturnal drying of the ocular surface increases the adhesive force between the tarsal conjunctiva and corneal epithelium. Upon awakening, the resultant shearing forces from opening eyelids pulls/tears away the corneal epithelium from the underlying basement membrane

Question 6

Do recurrent corneal erosions ever heal?

Answer 6

Unless there is an ongoing underlying corneal disease/dystrophy, most patients will ultimately heal completely and not have any more episodes. However, it may take years for this to happen at the longest

Question 7

How does EBMD appear on anterior examination?

Answer 7

Map-dot-fingerprint

Question 8

What may be considered for pain relief in a patient with recurrent corneal erosion? What should you use in conjunction with this?

Answer 8

Soft bandage contact lens + prophylactic chlorsig 0.5% gtt QiD

Question 9

What might be an appropriate choice for a bandage lens?

Answer 9

Air optix night and day [it’s approved for up to 30 nights of continuous extended wear]

Question 10

What may be an appropriate initial treatment for an acute case of recurrent corneal erosion? (4)

Answer 10

Artificial tears (preferably non-preserved): e.g. refresh, xailin, hyloforte QiD-8x or prn
Oral nsaid: ibuprofen 250mg BiD (or as needed)
Antibiotics: chlorsig 1% ointment [or erythromycin?]
Corneal debridement

[https://www.icliniq.com/articles/eye-health/how-to-relieve-the-pain-caused-by-corneal-abrasion] + research online from e.g. wills eye manual.

Question 11

List 3 things to rule out when examining a recurrent corneal erosion

Answer 11

Infectious keratitis
Subtarsal foreign body (do lid eversion)
EBMD/corneal dystrophies

Question 12

When are recurrent epithelial erosion symptoms at their worst, typically?

Answer 12

in the morning

Question 13

does patching a corneal abrasion with a bandage lens improve the rate of healing?

Answer 13

no

Question 14

How might a bandage lens help improve/lessen symptoms of a recurrent corneal erosion?

Answer 14

It can protect the epithelium from the shearing force of the opening eyelids on awakening. (so you should sleep in them)

Question 15

How often should you review cases of recurrent corneal erosion?

Answer 15

Every 1 to 2 days until the epithelium has healed and then every 1 to 3 months depending on the severity and frequency of the episodes.

[Wills eye manual]

Question 16

When are bandage contact lenses indicated in recurrent corneal erosion? (2)

Answer 16

Acute attack where the epitihelial defect is large or along the optical axis
When lubrication and punctal occlusion have failed

Question 17

List 3 interventions for chronic episodes of recurrent corneal erosion

Answer 17

Continuing artificial tears (e.g. refresh QiD-8x) or increase dosage
Night-time ointment [e.g. vitapos]
Hypertonic saline/NaCl 5% QiD.

Question 18

should you patch/use bandage contact lenses in patients with recurrent corneal erosions who are contact lens wearers?

Answer 18

No. NEVER.

Question 19

Should you prescribe topical anaesthetic drops to patients with recurrent corneal erosions?

Answer 19

NO. Only use them during your examination

Question 20

How long should bandage lenses be used in patients with recurrent corneal erosions?

Answer 20

2-8 weeks, with a prophylactic antibiotic. Time frame depends on resolution

Question 21

What intervention can you try for patients with chronic recurrent erosion resistent to lubrication alone? What is the benefit of this intervention?

Answer 21

Punctal occlusion (punctal plugs): block the drainage channel, thus increasing the ocular surface residence duration of both applied and natural tears, thereby promoting more rapid healing and preventing further attacks

[https://www.aao.org/eyenet/article/treatment-of-recurrent-corneal-erosions]

Question 22

How can you determine if punctal plugs may be successful in improving healing and symptoms in a patient with recurrent corneal erosions? In what type of dry eye level would we do this?

Answer 22

could trial dissolvable short-term collagen punctal plugs. Would do this for mild/moderate dry eye, whereas for severe tear film insufficiency we’d just go straight to the long-term silicone plugs

Question 23

After epithelial healing is complete in a patient with recurrent corneal erosion, how should we continue management?

Answer 23

Continue lubricants QiD-8x + artificial tear ointment (vitapos) NOCTE for at least 3 to 6 months OR

5% NaCl drops QiD + 5% NaCl ointment NOCTE for at least 3 to 6 months

[Wills eye manual] [qhs = NOCTE]

Question 24

What interventions may we consider for recurrent corneal erosions not responding to treatment from lubrication (drops + ointment) or punctal plugs (5)

Answer 24

5% NaCl [hypertonic saline] prophylactically NOCTE
Oral Doxycycline 50mg BiD +/- FML 0.1% BiD to QiD for 2-4 weeks
Extended wear bandage lens for several months with topical antibiotic + routine changing of lens
Anterior stromal puncture surgery
Epithelial debridement with diamond burr polishing of bowman membrane or PTK

[Wills eye manual + https://www.aao.org/eyenet/article/treatment-of-recurrent-corneal-erosions]. Wills eye manual suggests FML.

Question 25

How effective are epithelial debridement and PTK (phototherapeutic keratectomy) for recurrent corneal erosion?

Answer 25

Highly effective (90%) for large areas of epithelial irregularity and lesions in the visual axis

Question 26

When might excimer laser ablation of the superficial stroma be useful in patients with recurrent corneal erosion?

Answer 26

If repeated erosions have created anterior stromal haze or scarring

Question 27

How should you educate a patient with recurrent corneal erosion? (no dystrophies)

Answer 27

Persistent usage of lubrication/ointment for 3 to 6 months following the healing process reduces the chance of recurrence

Question 28

Where can anterior stromal puncture be applied?

Answer 28

to localized erosions outside the visual axis, such that any subsequent corneal scarring does not interfere with vision

Question 29

Why are MMP inhibitors useful for patients with recurrent corneal erosion?

Answer 29

Patients with RCE have upregulated MMP-2 and MMP-9. Increased MMP-9 activity has been associated with disruption of the corneal epithelial barrier function and corneal surface irregularity.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594995/]

Question 30

What to cover next:

Answer 30

EBMD in a little more specific detail

Regular dry eye syndrome [check wills eye manual]