Mx Exam Anterior revision Flashcards
List 5 causes of recurrent corneal erosion
previous abrasions (even years prior) EBMD or Other corneal dystrophies Band keratopathy Prior ocular/corneal surgery Dry eye disease
What is the most common cause of recurrent corneal erosion?
Mechanical trauma/abrasions [45-65%]. These are typically shallow corneal abrasions like fingernail scratch.
What is the second most common cause of recurrent corneal erosion?
EBMD [19-29%]
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376883/]
Explain the basic pathophysiology behind recurrent corneal erosion.
Weakened adherence of the corneal epithelium to the basement membrane.
Explain the pathophysiology behind why symptoms of recurrent corneal erosion are greatest on waking
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
Do recurrent corneal erosions ever heal?
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
How does EBMD appear on anterior examination?
Map-dot-fingerprint
What may be considered for pain relief in a patient with recurrent corneal erosion? What should you use in conjunction with this?
Soft bandage contact lens + prophylactic chlorsig 0.5% gtt QiD
What might be an appropriate choice for a bandage lens?
Air optix night and day [it’s approved for up to 30 nights of continuous extended wear]
What may be an appropriate initial treatment for an acute case of recurrent corneal erosion? (4)
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.
List 3 things to rule out when examining a recurrent corneal erosion
Infectious keratitis
Subtarsal foreign body (do lid eversion)
EBMD/corneal dystrophies
When are recurrent epithelial erosion symptoms at their worst, typically?
in the morning
does patching a corneal abrasion with a bandage lens improve the rate of healing?
no
How might a bandage lens help improve/lessen symptoms of a recurrent corneal erosion?
It can protect the epithelium from the shearing force of the opening eyelids on awakening. (so you should sleep in them)
How often should you review cases of recurrent corneal erosion?
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]
When are bandage contact lenses indicated in recurrent corneal erosion? (2)
Acute attack where the epitihelial defect is large or along the optical axis
When lubrication and punctal occlusion have failed
List 3 interventions for chronic episodes of recurrent corneal erosion
Continuing artificial tears (e.g. refresh QiD-8x) or increase dosage
Night-time ointment [e.g. vitapos]
Hypertonic saline/NaCl 5% QiD.
should you patch/use bandage contact lenses in patients with recurrent corneal erosions who are contact lens wearers?
No. NEVER.
Should you prescribe topical anaesthetic drops to patients with recurrent corneal erosions?
NO. Only use them during your examination
How long should bandage lenses be used in patients with recurrent corneal erosions?
2-8 weeks, with a prophylactic antibiotic. Time frame depends on resolution
What intervention can you try for patients with chronic recurrent erosion resistent to lubrication alone? What is the benefit of this intervention?
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]
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?
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
After epithelial healing is complete in a patient with recurrent corneal erosion, how should we continue management?
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]
What interventions may we consider for recurrent corneal erosions not responding to treatment from lubrication (drops + ointment) or punctal plugs (5)
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.
How effective are epithelial debridement and PTK (phototherapeutic keratectomy) for recurrent corneal erosion?
Highly effective (90%) for large areas of epithelial irregularity and lesions in the visual axis
When might excimer laser ablation of the superficial stroma be useful in patients with recurrent corneal erosion?
If repeated erosions have created anterior stromal haze or scarring
How should you educate a patient with recurrent corneal erosion? (no dystrophies)
Persistent usage of lubrication/ointment for 3 to 6 months following the healing process reduces the chance of recurrence
Where can anterior stromal puncture be applied?
to localized erosions outside the visual axis, such that any subsequent corneal scarring does not interfere with vision
Why are MMP inhibitors useful for patients with recurrent corneal erosion?
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/]
What to cover next:
EBMD in a little more specific detail
Regular dry eye syndrome [check wills eye manual]
