THE CASE: Martha, a 62-yearold, was hit in the left eye with a tree branch. She suffered a corneal foreign body and a large abrasion. She was treated at an eye clinic (not mine) and first presented to me 10 months later. Martha was taking atenolol (Tenormin) for hypertension. Her vision was mildly blurred OS and her pressing complaint was that this eye always felt sore.

Martha had no discharge but did have slight tearing OU. The soreness was worst in the morning, immediately upon waking, she said. During severe episodes, her lid felt as if it were "catching" on her eye. The problem had existed for 1 month.

Martha's exam

At the time of injury, Martha's eye was patched for 2 days. She'd used an antibiotic drop, but now used only artificial tears. Her vision at 10:30 a.m. was 20/20 -2 OD and 20/25 OS with her current prescription. Slitlamp exam showed a white, quiet anterior segment OD.

My exam of Martha's left eye revealed her problem. The central corneal surface was very irregular, with two small areas of negative staining and two larger areas that stained positively with NaFI (see figure below). The frankly, staining lesions indicated an absence of epithelium. I saw no foreign body and except for mild conjunctival injection, the rest of the exam was normal.

Martha had a severe, recurrent corneal erosion (RCE) OS that would probably require protracted treatment. I discussed treatment options with her and placed a tight-fitting disposable contact lens on her eye as a bandage. I prescribed ciprofloxacin hydrochloride (Ciloxan) OS q.i.d., telling Martha not to manipulate the contact lens and to use rewetting drops between applications of ciprofloxacin drops as often as possible. She was to return to see me in 1 week.

A classic

With recurrent episodes of acute ocular pain with tearing, photophobia and redness, Martha's case was a classic. These episodes are most common immediately upon opening the eyes when awakening. Chronic bouts of pain may present daily, or may be intermittent. The condition frequently arises after corneal trauma, particularly from an organic source such as a tree branch, or from a corneal abrasion. It may also result from a corneal dystrophy, such as epithelial basement membrane disease.

A localized disruption of the corneal epithelial layer marks the condition. There may be accompanying "roughening" or elevation of the corneal epithelium adjacent to the defect. Negative staining is typical of this roughening.

Because the defect usually fills in as the day goes on, you may not see any staining with the slit lamp. Generally, though, there's a positive staining defect that's surrounded by areas of loose or poorly adherent epithelium.

The saga continues

One week later Martha's left eye felt "real good" with the contact lens in, but after the technician removed the lens, her eye felt irritated. Her vision was still 20/25-1 OS. Her clinical exam revealed a small-staining area of RCE and two areas of roughened, elevated epithelium.

I inserted a new bandage contact lens in her left eye, and advised her to continue the ciprofloxacin q.i.d. and the rewetting drops as often as possible. I scheduled her for a 2-week follow-up visit.

At that visit, Martha's cornea was free of positive staining but showed a small area of negative staining. Her epithelium wasn't completely healed, so I inserted another contact lens in her left eye. I asked her to stop the ciprofloxacin but to continue artificial tears q.i.d.

Over the next 3 months, Martha's eye followed the pattern: It felt fine while a contact lens was in place, but irritation resumed after it was removed.

Examining again

At the 3-month visit, a Schirmer's test showed decreased tear production of 9 mm OD and 4 mm OS. Tear breakup time (TBUT) was also abnormal, measuring 5 seconds OD and 4 seconds OS. Although the RCE seemed to be improving, the dryness of her eyes would prevent complete resolution.

I inserted 0.5-mm Freemantype silicone punctal plugs in the lower punctum of each eye and reinserted a bandage lens OS.

At her 2-week post-plug follow-up, Martha said her eyes "hadn't felt this good in years." The cornea was wetting much better; there was no epithelial defect and only a small area of irregular tissue OS.

I didn't reinsert a contact lens but encouraged Martha to use nonpreserved artificial tears at least q.i.d. OU and hoped the saga was over.

Martha: the sequel

I saw Martha 6 months after inserting the punctal plugs. Her eyes were doing well, but once a month she felt a sharp pain OS, with redness. Each time, the pain would take 3 days to subside.

Martha admitted using the artificial tears only "as needed." The OS showed intrapalpebral conjunctival injection and a 2mm area of elevated, negatively staining corneal irregularities just inferior to the pupil margin.

TBUT was consistently 15 seconds OD but was diminished focally OS. The central, roughened area exhibited a TBUT of 2 seconds. The remainder of the left cornea had a TBUT of 11 seconds.

This showed that, although there were no apparent epithelial defects, the irregular cornea was precipitating intermittent episodes of RCE OS.

A more aggressive approach was definitely indicated. Because the epithelium wasn't loose, I didn't think debridement was appropriate. I discussed the anterior stromal puncture (ASP) technique with Martha, and she decided to undergo it.

One last try

To begin the procedure, I anesthetized the cornea with 1/2% topical proparacaine HCI (Alcaine). Using a disposable needle designed for ASP, I punctured the epithelium in 22 spots within the treatment zone of the eye.

Afterward, I instilled 1 drop of 1% cyclopentolate HCl (Cyclogyl), inserted a bandage contact lens and prescribed ciprofloxacin OS q4h. I discontinued the ciprofloxacin after 1 week and removed the contact lens 2 weeks later.

Martha tolerated the procedure well and now, over 1 year later remains symptom-free using artificial tears.

As you can see, RCE doesn't go down without a fight. Be persistent and aggressively treat this condition. Your patients' health and comfort depend on it.

Contributing Editor Eric Schmidt, O.D., is Director of the Bladen Eye Center in Elizabethtown, N.C. He can be reached via e-mail at KINZSEKATE@aol.com.

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