From the Duke University Eye Center (SWR, PCK, DFZ, PKG, NAA), Department of Ophthalmology, Duke University School of Medicine, Durham, NC; and Department of Biostatistics and Bioinformatics (SS), Duke University School of Medicine, Durham, NC.
This study was supported in part by Research to Prevent Blindness Career Development Award (NAA) and Development Award EY 11725, National Eye Institute, NIH (SS).
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Natalie A. Afshari, MD, Duke University Eye Center, P.O. Box 3802, Durham, NC 27710.
Recurrent corneal erosion syndrome (RES) is characterized by repeated sloughing of the corneal epithelium. The syndrome can be a prolonged and debilitating condition that is frustrating to both the patient and the treating physician. Initial treatment is usually conservative with topical lubricants, ointments, or bandage contact lenses. However, for erosions refractory to conservative therapy, more invasive treatments, such as anterior stromal micropuncture (ASP), may be required. In this study, we reviewed a large number of patients with RES in order to determine the effectiveness of current treatment modalities used for this disorder.
A retrospective case series design study was employed. The Institutional Review Board of the Duke University Medical Center reviewed and approved the study design and protocol.
All patients with RES who presented to the Duke University Eye Center during the 7-year period from January 1st, 1995 to December 31st, 2002 were eligible for the analysis. Subjects with RES were identified through a computer database search at the Duke University Eye Center. The available patient charts were then reviewed to confirm the clinical diagnosis of RES. Subjects with RES were not excluded from the analysis for any reason.
Charts were reviewed for clinical data including patient age, gender, etiology of RES, type of treatment for erosive episodes, and history of recurrence after treatment. Reasons for developing RES were categorized as trauma, anterior basement membrane dystrophy (ABMD), other etiologies (such as Fuchs dystrophy, lattice dystrophy, dry eyes, prior keratitis, prior ocular surgery and/or contact lens use) or unknown. Recurrence after treatment was defined as additional erosive episodes occurring during the study period either while on therapy or after having completed therapy.
A total of 261 patients with RES were included in the study. During the study period, these individuals suffered 364 total RES episodes. The average age of the patients was 46.0 years with a standard deviation of 15.4 years. 158 (60.5%) of the patients were women and 103 (39.5%) were men (P < .001). Mean follow-up time was 6.8 years.
Among the subjects, etiologies of RES were trauma in 134 patients (51.3%), ABMD in 76 (29.1%), other etiologies in 27(10.3%), and unknown in 24 (9.2%).
Of all erosive episodes occurring in the study 303 (83.2%) were managed with conservative therapy (lubrication, patching and, or bandage contact lenses). 46 (12.6%) with ASP and 15 (4.1%) with PTK. All erosive episodes treated by ASP had previously failed conservative therapy during or prior to the study period, while episodes treated with PTK had failed all prior treatment efforts (conservative and/or ASP).
Of the 364 total episodes of erosion, 109 (29.9%) were recurrent episodes after initial treatment efforts during the study period. No single treatment modality was more effective than any other in preventing these recurrences. Of the 303 episodes initially treated with conservative therapy, 94 (31.0%) suffered recurrence, while 11 (23.9%) of the 46 episodes treated with ASP and 4 (26.7%) of 15 episodes treated with PTK recurred. Chi squared testing showed no difference of recurrence rates between therapeutic modalities (X2 = 0.66, P ≤ .7).
RES is characterized by episodic, painful corneal erosions secondary to a variety of etiologies. To our knowledge, this series is the largest collection of RES cases in the literature. Our findings that RES was most commonly associated with trauma and the female gender are similar to other published reports.1,2
In clinical practice, RES patients who fail conservative therapy are often subsequently treated with surgical intervention. PTK has been shown to be effective in patients with RES who have failed medical therapy.3,4 Long-term recurrence rates after PTK varies in the literature but in general, RES does not recur in most patients after one or two PTK treatments.3,4 In this analysis, approximately one quarter of subjects treated with ASP or PTK suffered recurrence, which is similar to previous reports. It is possible that this finding demonstrates a selection bias resulting from a subset of patients with especially recalcitrant disease in this referral population. Another application of PTK in the setting of RES is to manage irregular astigmatism. PTK has been shown to correct irregular astigmatism and significantly improve BSCVA in patients with RES.5
That erosions recurred in approximately one quarter to one-third of all therapeutic strategies used in this analysis suggests that current therapeutic measures may not be adequately addressing the underlying etiology of recalcitrant erosions. Patients with RES have defective basement membrane and abnormal cellular adhesion capability between the epithelium and stroma.6 Further study is needed to determine more definitive treatments for recurrent erosions.
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