Spark ImageWise 11 – Cornea

Dr Ravi Daberao, Dr Prabhat Nangia, Dr Sarang Lambat, Dr Vinay Nangia 
Suraj Eye Institute, 559 New colony, Nagpur 

Case Description
A female, 52 years of age, came for second opinion with complaints of redness, irritation, foreign body sensation and watering in left eye since one month, which was sudden in onset, progressive and associated with pain. Patient had history of epithelial defect and placement of bandage contact lens (BCL) in left eye 2 weeks prior elsewhere. There was no history of ocular trauma. Her best corrected visual acuity was 6/6, N6 in right eye (OD) and 6/9, N6 in left eye (OS).

Figure 1: Anterior segment examination of right eye shows corneal epithelial irregularity (pink arrows).
Figure 2: Anterior segment examination of left eye shows corneal epithelial irregularity (pink arrows).
Figure 3: Anterior segment examination of right eye on fluorescein staining of cornea shows stained epithelial irregularities in a linear pattern (pink arrow).
Figure 4: Anterior segment examination of left eye on fluorescein staining of cornea shows loose elevated epithelium showing negative staining (pink arrow) with punctate erosions (Micro erosions) (yellow arrow). 

Figure 5: Anterior segment examination findings of right eye(Fig. 3) better visualised with Wratten filter no.12. (yellow filter)
Figure 6:
Anterior segment examination findings of left eye(Fig. 4) better visualised with Wratten filter no.12 (yellow filter).
Figure 7: Retro illumination of right eye which highlights the corneal irregularities (white arrow).
Figure 8: Retro illumination of left eye which highlights the corneal irregularities (white arrow).

In this case patient had history of repeated episodes of recurrent corneal erosion (RCE). Epithelial erosion with corneal irregularity was more in left eye. Retro illumination examination after dilatation of the pupil helps to diagnose signs of basement membrane dystrophy or the reparative stage after previous erosion (as seen in right eye). Right eye RCES was mild and healed so we managed it conservatively with lubricating drops. In left eye micro erosions were seen with elevated epithelium and the patient was symptomatic so we had advised epithelial debridement with placement of bandage contact lens. We also advised lubricating, antibiotic and cycloplegic drops in left eye. 

Figure 9: Left eye anterior segment examination at 7 days follow up shows cellular debris following BCL removal (yellow arrow).
Figure 10: Left eye anterior segment examination on fluorescein staining shows healing epithelial erosions & reduction in fluorescein staining of cornea with early contact lens induced hypoxia in periphery (pink arrow).

She was started on combination eye drop (brimonidine tartrate and timolol maleate) BD and tablet acetazolamide 250 mg ½ tablet BD. 
On 2 week follow up her IOP was 24 mmHg and 26 mmHg in RE and LE respectively. She was advised to undergo trabeculectomy for IOP control in RE and Yag-PI in LE.
She underwent  Yag-PI in the LE followed by  trabeculectomy in the RE. Post surgery she had a large cystic bleb and an IOP of 22 mmHg which came down to 9 mmHg,  8 months post surgery. Her IOP in LE was 33 mmHg post Yag-PI on combination eye drop brimonidine tartrate + timolol maleate BD.   Patient was advised to undergo trabeculectomy in LE for better IOP control

Discussion

Recurrent corneal erosion syndrome is a chronic relapsing disease of the corneal epithelium characterized by repeated episodes of sudden onset of pain. Individual episodes may vary in severity and duration. These symptoms are related to corneal de epithelialization in an area in which the epithelium is weakly adherent. Recurrent corneal erosion syndrome may be either primary or secondary, depending on whether the defect in the epithelial basement membrane is intrinsic or acquired. In the majority of patients with RCES, minor trauma is the initiating factor, especially trauma from a scratch that damages or destroys the corneal basement membrane. 

In the majority of cases, the acute episode is managed by patching or placement of bandage contact lens, topical lubricants and antibiotics. In a minority of cases these measures are insufficient and may need alternative treatment modalities including epithelial debridement, anterior stromal puncture and most effectively, excimer laser therapy (phototherapeutic keratectomy, PTK). It is expected that the new epithelium which grows post debridement or PTK should be more firmly adherent to underlying basement membrane. 

It is important to understand the recurrent nature of the disease. Our patient presented three weeks later for follow up with fresh epithelial defect. These patients need frequent follow up and they need to be counseled about frequent recurrences. The use of hypertonic ointments in the chronic phase has been described, which may help prevent recurrences. 

ReadWise

  1. Sujata Das, Berthold Seitz,Recurrent Corneal Erosion Syndrome,Survey of Ophthalmology,Volume 53, Issue 1,2008, Pages 3-15, ISSN 0039-6257,  https://pubmed.ncbi.nlm.nih.gov/16021185/
  2. Ramamurthi S, Rahman MQ, Dutton GN, Ramesh K. Pathogenesis, clinical features and management of recurrent      corneal erosions. Eye (Lond). 2006 Jun;20(6):635-44. doi: 10.1038/sj.eye.6702005. Epub 2005 Jul 15. PMID: 16021185. https://www.sciencedirect.com/science/article/abs/pii/S0039625707002585

Correspondence 

Dr Prabhat Nangia
DNB, FICO, FMRF, FAICO
Consultant  
Department of Cornea and ocular surface
Suraj eye Institute
Email – education@surajeye.org

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