Recurrent Corneal Erosions

Many people at one time or another will have a piece of

grit fly into their eye and have to have it professionally
removed. Once the eye is patched for 24 hours, the
cornea repairs itself and the mishap is forgotten.

If however, the eye is injured by anything organic, such as a fingernail, the cornea may

heal but break down again weeks or months later.

The entire sequence of the initial accident is relived, and the person suffers pain,
sensitivity to light, watering eyes, redness of the eye, and marked blurring of vision.
The event may seem unreal because there is no antecedent injury the second or third
time.
For immediate relief, a local anesthetic will relieve the symptoms. Treatment consists of a
pressure bandage on the eye to promote the healing. Mechanical denuding of the loose
corneal epithelium may be necessary. The other eye should be kept closed most of the
time to minimize movement of the lid over the affected eye.
Bed rest is desirable for 24 hours. The cornea usually heals in 2 -3 days. To prevent
recurrence and to promote continued healing it is important for these patients to use a
bland ointment (e.g.. boric acid or other ocular lubricants) at bedtime for several months.
In more severe cases, artificial tears are instilled during the day. The use of hypertonic
ointment or saline drops
is often of value. Therapeutic soft contact lenses and needle micropuncture of Bowmans
layer have been useful in cases that do not respond to more conservative management.

http://www.interiorretina.com/recurrentcornealerosions.html

Corneal Abrasion

A corneal abrasion occurs when the outer layer of the

cornea, called the epithelium, is torn away. (The cornea is the clear outer coating of the front
of the eye.)This can occur by a variety of means such as a finger in the eye, a tree limb, flying
glass in an automobile accident, etc. It is one of the most common injuries to the eye.
The corneal has more nerve endings than virtually any other part of the body. Because of
these many nerve endings, any damage to the cornea is very painful. Abrasions usually heal
in a short time period, sometimes within hours. But while they are healing they can cause
excessive tearing, redness, blurred vision and light sensitivity. In many cases, the cornea will
heal overnight during sleep. If treatment is needed, it consists of a tight patch to keep the lids
from moving and pain relievers as needed for comfort.

An antibiotic may be used following an abrasion because the open area of the epithelium
invites infection. Small abrasions heal rapidly. However, if one covers more than one-third of
the cornea, it may take an extra day or two for the epithelium to completely recover the front
of the cornea.
Typically, an anesthetic is used in the eye doctors office to ease the pain and to aid in the
examination. After the examination, the pain typically returns. But, repeated use of anesthetic
can harm the eye and is therefore not used in the treatment of abrasions. It may take several
weeks for all the blurriness to resolve. Permanent loss of vision is very rare with superficial
abrasions.
DO NOT rub the eyes during the healing phase following an abrasion. New cells require time
to re-connect to the non-damaged layers of the cornea. These new cells can be easily rubbed
off.
If the new cells get removed, the pain returns and repatching is necessary.
Occasionally, long after an abrasion has healed it recurs spontaneously, often upon awakening
in the morning. This is called a recurrent erosion and represents an area of the epithelium that
is not re-connected well to the deeper parts of the cornea.
The treatment is similar to that for the abrasion. Sometimes the surface of the cornea is
treated with a special instrument in order to help form better connections between the corneal
layers. Extended use of bedtime ointments or lubricants may also help in preventing recurrent
erosions
Corneal Abrasions
Corneal abrasions are usually the result of either trauma or an anatomic corneal
defect that causes recurrent erosions. The overwhelming majority of patients will describe
trauma with a foreign object immediately before the onset of symptoms. Patient with
recurrent erosion from inadequate adhesion of the corneal epithelium to the basement
membrane typically describe onset of tearing, pain and foreign body sensation upon
awakening. A corneal epithelial defect that stains with fluorescein
is the finding on slit
lamp examination. Conjunctival injection and a swollen eyelid may also be present. It is
important to evert the upper lid to ensure there is no retained subtarsal foreign body. Topical
antibiotic should be given four times per day for one week. For non-contact lens wearers,
erythromycin ointment or polymyxin B/trimethoprim is sufficient. Contact lens wearers need
antipseudomonal coverage with ofloxacin or ciprofloxacin and should not use their lenses
until the abrasion resolves. Patching is generally not recommended and is contraindicated in
contact lens wearers. Rapidity of healing depends on the size of the abrasion, but generally
most abrasions heal in two to three days.
Fluorescein staining helps demonstrate corneal abrasions even if a cobalt blue light source is
not available.

Corneal Ulcers
Most corneal ulcers
are caused by bacteria. Fungal ulcers should be
suspected in cases of corneal injury with plant material. Acanthamoeba is seen almost
exclusively in contact lens wearers and herpes viruses cause corneal ulcers with distinctive
features on examination which will be discussed below. Pain, redness, photophobia, and
foreign body sensation are the usual symptoms. The physician should ask about contact
lens use, swimming with contact lenses, trauma, and a foreign body to the eye. A white or
yellowish-white infiltration of the cornea with fluorescein staining of the overlying epithelial
defect is the key finding. Herpes viruses often have a dendrite like appearance to their
epithelial defects.
Corneal ulcer. In this case, the ulcer was sterile and was due to corneal anesthesia with
subsequent breakdown of the epithelium, which could not heal. The eye was inflamed.

An ophthalmologist should be consulted to obtain corneal cultures. If the patient is

a contact lens wearer, their contact lens case and contact lens solution bottles should also
be sent to the microbiology lab. The appropriate antibiotic therapy can range from polymyxin
B/trimethoprim four times per day to fortified antibiotics every hour depending on the size
and location of the bacterial ulcer. An ophthalmologist should make this determination. For
fungal, Acanthamoeba and herpetic ulcer treatment, please see Table 3. Patients initially
need daily follow-up to ensure the ulcer is improving and to rapidly implement the results of
the cultures and sensitivities. If the ulcer is outside of the visual axis, recovery of vision is the
norm. If the ulcer is in the visual axis, scarring may limit vision and corneal transplantation
may be necessary for visual rehabilitation.
Disease
Fungal corneal
ulcers

Treatment
Natamycin 5% drops or Amphotericin B 0.15% drops initially every 1 -2 hours
with a slow taper over weeks once infection is controlled. Topical steroids should
be avoided. Consider adding oral fluconazole or voricanazole in severe cases.

Acanthamoeba
corneal ulcers
Herpes Simplex
epithelial keratitis
Herpes Zoster
ophthalmicus

Polyhexamethyl biguanide 0.02%, Chlorhexidine 0.02%, or Propamidine

isethionate 0.1% drops every hour. Discontinue contact lens wear.
Trifluorothymidine 1% drops 9 times per day with tapering as lesions heal over 14
days; subsequent prophylaxis with oral acyclovir 400 mg BID
Intravenous acyclovir 30 mg/kg/day in 3 doses, for 7 10 days in severely
immuncompromised individuals. Famiciclovir 500mg PO TID or Valacyclovir 1g
TID in immunocompetent patients or reliable, immunocompromised patients with
less severe disease. Bacitracin ointment to skin lesions.
Immune-recovery Topical prednisolone acetate with frequency depending on severity. Periocular
uveitis associated steroid injection for visually symptomatic cystoid macular edema or vitritis. Avoid
with healed CMV intravitreal injection of triamcinolone acetonide.
retinitis
Necrotizing
Intravenous acyclovir 1,500 mg/m2 of body surface area in three divided doses for 7
herpetic retinitis 10 days (associated with high rate of failure); consider addition of foscarnet to
improve efficacy.
Intravenous foscarnet and/or ganciclovir if no response to acyclovir, or patient
judged to be severely immunocompromised; complete induction courses of both
drugs, then place on maintenance therapy with oral valacyclovir or valganciclovir.

Toxoplasmosis
chorioretinitis

Pneumocystis
choroiditis
Syphilitic
chorioretinitis
Tuberculous
choroiditis
Bartonella
retinitis
Bacterial
endophthalmitis
Fungal
endophthalmitis

Intraocular
lymphoma

Adjunctive local therapy for severe disease: Intravitreal injections of ganciclovir

2.0 mg and/or foscarnet 1.2 to 2.4 mg three times per week for two weeks, then
once or twice per week until lesions healed
Oral pyrimethamine 200 mg load then 25 mg BID, sulfadiazine 2 g load then 1 g
QID, clindamycin 300 mg QID, folinic acid 10 mg twice weekly or 5 mg daily, for
4 to 6 weeks.
Alternatives: 1) Oral trimethoprim-sulfamethoxazole DS plus clindamycin 300 mg
QID for 4 to 6 weeks. 2) Oral atovaquone 750 mg TID, clarithromycin 500 mg BID
for 4 to 6 weeks (sulfa-intolerant patients or those who are uncontrolled on
clindamycin or clindamycin plus pyrimethamine).
Intravenous trimethoprim (5 mg/kg)/ sulfamethaxazole (25 mg/kg) Q 8 hours for 3
weeks or intravenous pentamidine 4 mg/kg daily.
Intravenous aqueous penicillin G 24 million units per day for ten days. Alternative:
intramuscular procaine penicillin G 2.4 million units per day for ten days; must be
given with oral probenecid 500 mg QID. Intravenous treatment preferred in HIV
infection.
Oral isoniazid 300 mg daily, rifampin 300 mg BID, ethambutol 15 mg/kg daily, or
other three or four drug regimen.
Oral doxycycline 100 mg BID and rifampin 300 mg BID for 4 - 6 weeks.
Intravitreal injection of vancomycin 1 mg and ceftazidime 2.25 mg. Treatment of
underlying infection if endogenous endophthalmitis.
Local: Intravitreal injection of amphotericin 5 micrograms or voriconazole 100
micrograms usually at the time of pars plana vitrectomy to clear vitreous fungal
colonies.
Systemic: Oral fluconazole 200 to 400 mg daily or intravenous amphotericin in
escalating doses. Alternative: voriconazole 200 mg PO BID
High-dose intravenous methotrexate with or without radiation therapy.
Intrathecal chemotherapy for CNS involvement.
Salvage therapy with intravitreal injection of methotrexate 400 micrograms weekly

X 4, then monthly for one year, for sight-threatening disease

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