Expert sheds light on treating EBMD and recurrent erosions

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Reviewed by Christopher J. Rapuano, MD

Recurrent erosions can occur with epithelial basement membrane dystrophy (EBMD), and medical and surgical management can be utilized, according to Christopher J. Rapuano, MD, director, Cornea Service, Wills Eye Hospital, professor, Jefferson Medical College, Philadelphia, Pennsylvania.

Rapuano lectured on taking the mystery out of EBMD and recurrent erosion treatment during the recent Walter Wright Symposium in Toronto, Canada.

“Abnormalities in the epithelial layer related to basement membrane irregularities are often an incidental finding,” he said. “Patients will come in for any number of unrelated reasons and you’ll see these changes in the cornea. But they also cause symptoms.”

Symptoms of EBMD include decreases in vision that can be mild to moderate or severe, with monocular diplopia or shadowy vision, noted Rapuano. “There could be mild foreign body sensation symptoms all the way up to debilitating painful recurrent erosions,” he said.

What is disconcerting to patients is not so much the pain associated with the erosions (although that can be considerable) but not knowing when the pain will occur, Rapuano explained.

“Patients often tell me that the worst aspect of the recurrent erosion syndrome is the unpredictability of the attacks,” Rapuano said. “It is like a sword of Damocles hanging over their heads. They say they don’t know if they will be able to go to work, a child’s birthday party, or a wedding. They often say they can’t continue to live that way. Being in this state makes them crazy. When they are treated and doing better, they become normal people again.”

Etiologies for recurrent erosions include corneal abrasions that typically stem from a shearing type of injury that may involve a fingernail or a tree branch, Rapuano said. “It is estimated that 10% of patients with EBMD will get recurrent erosions,” he said, noting other dystrophies can cause recurrent erosions.

When a patient presents with a history of painful episodes, a key to detecting EBMD is the use of fluorescein staining, Rapuano said. “If you look very hard, you will often see some mild epithelial irregularity and perhaps some mild negative staining; it’s important to look at both eyes,” he explained.

If patients have a history of herpes simplex keratitis because they’ve had an erosion, they may be told that this condition is what is causing their pain—but that diagnosis would be incorrect, said Rapuano. “The history does not really go along with that,” he added.

Medical treatment for recurrent erosions includes lubricating therapies such as tear gel or ointment, hypertonic drops and ointment, or steroid drops and doxycycline, according to Rapuano. “Therapies like Muro 128 can be helpful,” he added.

Preventive management consists of treating dry eye syndrome and blepharitis if present, noted Rapuano. Other preventive steps include preservative-free tears 4 times daily if eyes are even remotely dry, and ointment applied every 3 to 6 months, said Rapuano.

If medical treatment should fail, epithelial debridement can be performed at the slit lamp, but success is not guaranteed, noted Rapuano. “The success rate is only about 50%,” he said.

Anterior stromal puncture is also an approach if medical treatment is failing, said Rapuano. It is particularly useful if the erosions are always in the same location, relatively small, outside the visual axis, and if the patient is cooperative, according to Rapuano.

An anterior stromal puncture can be performed at the slit lamp, according to Rapuano. Topical anesthesia is applied and an eyelid speculum is used as well as a 23- to 25-gauge needle. Various papers suggest recurrence of erosions can be 0% to 37%, noted Rapuano.

An anterior stromal puncture can be repeated if necessary, and postoperative management should follow the patient closely as if there had been a corneal abrasion, Rapuano pointed out.

Other management interventions include diamond burr polishing of the Bowman membrane, explained Rapuano. The excimer laser is another option, he added.

“The diamond burr basically removes the epithelium basement membrane irregularities and allows for smoothing out the area,” Rapuano explained, suggesting that a diamond burr with a 5-mm diameter be used.

The diamond burr should be applied to the Bowman layer uniformly for 5 to 10 seconds. The advantage of using the diamond burr is that it does not induce much corneal haze or refractive change, noted Rapuano.

The recurrence with the use of the diamond burr ranges from 3% to 14.8%, noted Rapuano, citing studies from the literature. The mean recurrence rate in 224 eyes treated with a diamond burr is around 8.2%.

Compared with epithelial debridement, the use of the diamond burr resulted in fewer recurrences, fewer repeat surgeries, and less postoperative astigmatism in one study.¹

Excimer laser phototherapeutic keratectomy (PTK) also does not induce mean corneal haze or refractive change, and the treatment takes about 5 seconds, noted Rapuano. The recurrence rate ranges from 0% to 38%, according to studies in the literature, with the mean recurrence rate being approximately 21.3% for 570 eyes treated with PTK.

In a retrospective study by Rapuano comparing PTK to diamond burr as interventions, results for recurrence were 27% in the PTK arm and 11% in the diamond burr arm—a difference that was not statistically significant.²

Occasional mild, corneal haze can develop postoperatively, but it usually resolves on its own or can be treated with low-dose topical steroids, noted Rapuano.

Recurrent erosions are a common problem, and recognition of them is key, emphasized Rapuano. Medical therapy is first-line management, but surgical options should be initiated if medical treatment is not successful, he added.

Christopher J. Rapuano, MD

E: cjrapuano@willseye.org

Rapuano has no relevant financial disclosures related to the content.

References:

1. Wong VW, Chi SC, Lam DS. Diamond burr polishing for recurrent corneal erosions: results from a prospective randomized controlled trial. Cornea. 2009;28(2):152-156. doi:10.1097/ICO.0b013e31818526ec

2. Sridhar MS, Rapuano CJ, Cosar CB, Cohen EJ, Laibson PR. Phototherapeutic keratectomy versus diamond burr polishing of Bowman’s membrane in the treatment of recurrent corneal erosions associated with anterior basement membrane dystrophy. Ophthalmology. 2002;109(4):674-679. doi:10.1016/s0161-6420(01)01027-2