Corneal Erosion Syndrome (Shah)

Corneal Erosion Syndrome
Samir Shah, MD, MS, FACS
Cornea, Cataract, and Refractive Surgery
Beach Eye Medical Group
Huntington Beach, CA
Recurrent corneal erosion
• Definition
– Epithelial membrane
disturbance resulting in
a defective adhesion of
the epithelium to
Bowman’s membrane
• F>M
• Mean age of
presentation is mid-40’s
• Multiple recurrences
are common
Anatomy of the Cornea
Layers
Thickness
Composition
Epithelium
50 um
Stratified Squamous
Epithelium
Bowman’s
Membrane
8-14 um
Compact
unorganized
collagen fibers
Stroma
500 um
Orderly
arrangement of
keratocytes and
lamellae
Descemet’s
Membrane
10-12
Fine lattice of
collagen fibers
Endothelium
5 um
Single layer of
hexagonal cells
Anatomy of the Corneal Epithelium
Anatomy of the Basal Epithelium
Oktoberfest Quiz
Oktoberfest is a festival that originated in
Munich, Germany. In which German state
(Bundesland) is Munich?
A. Hesse
B. Lower Saxony
C. Bavaria
D. Bremen
Pathophysiology
• Abnormal corneal adhesion complexes or aberrant BM
lead to abnormal epithelial adhesion
• Infiltration of polymorphonuclear leucocytes between
corneal epithelial cells and the anchoring layer
• Overexpression of matrix metalloproteinases (MMPs)
such as MMP-2 and MMP-9 by epithelial cells and tear
fluids
• Hypotonic tears at night can lead to subtle corneal
edema  defect in epithelium and BM adhesion
• Early AM saccades during REM sleep can further
aggravate adhesion
Classification
• Primary
– EBMD (~30%)
– Bowman’s Dystrophies
• Reis-Bucklers
• Thiel-Behnke
– Stromal Dystrophy
• Secondary
– Trauma (~45%)
• K abrasions
• Chemical/thermal injury
– Eyelid pathology
• Entropion, ectropion,
floppy eyelid
– Degeneration – Band K or
Salzmann’s
– Post ocular infection
– Post LASIK
– Diabetes
– Other Causes: Bullous K,
Keratoconjuctivitis Sicca
– Drugs – Thiomersol, topical
anesthetic
Presentation
• Symptoms/Signs:
– recurrent episodes of
ocular pain – history is key
in distinguising RCE from
K abrasion
– foreign body sensation
– Photophobia
– Blepharospasm
– decreased vision or
lacrimation upon
awakening or following
eye rubbing or eye
opening
– Corneal abrasion (~87%
inferior)
Oktoberfest Quiz
What was the occasion first celebrated at the first
Oktoberfest?
A.
B.
C.
D.
Wedding
Good harvest
Birth of heir to the King of Bavaria
Military Victory
It was for the commemoration of the marriage of Crown
Prince Ludwig of Bavaria and Princess Therese of SaxeHildburghausen.
Prevention is important
• Avoid triggers
– Environmental triggers like smoking
• Wear protective glasses to decrease risk of
trauma or abrasion
• Hydration – AFT’s, plugs, lubricating ointments
• Minimize eye rubbing
Medical Treatment
–
–
–
–
Lubricant and antibiotic
Patching
Oral analgesics
Contact Lens – high water content,
large diameter
• May need to wear up to 6 weeks
• Scleral CTL may be used with concurrent
ocular surface disease
• Collagen BCTL
– Combination of Doxycycline 100 mg
BID for 12 weeks with topical
Prednisolone for the first week
– Autologous serum
Surgical Treatment
• Debridement
– Useful for removing loose
epithelium
– No more effective than
medical treatment in
preventing recurrences
• Diamond Burr Superficial
Keratectomy
– Leaves smooth surface
– Decreases recurrence
– Ideal for EBMD-related RCE
Surgical Treatment
• Anterior stromal
micropuncture
– 25 to 27 g needles used to
create an insertion depth of
0.1 mm
– Should be out of 6 mm
optical zone
• Nd:YAG Laser Anterior
Stromal Puncture
Surgical Treatment
• Phototherapeutic Keratectomy (PTK)
– Photoablation after epithelial removal
– Can lead to hyperopic shift
– Expensive relative to other options
Oktoberfest Quiz
Oktoberfest is about eating as well as drinking.
Which of these would you drink instead of eat at
Oktoberfest?
A. Skelt
B. Saurkraut
C. Hendl
D. Käsespätzle
Skelt is sparkling white wine. Hendl is chicken,
Käsespätzle is cheese noodles.
Surgical Treatment
• Epithelial Debridement +
• Amniotic Membrane Transplantation (AMT)
• 2013 study shows recurrences of under 10%
Self-retained Amniotic Membrane Transplantation for Recurrent Corneal Erosion - Yukan Huang, Hosam Sheha, Scheffer CG Tseng
J Clin Exp Ophthalmol 4:272. doi: 10.4172/2155-9570.1000272
AMT for Recurrent Corneal Erosion
Amniotic Membrane
• Amniotic membrane (AM) is the innermost lining of the placenta and
shares the same cell origin as the fetus
• AM Contains cytokines and growth factors
• Cryopreserved amniotic membrane is a biologic therapy that:
• Reduces inflammation
• Promotes regenerative healing
• Minimizes scar formation
• Inhibits angiogenesis
• Minimizes pain
Key Components of AM
Extracellular matrix (ECM) components found in cryopreserved amniotic
membrane regulate and promote regenerative tissue processes1,2,3
Key components
•
PTX 3 (HC-HA Complex)
•
Heavy chain hyaluronic acid (HC-HA)
•
Proteoglycans
•
Growth factors
•
Direct inhibition of pro-inflammatory cells 4,5
• Suppresses T-cell activation
• Inhibits giant cell formation
• Controls MMP production7
Regenerative healing 6
Collagens (types I, III, IV, V and VI)
•
Fibronectin
•
Laminin
Biological scaffolding
1. Rinastiti M, et al. Int J Oral Maxillofac Surg. 2006;35:247-251. 2. Jin CZ, et al. Tissue Eng. 2007;13:693-702. 3. Niknejad H, et al. Eur Cell Mater. 2008;15:88-99. 4. He H, et al. J
Biol Chem. 2009;284:20136-20146. 5. Data on file, Bio-Tissue, Inc., 2012. 6. Hopkinson A, et al. Invest Ophthalmol Vis Sci. 2006;47:4316-4322. 7.
http://www.iovs.org/content/46/11/4079.full.pdf. 8. Sambursky R, O’Brien TP. MMP-9 and the perioperative management of LASIK surgery. Curr Opin Ophthalmol. 2011
Jul;22(4):294-303.
Why controlling MMP
production is critical?
• “Increased MMP-9
activity…may contribute
to:
• Deranged corneal
epithelial barrier
function
• Increased corneal
desquamation, and
• Corneal surface
irregularity.”8
Summary
• Recurrent Corneal Erosion (RCE) is a common
disorder that occurs because of an
abnormality in the corneal adhesion complex
with increased inflammatory markers
• EBMD and Trauma are the most common
underlying reasons for RCE
• Various medical & surgical treatment options
• Low recurrences have been reported using
epithelial debridement with AMT
Thank you!
Please contact me with any questions:
18582 Main Street, Huntington Beach, CA 92648
714-965-9696
[email protected]