Avoiding surgery in recurrent corneal erosion: a regenerative approach

The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Optometry 360.

By Ahmad Fahmy, OD 

Recurrent corneal erosion (RCE) is one of the most painful and frustrating conditions patients encounter. It can interfere with work, sleep, and daily functioning, often prompting urgent medical visits due to intense pain, photophobia, and blurred vision.¹ However, many cases of RCE can be successfully managed without surgery by providing immediate relief for pain and inflammation, reestablishing a stable epithelial layer, and taking measures for the long-term prevention of recurrence. Optometric physicians are well-positioned to accomplish these goals, which require understanding RCE’s underlying structural and inflammatory mechanisms, how to comprehensively care for the ocular surface, and how to employ regenerative therapies to restore epithelial integrity.

Understanding the Mechanism of RCE

RCE occurs when the attachment between the corneal epithelium and basement membrane becomes damaged, allowing the epithelial cells to shift or erode.² The cornea contains roughly 7,000 nociceptors per square millimeter)³ (making it about 20 to 40 times more sensitive than the innermost layer of a tooth),⁴ so any disruption to its surface can cause severe pain. RCE often develops after a prior corneal injury, such as a scratch,² but if patients present with no identifiable trauma, they may have underlying epithelial basement membrane dystrophy (EBMD) or chronic inflammatory ocular surface disease. Approximately half of RCE cases stem from prior trauma, while 20% to 30% are associated with EBMD²; in both scenarios, instability in the bond between epithelial cells and the basement membrane predisposes the corneal surface to recurrent breakdown.

Autoimmune Disease and Ocular Surface Inflammation

Patients with autoimmune diseases may be at greater risk for RCE, as these patients often experience chronic surface inflammation and tear film deficiency.⁵ Reduced basal tear secretion causes friction between the eyelid and cornea, leading to microtraumas during blinking and lid movement. When combined with low-grade inflammation, this can result in lid wiper epitheliopathy, further damaging the fragile corneal surface. For these patients, aggressive management of both the inflammatory and aqueous-deficient components of their disease is essential. Topical anti-inflammatory therapy, tear supplementation, and treatments that stimulate natural tear production can all contribute to stabilizing their ocular surface and reducing the likelihood that they experience recurrent erosions.²

Recognizing the Clinical Picture

Most patients with RCE present urgently with sharp pain, tearing, and photophobia, especially upon awakening.² During sleep, incomplete lid closure and reduced tear production create dryness that makes the epithelium more vulnerable to shearing forces when the eyes open.⁶

On slit-lamp examination, the clinician may observe areas of loose or missing epithelium, conjunctival injection, or signs of EBMD like cystic and map-like changes. In other cases, the cornea may appear intact, yet the epithelium detaches easily when gently probed.⁶ A useful diagnostic maneuver taught to me by a former mentor is the “screwdriver test”: using a dry Weck-Cel^®, lightly rotate the swab over the suspected loose area of epithelium. If the epithelium is unstable, it may slough off easily, while healthy epithelium will remain firmly attached.

Complications and High-Risk Profiles

Recurrence is the most common complication of RCE and is strongly related to insufficient management. The use of passive healing approaches alone, such as lubricants or bandage contact lenses, often fails to rebuild strong epithelial adhesion complexes, and as such, patients with RCE may experience multiple painful recurrences each year. In particular, individuals with diabetes, ocular comorbidities like neurotrophic keratitis, and those using multiple preserved glaucoma medications are at increased risk of recurrence.² Thus, incorporating regenerative healing therapies into treatment plans for RCE is essential to keep these patients from returning with recurrent disease.

Stepwise Management

When a patient presents with an active erosion or loose epithelium, the first step I take is gentle debridement of any nonadherent tissue,⁶; during this process, be very careful to avoid disturbing the limbal stem cells. Following debridement, I apply a cryopreserved amniotic membrane (CAM) on a collagen shield and secure it with an eyelid patch for 72 hours, as this combination promotes rapid re-epithelialization while reducing inflammation and scarring.²

Because cryopreservation preserves the amniotic membrane’s natural growth factors and cytokines, CAM supports true regenerative healing benefits such as anti-inflammation and anti-scarring functions⁷, rather than just providing a scaffold for surface closure. Patients with autoimmune conditions may also benefit from a mild corticosteroid 4 times daily to help control any inflammation they may experience during the early healing phase.²  

For patients who require additional regenerative support, biologic basal tear supplements such as autologous serum tears, platelet-rich plasma, or recombinant human nerve growth factor (cenegermin) can be highly effective. These biologics deliver essential proteins and growth factors that are similar to the composition of normal tears and can help restore a healthy tear film necessary for epithelial function.²

After the cornea has re-epithelialized, I shift my focus toward maintenance of the ocular surface. When treating RCE, long-term success depends on controlling inflammation, restoring tear film stability, and reducing the mechanical friction caused by blinking and lid movement. Topical immunomodulators such as cyclosporine or lifitegrast can reduce chronic inflammation, while soft steroids can be used intermittently to manage flare-ups. Neurostimulation therapies, both topical and external, can act to enhance basal tear production. For patients with evaporative dry eye and meibomian gland dysfunction, thermal pulsation treatments such as TearCare^® and intense pulsed light therapy can improve the lipid layer of the tear film.² It’s important to note that these are not “treat-and-release” cases; ongoing surface maintenance is critical to preventing recurrence, so patients with EBMD or chronic ocular surface disease should remain under long-term observation.

When Surgery Becomes Necessary

In my practice, most patients who undergo regenerative therapy with CAM and biologic drops do not require surgical intervention. A minority of patients with RCE fail to respond to conservative management.⁸ In these cases, phototherapeutic keratectomy is typically the surgical treatment of choice,⁸ in which an excimer laser is used to ablate the irregular basement membrane, allowing healthy epithelium to reattach more securely.¹ An older method, anterior stromal puncture, involves creating small subepithelial scars to improve adhesion, but is now rarely performed due to its higher risk of haze.⁸

Conclusion

RCE is a multifactorial disease that requires a proactive, regenerative approach for proper management. By utilizing debridement with CAM, we can restore corneal integrity, while targeted maintenance therapy with biologic therapies, inflammation control, and treatment of the ocular surface disease can reduce recurrence, and in most cases, avoid surgical intervention. With access to modern regenerative tools and comprehensive surface management, true healing and lasting comfort are highly achievable goals for patients with this painful disease.

Ahmad Fahmy, OD, practices at Minnesota Eye Consultants in Bloomington, Minnesota. He can be reached at mailto:amfahmy1@gmail.com. Disclosure: Dr. Fahmy is a speaker for BioTissue, Inc.

References

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5. Kılıççıoğlu A, Oncel D, Celebi ARC. Autoimmune disease-related dry eye diseases and their placement under the revised classification systems: an update. Cureus. 2023;15(12):e50276. doi:10.7759/cureus.50276
6. Xu K, Kam KW, Young AL, Jhanji V. Recurrent Corneal Erosion Syndrome. Asia Pac J Ophthalmol (Phila). 2012;1(6):349-354. doi:10.1097/APO.0b013e31827347ae
7. Data on file. BioTissue, Inc.
8. Song MY, Chung JL, Kim KY, et al. Combined phototherapeutic keratectomy and peripheral anterior stromal puncture for the treatment of recurrent corneal erosion syndrome. Korean J Ophthalmol. 2020;34(4):297-303. doi:10.3341/kjo.2020.0023