Recurrent Corneal Erosion: Symptoms, Types, Causes and Treatment

Recurrent corneal erosion (RCE) is a frustrating and often painful eye disorder that disrupts the corneal surface, leading to repeated episodes of sudden discomfort and visual disturbance. Understanding RCE is essential not only for those who suffer from it but also for clinicians who aim to provide effective relief and long-term management. In this article, we will comprehensively explore the symptoms, types, causes, and treatment of recurrent corneal erosion, drawing upon the latest evidence and clinical experience.

Symptoms of Recurrent Corneal Erosion

RCE can be alarming and disruptive, frequently catching individuals off guard with sudden, intense discomfort. Recognizing the symptoms early is crucial for timely intervention and optimal care.

Symptom	Description	Timing	Sources
Pain	Sharp, sudden, sometimes severe	Often on awakening	4, 5, 3
Redness	Eye appears bloodshot	With/after pain episode	5, 2
Watering	Excessive tearing	During episode	5, 4
Photophobia	Light sensitivity	During/after episode	5, 2
Blurred vision	Vision may be temporarily reduced	During episode	5, 4

Table 1: Key Symptoms

Sudden Onset and Timing

RCE episodes typically begin abruptly, with patients often describing a sharp pain on opening the eyes in the morning. This occurs because the corneal epithelium, which is weakly attached to the underlying layers, becomes disrupted by the natural opening of the eyelids after sleep. The pain may be accompanied by watering, redness, and sensitivity to light (photophobia). Some individuals may experience difficulty opening the eye, particularly during or immediately after the episode 3, 4, 5.

Variability and Severity

The severity and duration of symptoms can vary greatly. Some episodes may last only a few minutes, while others persist for hours. The discomfort can range from mild irritation to severe pain that interferes with daily activities. During these episodes, vision may temporarily become blurred due to disruption of the corneal surface and excessive tearing 5.

Additional Manifestations

Apart from the classic symptoms, some patients may notice recurrent symptoms at specific times, such as just before or after waking. Others report persistent foreign body sensation or gritty feeling in the eye. In between episodes, the eye might feel normal, but careful examination can reveal subtle corneal changes such as microcysts or map-dot-fingerprint patterns 3, 6.

Types of Recurrent Corneal Erosion

RCE is not a uniform condition; it can present in various forms depending on its underlying cause and clinical features. Differentiating the types helps in tailoring treatment and predicting prognosis.

Type	Features/Origin	Laterality	Sources
Macroform	Large, discrete erosions, often traumatic	Usually unilateral	3, 8
Microform	Small, subtle erosions, often spontaneous or dystrophic	Often bilateral	3, 4
Primary	Due to intrinsic corneal dystrophies	Often bilateral/symmetrical	2, 9
Secondary	Resulting from trauma or acquired conditions	Often unilateral	2, 3, 7

Table 2: Types of RCE

Macroform vs. Microform

• Macroform RCE involves large, easily visible areas of epithelial loss. It is frequently associated with a history of trauma (e.g., fingernail injury), but up to 40% of cases can develop spontaneously. Macroform erosions tend to be more dramatic in presentation but are often isolated 3.
• Microform RCE features smaller, subtle erosions and is more often linked to underlying corneal dystrophies or systemic conditions. These may be less obvious but can be recurrent and bothersome 3, 4.

Primary vs. Secondary RCE

• Primary RCE is related to intrinsic abnormalities of the corneal basement membrane, commonly seen in inherited corneal dystrophies such as epithelial basement membrane dystrophy (EBMD) or epithelial recurrent erosion dystrophy (ERED). These types are often bilateral, symmetrical, and may affect multiple locations on the cornea 2, 9.
• Secondary RCE occurs as a result of external factors such as trauma, surgery, chemical or thermal injuries, or ocular surface disease. These are typically unilateral and correspond to the area of insult 2, 3, 7.

Clinical Patterns and Special Associations

RCE can also be classified by its association with meibomian gland dysfunction or post-surgical changes, such as following laser eye procedures. Specific patterns, such as the "map-dot-fingerprint" appearance, are characteristic of certain dystrophies and can be visualized with specialized imaging techniques 6.

Causes of Recurrent Corneal Erosion

Understanding what triggers and perpetuates RCE is essential for prevention and effective treatment. Multiple causes, both intrinsic and extrinsic, have been identified.

Cause	Mechanism/Association	Notes	Sources
Trauma	Disrupts epithelial adhesion	Fingernails common	2, 3, 8, 7
Corneal dystrophies (e.g., EBMD, ERED)	Abnormal basement membrane	Often hereditary	2, 3, 9, 6
Ocular surgery (LASIK/PRK)	Alters corneal architecture	Increases risk	8
Meibomian gland dysfunction	Affects tear film and surface healing	Strong association	1, 8
Ocular surface disease	Poor lubrication, inflammation	Includes dry eye, rosacea	1, 2, 8
Metabolic/systemic disease	Impairs healing	Diabetes, bullosa	2, 8
Unknown (idiopathic)	No clear cause identified	Up to 19% cases	8, 12

Table 3: Common Causes

Traumatic Causes

Trauma is the leading cause of RCE, especially in cases of macroform erosions. Even seemingly minor injuries, such as a scratch from a fingernail or a paper cut, can disrupt the adhesion between the corneal epithelium and its underlying structures, leading to recurrent breakdown 2, 3, 8.

Corneal Dystrophies

Inherited corneal dystrophies, such as EBMD and ERED, are significant contributors to RCE. These conditions result in intrinsic defects in the basement membrane complex, which impairs the secure attachment of epithelial cells. Genetic studies have identified mutations, such as those in the COL17A1 gene, that impact corneal epithelial integrity 9. These forms of RCE often present bilaterally and may display characteristic patterns on slit-lamp examination 2, 3, 6.

Post-Surgical and Secondary Causes

Ocular surgeries, particularly refractive procedures like LASIK and PRK, increase susceptibility to RCE by altering corneal architecture and healing responses. Other secondary causes include chemical or thermal injuries, previous infections (such as herpetic keratitis), and chronic ocular surface inflammation associated with dry eye or ocular rosacea 2, 8.

Meibomian Gland Dysfunction and Ocular Surface Disease

An important, sometimes overlooked, cause is meibomian gland dysfunction (MGD), which leads to poor tear film quality and impaired corneal healing. Studies have shown a strong association between MGD and recalcitrant cases of RCE, especially when facial abnormalities such as rosacea are also present 1, 8.

Systemic and Unknown Causes

Systemic diseases like diabetes mellitus can also impair corneal healing, increasing the risk of RCE. In a notable number of cases, no specific cause can be identified ("idiopathic" RCE), emphasizing the complexity of this disorder 8, 12.

Treatment of Recurrent Corneal Erosion

Treating RCE involves both managing acute symptoms and preventing recurrences. A stepwise approach is typically used, ranging from conservative measures to advanced surgical interventions for recalcitrant cases.

Treatment	Approach/Modality	Effectiveness/Notes	Sources
Conservative therapy	Lubricating drops/ointments, patching	First-line, effective for many	5, 3, 7
Hypertonic ointment	Sodium chloride 5% at bedtime	Reduces recurrence	3
Bandage contact lens	Extended-wear soft lens	Facilitates healing, reduces pain	5, 13, 7
Autologous serum drops	Eye drops from patient's own serum	Reduces recurrences in recalcitrant cases	10
Oral doxycycline/corticosteroids	Inhibits matrix metalloproteinases	Useful for resistant cases	11, 2
Anterior stromal puncture	Needle or laser-induced micro-scarring	Promotes adhesion, high success	14, 2, 7
Debridement/keratectomy	Surgical removal of abnormal epithelium	Used in persistent cases	3, 12, 5
Phototherapeutic keratectomy (PTK)	Excimer laser ablation of superficial cornea	Safe, effective, especially for recalcitrant RCE	12, 5, 2

Table 4: Treatment Approaches

Conservative and Medical Therapy

Most patients respond well to conservative treatment, including:

• Lubricating eye drops and ointments to keep the eye moist and promote healing
• Patching the affected eye to reduce friction from blinking
• Hypertonic saline ointments (e.g., sodium chloride 5%) at night to prevent overnight drying and reduce recurrence 3, 5, 7

These measures are particularly effective when used consistently, especially at bedtime, as many erosions occur upon waking 3.

Advanced Medical Therapies

For persistent or severe cases:

• Bandage contact lenses provide a protective surface, allowing the epithelium to heal more securely. Extended wear over several months can significantly reduce recurrence rates 5, 13.
• Autologous serum eye drops contain growth factors and nutrients that promote healing and have shown to decrease recurrences in otherwise refractory cases 10.
• Oral doxycycline and topical corticosteroids target excessive matrix metalloproteinase activity, which is believed to play a role in poor epithelial adhesion. This combination has demonstrated success in recalcitrant RCE 11, 2.

Surgical and Procedural Interventions

When medical therapy fails, procedural options include:

• Anterior stromal puncture: Using a fine needle or laser to create micro-scars in the anterior stroma, enhancing epithelial adhesion. High success rates are reported, with minimal recurrences 14, 2.
• Epithelial debridement or superficial keratectomy: Removal of loose or abnormal epithelium, sometimes followed by smoothing the surface with a diamond burr 3, 12.
• Phototherapeutic keratectomy (PTK): This excimer laser procedure precisely ablates the superficial cornea, providing a smooth bed for epithelial regrowth. PTK is safe and effective, particularly for cases that have failed other treatments 12, 5, 2.

Long-term Management and Prevention

Preventing recurrence is central to RCE management. Long-term use of lubricants and hypertonic ointments at night is recommended even after apparent healing. Treating associated conditions, such as MGD or dry eye, is crucial to maintaining corneal health 1, 8.

Conclusion

Recurrent corneal erosion is a multifaceted condition that disrupts lives through repeated episodes of pain and visual disturbance. Effective management relies on understanding its symptoms, identifying the underlying type and cause, and employing a tailored, stepwise treatment strategy. Advances in both medical and surgical therapies have greatly improved outcomes for those affected.

Key points:

• RCE presents with sudden eye pain, especially upon waking, with redness, tearing, and light sensitivity.
• Types include macroform (often traumatic), microform (often dystrophic), primary (hereditary), and secondary (acquired).
• Causes range from trauma and corneal dystrophies to surgery, meibomian gland dysfunction, and systemic diseases.
• Treatment is stepwise: starting with lubricants and protective measures, progressing to bandage contact lenses, autologous serum, MMP inhibitors, and, if needed, surgical procedures like anterior stromal puncture or phototherapeutic keratectomy.
• Ongoing management and treatment of contributing factors (e.g., MGD, dry eye) are essential to prevent recurrences.

By recognizing the diverse presentations and underlying mechanisms of RCE, patients and clinicians can work together for effective relief and long-term eye health.