Special cases for healing the eye’s surface - Part 1: Recurrent Corneal Erosions (RCE).
Sometimes there are special situations that require special techniques or technologies to heal them. I’ll focus on a few, relatively common ones, starting with RCE, this week.
- Recurrent Corneal Erosions (or RCE).
When a cornea becomes relatively deeply injured (sometimes from something as otherwise innocuous as a baby’s fingernail), there can be times where the scratch – once healed, tends to “re-scratch” without an apparent cause. We call this “Recurrent Corneal Erosion” (or RCE). There tends to be a couple of common threads to this problem.
o First, the “Turf.” The very surface of your cornea (the clear “window” for your sight) is covered in thin, clear cells. These cells have a kind of “glue” as well as a kind of “root system,” that can be thought of like “turf” (or grass in soil). When you have good grass anchored in good soil, with lots of rain and nutrients, it can be very vigorous, lush and green (think putting green). When it is trying to stick to dry, rocky soil, it tends to be weak, brown and easily disturbed (like my lawn in August). Deep scratches tend to scrape off the “topsoil” and expose the “rocky subsoil.”
o Second, the “water and fertilizer.” If the support for this surface is the better “Salad Dressing” of the “Sprinkler System Tears,” then even with a deep scratch, the cells may have enough support to get back to their healthy, vigorous state and develop the kind of glue and roots that help them “stick.” But if the tears are too little, or overly diluted with salty “Fire Hose Tears,” (Not enough water and fertilizer), then these cells will tend to be weak, rough and prone to easily rubbing loose and “re-scratching.”
o Third, proper protection. If the patient with this problem sleeps with their eyes a bit open (the not-uncommon problem we call nocturnal lagophthalmos – see my earlier posting on what I called “Mom’s Eyes” or NL), then there is a tendency to wake up in misery, since the exposure from NL will cause even a healthy surface to get damaged from dryness – and a weaker, loosely stuck surface, to more easily “re-scratch” when the dry lids suddenly open over that weak, delicate surface.
So how to fix RCE? There are lots of techniques, but a common approach is as follows:
- Once identified by a dry eye or corneal specialist, it is not uncommon to protect by fitting a bandage contact lens – with-or-without an amnionic membrane (amnion may be used to “jumpstart” healing, as detailed in my last posting). This starts the ball rolling by letting the healing cells fill in the scratch without the rubbing of the dry lids, back and forth over the tenuous cells, as they lay down their “glue” to “stick.” If this has happened more than once, it may be necessary to smooth the surface (using a dry sponge that can even out the “subsoil” and remove any loose “glue” from prior attempts at healing). Alternatively, if the defect is not very central, a small, bent needle can lightly “prick” the surface to create little patches of looser “soil” for the cells to get a foothold (the roots go deeper and act a bit like a “thumbtack” to hold onto these tiny divots). In central problems - or those that are very problematic, a laser can be used to “sculpt” the surface in a way that removes the rockiest and roughest subsoil and paves the way for a smoother, better repair.
- Equally important to giving the cells the right, smooth and proper soil, is to also give them the best tear-support you possibly can. This adds the right “water and fertilizer”to help these cells grow vigorously - and gets us back to my earlier posts on how to make a better tear (and all the options if that tear is still deficient in quantity or quality). It may be necessary to keep a bandage contact over the surface for weeks – or even months (with cleaning or exchanges as needed) – until the deeper “roots” can be established. Sleep masks (or sleep goggles) can be a huge help for those with NL – though something a simple (and cheap) as Press ‘N Seal – or – a lubricating nighttime ointment (for some) can also be useful. While a good repair can take days in children, it can take weeks-to-months in older adults and in severe cases – even with fair support, it may take a year-to-years. Better support (as in the best tears) always seems to heal these problems better and faster, so it pays to have a dry eye specialist assist when you have a problem like RCE.