Improving the Efficiency of Treatment for Recurrent Corneal Erosion

Abstract

Background. Recurrent corneal erosion (RCE) is a chronic disease of the corneal epithelium that manifests as recurrent episodes of sudden onset of pain, usually at the first awakening or at night, accompanied by redness and corneal syndrome. Of great importance is the search for medications that can shorten the treatment period, accelerate epithelialization, and restore patients’ ability to work. Among medicines used to recover the structure of the cornea, preparations that affect the epithelial layer are used, and preference is given to eye ointments, which improve metabolic processes and recover the structure of the epithelium.

The purpose of the work was to improve the quality of treatment for recurrent corneal erosions after traumatic injuries.

Materials and methods. Under observation, there were 9 patients (aged 24 to 41 years) with RCE of different degrees of severity. In addition to the main therapy, an ophthalmic isotonic ointment Gilays® Care with sodium hyaluronate 0.4% was prescribed before bed for a month.

Results. After the treatment, already on day 5, patients noted subjective improvement of symptoms (reduction of the frequency of sudden pain on awakening, corneal syndrome, and cloudy vision). Objectively, on day 7, the area of a defect of varying degree decreased depending on the baseline data.

Conclusions. The inclusion of ophthalmic isotonic ointment Gilays® Care with sodium hyaluronate 0.4% in the general treatment complex for RCE is expedient, due to its ability to stay longer on the ocular surface and provide a more prolonged and powerful effect, to accelerate corneal epithelialization, improve the subjective condition of patients, and enhance the quality of life of such patients.

Keywords: recurrent corneal erosion; traumatic erosions; hyaluronic acid; ophthalmic isotonic ointment; epithelialization; quality of life

Introduction

Recurrent corneal erosion (RCE) is a common cause of disabling ocular symptoms and predisposition of the cornea to infection, and is characterized by one or more episodes of spontaneous breakdown of the corneal epithelium. This is a chronic recurrent disease of the corneal epithelium that manifests as recurrent episodes of sudden onset of pain, usually at the first awakening or at night, accompanied by redness, photophobia, and lacrimation. This clinical picture is associated with the fact that during sleep the eyes are dry, and the first opening of the eyelids may detach the epithelium [10, 18, 20]. Individual episodes may differ in severity and duration. The cause of the disease is considered to be a disruption of adhesion of the epithelial layer to the stroma, which is a consequence of abnormal regeneration of the basement membrane of the corneal epithelium. As a result, this leads to an abnormal process of corneal renewal — the formed cells are defective and therefore easily shed, exposing the underlying layers. The destruction of the formed adhesive complexes is facilitated by a number of biological factors, including inflammatory mediators and proteinases in high concentrations [2, 4, 7, 16].

Among the main causes of RCE the following are noted:

1. traumatic erosions arising from wood shavings, during application of makeup, from a nail scratch, trimming trees, and injury by a tree branch;
2. corneal erosions caused by contact with chemical substances, for example, during apartment cleaning, gardening, and at industrial facilities;
3. thermal burns that may occur during prolonged exposure to sunlight or artificial ultraviolet radiation;
4. corneal epithelial defect as a consequence of improper storage and use of contact lenses;
5. consequence of an untimely undiagnosed trichiasis;
6. anterior corneal dystrophies:
   • epithelial dystrophy (anterior basement membrane dystrophy) — map-like, dot, fingerprint type. Diffuse gray spots (map-like), large or small cysts (dot-like), thin broken lines (fingerprint type) on the corneal epithelium are noted, well visible under retroillumination or in a broad beam of the slit lamp with lateral illumination;
   • Meesmann dystrophy — an autosomal dominant rare corneal disease. The disease can begin in childhood and has an asymptomatic course until middle age. Under retroillumination, individual small epithelial vesicles diffusely distributed over the cornea are visible;
   • Reis–Bücklers dystrophy: a progressive autosomal dominant disease, manifesting in early childhood. Subepithelial gray reticular opacities are found predominantly in the central cornea;
7. corneal stromal dystrophies:
   • lattice dystrophy — an autosomal dominant disease characterized by broken branching lines, white subepithelial dots, and central stromal scarring, best visible under retroillumination. The peripheral cornea is unaffected;
   • macular dystrophy: an autosomal recessive disease manifesting as gray-white stromal opacities with indistinct edges extending from limbus to limbus with cloudy areas between them. The pathological process may involve the full thickness of the corneal stroma, being more superficial in the central part and deeper at the periphery;
   • granular dystrophy — an autosomal dominant disease characterized by white deposits in the superficial stroma of the central cornea, separated by intact areas. The corneal periphery usually remains intact. It appears in the first 10 years of life but rarely causes symptoms until middle age [1, 5, 12];
8. changes in the corneal layers following surgical intervention for refractive anomalies (radial keratotomy), corneal transplantation, or cataract surgery [8, 11, 14, 19].

The clinical course of a corneal epithelial defect can range from a superficial erosion requiring no special treatment to a potentially sight-threatening complication such as corneal ulcer, recurrent erosion, or traumatic iridocyclitis.

Depending on size, nature of occurrence, localization of the lesion, location, and course of the disease, RCE is divided into several types:

Given that the clinical symptoms of RCE severely limit the quality of life, the search for medications to shorten the treatment period, accelerate epithelialization, and restore patients’ ability to work is of great importance.

Curing RCE is not always easy to achieve, which is associated with the difficulty of restoring the normal structure of the basal layer of epithelial tissue. The main treatment approaches include using agents that regulate metabolism and improve corneal trophism, restoring epithelialization processes depending on the area of the lesion and the condition of the cornea, and preventing infectious complications.

At present, preparations of hyaluronic acid (HA) and its derivatives (sodium hyaluronate, SH) are among the most widely used. HA is a natural biopolymer with a high molecular weight, containing numerous hydrophilic functional groups capable of binding water. HA and SH are characterized by a high degree of structural homology with endogenous compounds and are absolutely biocompatible molecules for humans. The semi-synthetic SH molecule is significantly smaller than the HA molecule itself. Due to its mucoadhesive properties, SH binds and retains fluid for optimal hydration, allowing this molecule to remain on the ocular surface for a prolonged period of time. SH provides moisturizing, antioxidant, regenerating, and neuroprotective effects [6, 13, 17].

Preparations affecting the epithelial layer are used to restore the structure of the cornea, with preference given to eye ointments that improve metabolic processes and restore epithelial structure.

The following advantages of ointments over ophthalmic solutions can be identified:

• after application they affect only the damaged area and do not spread due to their dense consistency;
• the concentration of active components in such medications is quite high, and after treating the damaged surface with ointments, the required substance is retained in the eye for a prolonged period of time;
• compared to drops, ointments act for a longer period of time since they dissolve and are absorbed much more slowly.

The use of ointment formulations for the treatment of RCE has a number of advantages: long retention in the conjunctival cavity, prevention of corneal drying, which protects the nerve endings. Thus, ophthalmic ointments serve as a kind of protective bandage for the eye.

Recently, an ophthalmic isotonic ointment Gilays® Care with sodium hyaluronate 0.4% has appeared on the Ukrainian market, meeting these requirements. This medical device helps maintain moisture and protect the ocular surface using a protective film. Sodium hyaluronate consists of carbohydrate chains that are distributed over the corneal surface and form a structure capable of trapping water molecules, thereby improving the barrier function of the corneal epithelium. When applied topically, hyaluronic acid stimulates regeneration of the corneal epithelium and positively affects the epithelial layer. Additionally, the preparation contains liquid paraffin and white petrolatum, which give it a viscous structure and ensure prolonged retention on the ocular surface and protective action even during sleep, which is very important in the treatment of RCE specifically.

The purpose of our work was to improve the quality of treatment for recurrent corneal erosions after traumatic injuries.

Materials and Methods

Under observation were 9 patients (9 eyes) aged 24 to 41 years with RCE of different degrees of severity. The ocular condition was assessed by functional parameters and biomicroscopy data. All patients had been receiving moisturizing and epithelializing agents exclusively as eye drops for the past several months. In addition to the main therapy, an ophthalmic isotonic ointment Gilays® Care with sodium hyaluronate 0.4% was prescribed at night for one month. The criteria for treatment efficacy were: the rate of corneal epithelialization and shortening of treatment duration.

Results

Before treatment, patients noted sudden onset of unilateral pain in the eye with RCE, usually at the first awakening or at night, accompanied by redness, photophobia, and lacrimation. They periodically experienced the sensation of “foggy vision.” Patients indicated that symptoms recurred after rubbing their eyes or under the influence of external factors.

On examination under direct illumination, most often paracentrically, an area of absent epithelium was identified, predominantly in the lower third of the cornea, with grayish inclusions.

After adding the ophthalmic isotonic ointment Gilays® Care with sodium hyaluronate 0.4%, already on day 5, patients noted subjective improvement of symptoms (reduction of the frequency of sudden pain on awakening, corneal syndrome, and “foggy vision”). Objectively, on day 7, the area of the defect decreased to varying degrees depending on the baseline data.

Conclusions

The inclusion of ophthalmic isotonic ointment Gilays® Care with sodium hyaluronate 0.4% in the general treatment complex for RCE accelerates corneal epithelialization, improves the subjective condition of patients, and enhances the quality of life of such patients. The rationale for its use is explained by the higher viscosity of the ointment compared to drops, which allows it to remain on the ocular surface longer and provide a more prolonged and effective action.

Conflict of interest. The authors declare no conflict of interest and no personal financial interest in the preparation of this article.

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