Epithelial Map Guided Management Of Recurrent Corneal Erosions : A Prospective Study

Recurrent corneal erosions (RCEs) affect life style of patients, where there is repeated breakdown of corneal epithelium and causes pain, photophobia and blurriness of vision. The purpose of this study is to increase the predictability of knowing recurrences in RCEs and to aid in treatment like - debriding or diamond burr polishing using epithelial maps as guide for the area with loose epithelium.

This is a single centre, prospective study interventional done at a tertiary hospital in Eastern India . The study has been approved by institutional review board. Successive patients diagnosed as RCE underwent epithelial mapping and were subsequently treated to decrease their recurrences . There were 17 patients (N = 20) enrolled in this study , 10 females and 7 males over a period of 18 months . 3 out of 17 patients were bilaterally affected.

We propose a step ladder pattern of treatment for this disease, where using the epithelial maps we can identify the areas of loosening and monitor the progression and aid in cessation of future attacks. Depending upon severity and chronicity of disease, patients were treated from medical to surgical management in 4 steps . Step 1 is the conservative treatment using preservative free artificial lubricants , hypertonic saline and mild steroids in case of exaggerated inflammation . Step 2 is the debridement followed by application of bandage contact lens (BCL). Step 3 is debridement and BCL , along with topical insulin (1iu/ml) for re-epithelization . Step 4 is surgical management with diamond burr polishing and anterior stromal puncture. 

All patients underwent epithelial mapping (ANTERION, Heidelberg Engineering GmbH )  at presentation and during their follow ups . Interesting insights were noted in form of persistence of changes on epithelial maps for long after epithelial healing and it also guided on continuation of topical insulin till flattening on epithelial maps were noted . 17 patients were divided into 4 groups and even in the surgical group 4 , the burr polishing and anterior stromal puncture (ASP) were done over actual edematous areas noted on epithelial maps. In the subsequent followup period , all eyes reported no recurrences , shortest followup being 4 months. 3 eyes of 2 patients underwent burr polishing with ASP for their inferior corneal erosions.

Currently, epithelial maps have proven useful in various indications and they can be useful in diagnosing , monitoring , predicting recurrences and aiding treatment of RCEs. Strength of the study has been a novel concept of combining the treatment of RCEs using swept source OCT. This study also highlights use of topical insulin in such cases, which can act a a supplementary armamentarium for re-epithelization.Limitations being short duration of study as recurrences in RCEs have been reported to happen even after many years of recurrence free period .Till date, there is no consensus , on classification and treatment of RCEs, but with advances in diagnostic tools and better prediction , the future looks promising in treating this disease.