Recurrent erosions after PRK can be treated with anti-inflammatory protocol

A small percentage of patients who had PRK may have recurrent erosions postoperatively.

In most patients, these erosions resolve on their own as the epithelium recovers and adheres to the cornea. But in some patients, recurrent erosions may persist. It can be frustrating, especially when the vision outcome is great.

Typically, we would treat the patient with artificial tears, nighttime gels, and hypertonic saline and ointment. In some patients, however, these methods would not help, and they would continue to have recurrent erosions. We found hypertonic saline and ointment, for example, to be not only unhelpful in post-PRK patients but also irritating and uncomfortable. So, we started looking into alternative treatment methods. We found several articles on successful treatment of corneal erosions in patients with epithelial basement membrane dystrophy (EBMD) using a combination of topical steroids and oral doxycycline. These were not post-PRK patients, just patients with EBMD.

How do these medications work?

When there is chronic, mild lid inflammation, the inflammatory mediators in the tear film can interfere with epithelial adherence to the underlying cornea. Topical steroids reduce inflammation and inflammatory mediators in the tear film, and this can improve epithelial adherence. In addition to steroids, medications such as doxycycline, for example, specifically reduce the amount of MMP-9, one of the inflammatory mediators in the tear film. By reducing inflammatory mediators in the tear film, epithelial adherence is improved.

We developed the following protocol to treat patients with recurrent erosions after PRK:

1. Start omega-3s at 4,000 mg once a day.
2. At the same time, start Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Alcon) four times a day for 2 weeks (less chance of IOP rise than with other topical steroids), followed by FML (fluorometholone, AbbVie) four times a day for 1 month.
3. If symptoms resolve, decrease FML to twice a day for another month and then stop.
4. If symptoms persist, add oral doxycycline 50 mg twice a day and decrease FML to three times a day for a month and then stop.
5. Symptoms should resolve by then.
6. If symptoms do not resolve, consider referral to a dermatologist to treat skin conditions such as eczema, for example.

We typically wait about 6 months postop to initiate this protocol. It is not uncommon for patients to experience some recurrent erosions during the first 3 to 6 months after PRK, and these typically resolve on their own. Do not forget to check IOP while patients are on steroid drops.

Results

In the past 2 years, we had six patients with more than one incidence of recurrent erosion. Several of the patients had tried Muro drops (Bausch + Lomb) and ointment in the past without success. All but one patient had complete resolution of symptoms after step 3 of the anti-inflammatory protocol. That patient went on doxycycline without improvement and was referred to a dermatologist for treatment of lid eczema.

Other applications

The same protocol can potentially be initiated in patients with recurrent erosions due to EBMD without previous PRK. It may be especially effective in patients with chronic, mild lid inflammation due to rosacea, for example.

• For more information:
• Ella Faktorovich, MD, founder and director of Pacific Vision Institute in San Francisco, can be reached at ella@pacificvision.org.

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