Recurrent Corneal Erosion

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1 Recurrent Corneal Erosion
Pf. 김만수/R3 김준용

2 M/60 C.C. Ocular discomfort(OS)
P.I. 좌안 반복성 헤르페스 각막염으로 local에서 치료 받던 중 전원됨. 증상 발생 시기 : 주로 피곤할 때 생기는 부위 : 항상 동일하게 가운데 부분 증상의 fluctuation (+) 증상 심할 때도 충혈은 없음 2003년 본원 초진 Cornea pseudodendritic lesion(OS) Corneal sensitivity 양안 비슷 Imp) Herpes simplex keratitis (OS)

3 Ant. Segment & Plan VA OS 0.8 Conj mild injected, follicle(+)
Cornea relatively clear /(OS) Corneal sensitivity 저하 (-) Impression) R/O Herpes simplex keratitis(OS) History of Pseudodendritic lesion, Follicular conjunctivitis R/O RES(OS) Corneal sensitivity 이상 없음, 증상 심할 시에도 충혈은 없다고 함 Plan) Hyalein mini eye drop 0.3% x prn Virgan ophthalmic gel x hs /(OS) Acyclovir 1000mg #5 x 30days F/U 1month later 모양은 herpes 같지만 active lesion 으로 보이지 않음.

4 1 month later S : 많이 좋아졌어요 VA OS 0.8 Conj Not injected, follicle(-) Cornea Multiple pseudodendritic lesion, terminal bulb (-) 모양은 herpes 같지만 active lesion 으로 보이지 않음.

5 Plan T-lens Hyalein mini eye drop 0.3% x prn /(OS)
Acyclovir 600mg #3 x 7days F/U 7 days later

6 1 week later S : 통증이 3~4일 전부터 심했음 VA OS 0.5 Conj Not injected, follicle(-) Cornea infiltration 심함, elevated lesion but terminal bulb(-)/(OS) 모양은 herpes 같지만 active lesion 으로 보이지 않음.

7 Plan Plan) Patch (OS) teaching Vigamox x 4 Ocumethorone x 4 /(OS) F/U 3 days later 모양은 herpes 같지만 active lesion 으로 보이지 않음.

8 3 days later 3일뒤 S : 통증 감소. VA OS 0.8 Cornea epidefect healing (+)
모양은 herpes 같지만 active lesion 으로 보이지 않음.

9 Plan Plan) Patch 하루만 더 Vigamox x 2 Ocumetholone x 2 for 1 wk Hyalein mini eye drop 0.3% x prn /(OS) F/U 1month later 모양은 herpes 같지만 active lesion 으로 보이지 않음.

10 Recurrent Corneal Erosion
Corneal disorder characterized by recurrences of epithelial erosions Trauma, Corneal dystrophy Abnormal basal epithelial layer Abnormal epithelial basement membrane Abnormal hemidesmosome Loss of anchoring fibrils 모양은 herpes 같지만 active lesion 으로 보이지 않음.

11 Recurrent Corneal Erosion
Clinical feature Ocular pain, redness, tearing, photophobia Typically occur on waking -> rapid eye movements during sleep 1:150 cases following traumatic abrasion 모양은 herpes 같지만 active lesion 으로 보이지 않음.

12 Recurrent Corneal Erosion
Appearance of affected cornea Loosely adherent and elevated epithelium Epithelial microcysts Epithelial defects Corneal infiltrates Stromal infiltrates and opacities Majority of erosion : within the lower half Last area to re-epithelize : in the midline below the horizontal meridian due to centripetally moving of healing epithelium 모양은 herpes 같지만 active lesion 으로 보이지 않음.

13 Recurrent Corneal Erosion
모양은 herpes 같지만 active lesion 으로 보이지 않음.

14 Recurrent Corneal Erosion
Differential diagnosis - Recurrent breakdown of corneal epithielium Self-inflicted corneal injury ; rare, history Exposure keratitis ; history, lid exam Neurotrophic keratitis ; painless Foreign bodies under the tarsal plate ; history, careful exam of conjunctiva 모양은 herpes 같지만 active lesion 으로 보이지 않음.

15 Recurrent Corneal Erosion
모양은 herpes 같지만 active lesion 으로 보이지 않음.

16 Recurrent Corneal Erosion
모양은 herpes 같지만 active lesion 으로 보이지 않음.

17 Recurrent Corneal Erosion
Differential diagnosis Recurrence of herpes simplex keratitis Past history of dendritic ulceration Gradual onset of pain Deep stromal infiltration Acute follicular conjunctivitis or keratoconjunctivitis Preauricular adenopathy Pseudomembrane in fornix Diffuse nature of primary epithelial involvement Decrease in sensitivity 모양은 herpes 같지만 active lesion 으로 보이지 않음.

18 Recurrent Corneal Erosion
Differential diagnosis Recurrence of herpes simplex keratitis 48 eyes with diagnoses of nonherpetic condition → 11 eyes positive reaction on immunofluorescent staning → 9 eyes was diagnosed as RES 9 eyes with wrong diagnosis → epithelial defects that were oval and central with hazy surrounding edges 모양은 herpes 같지만 active lesion 으로 보이지 않음.

19 Diagnosis Heidelberg Retina Tomograph Rostock Cornea Module (HRT II RCM) laser confocal microscope Anterior basement membrane dystrophy Abnormal epithelial basement membrane protruding forward into the corneal epithelium, the presence of epithelial microcysts Normal superficial epithelial cells and stroma Trauma Altered epithelial cells, activated keratocytes in shallow stroma and inflamed mid-stromal keratocytes

20 Diagnosis The tears of patients with a history of traumatic corneal abrasions and RCEs Increase MMP-9 and MMP-2 in affected and fellow eyes as compared with control eyes Basement membrane degradation and poor epithelial basement membrane adhesion

21 Medical Treatment Lubrication of the ocular surface
Maximizing the health of the tear film Topical antibiotics Artificial tears Hypertonic solutions Bandage contact lens Doxycycline and steroids Autologous serum

22 Surgical Treatment Anterior stromal puncture Debridement
To improve epithelial adherence by inducing scar tissue Debridement High recurrence rate Diamond Burr Polishing Epithelium removal with cellulose sponge 10-15 sec of treatment with a diamond burr to remove irregular basement membrane PTK