Identifying a case of recurrent corneal erosion syndrome

Under the radar: Continuing our series exploring diagnoses that can be overlooked in primary care, Dr Keith Hopcroft describes a case of recurrent corneal erosion syndrome which was initially treated as conjunctivitis

The case

A 43-year-old woman presents to the surgery complaining of recurrent pain and watering in one eye. This has been going on intermittently for a few months and she has already attended three times. She was first thought to have possible conjunctivitis and subsequently dry eyes, but treatment with topical antibiotics and lubrication have not proved effective.

Going into the history in more depth, she recalls getting a slight scratch to her eye from the fingernail of a friend’s baby a few months ago. This remained sore for a few days but then seemed to settle.

About a week later, she woke with significant discomfort in the same eye, associated with watering and photophobia, which resolved after an hour or two. A few days later, she suffered another episode, with an identical pattern. And since then she has had repeated attacks, always on waking, in the same eye.

At point of consultation, she is asymptomatic, and examination – including visual acuity and staining – is normal.

She is referred for an urgent appointment at the local eye unit.

Outcome

She is diagnosed by the ophthalmologist with recurrent corneal erosion syndrome, and treated with frequent liquid eye lubricant by day, and gel by night, to be used prophylactically for six months.

Background

Recurrent corneal erosion syndrome is a recurrent eye condition typically resulting from corneal trauma, such as a twig injury or papercut. This usually heals, but about a week or so after – though, sometimes, up to months later – the typical symptoms of recurrent pain, watering, photophobia and blurring begin. These occur on waking because the opening eyelid tends to strip off the healing layer of corneal epithelium. Symptoms usually settle after a few hours and may not occur every morning. If not seen early in the morning, there may be few symptoms and no examination abnormalities in the surgery. 

The syndrome can arise spontaneously and has associations with corneal dystrophies, previous infections, meibomian gland dysfunction and diabetes. Treatment may include topical antibiotics, lubricants, or, in persistent cases, secondary care input with abrasion or a ‘contact lens bandage’. Complications include infection and scarring.

Diagnosis

This is based largely on the history, unless the patient is seen with an episode. Most cases will need confirmation via specialist referral. The differential includes corneal foreign bodies, corneal ulcers and dry eyes.

Learning points

Sore, watering eyes are common in primary care, but this is a diagnosis which may not be considered. The key is the unilaterality, the history of recurrence and, in particular, the pattern of symptoms occurring in a stereotyped way as soon as the eye is opened in the morning.

Dr Keith Hopcroft is a GP in Essex

Sources

• Ramanurthi S et al. Pathogenesis, clinical features and management of recurrent corneal erosions. Eye 2005;20:635–44
• Moorfields Eye Hospital NHS Foundation Trust. Patient information: Accident and Emergency. Recurrent corneal erosion syndrome. 2018
• Lin SR et al. Recurrent corneal erosion syndrome. Br J Ophthalmol 2019;103:1204-8