extreme pain, red eye, blurriness:recurrent corneal erosion?

[ManiG]

Hi all,

I've posted previously about dry eye issues I've been experiencing here: http://www.usaeyes.org/ask-lasik-expert ... =9707#9707

Last night, I forgot to wear my swimming goggles before going to sleep.

I woke up this morning with severe pain in my right eye after opening my eyes. The pain can be described as excruciating. This has happened to me before, a few times, and the pain always subsided after a couple hours.

Today, however, the pain has not gone away. What a miserable day. I have constant excruciating pain in my right eye (feels like someone just poked me in the eye), extremely blurred vision, and the eye is very, very red.

Unfortunately, since it is the 1st, my LASIK clinic is closed. I thought about going to the emergency room.

Not being able to get properly diagnosed, I've gone on the internet looking for help. My symptoms seem to match "recurrent corneal erosion" quite closely. Could this be the case? I will bring it up with my doctor as soon as I see her (hopefully, early tomorrow morning).

Is RCE caused by dry eyes? If I am experiencing RCE, is this something that goes away after the 6 month healing period, or if my dry eyes resolves? I am about 3 months post-custom wavefront LASIK.

Would greatly appreciate any help.

Stressed out & worried,
Mani

[LasikExpert]

A diagnosis of RCE requires an examination to determine if this is an issue of dry eyes or RCE, however what can be helpful to you now is using a night time gel lubricant - even during the day. You will not be able to see very well, but the heavy gel can protect the cornea from the friction of normal blinking.

You should be able to find an optometrist open at least by tomorrow. An OD would be able to assist you until you are able to see your normal surgeon.

[ManiG]

Thanks for the reply Glen.

So On Jan 1st, I spent almost the entire night in the emergency room, being urged to go there by my GP father in law who did not like the sound of my symptoms and wanted to rule out something more serious.

The opthalmologist (being on call and finally arriving at 2am) eventually confirmed that I was missing a large piece of epithelium, nearly covering my entire cornea. She was extremely concerned of this being caused by an infection. However, thanks to my own online research, I politely suggested whether RCE is a possibility since the symptoms started after opening my eyes.*** She then agreed that this was probably the case. She assigned me with 2 antibiotic drops to take every half hour through the night, forcing me to stay up well over 24 hours, in severe pain.

Suffice to say, my first day of 2009 was not pleasant in the least.

Today, I went to my LASIK surgeon and explained everything. They confirmed the epithelial defect and that it was in fact very large (6mm diameter), covering nearly my entire cornea. A big piece of my epithelium was basically gone. One optometrist said that I had effectively performed PRK on myself. (!!)

Next steps are to heal my extremely irritated, inflamed eye. I am on pred-forte four times a day as well as continuing the anti biotics, but only 4 times a day for those as well. To my great relief they also put a bandage contact lens in my eye to ease my discomfort.

Next step, after healing, is to probably put on some kind of contact lens for 4-6 weeks to treat the underlying RCE. Though, this will be discussed further with my surgeon tomorrow morning.

I have been through an incredible amount of physical pain and mental strain the last couple days and really hope that I am on track for recovery. The doctors did say that my cornea looks fine and they see no signs of epithelial infiltration, and that I should make a full recovery and have my vision fully restored in a matter of 4-6 weeks.

I am keeping positive. Complications exists in pretty much every surgery out there, even the simplest ones, and luckily there is no sign of permanent damage. My LASIK center has been nothing but courteous and helpful, and I only fault them for not being available on Jan 1st (couldnt find an emergency number, either), forcing me to experience Canada's awful emergency room service, and to visit opthalmologists I who were not familiar with my history.

I will continue to keep this thread updated to help anyone in the future who might experience similar problems.

*** note to readers - I have several doctors in my family, all of whom really, really hate it when people diagnose themselves on the Internet. If you want to bring up something you found online, I highly recommend bringing it up as gently and humbly as possible. Just my personal suggestion and YMMV!

[LasikExpert]

I totally agree with the self-diagnosis over the Internet issue. It's not the best way to treat a problem, but it can provide some immediate information and, in your case, apparently helped the ER doctor come to an accurate diagnosis.

A large epithelial defect explains the pain - and lots of it. The eye gets very angry when it suffers a wound. I had PRK and (due to my own foolish acts) a severe epithelial defect. I know of the pain you are experiencing. You have the healing response of PRK, but without the prior knowledge and planned pain medications. Total bummer.

The corneal epithelial cells are the fastest reproducing cells in the human body, but it will take time for them to cover the area, thicken, and smooth. You will undoubtedly have some corneal edema (inflammation) from the insult, which will cause fluctuations in your refractive error and likely an uneven healing pattern until things settle down. Your poor vision will wax and wane and change over the next 2-3 weeks. You will likely not get the really good vision you want until 4-6 weeks or even a bit longer. You will undoubtedly have functional vision within a week, but you won't be threading any needles with that eye.

The toughest part for you now is not totally freaking out from fear and frustration. You can expect to be beating yourself up every now and again ("I really didn't need to do this.") and questioning the wisdom of your decision, but what you have is something that will heal and can be treated and is undoubtedly temporary.

Your continued updates to this forum will be very, very helpful to others who suffer similar problems. Please do keep us informed.

[ManiG]

Once again, thank you Glen. You have no idea how helpful and reassuring this forum and your responses have been.

Visited my original surgeon this morning. The epithelium is healing quickly, as expected. The epithelial "hole" was 6.5mm x 6.5mm yesterday, and today it is about 1.5mm x 1.5mm. My pain has been reduced greatly. I will be visiting again tomorrow.

I would describe the pain now as somewhere between "uncomfortable" and "very unpleasant", where yesterday I would have described it as "debilitating" and "excruciating" ... so the improvement is very nice.

My eye is still extremely red, and as Glen described, "angry" looking.

I pressed my surgeon about what happens after my eye has completely healed over. I do not want to live with the fear that any morning after waking up, this could happen again. One relative optometrist mentioned saline drops (Muro 128?) that might help, and the surgeon yesterday described some kind of lens to be worn for several weeks. My surgeon this morning only discussed using an ointment at night for several months.

I just want to make sure that the underlying epithelial weakness is treated. Glen, any ideas what my options are here? Is it possible that the epithelium will heal "better" this time around without directly addressing the RCE?

Thanks again, and I'll keep this updated!

[LasikExpert]

Thank you for your kind words. Many who visit here arrive in a bit of a panic. After all, why would someone with a great outcome bother to research problems?

I do not believe what you have experienced is RCE. I doubt it will re-occur.

At night your eye became very dry. The tear film that normal insulates the underside of your eye lid from the epithelium was depleted, probably due to a combination of inflammation, medications, nerve disruption, change in corneal curvature, and perhaps other issues. Without the lubricant between the cornea and the inner eye lid, they stuck to one another.

The epithelium is a very soft layer of corneal cells. At some point, either from rapid eye movement (REM) or opening your eye lid, the epithelium stayed stuck to the inside of your eye lid and tore off from the cornea. Ever ripped a large band-aid off a hairy arm? Yea, that kind of pain is just the start.

Humans have evolved to protect the "flight and fight" components of our body. Vision is very valuable to both. It seems that as a defense mechanism, any damage to the eye is met with an immediate and strong response so you won't do it again. That response is PAIN. It is also very fast wound healing. That's why the corneal epithelial cells heal so fast. The body is trying to restore a valuable asset for "flight and fight" as quickly as possible.

While the epithelium may have already covered all but 1.5mm of cornea, it has not yet thickened nor has it smoothed. Once the cornea is covered, the protection offered by the epithelium will reduce the pain. As the wound response slows and gets under control, the inflammation should go down. As the inflammation goes down, tear fluids again flow. At least, that is how it most often works out.

The epithelial damage will re-occur only if you suffer from a similar dry eye problem again. As the Lasik heals, the dry eye will normall resolve. In the interim, you will be using artifical tears and nighttime gels to protect the eye. This also promotes healing.

When you get to the balance of tear production, the likelyhood that you would suffer a similar problem becomes very slim. Yes, it could happen. You may have a long-term epithelial defect issue, but that is not the likely result.

I look forward to your continued reports.

[ManiG]

visited my surgeon again this morning.

the epithelial "hole" had completely closed, but i had more bad news. my surgeon noticed inflammatory cells under the flap.

she proceeded to lift the flap and wash out the cells immediately. the unexpectedness of this procedure and the way it is done rattled me. i pretty much hit a low point, mentally after this procedure and needed a moment to collect myself.

she upped my pred-forte to once every hour also.

she said some epithelial scratching occurred as she flushed the inflammatory cells, so i will be feeling some pain again and she re-applied a bandage contact lens. she said these scratches are relatively minor should resolve quickly.

Here's hoping that this is the last complication i'll have to experience.

Will keep you updated after my follow up tomorrow. Glen, any thoughts? Do you think it is appropriate that I seek a second opinion at this point?

Kind regards,

[LasikExpert]

What the doctor found was epithelial ingrowth. Since your epithelium was already compromised, it was probably wise to go ahead and lift the flap, remove the cells, flush the area, and reposition the flap now, rather than waiting to see if the cells spread.

Your discomfort from the flap lift will likely be nothing compared to the epithelial defect that started this all.

Although it is scary and painful, both the epithelial defect and the epithelial ingrowth are relatively benign problems that have a good history of full resolution with no long-term effects. Of course, we don't "see" long-term.

[ManiG]

Glen - interestingly, the issue *is* in fact RCE, as confirmed by my surgeon today.

Pain - much reduced, irritating now more than painful. Some drops they put in (don't know which), have caused increased pupil size which is supposed to last a few days, which is adding to the discomfort so I often have my injured eye closed because of the brightness.

Vision - marginally better. It is a relief to see it improve, since the past few days it was so blurry and bad that I was beginning to get nervous. It's not myopia or hyperopia, it just looks like there is a thick blur filter over everything.

I saw a different surgeon today, who is actually one of the owners of the LASIK establishment I'm going to, who has performed over 50,000 corrections. On top of this, his expertise is in epithelial defects, so I guess I got lucky.

He noticed some DLK remaining under the flap, but said that they are not clustered and shows a good response to having my flap flushed of the cells yesterday. I will be continuing pred-forte every hour which will hopefully resolve these remaining cells.

As for the epithelial weakness, I have been prescribed Muro 128 as I had expected, to be taken nightly for the next 8 weeks.

If I do not respond to the Muro 128, then he will recommend using PPK laser to solve the problem. He noted that it is statistically supposed to resolve the underlying epi weakness 50% of the time, but in his experience it has been very successful in treating this problem.

Hopefully, I will not need this and the Muro 128 combined with my eyes producing tears again will solve the problem.

Also worth noting, my bandage contact lens fell out just before my appointment this morning. The surgeon decided to leave it off for today, since my epithelium has healed over and my pain levels are down, and he'd like better absorption of the pred-forte (corticosteroids) I am taking. He said he may or may not re-apply the bandage contact lens tomorrow.

Really looking forward to getting these past few days behind me!

Glen, a question. Before this whole thing happened, I was having ghosting issues in my right eye in low light conditions. This seemed to be consistent with uncorrected astigmatism. Do the issues I am experiencing now preclude me from having my right eye enhanced after it has fully healed?

[ManiG]

More updates:

Eyes are *much* better, redness is almost resolved. Pain is gone.

Vision is very much improved though still a blurry mess. This is expected.

Saw the doc this morning. I'm reducing pred-forte drops to 4x a day, as the inflammation is almost entirely resolved.

Apparently vision problems now are simply due to the epithelium healing and smoothing out, as Glen has mentioned earlier.

I will be putting in Muro 128 (saline ointment) in my eyes nightly for the next 8 weeks.

I will also start wearing a contact lens starting next week, to promote thickening and strengthening of the epithelium.

Cheers,
Mani

[LasikExpert]

It sounds like you are on a normal course of healing and resolution to the problem. Please keep us up to date.

The contact lens also protects the epithelium as it heals underneath.

[ManiG]

Here's an update, 11 days after waking up to a corneal erosion:

- great news. physically, the eye feels entirely back to normal. No pain, no discomfort, no irritation. the redness is also totally gone.

- vision. i'd say it is still a little blurry but every day inches a little closer to where it was. this was confirmed by the optometrist today who noticed great improvement from the last time. i have strong double vision in the right eye in dimly lit rooms or when watching tv, which i believe is astigmatism. the optometrist confirmed a 1.25 astigmatism in my right eye.

my surgeon also took a look today. no inflammation at all, which is great news. he did notice a "remaining 20% of swelling" in the eye, which he believes should explain the 1.25 astigmatism.

the next steps are to continue my Muro 128 drops at night, for the next 6-8 weeks. hopefully the astigmatism will resolve on its own, that is my greatest concern at this point.

if i have another corneal erosion episode, then i will go on a contact lens. if after contact lens treatment, i have another erosion episode, then i will go for PTK laser treatment. i am hoping that these will not be necessary, and the Muro 128 combined with my eyes producing tears again will resolve the problem.

again, biggest concern at this point is the double vision in my right eye, which i did experience before the erosion on jan 1st (see http://www.usaeyes.org/ask-lasik-expert ... =9707#9707 ). fingers crossed it will go away. if not, i will get some lenses and consider touch up surgery, which will honestly be a tough choice given the complications i've experienced.

[LasikExpert]

Thanks for keeping us up to date. The doubled vision may be due to inflammation and may resolve. Let's hope so.

[ManiG]

Here's an update, about 7 weeks after my epithelium eroded:

- I've been on Muro 128 ointment (before going to bed) ever since, and have had no issues whatsoever.
- I "tested" one night without the ointment -- woke up with no issues, which is a good sign but not indicative that the epithelial weakness has resolved.

My post-LASIK dryness has pretty much resolved, which should help prevent erosions from reoccurring. In a few weeks I will be stopping the ointment treatments, and I will report again when that time comes.

As a side note, the ghosting, starburts, and lack of contrast sensitivity I've had since the operation have not resolved even though I am 4.5 months post LASIK. Even worse, these problems are not helped by prescription. :( My doctor thinks they are due to microstriae/mud crack formations. Normally he would wait for them to resolve on their own. For me however they are very visually significant, so he will treat them aggressively by stretching my corneal flap with sutures in 2 weeks.

[LasikExpert]

Sorry to hear of the continuing difficulties, but do keep us informed of your progress.