PATHOGENESIS

Persistent corneal epithelial defects are generally related to some underlying

disease process. Common causes of these defects include

herpetic corneal disease

delayed postsurgical epithelial healing
chemical burns
toxicity from topically applied medications
recurrent corneal erosions
dry-eye syndromes
infections
neuroparalytic keratopathy
neurotrophic keratopathy
anterior segment necrosis

CLINICAL PRESENTATION Persistent corneal epithelial defects are characterized by central or

paracentral areas of chronic nonhealing epithelium that resist maximal therapeutic endeavors.
They frequently have elevated, rounded edges and may be associated with significant
underlying stromal inflammation. Corneal anesthesia is frequently an accompanying
sign, and it should always be evaluated. Left untreated, this condition can progress to
vascularization
and corneal opacification or scarring. Alternatively, progressive inflammation
can lead to necrosis and thinning of the stroma, occasionally resulting in perforation.
LABORATORY EVALUATION The d iagnosis is based on careful history taking, with
particular
attention to the preservatives present in any ophthalmic medications being administered.
The lesions are frequently round or oval epithelial defects with grayish edges that are
rolled under without heaped margins. The defects tend to be inferior or inferonasal and
can be associated "'-lith an intense, coarse superficial keratitis. The inferonasal predilection
of these lesions may be a result of th e area's easy access and the protective effect of Bell
phenomenon on the superior cornea. KCS is a frequently accompanying disease. Other
associated conditions include corneal hypoesthesia as a result of previous cataract extraction
or keratoplasty and prior herpes zoster or herpes simplex infections.
MANAGEMENT Some medications used to treat ocular surface disease and glaucoma
may impair epithelial wound healing and result in the formation of persistent corneal
epitheli al defects. The drugs most frequently implicated include topical anesthetics; topical
nonsteroidal anti-inflammatory agents (1 SA IDs); t rifluridine; ~ -blockers; carbonic
anhydrase inhibitors; and, in sensitive ind ividuals, all drops containing the preservative
benzalkonium chloride (BAK). Some authors refer to the condition as toxic ulcerative
keratopathy.
This clinical problem is frequently unrecognized and usually presents as a diffuse
punctate keratopathy. In some instances, pericentral pseudodentritiform lesions and
pseudogeographic defects may occur. These cli nical fi ndings are often miSinterpreted as a
worsening of the underlying disease and thus may lead to even larger doses of the offending
medication . Frank ulceration and even corneal perforation can result.

In addition to removing the offending stimulus or aggravating drugs or treating the

underlying condition, a number of strategies have been llsed to manage persistent epithelial
defects. Pharmacologic therapies have included systemic tetracycline, chosen for its
anticollagenolytic effect, unrelated to the drug's antimicrobial properties.
Generally, conventional therapies can be effective in promoting closure of the epithelial
defect. These include frequent lubrication with nonpreserved ointments and, if necessary,
temporary tarsorrhaphy or permanent lateral canthoplasty to encourage epithelial
migration and minimize mechanical trauma from exposure and desiccation.
Persistent epithelial defects often occur in patients with diabetic retinopathy following
epithelial debridement during vitreoretinal procedu res. Diabetic neuropathy is thought to
be a potential cause of neurotrophic keratopathy and nonhealing epithelial defects.
For more extensive insults, such as alkali injuries or other causes of devastating ocular
surface trauma, damage to limbal stem cells cannot be overcome by conventional
conservative therapies. Various strategies using healthy conjunctiva or limbal stem cells
have been used with success in ocular surface reconstruction. (Limbal stem cell dysfunction
is discussed at the end of this chapter; surgery of the ocular surface is covered in
Chapter 14.)

Cornea
The cornea is a transparent, avascular tissue that measures 11-12 mm horizontally and
10-11 mm vertically. Its refractive index is 1.376, although, in calibrating a keratometer, a
refractive index of 1.3375 is used to account for the combined optical power of the anterior
and posterior curvatures of the cornea. The cornea is aspheric, although its radius of
curvature is often recorded as a spherocylindrical convex mirror representing the central
anterior corneal surface, also called the corneal cap.
The average radius of curvature of the central cornea is 7.8 mm. The cornea thus contributes
74%, or 43.25 diopte rs (D), of the total 58.60 dioptric power of a normal human
eye. The cornea is also the major source of astigmatism in the optical system . See Measurement
of Corneal Topography in Chapter 2 for more information on corneal opticS.
For its nutrition, the cornea depends on glucose diffusing from the aqueous humor
and oxygen diffusing through the tear film. In addition, the peripheral cornea is supplied
with oxygen from the limbal circulation.
The cornea has one of the body's highest densities of nerve endings, and the sensitivity
of the cornea is 100 times that of the conjunctiva. Sensory nerve fibers extend from
the long ciliary nerves and form a subepith elial plexus. Neurotransmitters in the cornea
include acetylcholine, catecholamines, substance P, calcitonin gene- related peptide,
neuropeptide
Y, intestinal peptide, galanin, and methionine-en kephalin.

INTRODUCTION
When the cornea is wounded, the healing process is usually initiated to reestablish epithelial
continuity. Persistent (or nonhealing) epithelial defects (PEDs) occur when the corneal
epithelium fails to regenerate steadily over a corneal wound within due course (usually less than
2 weeks in normal corneas). Only after the epithelium has completely covered a tissue defect can
appropriate adhesions to the underlying stroma begin to develop. Recurrent epithelial
breakdowns may occur as a result of poor adhesion. The potential causes of PEDs are myriad.
Regardless of the cause, PEDs may progress through the subjacent corneal stroma and eventually
lead to stromal ulceration. As our understanding of the mechanisms of corneal epithelial
homeostasis and related tissue reaction to injury continues to evolve, so will our therapeutic
regimens become more targeted towards the underlying mechanisms.
EPITHELIAL HOMEOSTASIS
The human corneal epithelium consists of five to six layers of stratified squamous cells, with
three subdivisions: superficial cells (outer 2-3 cell layers), wing cells (middle 2-3 cell layers) and
basal cells (innermost 1 cell layer). In an X, Y, Z hypothesis, Thoft postulated that the forces X
(which represents the proliferation of basal cells) and Y (which represents centripetal migration
of cells) must be balanced by Z (the loss of surface epithelium) during homeostasis.[1] The basal
cells comprise mitotically active cells, with higher proliferative capacities at the corneal
periphery, known as the limbus. The limbus, a transitional zone between avascular corneal and
vascular conjunctival tissues, contains corneal epithelial stem cells (SC) which undergo mitosis,
giving rise to daughter cells (known as transiently amplifying cells, TAC) in the basal
epithelium. As basal cells migrate superficially, they lose their mitotic ability (postmitotic cells,
PMC) and differentiate into wing and then superficial cells (terminally differentiated cells, TDC).
The superficial cells desquamate into the tear film and are steadily replenished by more
migrating cells. The entire process takes 7-14 days.[2] The process of desquamation is generally
regulated by apoptosis (programmed cell death).[3]
As mentioned above, as epithelial cells migrate centripetally and superficially they also become
further differentiated. Various types of adhesion complexes are formed: desmosomes and tight
junctions in superficial cells; desmosomes and gap junctions in wing cells; desmosomes,
hemidesmosomes, and gap junctions in basal cells. It is these hemidesmosomes, through
anchoring fibrils and plaques, which mediate attachment of the basal epithelium to the basement
membrane.[4] Tight adhesion of the corneal epithelium to the underlying stroma is crucial for
maintaining the corneal surface integrity. When only corneal epithelium is removed, the
regenerating epithelial cells can migrate along an intact underlying basement membrane. The
new epithelial sheet does not develop tight adhesions via basement membrane complexes until 7
days. However, when the corneal epithelium along with its underlying stroma is removed,
regenerating epithelial cells cover the defect in 4 days but do not adhere to the underlying
stroma until 8 weeks or later. This observation indicates that delayed development of epithelial
adhesion to the underlying stroma may play a significant role in recurrent epithelial breakdowns
and PEDs.[5]

NORMAL CORNEAL RESPONSE TO INJURY

After corneal injuries, both disrupted epithelial cells and exposed underlying basement
membrane or stroma are responsible for generating various signals to surrounding cells and into
the overlying tear film.[6] Although the precise mechanisms by which these signals lead to
epithelial migration and healing are poorly understood, it has been shown that various factors
responsible for epithelial healing are elevated in the wounded cornea and tear film. Amongst
these are fibronectin (FN),[7] vinculin,[8] plasmin, tissue plasminogen activator (tPA),[9] urokinase
plasminogen activator (uPA),[9] cell surface receptors such as integrins,[10] epidermal growth
factor (EGF),[11] EGF receptors,[11] nerve growth factor (NGF),[12] and alpha-enolase.[13] Since
these factors are active in normal epithelial healing in response to injury, many of them have
been targeted as potential therapeutic options for PEDs.
The first step in healing an epithelial defect involves epithelial migration to populate the defect.
EGF, which is present in epithelial cells and the tear film, promotes epithelial proliferation and
migration. After epithelial injury, increased levels of the glycolytic enzyme, alpha-enolase, are
found in the mitotically and metabolically active limbal basal cells, suggesting their role as the
epithelial TACs.[13] High levels of alpha-enolase are found up to 4 weeks after wounding, further
suggesting its role in epithelial restratification.[13] Time-lapse phase-contrast cinematography
studies have demonstrated that the migration of epithelial cells is not simply an X and Y
phenomenon.[14] That is, epithelial cells migrate centripetally, but in a vortex type pattern while at
the same time migrating superficially. EGF, which is present in epithelial cells and the tear film,
promotes epithelial proliferation and migration.
EXTRACELLULAR MATRIX IN CORNEAL WOUND HEALING
FN is a multifunctional extracellular matrix protein. FN binds to specific molecules such as cell
surface receptors, collagen, and fibrin to facilitate cell adhesion.[7] Two forms of FN are present
on the wound surface. The soluble plasma fibronectin (pFN) in the tear film originating from the
conjunctival vessels covers exposed basement membrane of the denuded corneal surface creating
a temporary scaffold for migrating epithelium.[15] The insoluble cellular fibronectin (cFN)
derived from stromal keratocytes is localized under the migrating epithelium and disappears after
wound closure.[7] The resorption of the FN is mediated by proteolytic enzymes such as plasmin.
Other basement membrane matrix components such as collagens, laminins, keratan sulfate
proteoglycan, and heparan sulfate proteoglycans are also important to corneal epithelial cell
proliferation, differentiation, and migration.
Shortly after injury, epithelial cells at the edge of the injury change their cytoskeleton to form
pseudopodia[16] and cell surface integrins are upregulated (a process mediated by EGF).[10] These
actin-rich pseudopodia adhere via integrins to the FN matrix, a process mediated by vinculin.[8]
Actin-mediated contraction moves the epithelium in to the denuded area, directed by chemotactic
factors.[17] This migration requires the constant destruction and reformation of attachments
between the epithelial cells and their scaffold, a process mediated by several serine proteases
including plasmin, tPA, and uPA.[9]

Once the basal cells have spread over the defect they lay down a basement membrane to which
they form permanent attachments. Basement membrane constituents such as laminin 1 and
laminin 5[18] are laid down by migrating epithelium. At the same time, and possibly influenced by
the aforementioned cellmatrix interactions, cellcell adhesion complexes begin to be formed.
This suggests that even after the epithelium has begun to fill in the defect, a steady interaction
between epithelium and basement membrane or stroma is required for epithelial maturation. The
natural process of superficial migration and differentiation ensues to form a complete epithelial
layer.

PROTEOLYTIC ENZYMES AND METALLOPROTEINASES

THE PLASMINOGEN ACTIVATOR/PLASMIN SYSTEM
Plasmin is generated by plasminogen activators (PAs) via proteolysis. After an epithelial injury,
FN at the leading edge of the defect is degraded by the increased production of plasmin, thereby
compromising FN's adhesive functions. FN fragments can compete with intact FN and other
ligands for the epithelial integrin receptors or other adhesion receptors, leading to an epithelial
defect. Plasmin generated in the stroma may also contribute to collagenase activation,
fibrinolysis, and eventual stromal ulceration.[19,20]
Plasmin and PA have been found in tears. There are two well-known types of plasminogen
activator: the tPA and the uPA. Tissue-type PA is derived from the conjunctiva or lacrimal gland
and is the predominant type of PA in normal tears.[21] In contrast, uPA is derived from the corneal
or conjunctival epithelial cells and has been found to increase in rabbit tears and human corneas
with injury and inflammation.[21,22] Both PAs are synthesized as monomer enzymes. While tPA
has some biologic activity as a monomer, a dimer uPA is needed to achieve full enzymatic
activity. The primary role of tPA is in fibrinolysis[23] and it is activated upon binding to fibrin,
whereas uPA is involved in proteolytic events such as epithelial migration, matrix degradation,
and tumor invasion. Plasmin is one of a number of enzymes that can convert latent uPA to its
active form.[24] The release of cellular uPA causes degradation of FN, which is needed by the
migrating corneal epithelial cells for cell attachment.[25] Corneal stromal ulceration has been
correlated with the conversion of uPA from the latent to the active form.[26] When uPA is located
at the leading edge of epithelium after corneal wounding, a secondary epithelial defect can occur
as a result of further degradation of the subepithelial fibrin or FN by plasmin activation.[19,27]
Furthermore, uPA can induce corneal neovascularization in rabbits.[28] In turn, the vascular
response may mitigate the severity of subsequent stromal ulceration.[27]
Plasmin and PA can be inhibited by endogenous inhibitors such as -2 antiplasmin, -2
macroglobulin, and -1 antitrypsin.[22,29,30] These inhibitors are also present in tears and can be
increased by ocular inflammation associated with increased conjunctival vessel permeability. The
balance between plasmin/plasminogen activator and their inhibitors may thus modulate the
process of epithelial wound healing.
MATRIX METALLOPROTEINASES

Matrix metalloproteinases (MMPs) are enzymes capable of breaking down extracellular

matrices. MMPs, such as collagenases, gelatinases, and stromelysins are involved in the stromal
remodeling during corneal wound healing[31] and may contribute to the development of PED and
stromal ulceration. Many cell types are involved in the complex processes of MMP production
and related matrix degradation.
Collagenases that degrade type I collagen are present in fibroblasts, capillary endothelial cells,
macrophages/monocytes, and PMNs of corneal ulcers.[32] Cytokines from corneal epithelial cells
and macrophages/monocytes can modulate collagenase production by stromal keratocytes.[32]
Latent collagenases may be activated by plasmin[20] and result in the progression from a PED to
stromal ulceration. While collagenases cleave collagen fibril, gelatinases denature triple helix
chains of collagen. Following collagenase activation, both MMP-2 (78 kDa gelatinase) and
MMP-9 (92 kDa gelatinase) degrade collagen types I, II, and III.[33] In addition, these two
enzymes have specificity for native collagen types VI, V, and VII.[34] MMP-2 is found to be
upregulated in human corneal epithelium with recurrent erosions.[35] Loss of the epithelial
basement membrane after epithelial wounding has been noted to precede stromal ulceration.[3639]
Dissolution of the basement membrane may be crucial in initiating stromal ulceration and the
process can be activated by the remaining corneal cells without the involvement of inflammatory
cells. There is evidence suggesting that MMP-9 may be responsible for degrading the basement
membrane, while activated MMP-2 may be present in the basal epithelial cells to degrade the
epithelial anchoring system and contribute to the recurrent epithelial breakdown.[3335]
Stromelysins degrade proteoglycans, FN, and laminin.[40]
Naturally occurring inhibitors can modulate the production and activation of the MMPs.[20]
Tissue inhibitors of matrix metalloproteinases (TIMPs) and -2 macroglobulin are two principal
inhibitors of MMPs. At least two types of TIMPs have been known, TIMP-1 and TIMP-2. Both
are synthesized and secreted by many cell types. TIMP-1 inhibits collagenases, gelatinases, and
stromelysins. In addition to having potent inhibitory activity against MMPs, TIMP-2 has also
been effective in ameliorating corneal ulceration and perforation in rabbits after an alkali injury.
[41]

GROWTH FACTORS
Endogenous peptide growth factors such as EGF, transforming growth factor alpha (TGF-),
transforming growth factor beta (TGF-), insulin-like growth factor (IGF-1), and NGF are
involved in the complex interactions among epithelial cells, extracellular matrix proteins, and
proteolytic enzymes and they may be responsible for the development of PED or subsequent
stromal ulceration.[12,42,43]
EGF is produced by the lacrimal glands and secreted into tear fluids.[4345] In vitro, EGF can
stimulate the DNA synthesis of epithelial cells and stromal fibroblasts, as well as the synthesis of
FN by epithelial cells. It can enhance activities of the FN receptors,[46] and act as a chemotactic
factor for human corneal epithelial and stromal cells while not directly promoting the epithelial
migration.[46,47] TGF- is crucial for inducing the synthesis of extracellular matrix components
after corneal wounding and can modulate the effects of EGF.[47,48] In the presence of substance P,
a neuropeptide, EGF synergistically enhances epithelial migration, possibly via the tyrosine

kinase pathway.[49,50] Substance P and IGF-1 together can enhance corneal epithelial attachment
to FN and corneal epithelial migration.[51] In vitro, NGF has been found to be produced and
released by human and rat epithelial cells. Corneal epithelial cells also express NGF receptors. In
vivo, antibody neutralization of NGF results in delayed corneal epithelial healing.[12]
PATHOLOGIC RESPONSE TO CORNEAL WOUNDING
As discussed, the normal healing process of the corneal epithelium is quite complex, involving
matrix proteins, their corresponding integrin receptors, growth factors, and numerous proteolytic
enzymes. Any deviation of the normal response to epithelial injury as noted above can result in a
PED. Unregulated proteolytic degradation of stromal collagens and/or extracellular matrix
components may be associated with a PED and lead to subsequent corneal ulceration.[2126,5254]
For example, dysregulation of the plasminogen activator/plasmin system at the leading wound
edge leads to the prolonged presence of plasmin at the ocular surface[5557] and results in
compromised epithelial attachments to the subjacent FN, thereby producing a PED.[19] In
addition, plasmin can cleave complement C3 to generate C3a, a chemotactic factor for
polymorphonuclear leukocytes (PMNs).[42] These inflammatory cells elaborate various lysosomal
hydrolytic enzymes and further contribute to stromal melting.[54] Plasmin may also activate latent
collagenases to dissolve the epithelial basement membrane complex and lead to PED or stromal
ulceration.
Other than the biochemical basis of epithelial/stromal wound healing, a biomechanical
homeostasis between ocular surface and the surrounding lids/adnexae is of utmost importance to
ensure proper corneal wound healing. Consequently, a wide variety of conditions that can lead to
PEDs can be divided into the following categories: (1) defective epithelial adhesion or abnormal
proliferation and migration (limbal stem cell deficiency), (2) ocular surface inflammation, (3)
neurotrophic cornea, (4) mechanical irritations, and (5) idiopathic/hereditary ocular surface
disorders (Table 55.1).
TABLE 55.1 -- Principal Causes of PED
Etiology

Common Disease Entities

Management

Epithelial/limba
l

EBMD[*]
Recurrent erosions
Posttraumatic scar
Salzmann's nodular
degeneration
Band keratopathy
Bullous keratopathy
Toxic medicamentosa
Malnutrition (vitamin A
deficiency)
Limbal stem cell deficiency

Preservative free tears or medications

Topical lubricants (gels/ointments)
Punctal occlusion
PTK
Bandage soft contact lens
Amniotic membrane graft
Limbal stem cell transplant

Inflammatory

Keratoconjunctivitis sicca

Oral tetracyclines

Etiology

Common Disease Entities

Ocular rosacea
Chemical/thermal injury
Postinfectious keratitis
Autoimmune disorders
Sj?gren syndrome
Mucous membrane
pemphigoid
StevensJohnson syndrome
Graft vs host disease
Peripheral ulcerative keratitis
Mooren's ulcer
Rheumatoid arthritis

Neurotrophic

Diabetes mellitus
Herpes simplex
Herpes zoster
RileyDay syndrome
Anesthetic abuse
Postradiation
Postkeratoplasty

Mechanical

Entropion/ectropion
Lagophthalmos
Trichiasis
Blepharospasm
Pseudomembranes/tarsal scar
Trachoma
Factitious

Idiopathic

Aniridia
Corneal stromal dystrophies

Management
Punctal occlusion
Topical corticosteroid[]
Topical cyclosporine A
Topical medroxyprogesterone
Amniotic membrane graft
Systemic immunosuppression
Conjunctival resection

Punctal occlusion
Tarsorrhaphy
Conjunctival flap
Autologous serum drops
NGF

Bandage soft contact lens

Oculoplastic surgeries
Botulinum toxin

Treat as limbal stem cell deficiency

Treat as recurrent erosions, PTK, or
corneal transplant

EBMD, epithelial basement membrane dystrophy.

Corticosteroids should be used judiciously under close observation with PED.

1A. DEFECTIVE EPITHELIAL ADHESION

After successful closure of an epithelial defect over a temporary matrix, a permanent basement
membrane is produced by the basal epithelial cells. Formation of hemidesmosomes is necessary
for permanent adhesion. Therefore, any condition that causes a prolonged disruption of basement
membrane or inability to form attachments to it will result in defective epithelial adhesion and
consequently PEDs. In cases of recurrent corneal erosions, increased levels of MMPs have been

described,[35] which cause degradation of epithelial basement membrane as well as the anchoring
fibrils through which the epithelium attaches to the basement membrane. In epithelial basement
membrane dystrophy, there is a reduplication of epithelial basement membrane and defective
adhesion of the epithelium to its basement membrane.[58] Toxic keratopathy, from topical
anesthetics or preservatives, can be induced by poor adhesion caused by disruption of
hemidesmosomes and/or impairment of epithelial migration due to various causes such as
disruption of vinculin/actin-mediated migration and poor cellcell adhesion from topical
anesthetics or preservatives.[59,60] Several corneal degenerations including Salzmann's nodular
degeneration, corneal scarring, and band keratopathy also can cause PEDs due to defective
epithelial adhesion from absent or abnormal basement membrane.[61]
1B. LIMBAL STEM CELL DEFICIENCY
As discussed, the first step in filling in an epithelial defect involves migration of epithelial cells.
In his hypothesis, Thoft described the necessary balance between production and loss of
epithelium, however, it was not until relatively recently that the corneoscleral limbus was
identified as the site of corneal epithelial SC.[6264] After loss of limbal SC, corneal epithelium
may continue to regenerate for up to 6 months, corresponding to the time that the TACs can
continue to replenish the pool of corneal epithelium.[65] However, epithelial progenitor cells are
eventually not available to supply new TACs. As a result, defective epithelial regeneration or
PED may arise. More devastatingly, without a steady supply of corneal epithelial cells,
conjunctival epithelial cells can invade the cornea and lead to an untoward conjunctivalization of
the corneal surface, a hallmark of limbal stem cell deficiency.[65]
2. OCULAR SURFACE INFLAMMATION
Injury to the corneal epithelium sets off a cascade of events which is only partially understood.
Among this cascade, there is the release of several inflammatory cytokines, notably interleukin-1
(IL-1) and tumor necrosis factor alpha (TNF-).[66] If there is a breach in the basement
membrane, these cytokines exert their effects on subjacent keratocytes leading to several
processes. The keratocytes, in response to IL-1, produce mediators of epithelialstromal
interaction such as hepatocyte growth factor (HGF) and keratocyte growth factor (KGF).[67]
These growth factors act to control the proliferation, migration, and differentiation of the
overlying epithelial cells.[68] IL-1 released by damaged epithelial cells also promotes production
of various proteases[69] and inflammatory cell chemotactic factors[70] to help with remodeling of
the corneal stroma. As mentioned above, these proteases (including MMPs and plasminogen
activators) break down the epithelialmatrix interactions or the substrates required (FN), leading
to PED. Under normal circumstances, once the epithelium has healed and IL-1 and TNF- have
abated, the inflammatory processes will cease. However, this is not always the case under
pathological conditions. In inflammatory conditions such as rosacea, chemical burns, infectious
keratitis, and others, there is an increase in levels of various proteolytic enzymes as discussed.
[21,55]
Although multifactorial, there is mounting evidence that keratitis from dry eye syndromes is
largely due to an induced decrease in antiinflammatory cytokines and an increase in
proinflammatory cytokines (such as IL-1 and TNF-) as well as proteolytic enzymes.[66] As a
result, various inflammatory conditions may lead to PED as a result of interruption of the normal
corneal healing processes by inflammatory cytokines.

3. NEUROTROPHIC CORNEAS
It is well established that corneal innervation is necessary for normal epithelial homeostasis and
wound healing, in addition to detection of sensory input. A bidirectional control of epithelial
proliferation has been proposed with sensory neuromediators promoting epithelial mitosis and
sympathetic neuromediators reducing mitosis.[71] As a result, conditions such as diabetes mellitus
and herpes zoster ophthalmicus which lead to sensory denervation would be expected to lead to
an imbalance and potentially PEDs. After denervation, there is a decrease in production of
several constitutively expressed neuropeptides that are usually increased in wounded corneas
such as substance P, calcitonin gene-related peptide (CGRP), and several neurotrophins
(including NGF).[72] Substance P has been shown to increase epithelial adhesion to FN through
upregulation of integrin.[51] Substance P also seems to have effects on epithelial proliferation and
migration, and the effects are synergistic with EGF and IGF.[51] CGRP may also play a role in
epithelial proliferation and migration[73] but its role is less clear. NGF is a neurotrophin that has
been shown to promote recovery of nerves after injury,[74] allowing reestablishment of substance
P production. In addition, NGF appears to have direct effects on corneal epithelium by enhancing
epithelial proliferation and migration.[75] Loss of the expression of these factors can impair the
ability to heal a wounded cornea, leading to PEDs.
4. MECHANICAL IRRITATIONS
When there is persistent irritation of the ocular surface, as can be seen with abnormal lid
pathologies such as trichiasis, lid mal-positioning, blepharospasm, foreign body, or other causes
there may be an increase in epithelial turnover. In many cases, the underlying problem (such as
after zoster infection or neurosurgical intervention) and a dry or inflammatory ocular surface
(erythema multiforme, mucous membrane pemphigoid, trachoma) may cause not only eyelid
abnormality but cause a neurotrophic cornea. The mechanical factors causing epithelial trauma
may lead to focal or diffuse limbal stem cell attrition. In any case, if the increase in loss of
epithelium exceeds the ability to heal, a PED will ensue.
5. IDIOPATHIC/HEREDITARY OCULAR SURFACE DISORDERS
A vast array of hereditary or idiopathic disorders can cause delayed healing of epithelial defects
by an equally vast array of pathogeneses. For instance, PEDs in RileyDay syndrome are a
predominantly neurotrophic etiology, while corneal stromal and epithelial basement membrane
dystrophies belong to the category of aberrant epithelial adhesion due to abnormal basement
membrane and adhesion complexes. PEDs in aniridia are largely due to deficiency of limbal SC.
In general, most conditions in this category also fall into one of the above categories and can be
addressed as such.
TREATMENT FOR PED
As listed in Table 55.1, the causes of PEDs and related stromal ulceration are diverse. Ideally
each case of PED could be attributed to a defect in normal epithelial response to injury, or the
perpetuation of a pathologic response to injury as outlined above. However, our current
understanding of these conditions does not always allow us to do so. PEDs after herpetic keratitis

can de due to at least two of the listed categories, namely neurotrophic and inflammatory.
Similarly, PEDs after alkali burns can be caused by limbal deficiency or intense inflammation. In
addition, many of the conditions likely cause PEDs by disturbing multiple steps of normal
epithelial reaction to injury. Therefore, effective treatment algorithms rely on a stepwise
approach and specific targeting of underlying etiologies (Table 55.1).
Determining the etiology of a PED should begin by obtaining a thorough patient history and
performing careful examination. Previous ocular surgery, infection, and trauma are important in
establishing a diagnosis. Topical ophthalmic medications and preservatives must be considered
as potential toxins to the ocular surface, and should be discontinued if possible. Diabetes
mellitus, malnutrition (Fig. 55.1), autoimmune disorders, and other systemic ailments need to be
managed appropriately as they are often associated with delayed healing of the corneal
epithelium. Many oral medications have anticholinergic and antihistamine properties which may
disrupt the lacrimal functional unit.

FIGURE 55.1 A PED with irregular epithelial borders and without stromal infiltrate was noted
in a patient with systemic vitamin A deficiency due to chronic alcoholism. There were deep
stromal folds and corneal edema. Peripheral corneal vascularization was also noted. The PED
was refractory to antibiotics and corticosteroids. The PED and night blindness resolved after
using systemic vitamin A and nutrition supplements.

Prudent external observation of the patient may reveal a seventh nerve palsy, subtle
lagophthalmos, incomplete blinking, or blepharospasm. The eyelids should be examined for
structural abnormalities, blepharitis, rosacea, and meibomian gland dysfunction. The tarsal and
bulbar conjunctiva should be inspected for mechanical factors such as pseudomembranes or
scarring causing chronic irritation to the ocular surface. Corneal sensation should be checked
before anesthetic instillation, especially if herpes simplex or herpes zoster (Fig. 55.2) is
suspected. Finally, slit lamp biomicroscopy of the ocular surface may provide clues to the
etiology and management of the disease. Once diagnosis is obtained, appropriate targeted
treatment can be administered.

FIGURE 55.2 A central corneal epithelial defect with underlying stromal opacity was noted in
a patient after herpes zoster ophthalmicus with an anesthetic cornea. The PED was noted to
have slightly raised epithelial edges, characteristic of neurotrophic epithelial defects. The lesion

failed to respond to medical treatment and eventually required tarsorrhaphy to facilitate the
epithelial wound healing.

In addition to correcting the underlying disorder, PED is principally treated with ocular surface
lubrication. We recommend frequent use of preservative-free artificial lubricants to avoid
potential toxicity from preservatives. Patients and their caregivers should be instructed on how
and when to instill eye drops, and the physician must realize that compliance is often a problem.
Management of PED is often frustrating for the patient and challenging for the physician due to
frequent treatment failures and recurrences. Various medical and surgical options are discussed
below.
NONSURGICAL MANAGEMENT
Contact Lens
Extended-wear therapeutic contact lenses can serve as a bandage to protect the healing
epithelium from mechanical trauma from the eyelids. This treatment is very useful for PED when
palpebral conjunctival scarring or lid marginal abnormalities are present. Bandage lenses may
also protect a fragile epithelium from sloughing off, as seen in recurrent erosion disorders.
Finally bandage lenses may provide significant ocular surface comfort for the patient with PED.
Therapeutic soft contact lenses usually have to be worn for at least 2 weeks and sometimes up to
3 months to ensure healing. A lens with high oxygen permeability (Dk/L) should be chosen to
minimize potential corneal complications. An extended-wear soft contact lens should have a
Dx2k/L of at least 87 ? 109 cm2 mL O2/s mL mmHg to avoid corneal edema and
neovascularization.[76] Silicone matrix hydrogel thin lenses with high water content generally
provide the highest Dk/L. They can be changed on a weekly basis, however if the PED is not
closed they are probably best left untouched as long as they are free of mucus and debris. The
risk for corneal infection in extended versus daily wear is five times as high,[77] therefore
prophylactic topical antibiotic or frequent follow up is advisable.
Collagen shields made of porcine scleral tissue or bovine dermis were initially developed in 1984
by Fyodorov.[78] These substrates gained popularity because the collagen was able to support
corneal epithelial cell growth in culture. They are currently labeled for ocular surface protection
following surgery, but are also used for traumatic epithelial defect. Stored dry, they are usually
soaked in an antibiotic solution before being placed on the cornea much like a soft contact lens.
The advantage is that the collagen increases the bioavailability of the antibiotic (or other drug) to
the cornea. However, the collagen shield biodegrades in 12-72 h, which limits its usefulness in
chronic epithelial defects. One study showed they were not helpful in treating PED following
penetrating keratoplasty.[79]

Gas-permeable extended-wear scleral lenses have been reported to heal PED in some refractory
cases, however there is a high risk of microbial keratitis with this treatment.[80] These lenses also
require custom fitting and are difficult to insert, thereby limiting their utility in PED.
Tetracyclines
Topical and systemic tetracyclines can effectively inhibit MMPs in animal and human subjects in
a mechanism independent of their antimicrobial activity.[81] High levels of MMPs cause corneal
stromal lysis via collagen degradation and injury to the epithelial basement membrane adhesion
complexes resulting in poor epithelial adherence. MMP-9, a gelatinase in corneal epithelial cells,
has been detected at the edges of nonhealing corneal ulcers.[82] Oral doxycycline at 50 mg twice a
day has been demonstrated to inhibit MMP-9, resulting in rapid healing and preventing
recurrences of recurrent corneal erosions.[83]
Adjunctive treatment with systemic tetracycline 250 mg four times a day was shown to be
beneficial in a series of patients with PED.[84] Concomitant rosacea or meibomian gland
dysfunction should also improve with tetracycline therapy. These antibiotics should not be used
in pregnant women or children due to the risk of permanent discoloration of teeth. In adults,
common side effects are gastrointestinal irritations, photosensitivity, and mucosal yeast
infections. The typical initial dose of doxycycline for ocular rosacea is 100 mg twice a day for 46 weeks, then tapering to a maintenance dose of 50-100 mg a day. Lower doses of doxycycline
(20 mg twice a day) may be just as effective as standard dosing[85] if side effects are problematic.
Topical tetracycline can be formulated in a 1% suspension or 3% ointment for local treatment.
Antiinflammatory Agents
Caution should be exercised when using antiinflammatory therapy to inhibit migration of
inflammatory cells and limit tissue inflammation. Topical corticosteroids may have a role in PED
therapy only when there is concomitant ocular inflammation. Externally, this includes active
mucous membrane pemphigoid, peripheral ulcerative keratitis, chemical burns, and Stevens
Johnson syndrome (erythema multiforme). The use of topical corticosteroids to limit
inflammation for alkali burns remains controversial. Corticosteroids work by inhibiting
phospholipase A2, an enzyme at the beginning of the inflammatory cascade. Patients should be
warned about possible cataract and glaucoma complications. Corticosteroids should be used
judiciously with frequent follow-up, as they may increase stromal ulceration by inhibiting
collagen synthesis and cause increased risk of microbial keratitis.
Specially compounded preservative-free topical steroids, medroxyprogesterone 1% and
methylprednisolone 1% may prevent stromal lysis, but must be kept refrigerated to avoid
contamination. Medroxyprogesterone prevents stromal melting by inhibiting local collagenases
that degrade the corneal stroma, while at the same time exhibiting a mild antiinflammatory
property.[8689] Both doxycycline and corticosteroids can inhibit MMP-9. In patients with
recurrent corneal erosions unresponsive to the conventional therapy, administration of oral
doxycycline and topical corticosteroids reduces pain and heals epithelial defects within 2-10
days.[83] Methylprednisolone also provides symptomatic relief and resolution of filaments in
severe keratoconjunctivitis associated with Sj?gren syndrome.[90] These two steroid preparations

should only be considered when a PED is associated with intense surface or intraocular
inflammation.
Topical cyclosporine, mycophenolate mofetil, and tacrolimus, are available as alternative or
simultaneous antiinflammatory treatment. Cyclosporine, most commonly used, can be found
commercially (Restasis 0.05%), but higher doses can be specially compounded at a 0.5-2%
concentration used 2-4 times per day. Oral immunosuppressive therapy is required when there is
active systemic inflammatory disease such as rheumatoid arthritis, Wegener's granulomatosis,
and recalcitrant scleritis.
Serum and Fibronectin
Autologous serum drops contain neurotrophic factors which have been shown to promote healing
in PED unresponsive to conventional treatment with a success rate of 56-81%.[9193] These factors
which promote epithelial healing are thought to include EGF, fibroblastic growth factor (FGF),
NGF, FN, vitamin A, substance P, and corneal collagenase inhibitors.[91,93] The drops are easily
prepared by drawing 30-50 mL of blood from the patient and centrifuging the tube to separate
the blood components. The serum is removed in a sterile environment and mixed with balanced
salt solution to a concentration of 20% with or without antibiotics. The drops must be kept
refrigerated to avoid contamination. Umbilical cord serum, also thought to contain several of
these important epithelial promoters, may also be used. One prospective randomized controlled
clinical study demonstrated that human umbilical cord 20% serum had a faster healing rate than
autologous serum in patients with PED.[94]
FN is a glycoprotein found in serum that helps cellular adhesion and binds collagen during
wound healing. Small case series have reported success with use of topical FN for resolution of
PED.[95,96] However, a moderate-size randomized double-blinded control trial in 1995 showed
that topical FN was no better than vehicle or placebo in decreasing epithelial defect size after 21
days of treatment.[97] Due to conflicting reports regarding its efficacy, exogenous pFN is no
longer used widely for PEDs.
Lecithin-bound superoxide dismutase reduces potentially toxic free oxygen radicals produced by
neutrophils by converting superoxide radicals to hydrogen peroxide. This topical medication at a
concentration of 0.1% was shown to promote epithelial healing in chronic noninfectious
inflammatory corneal ulcers.[98]
Growth Factors
Application of growth factors to promote corneal wound healing and to treat PED or stromal
ulcers has been of major interest in ophthalmology. Although numerous growth factors have been
characterized and purified, only EGF, NGF, and IGF-1 have been investigated clinically for the
corneal epithelial wound healing.
EGF stimulates mitosis of corneal epithelial cells in vitr o and in vivo. It can also enhance
epithelial migration, stimulate wound healing, and improve stromal wound strength.[47,55,99] Both
mouse-derived EGF (mEGF) and recombinant human EGF (hEGF) have been studied

experimentally. In rabbit corneas with alkali burn, mEGF enhances epithelial wound healing;
however, it does not prevent recurrent erosions and subsequent epithelial breakdown.[100] In
humans, mEGF significantly accelerates the epithelial healing of various nondystrophic corneal
diseases.[101,102] The therapeutic effect of mEGF seems to be inversely related to the magnitude of
stromal damage. There is a significant homology between mouse and human EGF with the same
receptors and identical biologic activity for both forms.[101] In rabbit corneas after anterior
keratectomy and alkali burns, hEGF accelerates corneal reepithelialization. A double-masked
multicenter clinical trial showed that recombinant hEGF accelerated the healing of traumatic
epithelial defects when compared with control treatment.[103]
NGF is a polypeptide that is important for neuronal health and stability. A study showed that
NGF 200 g/ml for 2 weeks completely resolved a PED in 45 consecutive eyes with
neurotrophic keratitis unresponsive to other medical therapies.[104,105] Some patients in the study
had improved corneal sensitivity, suggesting that NGF restored function of injured neurons. The
exact mechanism of NGF is not well understood.
Topical administration of substance P and IGF-1 to a patient with PED results in complete
epithelial healing within 1 week with nonrecurrence in the following 8 months.[106]
SURGICAL MANAGEMENT
Punctal Occlusion
Punctal occlusion via plugs is a quick office procedure that will rapidly facilitate increased
surface hydration and decrease tear osmolarity.[107,108] Absorbable (i.e., collagen) and
nonabsorbable (i.e., silicone) plugs exist which can be placed in the lower and/or upper puncta.
Silcone plugs are most often used for dry eye syndrome, and have an 81-86% success rate of
improved subjective symptoms and decreased staining in patients.[109,110] Success was only 40%
for PED; however, there were only five patients with that diagnosis in the study.[110] The most
common complication from silicone plugs is extrusion seen 50% of the time, with even higher
rates of extrusion on second or third placement.[109,110] Other potential complications include
epiphora, subconjunctival hemorrhage, conjunctival erosion, pygogenic granuloma, and
migration into the canaliculus. If punctal plugs are found to be beneficial, the puncta may also be
permanently closed by electrocautery, thermocautery, or argon laser to avoid many of the
potential complications.
Botulinum Toxin
Injection of a small amount of botulinum toxin (5-10 units) into the upper eyelid to paralyze the
levator muscle is an effective approach in some patients with PED from exposure keratopathy.[111]
The neurotoxin works by inhibiting the release of acetylcholine at the neuromuscular junction to
induce clinical paralysis for 3 months. This is not the procedure of choice for a monocular
patient as the induced ptosis will obstruct the visual axis or for younger children with
amblyogenic potential. Persistent blepharospasm, which can also cause PED, can be relieved by
botulinum toxin injection into the obicularis oculi muscle.
Tarsorrhaphy

Partial or complete tarsorrhapy is a low-risk surgical option for PED. It has been shown to be
very beneficial in postkeratoplasy patients[112] and is useful in cases of chronic neurotrophic and
neuroparalytic keratitis. Noncompliant and debilitated patients who cannot reliably put in
therapeutic topical medications perhaps profit from this intervention the most. Techniques vary,
but care must be taken to avoid suture chafing the cornea epithelium and iatrogenic trichiasis
when a temporary or permanent tarsorrhaphy is constructed. One small randomized prospective
study showed there was no statistical difference in epithelialization between lateral tarsorrhaphy
and amniotic membrane transplantation for PED.[113]
Amniotic Membrane
The preserved amniotic membrane is nonantigenic, and is composed of a single epithelial cell
layer, a basement membrane, and an avascular stroma. The thick basement membrane is very
similar to the epithelial basement membrane and acts as a matrix substrate for epithelial adhesion
and migration. Several series of reports have shown that amniotic membrane transplantation
(AMT) can be a successful surgical treatment for PED refractory to medical treatment.[114117]
Typically, the fresh or frozen amniotic tissue is grafted with stromal side down over the PED
with 10-0 nylon suture or fibrin adhesive glue (Tisseal glue). For PED with stromal thinning or
minute perforation, multilayer amniotic membrane grafting can be performed.[118] In this
procedure, the membrane is cut into several pieces and layered on top of each other or folded in
multiple layers, to match the ulcer bed. Only the top layer is sutured to the host. Often a lateral
tarsorrhaphy is performed simultaneously or a bandage soft contact lens is used until complete
reepithelialization.
The amniotic membrane can also be used as a patch, in which the basement membrane side is
oriented down.[119] This technique may be useful for PED without ulceration, as the membrane
consistently dissolves or is easily removed after epithelialization. Amniotic membrane patching
may permit better visual clarity compared to grafting.
Successful epithelialization with AMT has ranged from 73% to 82% in these obstinate cases of
PED.[113,115,119] The tissue works because the basement membrane acts as a scaffold to support
epithelial adhesion, growth, and differentiation.[120,121] The amniotic membrane suppresses TGF-
signaling and may release important epithelial growth factors as well.[122] In addition, the
avascular stroma contains various protease inhibitors which reduce ocular surface inflammation
and vascularization, and may restore corneal stromal thickness when ulceration is concomitantly
present.
Conjunctival Flap
While cosmesis may be superior with AMT due to increased clarity and reduction of
vascularization, partial or full (Gundersen flap) conjunctival autografting is another surgical
option for PED.[123126] A thin free or rotational conjunctival flap without Tenon's capsule is
dissected. Meticulous care must be taken not to buttonhole the harvested graft. The remaining
corneal epithelium must be removed entirely to prevent postoperative cyst formation. The flap is
sutured over the defect. The most common complication (11%) is conjunctival retraction
requiring surgical revision.[126] This procedure should not be considered in patients with active

conjunctival disease, with functioning filtering bleb, or if future glaucoma filtering surgery is
planned.
Cyanoacrylate Glue
As discussed, stromal ulceration, descemetocele, and perforation may accompany a chronic
PED. Tissue adhesive (cyanoacrylate glue) application to the thinned or perforated cornea
frequently negates the need for emergency tectonic corneal transplantation. The glue will
polymerize immediately upon contact with water, so care must be taken to distribute the glue
evenly in the desired area while at the slit lamp or under operating microscope. A bandage soft
contact lens is placed over the glue patch for patient comfort (Fig. 55.3). The glue may induce
stromal neovascularization, which will help prevent further ulceration.[127] The glue will extrude
or can be removed once epithelialization occurs, and optical corneal transplantation can be
considered.
Phototherapeutic Keratectomy
As in treatment for recurrent erosions, the excimer laser may be effective in surgically managing
PEDs unresponsive to conventional treatment by laser ablation of the basement membrane and
superficial Bowman's layer.[128,129] The exact mechanism by which phototherapeutic keratectomy
(PTK) exerts its effect remains unclear; however, it probably modifies the basement membrane
and Bowman's layer to facilitate stronger cell anchorage.[128] In a randomized prospective trial
comparing epithelial removal only with epithelial removal followed by excimer laser ablation,
those patients undergoing PTK had fewer recurrences and better symptomatic relief.[130] Instead
of LASIK, PTK is the preferred procedure for patients with recurrent corneal erosions or corneal
stromal dystrophies, since the treatment may correct the refractive error and epithelial
pathologies simultaneously.
In summary, treatment failure or recurrence of PED may occur after enduring effort with these
medical and surgical therapies. An intact healthy epithelial layer is crucial in preventing ocular
infection and progressive stromal ulceration. It is also vital for the survival of optical corneal
transplantation. Limbal stem cell deficiency may be the underlying pathology present in these
refractory cases; if so, stem cell transplantation should be considered. The above treatment
strategies can be employed while nurturing the grafted tissue. Keratoprosthetic surgery may also
be considered in chronic ocular surface disease that is nonrespondent to transplantation.

1.3
Clinical Results
Serum eyedrops have predominantly been used
for persistent epithelial defects and severe dry
eye, but also as a supportive measure in ocular
surface reconstruction and for a number of
other indications.

1.3.1
Persistent Epithelial Defects
A persistent epithelial defect (PED) is defined as
a defect of the corneal epithelium that in the
absence of microbial keratitis fails to heal
within the expected time course (e.g. 2 weeks)
despite topical lubricants [26, 50]. A PED can
occur as a result of many different pathologies,
including rheumatoid arthritis, neurotrophic
keratopathy or dry eye [8]. Success of treatment
is best defined as percentage of defects
healed in a given time or as total time to complete
epithelial wound closure.
1.3.1.1
Currently Available Published Data
In five prospective case series, 20% serum
diluted in 0.9 % saline has been used 514 times
daily for this indication (Table 1.2). In 1999
Tsubota was the first to report a series of 16 eyes
(15 patients) in whom the PEDs had persisted
despite medical treatment with lubricants
or bandage contact lenses for a mean of
7.29.4months. Ten out of these 16 defects
healed completely within 4 weeks after initiation
of therapy [11, 46].Garcia-Jimenez reported
complete epithelial wound healing in 6 of 11 eyes
with persistent epithelial defects with healing
beginning within 34 weeks of treatment with
serum eyedrops [1, 52]. In a group of 9 patients
with predominantly diabetic or postherpetic
neurotrophic keratitis, all 12 epithelial defects
healed within 15.87.9 days and this was associated
in 9 eyes with an improvement of corneal
sensitivity [27] (Fig. 1.3).
A different concentration of serum was used
in two other studies. Poon et al. substituted
unpreserved pharmaceutical lubricants with
50100% serum eyedrops and observed closure
of a PED with a mean duration of 7.55.8
(124) weeks in 9 of 15 eyes after 3.62.5 weeks
(3 days8 weeks) [33]. De Souza et al. treated 70
epithelial defects with undiluted serum hourly
in addition to routine medication, 45 of which
had occurred early after penetrating keratoplasty
[8] and had persisted for a mean of
1517 days. Eighty-one percent of these defects

with a relative short history healed within

1412 days.
Healing generally starts within 2 weeks after
initiation of the serum therapy [33]. So far no
study has been able to show a correlation between
size or localisation of the defect with success
or failure, but the older and deeper stromal
defects tended to heal less successfully. Also,
when serum eyedrops are changed back to
pharmaceutical lubricants the epithelial defects
may recur, as happened in 6 out of the 9 eyes in
Poons and 9 out of 70 eyes in De Souzas group.
These figures are difficult to compare since
none of the studies was placebo controlled and
the study population seems to differ significantly
in terms of underlying pathogenesis and
duration of the PED.
Summary for the Clinician
Pathogenic factors that can be avoided or
treated, such as toxicity due to preserved
eyedrops, steroids or active herpetic keratitis,
should be ruled out before a PED is
treated with serum eyedrops
1.3 Clinical Results 9
Table 1.2. Clinical studies using serum eyedrops to treat persistent epithelial defects. The
production parameters
and results are given. Success is defined as percentage of eyes/patients with complete
epithelialisation.
Note that the scale used to measure these changes as well as the baseline level varied between
the studies (NA,
not applicable; NR, not reported; rpm, revelations per minute)