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How common for astigmatism to increase after cataract surgery?

I am an avid follower of this community and of Dr Hagan’s responses. I searched for an answer to my question but did not find anything recent. I believe Dr Hagan is not a believer in toric IOLs, and perhaps I understand a bit more now. I am 75 years old, and had cataract surgery 5 years ago and had Symphony toric IOLs implanted. I was very happy, having been -12 myopic and 2.5 D of astigmatism before IOLs. I still have good near, mid and far vision but seemingly my astigmatism has increased from OD .75D, OS .5D  just after the cataract surgery to OD 1.75D. OS 1.25D presently. I do not wear glasses for anything.(Part of the increase in the right eye, I believe, is due to a scratched cornea directly in front of the pupil.) Perhaps, Dr Hagan, is this one reason why you do not recommend toric IOLs? Because astigmatism will sometimes or often change and/or increase with a person’s age after IOL implant, making the toric lens less than a perfect solution? So my questions are these: Are changes to astigmatism common after cataract surgery, just as they might be for anyone with aging? Is laser surgery an option assuming my cornea is thick enough (which I believe it is (650ish)?  If laser surgery is an option, and assuming it corrects the increased astigmatism, is it possible/probable that my astigmatism might continue to worsen after the laser treatment, if the laser treatment is successful?  If there are any studies on this topic on the web, I would be most grateful for a link to them. Many thanks, in advance, Dr Hagan.
PS: I know a simple option would be to have glasses made just to correct the astigmatism and keep them handy for driving (or looking at the stars).
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177275 tn?1511755244
Hello Jim in Pastaland.    First you have misinterpreted my opinion.  I am NOT against toric IOLs and regularly recommend them for people with cornea astigmatism over 1 diopter that would like the best possible vision without glasses. The cost is reasonable and in our practice with very experienced surgeons the need for a second procedure to re-align the toric IOL is 1% or less.  Several of my best friends have had torics and are happy.       Now your case is unusual. I dobut the cornea abrasion is a big deal as there is only 0.5 diopter difference in the two eyes.  Your surgeon, whom I hope is also a cornea/refractive specialist with extra fellowship training. Should be able to do a cornea topography and see if there is any significant central irregular astigmatism in the RE.    You have developed about 1 diopter of astigmatism in each eye from the last post op visit (usually about 4-5 weeks post op)  again very unusual if small incision, no stitch surgery was used. If you had large incision or had stitches then that would be the usual cause.    Let me assume you had small incision, no stitch surgery.   MOST COMMON reason for your problem toric IOL has rotated.  There is a way an experienced cornea/refractive surgeon could determine the problem.   1. do a careful refraction.  2. do careful measurement of corneal astigmatism with a keratometer.     If the glasses RX and Cornea RX agree (same) the problem is on the cornea and  femtosecond laser cornea surgery might be very helpful.   If the cornea astigmatism does not agree with the glasses RX then it is IOL induced astigmatism.  It might be difficult to rotate the toric IOL with a second surgical procedure. That would be up to the surgeon.   So you need to determine if this is CORNEA ASTIGMATISM or  PSEUDOPHAKIC (IOL) ASTIGMATISM.  You should probably get several opinions about your option. If you stick with the original surgeon you might ask for a discount due to having to have the extra procedure.
11 Comments
Dear Dr. Hagan, so many thanks again for taking the time to elaborate with such a comprehensive answer. here in “Pastaland”, we are still operating under a near total “lockdown”. My IOL surgeon is in Vienna (Dr Findl); the best ophthalmologist in the area is unavailable to me 20 km away. But I am fortunate to have a visiting doctor who comes to our town of Todi once a week.

As I wrote, I was left with a little residual astigmatism from my IOL surgery 5 years ago, multifocal lenses by the way. (Yes, you assumed correctly: small incision, no stitch). I have lived with that with no problems, though I am sorry to always have a halo around the beautiful super moons, of which we have just yesterday seen the third this year. The RE corneal abrasion TWO MONTHS AGO has definitely increased the RE blurriness and that has prompted my investigation into possible laser surgery “down the line” if we ever return to normalcy.

When I visited the local doctor a few days ago, and sat meters from the eye chart, he determined using the different lenses in the “eye glasses” instrument, that I could see BETTER than 20/20 with a prescription to correct the 1.75 / 1.25 astigmatism.  Nothing needed for myopia. IS THIS THE “CAREFUL REFRACTION” that you mentioned above?

DOES THAT PROVIDE ANY INDICATION THAT THIS IS CORNEA ASTIGMATISM RATHER THAN IOL ASTIGMATISM?  of course, as you suggest, i will have the  keratotomy done in a months time.

If I am not taxing your patience, may I also ask:

Can laser surgery correct IOL rotation-induced astigmatism? I will not have surgery to rotate the IOL

You mentioned twice above that my case is unusual. Is that because  you would not expect astigmatism to increase EXCEPT for IOL rotation?

After  femtosecond laser surgery to correct astigmatism, might the cornea continue to change resulting in some astigmatism? Or is the cornea “stable” at some point? Restating: is it “normal” in older people to see astigmatism increase regardless of IOL surgery?

As stated above, Dr Hagan, if there is any study/document that relates to my questions, I would be most grateful to be directed to it.

many thanks.



If you were able to be glasses tested (refracted) to 20/20 or better in both eyes   a. you don't have any major eye pathology b. the central cornea in your RE does not have significant irregular astigmatism or your vision would not be 20/20 glasses don't correct irregular astigmatism.  

If your surgery was 5 years ago  1. it unusual for toric IOL to rotate after 6 months  2. It is unusual for the eye to develop 1 diopter of astigmatism following small incision no stitch surgery after 6 months.

It still would be useful to ask the doctor locally that did the glasses test if the astigmatism in your glasses RX is the same as your cornea astigmatism as measured with a keratometer. If it is then it is ALL corneal astigmatism and the femtosecond laser should be able to completely eliminate it.  Both LASIK and femtosecond always change the cornea shape, that is why the surgery is being done.

I  don't have the time to direct you to any study, you have good internet skills. You can use Google or PubMed to search for articles.

Small incision cataract surgery done temporally (out towards ear)  generally will decrease "against the rule' astigmatism by about 0.5 diopter or increase with the rule astimatism by same amount.   That is why some surgeons try and place the incision "in the steep axis".
Dear Dr Hagan, once again, so many heart-felt thanks for your guidance and information. You are an incredibly helpful resource. Stay safe !!
PS: I will have the astigmatism checked with a keratometer when the lock-down here ends in June, most likely. In older folks, prone to astigmatism as I was,  does the cornea continue to change increasing astigmatism throughout one’s lifetime?
PSS: I don’t know where you find the time to respond to all of our questions !!!!
Dr. Hagan, thanks for your referring me to PubMed. I went directly to it instead of my normal Google search. I immediately found this:
J Refract Surg
. 2017 Oct 1;33(10):696-703.  doi: 10.3928/1081597X-20170718-04.
Age-Related Changes in Corneal Astigmatism

Xu Shao, Kai-Jing Zhou, An-Peng Pan, Xue-Ying Cheng, He-Xie Cai, Jin-Hai Huang, A-Yong Yu
PMID: 28991338  DOI: 10.3928/1081597X-20170718-04
Abstract

Purpose: To analyze the changes in corneal astigmatism as a function of age and develop a novel model to estimate corneal astigmatic change according to age.

Results: Two turning points of age on total corneal astigmatism were 36 and 69 years. The average change of total corneal astigmatism toward against-the-rule astigmatism was 0.13 diopters (D)/10 years from 18 to 35 years, 0.45 D/10 years from 36 to 68 years, and decreased after 69 years, mainly caused by anterior corneal astigmatism.
Right now I have lots of time as only this past week returned seeing patients.  IF ANYONE BESIDES JIM READS THIS DO NOT NEGLECT YOUR GENERAL HEALTH AND VISION OUT OF UNWARRANTED FEAR OF COVID-19.  OUR PRACTICE HAS HAD MANY CASES OF PERMANENT LOSS OF VISION AND FEW OF TOTAL BLINDNESS FROM NOT COMING IN TO HAVE CHANGES IN VISION CHECKED.  ALSO MY FRIENDS IN GENERAL MEDICINE ARE SEEING HEART ATTACKS, STROKES, DIABETICS OUT OF CONTROL, ETC.  GET BACK INTO THE SYSTEM.  PHYSICIAN OFFICES, CLINICS AND HOSPITALS ARE OPENING BACK UP TAKING REASONABLE PRECAUTIONS.
Dear Dr. Hagan, I have read and re-read your May 8 posting. A week ago, I had a follow-up with my local ophthalmologist and we did a thorough eye exam with the eye chart and with  a keratometer, as you suggested. . I was pleased to note that the prescription was the same.  So, as you have written, “it is all corneal astigmatism and femtosecond laser should be able to completely eliminate it.”  That was good news. And there was no corneal scarring in the RE from the corneal scratch in front of the pupil.

But unfortunately it doesn't explain why I have developed so much astigmatism in both eyes following the 2015 cataract surgery. Then I had none in the right eye, and -.025 in the left.  Could OSD be playing a role?

TWO years ago, following YAG laser to correct PCO, my prescription was;
RE -0.25 -0.75 x140 20/25
LE -0.75  -0.50 x85 20/20
So, I have just noted that some astigmatism was developing then, but I could live with that, so did not pay any attention. (Having been -12D myopic, the IOLs were a real gift!).

The correction i mentioned above of a week ago was
RE  -0.25 -1.75 x 110
LE -0.50 -1.50 x 80
And this gave me 20/20 vision (or even better)

BUT, I was told I had “against the rule astigmatism” which I assume is that same as “irregular” astigmatism and I noted that you said “glasses do not correct irregular astigmatism “.  So I am confused about this.  Could you comment perhaps?

I was/am considering glasses for the moment to correct the astigmatism especially in the RE. I went to my optician and discussed correcting just the astigmatism or having graduated lenses, the latter costing 4 times as much. When the optician corrected for the astigmatism alone, and showed me the reading test, I no longer could see to read  AS I CAN NOW without glasses. Now, I can easily read “smallish” print though there is of course a RE blur because of the astigmatism.

I asked WHY? And was told because I have “myopic astigmatism “ (which I have never heard mentioned) and correcting the astigmatism, he said, makes it impossible to read without an “add”.
Does this seem reasonable, Dr Hagan? After my cataract surgery, with little or no astigmatism, I COULD read, but now, correcting the “residual” or “developing” astigmatism, I lose the reading capability???

(I did not think to ask the ophthalmologist about this, nor did I try reading in his office when he corrected me with the eye chart)

Finally, when our Italian hospitals open for “normal business” , I plan on having a corneal topography which hopefully will shed a bit more light on all that I have written.

Thank you, Dr. Hagan. As always, your excellent counsel is very much appreciated.  STAY SAFE !
1. Against the rule astimatism means the steepest axis is horizontal (towards the ear).   Generally the standard small incision cataract surgery is placed horizontally (180 degrees) and decreases ATR astimatism.  The other is that normal ageing changes generally means that there is less steepening at 90 degree (reduction of with the rule) and increase of against the rule.  So could be just ageing change.    Look up the formula for finding the "spherical equivalent" of a glasses RX.  If it is myopic then vision at near is better if it is hyperopic it is at distance.  Your spherical equivalent is about -1.00 in both eyes so without glasses at certain distances your vision should be quite good. If you have a pupil that closes very small in good light you should be able to read without glasses.
Many thanks.  Hope you have stayed well and are resuming normal practice.  
I am well, practice much better but not back to normal. What is?
Dear Dr. Hagan, I hope this finds you and family safe and healthy and that your practice has returned to near-normal. I add my heartfelt thanks to those recently expressed by the lady in France who wrote you the long responses.

I have read and re-read all of our correspondences above for which I am most grateful.  I cannot believe that in all my messaging I neglected to mention that in January 2018 (2.5 years after the cataract surgery) I was diagnosed with glaucoma and have been on different meds ever since. Presently I am on latanoprost with average IOP around 14-16 (and I have higher than normal corneal thickness, approaching 600 um.)

Recently I listened to a webinar hosted by the Glaucoma Research Foundation in which Dr David Richardson from San Marino CA gave a lecture on “what’s new Glaucoma meds”.  I asked a follow-up question to him about whether meds could cause changes to the cornea shape resulting In astigmatism. (This has been the central question I put to you, when I asked Why has my astigmatism increased post-cataract surgery. How stupid of me not to have mentioned my glaucoma condition!)

Unfortunately, after my glaucoma diagnosis in January 2018, i did not have any refraction done - since I was pleased with my vision acuity. Therefore I have no way of knowing when astigmatism started to increase, be it with the start of glaucoma meds or sometime earlier or soon after.

Dr Richardson replied to me.  (He is like you, extremely generous with his time and shows utmost patience as do you.). He mentioned, as you did, about ATR astigmatism increasing with age. But he also mentioned something I had not heard about before: “prostaglandin associated periorbitopathy “ or PAP, a syndrome in which the eyelids “tighten” around the eye.  He went on to add that PAP is partially reversible in most patients with discontinuation of the prostaglandin analog, latanoprost in my case.

Again, my apologies for not having mentioned my glaucoma condition to you before, a huge oversight. If I haven’t already taxed your patience, I would be very appreciative to have YOUR thoughts on the PAP connection to astigmatism, since I have shared with you so much of my history. Have you encountered this in your practice?

Thank you, Dr Hagan. Stay well and safe
Kind regards
Jim in Pastaland as you say.  BTW, Italy is doing very well with controlling the coronavirus, though economically many Italian friends here are still suffering.
Avatar universal
PS: Dr Hagan, I have read a few informative articles about cosmetic changes to the eyelids and possibly sunken eyes. But I have not found a linkage between PAP and resulting astigmatism.
2 Comments
Sorry, please define PAP and  what cosmetic changes to eyelids you are talking about.
Sorry, Dr. Hagan, did you perhaps see my post ABOVE the PS comment where i described the PAP condition?
Avatar universal
PAP prostaglandin associated periorbitopathy “  I am more curious about the eyelid tightening aspect than the cosmetic side effect

https://www.eyeworld.org/article-put-a-lid-on-it

PAP: New Concerns for Prostaglandin Use by Stanley Berke, Review of Ophthalmology October 2012
11 Comments
That is an old paper. It has been known for decades that certain eyelid problems can cause astigmatism such as tumors or chalazia of the eyelids. I don't recall anyone ever implicating prostaglandin use as causing astigmatism.  I would think it extremely rare as prostaglandins are the most widely used glaucoma medications in the world. It is known that prostaglandins especially lumigan can cause atrophy of orbital fat, sunken eyes and dark rings around the eye.
Grazie
De nada
Dear Dr Hagan, I do hope you are still following this thread. And thank you for your diligence and patience, if you are. This is a follow-up to our June 22 exchange, recapping details in one place.

The subject of my original question was to understand increasing astigmatism after cataract surgery (5 years ago). My interest was triggered by a corneal abrasion on the pupil, and I became aware of a blurriness/slight double image similar to what one expects with astigmatism. As it turns out, thanks to what you wrote, i have confirmed that I have no permanent damage from the abrasion. Seemingly,  this blurriness has been with with me for a few years and increasing. I just haven’t paid much attention to it since I was a high myope (-12D) before the cataract surgery, and everything since has been a blessing without needing glasses. I do not NEED glasses for anything, not reading or distance, although I am aware of that “astigmatic” blurriness, especially at distance and  especially at night looking at the stars, for example.

Finally here in Italy, after the lockdown for 4 months, I was able to have a corneal topography. And that is what I wish to share with you to understand HOPEFULLY the difference between “anatomical” astigmatism and ” refractive” astigmatism (terms I was told here by doctors).

In a nutshell, I was told that my anatomical astigmatism was/ is WTR while my refractive astigmatism is myopic and ATR. Back in 2015, before the cataract surgery, one OCULUS topography showed OD 2.1D and OS 2.2D. Another ORBSCAN gave results OD -2.5 D and OD -2.2 D. To put this in perspective, the July topography here in Italy gave results:
OD 2.7D and OS 2.4D. My ophthalmologist explained that this increase over 5 years is not that significant. BUT,  to correct the astigmatism I now have, which I am told is ATR, I need glasses (which I have had made) and the RX is:
OD +2.25 -1.75 (110)
OS +2.25 -1.0 (85)
(The add for reading, I was told, is necessary because to correct only astigmatism would make reading more difficult, and indeed “in the chair” with MR, that seemed correct.) With these glasses, one for reading and one for distance without the add, I see amazingly clearly. No blurriness.

Some history if it might help:
Back in 2015 after the surgery:
VISUS S.C, OD 1.5; OS 0.9 -1.0 pm
Bin Vis Distance 1.5; near 0.8
VISUS C.C:  OD none; OS: 0.75 +0.50 x 180 VISUS 1.2
(I was under-corrected in OS for monovision)

Also back in 2015, when I went for a data point with a Rome ophthalmologist,
Using a NIDEK topography, the exam showed:
OD  +0.75 0.00 x0
OS    +0.50 -0.50 x 61
A “suggestive” (soggettivo) refraction showed a need for RX OS -0.25 -0.50 x90; VISUS10/10

Back in 2018, some 3 years after the cataract surgery when I had YAG laser for PCO, the VISUS C.C MR Dry was:
OD -0.25 -0.75 x 140 Dist 20/25 J2 (I question this axis reading)
OS -0.75  -0.50 x 085        20/20 J3

Repeating from what I wrote above, RX today
OD +2.25 -1.75 (110)
OS +2.25 -1.0 (85)

So, if i haven't lost you to here, you are a very patient human being. My question, kindly: could you explain what has happened, that I still have modest increase in WTR anatomical astigmatism, while I have developed “from nowhere” this ATR astigmatism?

Back in June 22, you wrote “ The other is that normal ageing changes generally means that there is less steepening at 90 degree (reduction of with the rule) and increase of against the rule.  So could be just aging change.“

Do you think that is what has happened? Is it not more than “normal”? And. Most importantly, is it likely to increase? (I am probably not a candidate for LASIK because of OSD and my age.)

Many thanks, Dr Hagan, for your time and trouble to respond.

Okay,  astigmatism means aspherical.  In the eye prior to surgery (phakic) eye the astigmatism usually comes from the cornea.  We usually call this corneal astigmatism but your surgeons are calling anatomic astigmatism.  This is where most or all of the astigmatism comes from before surgery.  In some people the natural lens of the eye, especially as it develops cataracts can cause astigmatism. We usually call this 'lenticular (lens)" astigmatism.   I don't know what your surgeons call it.  After surgery the amount of cornea astigmatism can change usually not a lot but sometimes considerably.  There is usually flattening or less in the axis of the incision. The smaller the incision the less the change. That is why over the past 3 decades as we have moved to smaller and smaller incisions the amount has become less and less.   After an intraocular lens (IOL) is put in the eye the IOL can cause astigmatism especially if it is dislocated, rotated, not in the capsular bag or torqued.  This is often referred to as pseudophakic (IOL) astigmatism. Your surgeon is calling it refractive astigmatism, I don't have a problem with that.   Refractive astigmatism is often more of a problem with toric/multifocal/accommodating/trifocal IOLs.

In any case with small incision surgery and an IOL that is secure in its fixation the amount of anatomic or refractive astigmatism should not change much.   Given your history it might be best to just accept your present situation and wear glasses since that clears things up.    Cornea refractive surgery generally only corrects anatomic astigmatism and would not affect refractive astigmatism. To try and parse out how much is refractive and how much anatomic is difficult. To do surgery on the cornea and try and correct both is extremely difficult.   At this this point the risk benefit favors just wear glasses when you want to see as clear as possible and that it is NOT likely that either type of astigmatism will change very much.
Thank you most sincerely Dr  Hagan for your thorough explanation. I agree completely to be thankful for the vision the IOLs have given me and not to take a chance on further surgery.  Since I was part of a study group with the Symfony IOLs,  I will write to my Vienna surgeon and let him know of these developments. I would think he would want to know, especially if there are more cases such as mine.  let me know if COVID ever allows you and Mrs H to travel to Italy. You would be my guest here in Umbria. Stay well.
Thank you.  Yes it would be important to report this to your surgeon especially if in study group.   Some complications don't show up until after study over, important to document them.
Dear Dr Hagan, it has been a while since you and I communicated. I sincerely hope that you and Mrs H are well and COVID hasnt found its way into your family and community. Before posting this, I reread  your detailed last response and was again struck by the sincerity and thoroughness of your answer. Thank you again,  (you might skim it before responding to my next question.)

I have always thought i had Dry Eye OSD because of night time/waking discomfort. (Not during the day!) For background, I have sleep apnea, blepharitis (which I cannot cure), bradycardia, nocturia,  of course IOL implants (Symphony toric), and glaucoma for which I use latanoprost in the evenings.I have tried (like most OSD sufferers) all types of over-the-counter drops. None helps. Restasis too expensive here in Italy.

By chance, I asked a question on DRY EYE FORUM and learned for first time of ABMD. (My BAD for not learning of this before!) That was never mentioned to me by docs here in Italy. My symptoms are classic EBMD / ABMD / Map-dot-fingerprint Dystrophy:  Blurry vision, (which I associated as you will see In above postings with residual astigmatism) acute pain in the morning lessening during day, foreign body sensation and conjunctivitis (which I associated with blepharitis and continual use of preservative-free latanoprost eye drops.

Since eye glasses DO correct my vision to around  20/25 ish, I am assuming that  blurriness is largely due to corneal or refractive astigmatism as you document thoroughly above,  But I am anxious to address the ABMD because of the severe pain, and I mean severe, when I try to open my eyes maybe once or twice a week upon wakening (or during the night when I have to go to the bathroom).

I would like to ask your expert opinion on the following, if I may:

is it possible that ABMD has gone undetected in spite of semiannual visits to doctors here for IOP checks-up?  I have asked repeatedly about dry eye meds and have mentioned my symptoms .  I don’t recall if they have done a recent corneal topography but I will ask for one on my next appt in April. (COVID makes these appts difficult in Italy)

Would you recommend I start with topical antibiotic drops or ointments ? If so, which one?  I have used Erythromycin in the past

I have read that hypertonic eye solutions are often a first step and B&L Muro 128 is most often mentioned. I have found two generic 5% sodium chloride solutions in Italy which I have ordered. They are drops not ointments  like Muro 128, and I would have preferred an ointment/gel for nighttime use, but I will start with the drops. DO YOU HAVE OTHER RECOMMENDATIONS?  Is a gel truly much better for nighttime use? Could I add another “simple”  gel with lanolin and white petrolatum Such as  Refresh PM to use with my 5% drop to get the benefit of an ointment?

Your suggestions for my further investigation on ABMD? As you once noted, I do a lot of internet searches.

I doubt that I will immediately consider surgical approaches like superficial keratectomy or PTK, for a multitude of reasons including my age (75) and COVID ,

Finally, i wonder if a moisture mask at night to treat dry eye (which I was considering before learning about ABMD) might actually worsen the ABMD condition. The mask wants to add moisture but hypertonic solutions, as I understand, DRAW OUT THE WATER in  the epithelium.  Do these two “treatments” counteract each other?

Dr Hagan, if you have managed to read this far, I commend you for your patience and diligence, as always.  Would you suggest I start a new thread with ABMD or EBMD in the subject box?

Kind regards
Jim in “pasta land”

Hello Jim.  I didn't know you were having trouble.   Right now this discussion is not too long and is only you posting.  So we can continue this on.   I'm going to make a long post which is based on other posts about Basement Membrane Disorder (BMD)  other names Cogan Dystrophy,  Map-Dot-Fingerprint.  
1. Read the post below.  2. I'll make some comments to you in a third post.  JHaganMD
PREVIOUS
You have "recurrent corneal erosion syndrome". The condition is common and will not destroy your sight or cause serious loss of vision. It has been discussed in the past in the eye care forums. It usually starts after a scratched cornea that does not heal properly. In some instances, it occurs due to a common disease of the outer layer of the cornea (basement membrane disorder). Use the search feature and type in "corneal erosions".
Problem is more common in people with sleep apnea especially full face masks, can occur with smaller ‘pillow’ type CPAP.  More common in those having eyelid surgery, or facial paralysis (stroke, Bell’s Palsy),  eyelid that falls away from the eye (ectropion).

Here is part of a recent post on the problem:

Recurrent corneal erosions are the bane of the practice of ophthalmology for both the ophthalmologist (Eye MD) and the poor patient. I saw 2 of them in the office today. They can be very difficult and recalcitrant to treat. Not infrequently they are controlled with drops and ointments but reoccur if these medications are stopped. I'm sure you're well versed on the medical and preventive treatment of corneal erosions.

Treatment is to avoid anything that dries the eye. So keep it moist with artificial tears. At bedtime a lubricating drop with normal saline (Muro 128 ointment---available over the counter) is put in the eye.  Extreme care must be used in the morning on awakening as this is when the tissue usually tears. Avoid rubbing the eye. If the eye wants to stay shut from the ointment leave it shut, splash with warm water till it opens then put in an artificial tear or Muro 128 DROPS (available as 2% or 5% [which often stings] also available over the counter. If Muro 128 products are irritation try Refresh-PM ointment at bedtime and a good artificial tear on awakening and several times during the day (Systane, Opteve, Soothe, Refresh, Tears Naturale, etc).

Do not sleep under a fan or with a fan running in the bedroom. If have sleep apnea. Smaller devices better (‘pillows’) but sure settings are proper for you. During winter months your home especially, your bedroom should be humified and you should measure the moisture in the bedroom with an inexpensive relative humidity device like the one below. If you do not have a furnace humidifier you may need to buy a room humidifier for your bedroom.

Keep bedroom humidity in “best” or “comfort” zone. The figure above is too dry.

Long plane and car trips are very stressing for corneal erosions. In the car, run the air conditioner or heater on the feet vents not into the face. Put artificial tears in the eye every couple of hours on a car trip and every hour on a plane trip.

You should go a minimum of 4 months without any pain from the erosion (usually during sleep or upon wakening) before trying to stop the ointment. Be aware that some people are never able to stop the medications and must use drops, ointments and precautions indefinitely (years and years).

The next step is often corneal stromal micro-punctures. This is an office procedure done with just eye drop anesthesia; a bandage contact lens is put in the eye for several days. You may return to normal physical activities immediately.  

If the problem persists then you may need to discuss these treatments with your ophthalmologist. He/she should be able to do the first method. The second he/she may or may not be able to do, sometimes referral to a cornea specialist is indicated.

1. There is a new method of treatment when all else fails. It involves taking oral tetracycline for a couple of weeks coupled with steroid eye drops. If your ophthalmologist is not familiar with the method he/she can do a literature search of the medical ophthalmology journals. The first time I read of it was in the journal "Ophthalmology". I have used this method on two patients that were "at their wits end and had tried everything else. In both cases it worked. I still have them use an ointment at bedtime such as Muro 128 or Genteal Gel but the severe pain has stopped.

2. The last technique would be to use the eximer laser to "resurface" the corneal epithelium and soft contact lens wear during the healing. This technique is most often used when the cornea has disease that keeps causing the erosions, the most common of these is corneal epithelial basement membrane disorder.

Keep trying and good luck.
You have "recurrent corneal erosion syndrome". The condition is common and will not destroy your sight or cause serious loss of vision. It has been discussed in the past in the eye care forums. It usually starts after a scratched cornea that does not heal properly. In some instances, it occurs due to a common disease of the outer layer of the cornea (basement membrane disorder). Use the search feature and type in "corneal erosions".
Problem is more common in people with sleep apnea especially full face masks, can occur with smaller ‘pillow’ type CPAP.  More common in those having eyelid surgery, or facial paralysis (stroke, Bell’s Palsy),  eyelid that falls away from the eye (ectropion).

Here is part of a recent post on the problem:

Recurrent corneal erosions are the bane of the practice of ophthalmology for both the ophthalmologist (Eye MD) and the poor patient. I saw 2 of them in the office today. They can be very difficult and recalcitrant to treat. Not infrequently they are controlled with drops and ointments but reoccur if these medications are stopped. I'm sure you're well versed on the medical and preventive treatment of corneal erosions.

Treatment is to avoid anything that dries the eye. So keep it moist with artificial tears. At bedtime a lubricating drop with normal saline (Muro 128 ointment---available over the counter) is put in the eye.  Extreme care must be used in the morning on awakening as this is when the tissue usually tears. Avoid rubbing the eye. If the eye wants to stay shut from the ointment leave it shut, splash with warm water till it opens then put in an artificial tear or Muro 128 DROPS (available as 2% or 5% [which often stings] also available over the counter. If Muro 128 products are irritation try Refresh-PM ointment at bedtime and a good artificial tear on awakening and several times during the day (Systane, Opteve, Soothe, Refresh, Tears Naturale, etc).

Do not sleep under a fan or with a fan running in the bedroom. If have sleep apnea. Smaller devices better (‘pillows’) but sure settings are proper for you. During winter months your home especially, your bedroom should be humified and you should measure the moisture in the bedroom with an inexpensive relative humidity device like the one below. If you do not have a furnace humidifier you may need to buy a room humidifier for your bedroom.

Keep bedroom humidity in “best” or “comfort” zone. The figure above is too dry.

Long plane and car trips are very stressing for corneal erosions. In the car, run the air conditioner or heater on the feet vents not into the face. Put artificial tears in the eye every couple of hours on a car trip and every hour on a plane trip.

You should go a minimum of 4 months without any pain from the erosion (usually during sleep or upon wakening) before trying to stop the ointment. Be aware that some people are never able to stop the medications and must use drops, ointments and precautions indefinitely (years and years).

The next step is often corneal stromal micro-punctures. This is an office procedure done with just eye drop anesthesia; a bandage contact lens is put in the eye for several days. You may return to normal physical activities immediately.  

If the problem persists then you may need to discuss these treatments with your ophthalmologist. He/she should be able to do the first method. The second he/she may or may not be able to do, sometimes referral to a cornea specialist is indicated.

1. There is a new method of treatment when all else fails. It involves taking oral tetracycline for a couple of weeks coupled with steroid eye drops. If your ophthalmologist is not familiar with the method he/she can do a literature search of the medical ophthalmology journals. The first time I read of it was in the journal "Ophthalmology". I have used this method on two patients that were "at their wits end and had tried everything else. In both cases it worked. I still have them use an ointment at bedtime such as Muro 128 or Genteal Gel but the severe pain has stopped.

2. The last technique would be to use the eximer laser to "resurface" the corneal epithelium and soft contact lens wear during the healing. This technique is most often used when the cornea has disease that keeps causing the erosions, the most common of these is corneal epithelial basement membrane disorder.

Keep trying and good luck.
233488 tn?1310693103
MEDICAL PROFESSIONAL
Jim: I assume you have read above.  Dry eyes and exposure keratitis and BMD often cause the same symptoms.   So the symptoms you describe could be due to just dry eyes and exposure keratitis.   BMD can be very easy to over-look especially if there are only a few 'spots' on the eye.  Use your Google images and pull up images of BMD. Some cornea are so cloudy its almost impossible to miss the diagnosis.  While others are not going to show up unless the ophthalmologists takes extra time to look at the entire cornea for the opacities.  I would suggest you see the ophthalmologist you have the most faith in, don't let the technicians put any drops in eye or touch it. Tell the EYE MD you are worried about BMD and see if he/she see's it.

Several other suggestions:  blepharitis is not cured but controlled like dry skin or dandruff. Be sure you are using a good lid cleaner. In USA if over the counter not helping we use prescription Avenova lid cleaner.  Don't put your latanoprost in at bedtime. Use it a hour or two before bedtime and at bedtime put a lubricating gel or ointment in the eye.   They do make a preservative free latanoprost but it is likely expensive and maybe unavailable in Italy (called Zioptin) In a small # of people that use latanoprost they develop sensitivity to the preservative in it.    I'm not sure I remember you had sleep apnea. Hopefully you use the small pillows type nosepiece and not the bulky face mask.  CPAP devices often make dry eyes, exposure keratitis, BMD and recurrent erosions worse.  So it seems the next thing is 1. put a lubricating gel in your eyes at bedtime and see 2 an ophthalmologist to look at your cornea.
11 Comments
Dear Dr Hagan, once again for the time and effort you have taken to educate me. Always eternally grateful
1/ First, did I see you have a blog on home page about REC syndrome / BMD . i didnt find it
2/ preservative free latanoprost is put in around 6 in the eves\ thanks for suggestion
3/ I use (sometimes) a generic version of Avenova available here. I will be more diligent to use it every morning. Thanks
4/ I cannot use CPAP so i have to live with consequences of sleep apnea unfortunately. Am up a few times at night because of nocturia and prostatitis. I take meds for this: doxazosin and Dutatsteride. I wonder if these play a role in OSD or BMD
5/I have ordered Mura 128 ointment for night and drops during the day. Let’s see.
6/ Do you recommend at this stage topical antibiotics? Erythromycin or azythromycin?
7/Should I add a moisture mask to my arsenal? It seems it might be counterproductive if the Mura 128 is drawing out water in epithelium
8/ Finally and MOST IMPORTANTLY perhaps, I will have slit lamp exam in april. I had a corneal topography CT done last August which is referenced in my August post above. I have read that the CT is a diagnostic tool. Might I be able to send these to you somehow? Not for you to diagnose BMD, because I know you cannot do this for med practice reasons, but rather to know if these particular exams (which I could have redone in a hospital in spite of COVID restrictions) are the exact correct type of CT to pick up on RCE /BMD.  Or is there a variation?  I was having the dry eye/ BMD symptoms last year when I had the CT and saw the doctor, but I have always mentioned dry eye not BMD. I cannot be sure if he did a thorough enough exam of cornea
9/ Finally, you mentioned to keep my comments on this thread. I wonder if many sufferers of Dry Eye OSD actually have RCE BMD and they don’t realize it. There are SO MANY posts for DRY EYE and “relatively little “ written on BMD, it makes me think that the latter is not being picked up on. Although I have posted and you have kindly responded about dry eye , I never myself started investigating BMD
10/ Thank you once again for your professional and thorough approach to all your responses. You are a credit to your profession. When COVID is over, come visit bel italia
1 through 3 no comment needed.  4. I would try and find and work with a sleep specialist, as untreated sleep apnea is associated with increased risk heart attack, stroke and death.   5 see if it helps.  6. antibiotics play no role in BMD.  7 You will need to continue artificial tears even if you have BMD (which you don't know or not) and tears will not negate the hypertonic drops/ointment.  8.  BMD dx is made by direct observation with slit lamp NOT cornea topography.  9 I saw a BMD this morning, completely assymptomatic even though widespread findings. Had map and dot type.        AND you cannot send any test to me. Direct contact is forbidden by MedHelp.org   I get phone calls frequently but cannot take or return them.  
Many thanks again
Dr. Hagan, please forgive my further inquiry on this point. I was wondering about your comment that corneal topography won’t help RCE or BMD dx.  I wondered why I thought it might. I have had numerous slit lamp exams over the years when I have mentioned  the extreme morning pain, thinking it was nothing more than extreme dry eye. . No doc has picked up on RCE (or BMD)
In reading up on RCE before writing you, I found via Medscape an article from Sep 07 2018, author Arun Verma, coauthor M P Ehrenhaus “Recurrent Corneal Erosion” in which was stated in Workup/Other Tests: “ Corneal topographic analysis (using computerized videokeratography) often reveals focal areas of corneal flattening (called corneal topographic lagoons) in eyes with RCE syndrome. This finding is important, as the identification of areas of focal abnormality in RCE syndrome remains a significant clinical problem in those patients with frank symptoms but no evident epithelial abnormalities.”

Since it is very hard to see this leading ophthalmologist here in Umbria (more so with Red Zone Covid restrictions), I wanted to be sure to be prepared before I see him. He does the slit lamp exam in his office,  of course, but not others like the corneal topography.  

That was my reason for asking about having a new corneal topography before my April visit.  If you feel it is of no benefit, I will be relieved not to visit the hospital where it is done.
The findings of RCE on corneal topography are non-specific and usually absent.  I can't emphasize this enough. If a competent Eye MD is looking for BMD  it is an easy diagnosis. It becomes difficulty when you are not looking for it and make a 5 second exam then move the focus back to the iris and lens.
That is a great help. Thank you. I will make sure the doc takes a good look. And follow your advice:  “ don't let the technicians put any drops in eye or touch it. Tell the EYE MD you are worried about BMD and see if he/she see's it. ”
My wife volunteered this question to you: we know that some meds for prostatitis (I think it is finesteride) can bring about floppy iris syndrome. Because of that connection, have you ever come across research linking other prostate meds that might, just might, be related to BMD?
No not at all.  BMD is basically a disruption of the orderly layered (lamellar) growth of the epithelium layer of the cornea. It is a primary, rather than a secondary disease.
Dr Hagan, good morning. I still havent received Muro 128 for BMD. It has been shipped from US but no idea when it will arrive, The Muro 128 I ordered is a an ointment with 5% sodium chloride and inactive ingredients lanolin, mineral oil and white petrolatum, as you know. Meanwhile I have found solutions here in Italy for the active ingredient 5% sodium chloride. I also have tubes of nighttime gels/ointments (Refresh PM as example) which contain the same inactive ingredients as the Muro 128 Ointment (which I am waiting for. )(These dont have any active ingredients. )

1/ My question: can  I use together the Italian 5% sod chloride Solutions along with the nighttime ointments that have above-mentioned inactive ingredients and get the same benefit as the very expensive Muro 128 ointment? If so, one after the other or together or ??
2/ Apart from this, have you any experience with FRESHKOTE  which users of the Dry Eye Forum have highly recommended? It contains: Polyvinyl pyrrolidone2.0%, Polyvinyl alcohol 2.7%

Again, thanks for your kind help and most beneficial advice.
The 5% sodium chloride is what makes it effective but using something at bedtime is extremely important. I really can't comment about the Italian products. If they are approved there on the surface that would seem a reasonable substitute.   The purpose of the Italian product: It should be an ophthalmic product approved for use in the eye and hypertonic to dehydrate the cornea.  Freshkote is hard to find even in USA. It is like every lubricating product some people like it, some people it doesn't help. Try it and see what you think.
Thanks you for your prompt response.  yes, Italian products are approved ophthalmic products. No worry about that. My real question is could I ADD ALONG  WITH THIS 5% SOLUTION the Ointment containing ingredients lanolin, mineral oil and white petrolatum, which would make it similar to Muro 128 OINTMENT for nighttime use? If so, how to combine these two, the solution with the ointment?  Which one first? Just for your professional info, I have started using the Italian brand 5% solutions by themselves, and I have a feeling that they might be relieving the BMD. I use them prophylactically during the day and again before sleep.
Thank you
I don't know and would not want to speculate.
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