Optometry Dx: The Roadmap to Relief

Slideshow

  • Figure 1. This image shows a 66-year-old patient’s clinical presentation under white light. She reported sudden and increasing pain since the day before. Can you identify the cause?

  • Figure 2. This clinical image shows the patient at presentation under UV light with staining.

  • Figure 3. This photo shows our patient 4 days after starting treatment. The staining seen earlier had resolved as had her pain, and the defect was healing.

A 66-year-old woman presented to the clinic with pain in her right eye. She reported experiencing several episodes of foreign body sensation in both eyes during the prior 5 years. She had been taking artificial tears for dry eye and her systemic medical history was notable for thyroid disease, for which she took levothyroxine 150 mg. She said the pain in her right began the day before but had gotten “much worse.” She was prescribed tobramycin and nonsteroidal eye drops, both to be taken TID, and an artificial tear ointment to be taken at night. She was seen 4 days later and said the pain had resolved. 

Epithelial basement membrane dystrophy (EBMD), also known as Cogan’s microcystic dystrophy, is an anterior basement membrane dystrophy. It is also called map dot fingerprint dystrophy because of the corneal findings. EBMD is a disease that affects the anterior cornea causing...

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Epithelial basement membrane dystrophy (EBMD), also known as Cogan’s microcystic dystrophy, is an anterior basement membrane dystrophy. It is also called map dot fingerprint dystrophy because of the corneal findings. EBMD is a disease that affects the anterior cornea causing characteristic corneal slit lamp findings causing decreased vision and/or recurrent corneal erosions. Extra sheets of basement membrane extend into the corneal epithelium appearing as “maps.” Maturing epithelial cells migrate toward the anterior surface and become trapped in these sheets and form cysts and appear as “dots. Parallel or concentric lines of thickened basement membrane present as “fingerprints.”1 

Abnormalities of the epithelial basement membrane, in the area that anchors the undersurface of the membrane, the hemidesmosome layer, may disrupt its reattachment, and cause painful recurrent erosions. If the area is over the pupil, the patient may experience visual problems. The hemidesmosome layer may take as long as 3 to 4 weeks to repair.

EBMD is not difficult to diagnose, but deciding on the treatment for some cases can be challenging. Many patients can have asymptomatic EBMD in the corneal periphery and physicians do not necessarily need to do anything about it. If significant epithelium loss around the area is noted, clinicians can consider removing it and applying an antibiotic drop and a nonsteroidal drop, and then fitting the patient to a bandage soft contact lens. Have the patient return the next day, and a few days later when you can remove the contact lens if the area appears to have healed. The patient should use lubricant ointment at night for the next few months to help the epithelium tack down and prevent recurrences. If the cornea is swollen, use long term hypertonic salt solutions either drops or ointments. In recurrent cases, some surgeons may resort to stromal puncture if the recurrent erosions is out of the visual axis, as the needle as the punctures can cause scars that can be permanent.2 Manual superficial keratectomy (SK), where all of the surface epithelium is removed in the area of the erosion, and is as effective as laser PTK in preventing recurrences. Laser PTK is more expensive than SK, requires a certification course and a laser, has some risk of haze or scar formation, and insurance may not pay for it.3 Amniotic membrane can also be useful for treatment of recurrent corneal erosions.4

Matthew Garston, OD, is an adjunct professor at the New England College of Optometry and was a senior staff optometrist in the medical department at MIT for 43 years.

References

  1. Edell E, Bunya V, Woodward M Bernfeld E. Epithelial basement membrane dystrophy. AAO – EyeWiki. https://eyewiki.aao.org/Epithelial_Basement_Membrane_Dystrophy. Updated January 12,2022. Accessed March 3, 2022. 
  1. Miller DD, Hasan SA, Simmons NL, Stewart MW. Recurrent corneal erosion: a comprehensive review. Clin Ophthalmol. 2019;13(2):325-335. doi:10.2147/OPTH.S157430.
  1. Pham LTL, Goins, KM, Sutphin JE, Wagoner MD. Treatment of epithelial basement membrane dystrophy with manual superficial keratectomy. EyeRounds.org. http://www.eyerounds.org/cases/78-EBMD-treatment.htm. Updated February 22, 2010. Accessed March 3, 2022.
  1. Huang Y, Sheha H, Tseng S. Self-retained amniotic membrane for recurrent corneal erosion. J Clin Exp Ophthalmol. 2013;4(2):272. doi:10.4172/2155-9570.1000272
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