September 14, 2012 | POSTED BY | Clinical Pearls
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Many affected individuals with (RCE) exhibit symptoms for years and tend to experience poor treatment outcomes. Published research outlines a particular treatment cocktail that is proven to be effective.

One study indicated that the enzyme responsible for RCE is matrix metalloproteinase-9 (MMP-9). Furthermore, the researchers documented that corticosteroids and oral doxycycline inhibit production of this enzyme. Also, other medications, such as AzaSite (azithromycin) have been shown to inhibit MMP-9.

Also, because almost all cases of RCE occur overnight likely due to an increase in corneal edema during sleep, bedtime use of hypertonic therapeutic ointments, such as Muro 128 ointment (sodium chloride hypertonicity ophthalmic solution 5.0%, Bausch + Lomb), is recommended.²

FreshKote (Focus Laboratories), a newer prescription artificial tear for moderate to severe dry eye, also appears to work well for patients with recalcitrant RCE. This drop works via oncotic pressure (104 mmHg) and appears to be well tolerated by patients who use it during the daytime.³

Finally, patients with recalcitrant RCE have responded well to low-dose doxycycline.1,2

Here is the recommended two-month treatment cocktail for recalcitrant RCE:

  • FreshKote t.i.d.
  • Loteprednol 0.5% q.i.d. for two weeks, then bi.d. for six weeks. (Check the patient’s IOP around week three or four.)
  • Doxycycline 20mg b.i.d.

Further research on recalcitrant RCE management strategies is required. But for now, it appears that inhibition of MMP-9 production may be the fundamental key to a successful treatment approach.


1. Dursun D, Kim MC, Solomon A, Pflugfelder SC. Treatment of recalcitrant recurrent corneal erosions with inhibitors of matrix metalloproteinase-9, doxycycline and corticosteroids. Am J Ophthalmol. 2001 Jul;132(1):8-13.

2. Foulks GN. Treatment of recurrent corneal erosion and corneal edema with topical osmotic colloidal solution. Ophthalmology. 1981 Aug;88(8):801-3.

3. Holly FJ. Biophysical aspects of epithelial adhesion to stroma. Invest Ophthalmol Vis Sci. 1978 Jun;17(6):552-7.

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