Epithelial Basement Membrane Dystrophy and Dry Eye Disease

Epithelial basement membrane dystrophy (EBMD). Anterior basement membrane dystrophy. Cogan’s Fingerprint Map/Dot Dystrophy.

Known by these various names, this type of dystrophy can and does masquerade as dry eye disease. With many of the same symptoms, it can progress to become recurrent corneal erosion. During the fluorescein staining evaluation of your slit lamp examination, be aware of a subtle negative staining pattern on the patient’s cornea. Negative staining or inability to hold tear film intact can occur anywhere on the cornea, but the hallmark to this apparent tear break-up area is that it repeatedly occurs at the same location with a sharp delineation on your patient’s cornea. Often in the early stages, it is not possible to view the dystrophy in the white light of the slit lamp. Instead, we will see the well delineated and defined negative stain where the epithelium is not firmly attached to the basement membrane.

The loosely attached epithelium tends to swell and cause many symptoms of discomfort, including symptoms of dry eye, and these patients often have dry eye disease co-morbidly. When and if the swelling gets near the center of the cornea, the patient will also experience visual fluctuation. A key question to ask these patients is how their eyes feel when they wake up at night or first thing in the morning. Still, patients who experience both EBMD and dry eye become difficult to manage because of the similar symptoms. I always tell patients with both EBMD and dry eye disease that it will be difficult for them to differentiate their symptoms because we often can improve both the signs and symptoms of dry eye disease, but the symptoms of even a controlled EBMD can remain. Those patients require a thorough understanding of the two distinctly different forms of ocular surface disease.

As the EBMD becomes more advanced, the symptoms and signs will become much more apparent to you and your patient. EBMD will have a high matrix metalloproteinase count (MMP-9), so anti-inflammatories, such as loteprednol as well as a solution that has an osmotic gradient such as FreshKote (by Santen), are used to reduce the swelling between the epithelium and the basement membrane. As it progresses and affects the optical zone, a superficial keratectomy and amniotic membrane, as well as a Phototherapeutic Keratectomy (PTK), can be utilized. It is also essential to reduce the inflammation that occurs at night secondary to lid misalignment or nocturnal lagophthalmos with a nighttime eye cover/seal such as SleepTite (by Eye Sleep Tite).

If diagnosed early enough, many EBMD patients can be well controlled by reducing inflammation and edema before advancing to keratectomy procedures.

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