The real cost of persistent epithelial defects: Lessons from an NHS audit

A cornea that refuses to heal can quietly consume months of clinic time and thousands of pounds in NHS resources. A retrospective audit published in Eye, conducted by Maqsood and colleagues across 2 NHS centres, set out to quantify exactly that burden, examining outcomes and costs for conventional treatment of persistent epithelial defects (PEDs) and comparing them against a sutureless human amniotic membrane-derived dry matrix (HAMDM).¹

A demanding patient population

The study reviewed 30 eyes from 30 patients with refractory PED treated at Queen Victoria Hospital, East Grinstead, and Maidstone and Tunbridge Wells NHS Trust between 2017 and 2022. Patients were treated at Queen Victoria Hospital (67%) and Maidstone and Tunbridge Wells (33%). Mean patient age was 67 ± 19 years and 57% were male. Systemic comorbidities were common, affecting 80% of the cohort, most frequently hypertension (70%) and diabetes mellitus (47%). The most frequent underlying causes of PED were limbal stem cell deficiency (37%), microbial keratitis (20%), neurotrophic cornea (20%) and post-surgical epithelial breakdown (16%).¹

Standard care proved slow and resource-intensive

All patients began treatment with topical lubricants, antibiotics and corticosteroids, with adjunctive interventions including tarsorrhaphy (83%) and bandage contact lenses (73%) used frequently. Topical immunosuppressants were used in 50% of cases and serum or plasma eye drops in 27%. Despite this layered approach, only 57% of patients achieved complete healing, while 43% remained unresolved, including four patients (13%) who experienced clinical deterioration. Mean treatment duration was 176 ± 188 days, with the longest courses seen in trauma-related cases (560 days) and limbal stem cell deficiency (245 ± 255 days). Patients required an average of ten outpatient visits, and 93% needed further follow-up interventions beyond initial management, most commonly corneal grafting (48%) or amniotic membrane transplantation (35%). The mean total cost per patient was £4900 ± £3363, with the overall 30-patient cohort costing the NHS more than £146 000.¹

HAMDM showed favourable outcomes by comparison

Outcomes were benchmarked against pooled data (n = 127) from 2 previously published studies using HAMDM (Omnigen with OmniLenz, NuVision Biotherapies) at the same centres. HAMDM-treated patients achieved a higher complete resolution rate (63% vs 57%), required fewer outpatient visits (eight vs ten) and had a shorter mean treatment duration (98 vs 176 days), with an average of 1.2 applications per patient. Modelled against the same cost assumptions used for standard care, the average per-patient cost with HAMDM was £2508 including follow-up care, representing a potential saving of £2392 per patient, or roughly £71 755 across a comparable 30-patient cohort. According to the authors, this gap traces back to patients needing less hands-on care overall: fewer return visits, fewer trips to theatre and a quicker path to a healed eye.¹

A wider service-level problem

To contextualise these findings nationally, the authors reviewed NHS Digital Hospital Episode Statistics data for 2017 to 2018, which identified 161 471 corneal surface disease-related episodes across all care settings, of which over 138 000 were related to corneal ulcers or epithelial defects. The majority of these episodes (93%) were managed in outpatient settings rather than accident and emergency or inpatient care. The authors point out that PED has no dedicated ICD-10 code of its own, and that many trusts simply did not return complete figures during the period reviewed, meaning the true national caseload is likely higher than what the available statistics show.¹

Limitations

The authors acknowledge several limitations. The retrospective design and restriction to 2 centres limit generalisability, and NHS coding practices may have skewed case identification toward more severe or refractory presentations. The HAMDM comparison drew on a relatively small pooled sample from studies conducted at the same institutions, and outcome and resource-use data may not be generalisable beyond those centres and clinical teams. The authors also note that cost modelling was not extended to the national HES data, limiting the ability to estimate the true financial scale of PED across the NHS.¹

A case for earlier adoption

Maqsood and colleagues conclude that conventional PED management remains a lengthy and resource-heavy undertaking for the NHS, with most patients needing more than first-line therapy alone to reach resolution. They note that moving HAMDM earlier into the treatment pathway, rather than reserving it for refractory cases, could shorten healing time, ease pressure on outpatient clinics and reduce overall spend, while lifting resolution rates above what standard care currently achieves. Looking ahead, they call for larger trials run across multiple centres that weigh both the clinical and financial picture together, and that also capture how earlier treatment affects patients' day-to-day quality of life rather than cost alone.¹

Reference

1. Maqsood SE, Posnett JW, Elalfy M. Management of ocular surface disease involving inflammation and persistent epithelial defects utilising various treatment modalities in the UK National Health Service (NHS). Eye (Lond). Published online June 4, 2026. doi:10.1038/s41433-026-04314-6