Académique Documents
Professionnel Documents
Culture Documents
Corneal Opacity
Management Kumari Reena Singh
MD
www. dosonline.org l 53
Corneal Opacity Management
Classifications
ICD 9 CM ICD 10 CM
Minor corneal opacity 371.01 H17.81
Peripheral corneal opacity 371.02 H17.82
Central corneal opacity 371.03 H17.1
Adherent leukoma 371.04 H17.0
Phthisical cornea. 017.3, 371.05* A18.59, H44.52
CM = Clinical Modification used in the United States; (–) = 1, right eye; 2, left eye; 3, bilateral * Code first underlying tuberculosis (017.3).
Refraction with corrective glasses or contact lenses corrections PTK, lamellar surgical corrections
(both assessed with dialated and undialated pupil (manual, microkeratome, femtolaser assisted)
to consider for optical iridectomy), with or without (Figure 2a,b,c).
cosmetic corneal tattooing /cosmetic contact
• If deeper corneal involvement then depending
lenses.
on depth of involvement LK, DALK (manual,
b. Small, peripheral opacity not involving part microkeratome, femtolaser assisted) .Rotation
of pupillary opening (full thickness or partial autograft is another option.
thickness).
• If full thickness corneal involvement/adherent
These opacities may still compromise vision by leukomatous opacity is there and eye bank
inducing distortions of the corneal curvature. facility is present then pkp could be options
Refraction over a rigid contact lens can be helpful (Figure 3).
in assessing potential visual acuity and may in
2. Associated other vision decreasing problems
itself improve visual acuity. Also corrective glasses
can be prescribed. Like cataract, astigmatism, posterior segment disorders etc.
should be evaluated first then appropriate treatment should
c. Larger size corneal opacity involving pupillary
be planned.
opening ,no improvement in vision after dilation
3. End stage disorders without visual potentials
• If only nebular corneal opacity and visual
requirement is not much or any systemic Like in phthisical cornea or end stage glaucoma patients
or local disorders not allowing for surgical with opacity, should be treated for pain and discomfort also
correction then refraction for fitting glasses for cosmesis like corneal tattooing, contact lenses, artificial
and contact lenses , otherwise laser assisted eyes etc.
www. dosonline.org l 55
Corneal Opacity Management
(a)
(b)
Figure 4(a),(b): Corneal edema, poor ocular surface and intraocular inflammation
2. Lamellar keratoplasty: useful in anterior to mid- rejection, efficient visual rehabilitation relative to PK, and
stromal opacities in which endothelial function is also fewer complications including expulsive hemorrhage,
normal. anterior synechia, postoperative endophthalmitis, and
glaucoma in comparison to PK. This procedure also
a. Superficial Anterior Lamellar Keratoplasty
requires less rigid criteria for donor corneal tissue selection
(SALK): Particularly when treating deeper
that is often weighted toward donor endothelium in PK.
lesions which can not be treated by PTK.
There are different methods of dissections of host cornea
This procedure can be Automated or Hemi-
like ; direct Open Dissection (Anwar in 1972), closed
automated (HALK, cutting host bed with
Dissection (Melles Technique, 1999), dissection with
microkeratome) suture assisted or sutures less
Hydrodelamination (Sugita and Kondo), dissection with Big
with glue.
Bubble Technique, (Anwar’s 2002), Big Bubble technique
Anterior Lamellar Keratoplasty (ALK): Manual,
b. Combined with Femtosecond Laser Trephination. (Suwan-
Automated (microkeratome assisted) donor Apichon et al. 2006 and Price Jr. et al. 2009).
graft can be sutured into the recipient bed or
e. Posterior Lamellar Keratoplasty or Endothelial
suture assisted with glue.
Keratoplasty (EK)
c. Sutureless Femtosecond Laser - Assisted
Attempting to replace endothelial pathology, the first (PLK)
Anterior Lamellar Keratoplasty (FALK)
procedure was described by Barraquer in 1950. Melles
Depth of the recipient corneal pathology is measured using et al. offered sutureless PLK in 1998, using an air bubble
anterior segment OCT (AS-OCT). A femtosecond laser is for graft fixation. In 2001, Terry and Ousley introduced
used to create the lamellar cut in the recipient with donor endothelial keratoplasty (EK) and deep lamellar endothelial
corneas. Donor cut is adjusted according to the depth of keratoplasty (DLEK). Later in 2005 Price Jr. and Price
the lesions with an additional 10-20% thickness adjusted to performed Descemet stripping endothelial keratoplasty
compensate for donor tissue swelling. After putting donor (DSEK). A year later, Gorovoy added automation using
lenticule the incision is dried, and flap adhesion is checked. a microkeratome for Descemet stripping automated
A bandage soft contact lens is placed over the cornea. endothelial keratoplasty (DSAEK). Subsequently, Descemet
membrane endothelial keratoplasty (DMEK) was described
d. Deep Anterior Lamellar Keratoplasty (DALK)
by Melles et al. allowing transplantation of an isolated
(Figure 5a,b).
endothelium-Descemet membrane layer (EDM) without
It removes and replaces total or near-total corneal stroma adherent corneal stroma. Later on Price et al. described
while preserving host endothelium. The advantages Descemet membrane automated endothelial keratoplasty
of DALK include reducing the risk of endothelial graft (DMAEK). Endothelial keratoplasty has lesser risk of
(a) (b)
endothelial graft rejection, early visual rehabilitation for visualization of the anterior chamber before triple
relative to PK and also fewer complications. Two most procedure can be done4.
common early complications following DSAEK surgery
• Keratoprosthesis:
are graft dislocation (1 to 82%) and primary graft failure
(0-29%). Used for severe corneal bilateral opacity where other
surgical options are not viable.
• Rotation Autograft:
• Conjunctival flap:
Rotational autograft can be an effective alternative to
standard penetrating keratoplasty for some patients Surgical procedures to reduce the pain of corneal edema
with corneal scars. Area of clear cornea is placed in the (bullous and microcystic) in patients who are not candidates
geometric center of the cornea and the opacity is rotated for corneal transplantation.
toward the limbus. The objective is to achieve the largest
So each case of corneal opacity should be evaluated
possible optically clear zone. Mathematical variables
properly then managed. After visual rehabilitation,
are set to maximize postoperative visual acuity and for
postoperative care as well as treatment of complications
generalization of the geometric model3.
and recurrent disease is also important.
• Penetrating keratoplasty:
References
Penetrating keratoplasty should be performed when 1. Grünauer Kloevekorn C , Habermann A, Wilhelm F et.al.; Contact
nonsurgical measures or less invasive procedures not lens fitting as a possibility for visual rehabilitation in patients after
provide satisfactory visual outcome. Long term follow-up open globe injuries; [Article in German] Klin Monbl Augenheilkd.
care and patient cooperation are required to ensure success. 2004;8):652-7.
Patients remain at risk for allograft rejection throughout 2. S Pitz, R Jahn, L Frisch, A Duis, N Pfeiffer et. al.; Corneal tattooing: an
life. There are various complications following Penetrating alternative treatment for disfiguring corneal scars optimal Size and
keratoplasty including Intraoperative and Postoperative Location for Corneal Rotational Autografts A Simplified Mathematical
Model; British Journal of Ophthalmology, 2002;86:397-99
complications.
3. Natalie A. Afshari,Scott M. Duncan, Tasha Y et. al.; Optimal
• Triple procedure: Size and Location for Corneal Rotational Autografts A Simplified
Mathematical Mode. Arch Ophthalmol. 2006;3:410-13.
It involves cataract surgery and intraocular lens implantation
along with lamellar, DSEAK and PKP procedure. Mostly 4. N Ardjomand, P Fellner, M Moray, C Wohlfart,et.al.; Lamellar
corneal dissection for visualization of the anterior chamber before
open sky cataract surgery done in PKP with cataract surgery triple procedure; Eye 2007;21:1151–54.
in case of PKP planned with closed chamber cataract
surgery to increase visibility, Lamellar corneal dissection
www. dosonline.org l 57