Keratopathy
Keratopathy is a medical term describing abnormal changes of the cornea – a protective smooth layer covering the eye inside the eyelids. There are multiple problems and diseases that can cause keratopathy. They are divided by ophthalmologists into types based on mechanism causing it.
In this article:
- Treatment
- How is exposure keratopathy treated?
- How is band keratopathy (BSK) treated?
- How is bullous keratopathy treated?
- Allergy treatment
- Dry eye treatment
- Steroids
- Amniotic membrane
- Scleral lens
- References
Treatment
Treatment of the cornea disease usually prescribed by a cornea ophthalmologist. It will depend on the type and mechanism of the keratopathy. Treatment of underlying condition, such as control of a diabetic or thyroid-induced disease, is essential in preventing recurrence of the problem and other eye complications. There are several advancements that are used for the cornea repair with successful vision restoration, such as amniotic membrane and contact lens systems.
How is exposure keratopathy treated?
Exposure keratopathy is due to insufficient closure of the eye. While moisture barrier needs to be immediately restored, surgery to fix the eyelids is most likely treatment. a retina surgeon or oculoplastic specialists will be involved based on the original issue.
Bell’s palsy will cause multiple immediate problems, but is likely to resolve spontaneously. It rarely needs surgical correction, and is managed with moisturizing barrier eye drops and ointments.
In Exposure keratitis secondary to proptosis, the actual cause of proptosis needs to be addressed. In Thyroid eye disease, systemic control is of utmost importance and is also combined with orbital decompression surgeries in severe cases. If the proptosis is secondary to some orbital tumor, that needs to be taken care of simultaneously. Eye oncologist will need to be involved and lead the team approach.
For exposure keratopathy secondary to congenital or acquired lid coloboma, a pedicle graft or flap needs to be done.
How is band keratopathy (BSK) treated?
Surgical removal of band-shaped keratopathy is the main treatment modality; however, the local and systemic cause of band-shaped keratopathy needs to be controlled before surgical correction. Epithelial debridement followed by chelation with EDTA (ethylenediaminetetraacetic acid) is the main treatment modality.
Recurrence is common if the primary disease is not controlled. In cases with BSK, with no vision potential, patients should be counseled for colored contact lens also. Superficial lamellar keratectomy, EDTA chelation coupled with amniotic membrane transplantation has also been described.
How is bullous keratopathy treated?
Bullous keratopathy is the adverse result of endothelial cell loss during cataract surgery. The only treatment is replacing the damaged endothelial cells with healthy endothelial cells from a donor cornea. Descemet’s stripping endothelial keratoplasty (DSEK) and Descemet’s membrane endothelial keratoplasty (DMEK) is the viable treatment options.
Penetrating keratoplasty may be needed in cases with corneal stromal scarring. For cases with no vision potential (cases with compromised optic nerve head), anterior stromal puncture with or without Amniotic membrane transplantation is an option. This procedure induces subepithelial scarring and prevents bullae formation. Thus the patients are relieved of the symptoms caused by recurrent rupture of bullae.
Allergy treatment
Treatment of ocular allergy with topical steroids, mast cell stabilizers, and antihistaminics helps in keratopathy also. Lubricants are also added to the treatment regimen. Topical tacrolimus or cyclosporine are being used as steroid-sparing agents. Oral antihistaminics also have a proven role.
In Stevens-Johnson syndrome oral intravenous steroids and hydration will control immune reaction. If cornea lost the translucent quality, the only option is grafting. The Mucous membrane graft works well in children over prosthetic replacement of ocular surface ecosystem lens; while the opposite is true for adults. When combined together, give superior outcomes are seen in both adults and children.
Dry eye treatment
Treatment of the underlying dry eye is critical for cornea preservation. Proposed treatments include topical lubricants (drops and ointment) and topical steroid/nonsteroidal agents. Mechanical removal of filaments, the use of hypertonic saline, mucolytic agents, the use of punctal plugs, and bandage contact lens have also been advocated. The systemic disease like underlying connective tissue disease has to be controlled simultaneously to avoid recurrence.
Traditional dry eye treatments include over-the-counter artificial tears, warm compresses, and lid hygiene with baby shampoo. Topical cyclosporine A (CsA) 0.05%, a fungal antimetabolite, is a common next line dry eye therapy for those who have failed the conservative measures above. An estimated 48.2% of chronic dry eye disease patients have filled a prescription for CsA, despite mixed physician opinion on the drug’s efficacy.
Lifitegrast 5% is a topical anti-inflammatory medication with relatively rapid effect, long-term safety, and improvement in both the signs and symptoms of dry eye disease.
Steroids
One of the main treatments of the inflammation is topical and oral steroids. While other measures, such as surgery, might be necessary in a long run, steroidal treatment might provide an immediate rescue of the corneal cells from active inflammation.
Orbital steroid injections can be used for the treatment of active thyroid ophthalmopathy when the patient is resistant to or dependent on systemic steroids or has developed complications of systemic steroids.
Amniotic membrane
Amniotic membranes have been used for the treatment of various ocular surface disorders, including limbal stem cell deficiency, infectious keratitis, corneal burns, and persistent epithelial defects.
Not only do they provide coverage of the epithelium to allow healing, but also impart anti-inflammatory properties. There are currently two commercially available varieties, either cryopreserved at −80°C, such as the ProKera™ (Bio-Tissue, Inc, Miami, FL), or sterilized dehydrated and stored at room temperature, such as the AmbioDisk™ (Katena Products, Inc, Denville, NJ).
Scleral lens
Scleral lenses were previously used primarily for the treatment of corneal ectasias but more recently have been studied for use in ocular surface disorders. These lenses rest on the sclera, creating with a fluid-filled reservoir over the more sensitive cornea. There are several scleral lenses that are currently available that can be helpful in treating dry eye.
Perhaps the most well-known scleral lens used to treat ocular surface disease is the BostonSight® PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) lens (Boston Foundation for Sight, Needham, MA). The PROSE lens is custom designed using patient eye measurements so that the lens is not touching the apical or peripheral cornea but still maintaining minimal movement and optimizing fluid ventilation. An early retrospective review of 49 consecutive patients (76 eyes) with ocular surface disease treated with this lens found a 92% improvement in quality of life as a result of reduction in photophobia and pain. 53% of patients in this study achieved 2 or more Snellen lines of improvement in visual acuity.
References
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Graves Disease Orbital Decompression.
Gibson A, Kothapudi VN, Czyz CN.2021 Jul 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 29261978 Free Books & Documents. Review.
Intraorbital Steroid Injection for Active Thyroid Ophthalmopathy.
Bagheri A, Abbaszadeh M, Yazdani S.J Ophthalmic Vis Res. 2020 Feb 2;15(1):69-77. doi: 10.18502/jovr.v15i1.5948. eCollection 2020 Jan-Mar.PMID: 32095211 Free PMC article. Review.
Advances in dry eye disease treatment. O’Neil EC, Henderson M, Massaro-Giordano M, Bunya VY.Curr Opin Ophthalmol. 2019 May;30(3):166-178. doi: 10.1097/ICU.0000000000000569.PMID: 30883442 Free PMC article. Review.