Corneal Opacity

29 June 2020 Dr A R Patil 1

 Corneal Opacity
• Corneal opacity results from Corneal
scarring, due replacement of normal
corneal lamellae with fibrous scar tissue.
Whenever Bowman’s membrane is
destroyed some opacity remains
• The opacification is due to disturbance of
arrangement of corneal lamellae

29 June 2020 Dr A R Patil 2

 Types
Types of Corneal opacity, depending on
density of corneal opacity:
1. Nebular (Nebula) Corneal Opacity is slight
opacification of cornea allowing the details
of iris and pupil to be seen through corneal
opacity

29 June 2020 Dr A R Patil 3

 Types
2. Macular (Macula) Corneal opacity: it is
more dense than nebular corneal opacity,
through it details of Iris and pupil cannot
be seen but margins can be seen
3. Leucomatous (Leucoma) Corneal
Opacity: it is very dense, white totally
opaque obscuring view of iris and pupil
totally

29 June 2020 Dr A R Patil 4

 Types
Old leucomatous opacity may show
horizontal pigmented line/ calcareous
deposits in palpabral aperture
When iris is adherent to leucomatous
corneal opacity, which develops following
healing of perforation of corneal ulcer, the
condition is called adherent leucoma.

29 June 2020 Dr A R Patil 5

 Types
If iris is incarcerated in the scar tissue
which forms as a result of healing of
sloughed corneal ulcer it is called
Corneoiridic scar (if flat) and anterior
staphyloma if it is ectatic (ectatic cicatric
with incarceration/ incorporation of Iris is
called anterior staphyloma)

29 June 2020 Dr A R Patil 6

 Classification based on location

29 June 2020 Dr A R Patil 7

 Peripheral Corneal Opacity
1. Nebular : does not interfere with visual
axis, may cause some astigmatism. It
does not cause cosmetic disfigurement

29 June 2020 Dr A R Patil 8

 Peripheral Corneal Opacity
• Macular : does not interfere with visual
axis, may cause some astigmatism. It
causes some cosmetic disfigurement

29 June 2020 Dr A R Patil 9

 Peripheral Corneal Opacity
• Leucomatous : does not interfere with
visual axis, may cause some astigmatism.
It causes cosmetic disfigurement

29 June 2020 Dr A R Patil 10

 Peripheral Adherent Leucoma

29 June 2020 Dr A R Patil 11

 Central Corneal Opacities

29 June 2020 Dr A R Patil 12

 Nebular Corneal Opacity
A nebular corneal opacity in pupillary area
causes more visual disturbance by
causing irregular refraction of light rays
compared to macular and leucomatous
corneal opacities (occupying partial
pupillary area). The partial pupillary
macular and leucomatous Corneal
opacities only decreases contrast (patient
can still see objects, as light rays enters
from peripheral area)
29 June 2020 Dr A R Patil 13
 Nebular Corneal Opacity
• The visual disturbance (distortion is more
marked in cases of nebular corneal
opacity)
• Superficial corneal opacities does clear
with time specially in children

29 June 2020 Dr A R Patil 14

 Central Corneal Opacity
Small central nebular corneal opacity occupying pupil partially

It may cause significant visual disturbance by causing irregular refraction of

Light

29 June 2020 Dr A R Patil 15

 Central Corneal Opacity
Small central macular corneal opacity occupying pupil partially

29 June 2020 Dr A R Patil 16

Small Central Macular Corneal Opacity

29 June 2020 Dr A R Patil 17

 Central Corneal Opacity
Small central leucomatous corneal opacity occupying pupil partially

29 June 2020 Dr A R Patil 18

Small Maculo-leucomatous Corneal
Opacity in pupillary area

29 June 2020 Dr A R Patil 19

 Central Corneal Opacity
Central nebular corneal opacity occupying entire pupillary area

29 June 2020 Dr A R Patil 20

 Central Corneal Opacity
Central macular corneal opacity occupying entire pupillary area

29 June 2020 Dr A R Patil 21

 Maculo-leucomatous Corneal
Opacity in pupillary area

29 June 2020 Dr A R Patil 22

 Central Corneal Opacity
Central leucomatous corneal opacity occupying entire pupillary area

29 June 2020 Dr A R Patil 23

 Leucomatous Corneal Opacity

29 June 2020 Dr A R Patil 24

 Central Maculo-leucomatous
Corneal Opacity

29 June 2020 Dr A R Patil 25

Central and Peripheral Corneal Opacity

29 June 2020 Dr A R Patil 26

 Central and Peripheral Corneal
Opacity

29 June 2020 Dr A R Patil 27

 Central and Peripheral
Leucomatous Corneal Opacity

29 June 2020 Dr A R Patil 28

Central and Peripheral Corneal Opacity

29 June 2020 Dr A R Patil 29

Central and Peripheral Corneal Opacity

29 June 2020 Dr A R Patil 30

 Treatment of Corneal Opacity
I. Central Small Corneal Opacity
occupying pupillary area partially
a. Nebular – Tattooing to convert it in
opaque scar that does not cause
irregular refraction
b. Macular – Can be left alone
(Tattooing for cosmetic reason)
c. Leucomatous – Can be left alone
(Tattooing for cosmetic reason)
29 June 2020 Dr A R Patil 31
 Treatment of Corneal Opacity
II. Central Corneal Opacity occupying pupillary
area completely
a. Nebular – involving less than half thickness
of corneal – Lamellar Keratoplasty
b. Macular – Usually involves more than half
thickness of cornea – Penetrating
Keratoplasty
c. Leucomatous – Usually involves more than
half thickness of cornea – Penetrating
Keratoplasty

29 June 2020 Dr A R Patil 32

 Leucomatous Corneal Opacity

29 June 2020 Dr A R Patil 33

 Optical Iridectomy (Lower Temporal)

29 June 2020 Dr A R Patil 34

 Central Maculo-leucomatous
Corneal Opacity

29 June 2020 Dr A R Patil 35

 Optical Iridectomy (Lower Nasal)

29 June 2020 Dr A R Patil 36

29 June 2020 Dr A R Patil 37
 Treatment of Corneal Opacity
III. Corneal opacity involving pupillary area
and periphery , no scope of doing optical
iridectomy
a. for superficial corneal opacities
involving less than half thickness are
treated by lamellar keratoplasty
b. for corneal opacities involving more
than half thickness are treated by
penetrating keratoplasty
29 June 2020 Dr A R Patil 38
 Tattooing of Cornea
Indications:
1. Cosmetic purposes: when eye is blind and or
opacity is disfiguring (including disfiguring
peripheral corneal opacities)
2. For stopping entry of light rays through
nebular/ moderately dense opacity situated in
pupillary area (involving pupil partly). In this
case it converts nebular corneal opacity into
totally opaque black scar which cut off all
entering light rays

29 June 2020 Dr A R Patil 39

 Method of Tattooing
1. Explain the procedure
2. Retrobulbar anaesthesia and topical
anaesthesia
3. Removal of corneal epithelium
4. Application of Platinum Chloride 2%. Filter
paper strip soaked in 2% platinum chloride
solution and placed on area from where
epithelium has been removed (the area which
is to be stained)

29 June 2020 Dr A R Patil 40

 Method of Tattooing
5. Wait for 2 minutes and then remove the
filter paper disc
6. Put a drop of 2% hydrazine hydrate
solution, leave it for 25 seconds
7. Eye is washed with sterile distilled water

Indian ink can also be used in place of

platinum chloride
29 June 2020 Dr A R Patil 41
 Keratoplasty
(Corneal Grafting)

29 June 2020 Dr A R Patil 42

 Keratoplasty
• Keratoplasty is a procedure wherein
diseased cornea is removed and is
replaced with a healthy donor cornea
• Donor corneas are received from
cadaveric donor within 6 hours of death,
due to causes which do not contra-indicate
acceptance of donor eyes

29 June 2020 Dr A R Patil 43

 Aims of Keratoplasty
1. To remove corneal opacity to provide clear
visual axis for restoration of vision (Optical
Keratoplasty)
2. For restoration of globe (eye ball) integrity in
corneal diseases like corneal fistula, corneal
perforation with loss of tissue , descemetocele
3. To remove and replace infected corneal tissue
which is not responding to treatment
(Therapeutic Keratoplasty)

29 June 2020 Dr A R Patil 44

 Structural Types
1. Full thickness or penetrating keratoplasty
2. Partial thickness or lamellar keratoplasty
3. Small patch graft (lamellar or full
thickness)

29 June 2020 Dr A R Patil 45

 Steps of Keratoplasty
I. Penetrating Keratoplasty:
1. Counseling/ explain about procedure
2. Take informed consent
3. Suitable anaesthesia
4. Regional block anaesthesia
5. Painting and draping (preparation of
part)

29 June 2020 Dr A R Patil 46

 Steps of Keratoplasty
6. Application of eye speculum for keeping
lids apart
7. Application of Superior and inferior
rectus suture (may be applied or surgery
may be performed without it)
8. Measure corneal opacity / diameter of
cone of keratoconus
9. Select trephine for host and donor (in case
of donor size of trephine is usually 0.5 mm
larger)

29 June 2020 Dr A R Patil 47

 Steps of Keratoplasty
10. Recipient cornea is cut with
trephine and corneo-scleral scissors
11. Donor tissue is cut from the
endothelial side after covering
endothelial surface with visco-elastic
material
12. Donor tissue is placed on recipient
bed (area from where the diseased
cornea has been removed)
29 June 2020 Dr A R Patil 48
 Steps of Keratoplasty
13. Sutures are applied with 10-0 nylon
suture, interrupted 16 in number , or
combination of interrupted and
continuous
14.Subconjunctival injection of antibiotic and
steroids is given
15. Follow-up protocol: Daily for indoor
patients, weekly or fortnightly for first three
months then monthly or six months, then two
monthly for one year and then yearly for life
long

29 June 2020 Dr A R Patil 49

 Post-operative complications
1. Wound leak/ gapping
2. Infection
3. Persistent epithelial defect
4. Inflammation
5. Primary and secondary graft failure
6. Elevated intra-ocular pressure
7. Astigmatism
8. Inflammation
9. Cystoid macular edema and retinal
detachment

29 June 2020 Dr A R Patil 50

 Keratoplasty
• Cornea is avascular structure therefore it
is privileged. The chance of graft rejection
are less than that of other organs like
heart, liver, kidney and bone marrow

29 June 2020 Dr A R Patil 51

 Eye Bank
FUNCTIONS OF EYE BANK
1. Identification and screening of donors
2. Procurement of eyes and corneal tissue
3. Laboratory processing of tissue,
including preservation and bio-
microscopic examination of tissue
4. Storage of tissue
5. Distribution of tissue for transplantation,
research and teaching
29 June 2020 Dr A R Patil 52
 Donor Selection
1. Donor family
2. Recipient
3. Eye Bank
4. Surgeon

Donor Age considerations: donors of less

than 21/2 years and more than 70 years
are generally considered unfavourable
29 June 2020 Dr A R Patil 53
 Donor selection
• Optimum death to enucleation and
enucleation to interim storage time :
generally less than 6 hours, can be
extended upto 12 hours in selected cases

29 June 2020 Dr A R Patil 54

 Criteria for Ideal Corneal
Preservation method

1. Maintains endothelial viability

2. Allows assessment of endothelial viability
3. Maintains a clear, thin cornea during
preservation
4. Allows unlimited preservation time
5. Ensures sterility
29 June 2020 Dr A R Patil 55
 Ideal Corneal Preservation method
6. Allows transportation of donor tissue
7. Offers technical simplicity
8. Provides suitable tissue for lamellar
keratoplasty, epikeratoplasty or
penetrating keratoplasty
9. Cost effective

29 June 2020 Dr A R Patil 56

 Hazardous Donor material

29 June 2020 Dr A R Patil 57

Tissues from donors with the
following conditions is potentially
hazardous to eye bank personnel
and requires special handing:

1. Active viral hepatitis

2. AIDS / HIV seropositivity
3. Active viral encephalitis or encephalitis or
unknown origin
4. Creutzfeldt-Jakob disease
5. Rabies
29 June 2020 Dr A R Patil 58
 Contraindications
Tissues from donors with the following
conditions are potentially health
threatening for the recipients or pose a
risk to the success of the surgery and
should not be offered for surgical
purposes:
1. Death from unknown cause
2. Death due to viral diseases
29 June 2020 Dr A R Patil 59
 Contraindications
3. Death due to neurologic disease of un-
established diagnosis
4. Acute septicemia
5. Viral hepatitis

29 June 2020 Dr A R Patil 60

 Contraindications
6. Intrinsic eye diseases: Retinoblastoma,
malignant tumour of anterior ocular
segment , active ocular inflammatory
disease, congenital or acquired disorders
of the eye, corneal opacity, keratoconus,
keratoglobus, pterygia , prior intra-ocular
or anterior segment surgery
7. Leukemias, HIV, Rabies, Hepatitis B

29 June 2020 Dr A R Patil 61

 Methods of Corneal Preservation
I. Short term preservation: (upto 48 hours)
a. Moist chamber storage at 4 deg C,
most of the surgeons use cornea within
24 hours
b. M.K. Medium (Mc Carey and
Kaufman medium) : for preservation of
corneo-scleral segment. Human
Corneal endothelium may remain viable
for period up-to 4 days
29 June 2020 Dr A R Patil 62
 Methods of Corneal Preservation
II. Intermediate term storage (0 to 10 days):
K-sol, Corneal storage medium, Dexsol,
Optisol medium peservation

29 June 2020 Dr A R Patil 63

 Methods of Corneal Preservation
III. Long term preservation:
a. Cryopreservation, preservation of corneo-
scleral segment in cryoprotective solution and
stored at -70 deg C for an year or longer
Before use thawing of the tissue is a complex
process (not very popular method)
b. Organ culture at 34 deg C tissue can be
preserved for up 30 days

29 June 2020 Dr A R Patil 64

 Thank you for your attention

29 June 2020 Dr A R Patil 65