Band Keratopathy Treatment & Management
- Author: Michael Taravella, MD; Chief Editor: John D Sheppard, Jr, MD, MMSc more...
Superficial debridement or lamellar keratectomy in band keratopathy is usually effective in restoring normal vision. Various adverse outcomes can result from the procedure, including corneal scarring and vision loss, but the incidence of such complications is very low. Although medical therapy is ineffective in treating band keratopathy, underlying conditions associated with elevated levels of calcium or phosphate should be treated to prevent deposition from recurring.
As noted, excessive vitamin D intake has been associated with band keratopathy, as has milk-alkali syndrome. Excessive absorption and serum elevation of calcium is the consequence of these 2 diet-related problems.
Superficial Debridement and Lamellar Keratectomy
Superficial debridement can be performed in a minor operating room under topical anesthesia. Proparacaine or tetracaine drops can be used for this purpose. Use of an operating microscope is recommended.
Place a lid speculum to hold open the eyelids, and debride the epithelium overlying the calcium with an ophthalmic surgical blade or spatula.
Apply 0.05 mol, 1.5% neutral disodium ethylenediaminetetra-acetic acid (EDTA) to the corneal surface, if available. Weck-cel sponges soaked in this solution can be used for this purpose. Alternatively, the solution can be placed in a water bath over the cornea to limit ocular exposure.
Calcium deposits are then removed with firm scraping of the corneal surface with a blunt spatula or a No. 64 or No. 69 Beaver Blade. (A Paton spatula works well.) Often, it is necessary to apply solution, followed by scraping several times to remove the plaque. The primary goal is to clear the visual axis. Thin calcium deposits may come off in 5 minutes, while thick plaques may take 30-45 minutes to dissolve.
Once the deposits have been scraped, an assessment of the smoothness of the underlying stroma can be made. If the surface is very irregular, phototherapeutic keratectomy with an excimer laser can be performed to smooth the surface. Ideally, this procedure is performed in the same setting.
Note that the excimer laser should not be used to remove calcium. Attempting to remove band keratopathy with the excimer laser alone will result in significant irregular astigmatism, since the cornea, not calcium, will be ablated preferentially. The role of the excimer is to polish the surface after the plaque has been removed.
Irrigate the eye thoroughly following the procedure to remove EDTA solution from the conjunctival surface and fornices.
Place a bandage contact lens over the cornea. Alternatively, pressure patching or frequent antibiotic ointment can be used.
More advanced cases, particularly those that invade the Bowman membrane, may require a more extensive lamellar keratectomy technique with retrobulbar anesthesia and operating-room control of the surgical field. These procedures are best accomplished with a Beaver Blade followed by Weck-cel sponge polishing. More extensive polishing of exposed Bowman membrane with a rotating diamond burr may minimize irregular astigmatism after extensive keratectomy. Facilitation of calcium removal with the application of EDTA has been recommended in the past but has fallen from popularity owing to a lack of controlled trials, the absence of extensive case series, and difficulties in obtaining the EDTA from compounding pharmacies.
Extensive keratectomy inevitably creates limbal bleeding, particularly in cases associated with superficial corneal neovascularization or interstitial keratitis. It is important to control this bleeding with pressure or topical vasoconstrictors alone, since cautery application can damage limbal stem cells.
A therapeutic bandage soft contact lens (CTL) is instrumental in recovery following debridement or lamellar keratectomy. The CTL provides significant pain relief, protection from blink disruption of re-epithelialization, and a scaffold for epithelial migration from the limbus.
A sutureless amniotic membrane can be applied to enhance healing, particularly when delayed epithelialization is anticipated, such as in patients with neurotrophic disease, chronic ocular surface inflammation, or advanced age.
Postoperative care includes the insertion of a bandage contact lens that is left in place until the epithelium heals. Topical nonsteroidal agents are useful for pain control immediately following the procedure and for the first few days afterwards.
An antibiotic drop should be prescribed with the bandage contact lens in place. Use of a topical steroid drop (eg, prednisolone acetate, not prednisolone phosphate) is helpful for comfort and treatment of the inflammation and corneal edema that are often present in the early postprocedure period. These medications can be stopped when the epithelium is healed and the bandage contact lens is removed (usually within the first 1-2 wk).
The main complications related to the removal of calcium deposits on the corneal surface include the following (it is also possible that additional procedures will be needed):
Recurrence of the calcium band
Decreased vision or vision loss
Persistent or aggravated irregular astigmatism
Occasionally, a mild subepithelial haze can be seen weeks after EDTA chelation. This may resolve on its own. A mild topical steroid (eg, fluorometholone 0.1%) may help to resolve this haze. If there is significant damage to the Bowman membrane, the haze may be permanent.
Jhanji V, Rapuano CJ, Vajpayee RB. Corneal calcific band keratopathy. Curr Opin Ophthalmol. 2011 Jul. 22(4):283-9. [Medline].
Bernauer W, Thiel MA, Kurrer M, et al. Corneal calcification following intensified treatment with sodium hyaluronate artificial tears. Br J Ophthalmol. 2006 Mar. 90(3):285-8. [Medline].
Doostdar N, Manrique CJ, Hamill MB, Barron AR. Synthesis of calcium-silica composites: a route toward an in vitro model system for calcific band keratopathy precipitates. J Biomed Mater Res A. 2011 Nov. 99(2):173-83. [Medline].
Daniel E, Pistilli M, Pujari SS, Kaçmaz RO, Nussenblatt RB, Rosenbaum JT, et al. Risk of Hypotony in Noninfectious Uveitis. Ophthalmology. 2012 Jul 12. [Medline].
Federman JL, Schubert HD. Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology. 1988 Jul. 95(7):870-6. [Medline].
Sternberg P Jr, Hatchell DL, Foulks GN, et al. The effect of silicone oil on the cornea. Arch Ophthalmol. 1985 Jan. 103(1):90-4. [Medline].
Morphis G, Irigoyen C, Eleuteri A, Stappler T, Pearce I, Heimann H. Retrospective review of 50 eyes with long-term silicone oil tamponade for more than 12 months. Graefes Arch Clin Exp Ophthalmol. 2012 May. 250(5):645-52. [Medline].
Porter R, Crombie AL. Corneal and conjunctival calcification in chronic renal failure. Br J Ophthalmol. 1973 May. 57(5):339-43. [Medline].
Kennedy RE, Roca PD, Landers PH. Atypical band keratopathy in glaucomatous patients. Am J Ophthalmol. 1971 Nov. 72(5):917-22. [Medline].
Taravella MJ, Stulting RD, Mader TH, et al. Calcific band keratopathy associated with the use of topical steroid- phosphate preparations. Arch Ophthalmol. 1994 May. 112(5):608-13. [Medline].
Kompa S, Redbrake C, Dunkel B, et al. Corneal calcification after chemical eye burns caused by eye drops containing phosphate buffer. Burns. 2006 Sep. 32(6):744-7. [Medline].
Moisseiev E, Gal A, Addadi L, Caspi D, Shemesh G, Michaeli A. Acute calcific band keratopathy: case report and literature review. J Cataract Refract Surg. 2013 Feb. 39(2):292-4. [Medline].
Smolin G. Corneal dystrophies and degenerations. The Cornea. 1994. 500-503.
Anderson SB, de Souza RF, Hofmann-Rummelt C, et al. Corneal calcification after amniotic membrane transplantation. Br J Ophthalmol. 2003 May. 87(5):587-91. [Medline].
Klaassen-Broekema N, van Bijsterveld OP. Limbal and corneal calcification in patients with chronic renal failure. Br J Ophthalmol. 1993 Sep. 77(9):569-71. [Medline].
Sharma N, Mannan R, Sinha R, Kaushal S, Titiyal JS, Kumar A, et al. Excimer laser phototherapeutic keratectomy for the treatment of silicone oil-induced band-shaped keratopathy. Eye Contact Lens. 2011 Sep. 37(5):282-5. [Medline].
Najjar DM, Cohen EJ, Rapuano CJ, Laibson PR. EDTA chelation for calcific band keratopathy: results and long-term follow-up. Am J Ophthalmol. 2004 Jun. 137(6):1056-64. [Medline].