Corneal Opacity

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• Normal cornea is a transparent Structure.

• Any condition which upsets its anatomy or

physiology causes loss of its transparency
to some degree
• Corneal opacification – loss of normal
transparency
• Corneal opacity due to scarring
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 Causes
• Congenital a) Developmental anomalies
b) Birth trauma

• Healed corneal wounds

• Healed corneal ulcers

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 Clinical features
• Loss of vision – Covers pupillary area

• Blurred vision – other than pupillary area

due to astigmatic effect

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 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

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 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

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 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 simplex) Corneal
Opacity: it is very dense, white totally
opaque obscuring view of iris and pupil
totally

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 Types
4. Adherent Leucoma
When iris is adherent to leucomatous
corneal opacity, which develops following
healing of perforation of corneal ulcer, the
condition is called adherent leucoma.

5. Corneal facet
Corneal surface depressed at the site of
healing due to less fibrous tissue
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 Corneal facet

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 Types
• 6. kerectasia
• Corneal curvature increased at the site of
opacity (bulge out due to weak scar)

7. Anterior staphyloma
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
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 Types

anterior staphyloma if it is ectatic (ectatic

cicatric with incarceration/ incorporation of
Iris is called anterior staphyloma)

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 kerectasia

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 Anterior staphyloma

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 Classification based on location

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

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

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

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 Peripheral Adherent Leucoma

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 Central Corneal Opacities

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 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)
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 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

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 Central Corneal Opacity
Small central nebular corneal opacity occupying pupil partially

It may cause significant visual disturbance by causing irregular refraction of

Light

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 Central Corneal Opacity
Small central macular corneal opacity occupying pupil partially

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Small Central Macular Corneal Opacity

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 Central Corneal Opacity
Small central leucomatous corneal opacity occupying pupil partially

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Small Maculo-leucomatous Corneal
Opacity in pupillary area

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 Central Corneal Opacity
Central nebular corneal opacity occupying entire pupillary area

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 Central Corneal Opacity
Central macular corneal opacity occupying entire pupillary area

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 Maculo-leucomatous Corneal
Opacity in pupillary area

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 Central Corneal Opacity
Central leucomatous corneal opacity occupying entire pupillary area

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 Leucomatous Corneal Opacity

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 Central Maculo-leucomatous
Corneal Opacity

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Central and Peripheral Corneal Opacity

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 Central and Peripheral Corneal
Opacity

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 Central and Peripheral
Leucomatous Corneal Opacity

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Central and Peripheral Corneal Opacity

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Central and Peripheral Corneal Opacity

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 Secondary changes in Opacity
• Hyaline degeneration

• Calcareous degeneration

• Pigmentation

• Atheromatous ulceration

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 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)
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 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

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 Leucomatous Corneal Opacity

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 Optical Iridectomy (Lower Temporal)

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 Central Maculo-leucomatous
Corneal Opacity

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 Optical Iridectomy (Lower Nasal)

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 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
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 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

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 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)

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 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
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 Tattooing

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 Cosmetic coloured contact lens
• Ugly scar having no potential for vision

• Very Good cosmetic appearance

• Best option over tattooing

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 Keratoplasty
(Corneal Grafting)

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 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

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 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)

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

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 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)

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 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)

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 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)
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 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

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 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

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 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

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 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
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 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
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 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

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 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
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 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

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 Hazardous Donor material

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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
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 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
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 Contraindications
3. Death due to neurologic disease of un-
established diagnosis
4. Acute septicemia
5. Viral hepatitis

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 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

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 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
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 Methods of Corneal Preservation
II. Intermediate term storage (0 to 10 days):
K-sol, Corneal storage medium, Dexsol,
Optisol medium peservation

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 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

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 Thank you for your attention

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