Compressive C-shaped lamellar keratoplasty: A surgical alternative for the management of severe astigmatism from peripheral corneal degeneration

doi:10.1016/j.ophtha.2004.10.033

Ophthalmology

Volume 112, Issue 3, March 2005, Pages 425-430

Presented at: American Academy of Ophthalmology Annual Meeting, November, 2001; New Orleans, Louisiana.

https://doi.org/10.1016/j.ophtha.2004.10.033 Get rights and content

Objective

To describe a compressive lamellar surgical technique for treating severe astigmatism in peripheral corneal ectasia.

Design

Retrospective, noncomparative, interventional case series.

Participants

Four eyes of 3 patients with either pellucid or Terrien's marginal corneal degeneration were included in this series.

Methods

C-shaped lamellar keratoplasty using multiple trephines of different sizes, with deliberate undersizing of the donor graft for a controlled compressive effect, was performed on these patients.

Main outcome measures

Visual acuity outcome and refraction were measured at different intervals at up to 40 months of follow-up.

Results

All eyes achieved Snellen visual acuity of 20/40 or better and stable astigmatism ranging from 0 to −2.75 diopter cylinder within 6 months, with no recurrence of corneal thinning or peripheral corneal vascularization.

Conclusions

Compressive C-shaped lamellar keratoplasty is able to reduce severe corneal astigmatism in peripheral corneal ectasia and can result in good visual and refractive outcomes with early visual rehabilitation.

Section snippets

Surgical technique

All procedures were performed under general anesthesia. The conjunctiva adjacent to the superior or inferior ectasia first was incised and retracted away from the limbus for adequate exposure. The exact extent of peripheral corneal thinning and ectasia then was outlined carefully with a fine surgical marker. To regularize the size and shape of the ectasia, circular keratoplasty trephines (Solan; Xomed Surgical Products, Inc., Jacksonville, FL) of standard diameters were inked and used to mark

Patient 1

A 59-year-old Indian female had progressive decrease in visual acuity in the right eye for a few years. Slit-lamp examination showed presence of marked pellucid marginal degeneration of the right cornea with a peripheral corneal rim of severe thinning and bulging in the inferior cornea (Fig 4). The best-corrected visual acuity was counting fingers at 1 m. Corneal topography showed a classical butterfly-shaped configuration with severe against-the-rule astigmatism of −17.40 diopter cylinder (DC)

Results

Four eyes of 3 patients with pellucid marginal corneal degeneration or Terrien's marginal corneal degeneration were included in the study. There were 2 female and 1 male patients, with the age range of 48 to 64 years. Postoperative follow-up ranged from 16 to 40 months, with a mean of 23 months. The average postoperative refractive cylinder was −1.93 D. Before surgery, best-corrected visual acuity ranged from 20/80 to counting fingers at 1 m. After surgery, all eyes were able to achieve a

Discussion

Severe peripheral corneal degeneration, including pellucid marginal corneal degeneration and Terrien's marginal degeneration are rare disorders; however, there may be considerable underestimation of the incidence, because some patients may be misdiagnosed as keratoconus.13, 14, 15 Pellucid marginal corneal degeneration is a noninflammatory disorder showing a typical crescent-shaped area of thinning in the inferior portion of the cornea.¹ Protrusion of the cornea occurs above a band of thinning,

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Cited by (29)

Evaluation of Mooren's corneal ulcer by anterior segment optical coherence tomography
2023, Photodiagnosis and Photodynamic Therapy
This study evaluates the use of anterior segment optical coherence tomography (AS-OCT) to identify focal changes and inform surgical plans in eyes with Mooren's ulcer.
A total of 18 eyes of 17 patients with Mooren's ulcer were examined prospectively using the AS-OCT system.
Optical hyperreflectivity noted on AS-OCT images was in accordance with corneal ulceration, neovascularization, fibrovascular membranes, the junction of the native stromal bed, and the overlying lamellar corneal grafts. Focal corneal ectasia was observed in 13 eyes with a decrease in corneal thickness to ≤0.39 mm. There was a cut-off value of 0.39 mm in corneal thickness between the eyes with and without focal corneal ectasia in the thinned corneal area (Fisher = 0.383, χ² = 14.873, P = 0.000). Based on the AS-OCT findings, six eyes were subjected to an individualized lamellar corneal graft. The thickness of the residual cornea after surgery was 47 ± 34 μm less than the presumed healthy corneal thickness before surgery (t = 3.376, P = 0.02). A small corneal perforation covered by a pseudopterygium in Mooren's ulcer was found through AS-OCT but undetectable by slit-lamp biomicroscopy.
AS-OCT is a valuable non-contact technique for monitoring corneal thinning in Mooren's ulcer, and assisting surgical design. A decrease in peripheral corneal thickness to ≤0.39 mm may cause focal corneal ectasia.
Toric soft contact lens fit in a postoperative LASIK keratoectasia patient with high and irregular astigmatism
2011, Optometry
Citation Excerpt :
Such presentations exist in keratoconus and postoperative keratoectasia patients. Although irregular astigmatism is less successfully treated with surgery, attempts have been made via compressive C-shaped lamellar keratoplasty, stromal Intacs corneal implants implantation, corneal collagen cross linking, and conductive keratoplasty.12-15 The patient was amenable to correction with a contact lens because stromal Intacs corneal implants implantation, corneal collagen cross-linking, and conductive keratoplasty for the correction of high and irregular astigmatism were not approved by the U.S. Food and Drug Administration at that time.
Keratoectasia is a rare but well-known complication after laser-assisted in situ keratomileusis (LASIK). Patients with this condition can have high and irregular astigmatism. When the treatment of the high astigmatic correction cannot be accomplished surgically or when the keratoectasia patient rejects surgical enhancement, optical correction with devices such as soft or rigid gas-permeable contact lenses may be pursued. In fact, toric soft contact lenses are a good first option for fitting postoperative keratoectasia patients.
A 58-year-old white male presented for an examination with a complaint of decreased distance vision in the right eye (OD) after having traditional LASIK for myopia with astigmatism in both eyes (OU) in 1999 and limbal relaxing incision enhancement OD in 2003. Refraction showed high mixed astigmatism OD (+1.75 -5.75×075). Slit lamp examination found irregularity of the cornea, evidenced by an inferior cone with pigmented Fleischer ring OD. Video keratometry had keratometry readings of 43.50 at 160, 39.87 at 070, elevated shape measure (0.40), elevated corneal irregularity measure (3.96), an inferior cone on the elevation map, and asymmetric bowtie with elongation inferonasally on the axial map, which confirmed the diagnosis of postoperative keratoectasia. Because new surgical treatments at that time for corneal ectasia were in their infancy and not approved by the U.S. Food and Drug Administration, the patient opted for a trial toric soft contact lens fitting, which improved his corrected distance visual acuity to 20/25.
This case report confirms that toric soft contact lenses are a good first choice in fitting patients with high and irregular astigmatism from postoperative LASIK corneal ectasia. It also confirms that excellent vision and comfort with toric soft contact lenses is possible in these patients.
Peripheral corneal disease with thinning
2008, Corneal Surgery: Theory Technique and Tissue: Fourth Edition
Terrien marginal degeneration
2019, Survey of Ophthalmology
Citation Excerpt :
The second group of surgeries aims to both enhance the visual acuity and to restore the integrity of the eye. These surgeries include ectatic tissue excision and suture of the adjacent unaffected stroma,9 epikeratophakia,13 partial or total penetrating keratoplasty,8,41 and lamellar keratoplasty (LK).14,16,18,25,28,35,46,61 Table 3 demonstrates visual results of various surgical techniques.
Terrien marginal degeneration, a rare disease resulting in peripheral corneal thinning, commonly occurs in middle-aged males and usually manifests clinically with decreased visual acuity from increased corneal astigmatism. Although the exact etiology is unknown, hypotheses focus on possible degenerative and inflammatory origins. Histopathologic studies often reveal characteristic findings of innumerable intracellular and extracellular vacuoles in the affected stroma. Distinguishing Terrien marginal degeneration from other peripheral corneal diseases such as Mooren ulcer and pellucid marginal degeneration is important. Nonsurgical interventions include spectacles, rigid gas-permeable contact lenses, and scleral lenses; however, when the corneal thickness is ≤150 μm, surgical interventions including tectonic grafting and lamellar keratoplasty may be necessary.
Surgical management of peripheral corneal thinning disorders
2019, Survey of Ophthalmology
Citation Excerpt :
Use of undersized graft and tight sutures causes a flattening perpendicular to the circumference and corrects the steepening and high astigmatism occurring because of the disease process. Cheng and coworkers31 reported 2.75 D or less astigmatism in their 4 patients after the surgery with at least 6 months of follow-up; however, 2 patients later had against-the-rule astigmatic drift after they underwent cataract surgery that was corrected by astigmatic keratotomy.31 In another modification, Liu and coworkers78 developed the technique of double-layer peripheral keratoplasty combined with immunosuppression for management of Mooren ulcer.
The peripheral corneal thinning disorders are associated with degenerative, autoimmune, or infective causes. Corneal thinning can subsequently affect the visual acuity either by inducing severe astigmatism or by progressive involvement of the central cornea. In addition to this, the integrity of the eye is at risk. Medical management is necessary to address the underlying inflammatory or infectious causes; however, most of the cases require surgical intervention for tectonic support or for visual rehabilitation in patients with severe astigmatism. Preoperative investigations help in mapping the corneal curvature and thickness, thereby facilitating planning of treatment. Routine corneal transplantation techniques do not yield good results in peripheral corneal thinning disorders. Various surgical modifications have been described to manage these challenging cases. We review the available literature on causes and management of peripheral corneal thinning disorders.
Endothelium sparing – Air-assisted wedge resection for the treatment of pellucid marginal degeneration
2024, Indian Journal of Ophthalmology

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: Manuscript no. 230765.

: The authors do not have any financial interest in this study.

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Original articleCompressive C-shaped lamellar keratoplasty: A surgical alternative for the management of severe astigmatism from peripheral corneal degeneration

Objective

Design

Participants

Methods

Main outcome measures

Results

Conclusions

Section snippets

Surgical technique

Patient 1

Results

Discussion

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

J Cataract Refract Surg

Am J Ophthalmol

Ophthalmology

Original article
Compressive C-shaped lamellar keratoplasty: A surgical alternative for the management of severe astigmatism from peripheral corneal degeneration