I. Case History
45 year old Caucasian male Referral to the clinic for scleral lens fitting of the right eye after tectonic lamellar keratoplasty for corneal perforation secondary to peripheral ulcerative keratitis Ocular history: Peripheral Ulcerative Keratitis, OU; Glaucoma Suspect, OU; Post-corneal transplant, OD; Irregular Astigmatism, OU. Medical History: Depression, former smoker Medications: Latanoprost 0.005% QD OU; Timolol Maleate 0.5% BID OU; Prednisolone Acetate 1% QD OU
II. Pertinent findings
Visual Acuities (VA) with correction: OD 20/300-; OS 20/40. Refraction: o OD: +1.25 -1.25 x 015 VA: 20/300 o OS: +3.00 -0.50 x 010 VA: 20/20- Intraocular Pressures (IOP) o OD: 14 mmHg o OS: 28 mmHg . With compliant latanoprost and timolol treatment Anterior Segment: o OD: . Nasal pinguecula and 1+ conjunctival injection . Inferior tectonic lamellar graft from 3-9 o’clock arcing inferior to the pupil with sutures intact temporal and nasal, significant stromal scarring . Diffuse pigment on endothelium o OS: . Nasal pinguecula and 1+ conjunctival injection . s/p temporal pterygium removal . Stromal scarring and peripheral thinning inferior cornea
Topography via Pentacam o OD: K’s 35.6/[email protected] . 16.4 Diopters of Irregular Corneal Astigmatism o OD HVID: 11.9 mm
III. Differential diagnosis
Terrian’s Marginal Degeneration o Presents as bilateral marginal furrow o Non-ulcerative peripheral thinning beginning superiorly and progressing o (-) epithelial defect, pain, discomfort, redness, inflammation o Typically begins superior Pellucid Marginal Degeneration o Typically inferior non-ulcerative peripheral thinning o (-) epithelial defect, pain, discomfort, redness, inflammation o “crab claw” or “kissing dove” corneal topography
IV. Diagnosis and discussion
Peripheral Ulcerative Keratitis (PUK) o Characterized by crescent shaped lesion of the juxtalimbal corneal stroma. o Lesion typically shows stromal thinning and inflammation with an overlying epithelial defect. o Incidence of 3 cases per million per year. o Typically present with pain, redness, tearing, photophobia, and decreased vision. o Progressive thinning may lead to corneal perforation. o The tendency for peripheral location is due to characteristics of the limbal conjunctiva, which provides access for circulating immune complexes to the peripheral cornea via the capillary network.1 o Typically associated with autoimmune conditions in 50% of cases such as rheumatoid arthritis, Systemic Lupus Erythematosus (SLE), Wegener’s Granulomatosus, etc.1 o Mooren’s Ulcer – PUK with unknown etiology and no related autoimmune condition underlying the ulceration Tectonic Lamellar Keratoplasty o A tectonic graft only replaces the area of cornea that is damaged o Lamellar keratoplasty removes the corneal stroma down to Descemet’s membrane and replaces it with tissues from a donor cornea, leaving the host endothelium intact. o Lamellar keratoplasty is advantageous over penetrating keratoplasty (PKP) in cases of PUK o More host tissue and increase corneal thickness to help prevent repeat corneal perforations.2 o PKP has increased rejection rate due to inflamed limbal and conjunctival blood vessels surrounding area of ulceration1
V. Treatment, management
The patient was fit with ZenLens Oblate Design OD o Power: +1.00D o Base Curve: 7.9 mm o Diameter: 17.0 mm o VA: 20/20 o Central vault approximately 250 um, full limbal clearance 360, aligned edge Fit with Air Optix Aqua, OS o Patient’s habitual lens, did not want a scleral lenses OU o Power: +3.00D o VA: 20/20- Patient was extremely satisfied with the comfort of his scleral lens and improved vision from 20/300 to 20/20. Lens was evaluated and found to be acceptable at follow up appointments. Continue Latanoprost 0.005% QD, Timolol Maleate 0.5% BID, and Prednisolone Acetate 1% QD. Follow up 3 months for IOP check and visual fields for glaucoma suspect. Return to corneal specialty annually as directed for post-corneal transplant care. (1) Yagci, A. (2012). Update on peripheral ulcerative keratitis. Clinical Ophthalmology (Auckland, N.Z.), 6, 747–754. http://doi.org/10.2147/OPTH.S24947 (2) Bessant, D. "LAMELLAR KERATOPLASTY IN THE MANAGEMENT OF INFLAMMATORY CORNEAL ULCERATION AND PERFORATION." Eye 8 (1994): 22-28. Web.
VI. Conclusion
When fitting a scleral lens over a corneal transplant, fitting with an oblate scleral lens design will provide the best outcome Utilizing corneal and scleral topography to map corneal astigmatism, K’s, HVID, and scleral toricity help to improve scleral lens fittings. Maintain an open communication with the corneal surgeon to provide optimal patient care for post-transplant patients.