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Treatment of Band Keratopathy by Excimer Laser Phototherapeutic Keratectomy: Surgical Techniques and Long Term Follow Up

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Treatment of Band Keratopathy by Excimer Laser Phototherapeutic Keratectomy: Surgical Techniques and Long Term Follow Up 702B70tish27oumalof0phthalmolo2y 1993; 77: 702-708 Treatment of band keratopathy by excimer laser phototherapeutic keratectomy: surgical Br J Ophthalmol: first published as 10.1136/bjo.77.11.702 on 1 November 1993. Downloaded from techniques and long term follow up D P S O'Brart, D S Gartry, C P Lohmann, A L Patmore, M G Kerr Muir, J Marshall Abstract remove corneal tissue with extreme precision A series of 122 eyes with band keratopathy was and minimal adjacent tissue damage.>" The treated by excimer laser phototherapeutic second is large beam cross sections, typically keratectomy (PTK), with a mean foliow up of several millimetres in diameter, which allow over 12*3 months (range 3 to 60 months). A simultaneous treatment ofwide areas. single photoablation zone was used to remove Excimer lasers have been used to remove the opacity over the visual axis in smooth superficial opacities from the corneal visual axis surfaced band deposition. In eyes with and to smooth irregular corneal surfaces.7' 12-15 reduced vision, an improvement was reported The former results in an improvement in vision in 88% and in a series of 66 eyes mean Snelien and a reduction in glare7 12-14 and the latter visual acuity increased significantly (p<005, produces increased ocular comfort7 or allows the t=2-27). A reduction in glare was reported in subsequent use of contact lenses. 4I5 88% and in a series of 17 patients, visual The results of excimer laser phototherapeutic contrast sensitivity (p<001) and measure- keratectomy (PTK) in previous studies include a ments of disability glare (p<001) improved maximum follow up of 28 months, with only postoperatively. The mean hyperopic shift in small numbers treated for band keratopathies. 32 eyes at 6 months was 1.4 D (range 0-4-25 D). We present a series of97 patients (122 eyes) with Multiple overlapping ablation zones, with band keratopathy treated by PTK, with a maxi- mechanical debulking of large calcium mum follow up of 60 months. We also report on plaques, were used to smooth the irregular one pathological specimen, obtained 12 months corneal surface in eyes with rough bands. after laser surgery. Ocular discomfort was improved in 95%. Band keratopathy recurred in nine eyes (8%) within 2 to 30 months (mean 12 months) of surgery, Materials and methods with silicone oil responsible in five eyes. Reablation was necessary in three eyes and EXCIMER LASER performed successfuliy in all cases. Excimer A Summit Technology UV200 excimer laser was laser PTK is a safe and effective outpatient used with a spectral emission at 193 nm. The treatment for band keratopathy. pulse energy resulted in a radiant exposure of (BrJ Ophthalmol 1993; 77: 702-708) 180 tnJ/cm2 and the pulse frequency was fixed at http://bjo.bmj.com/ 10 Hz. The beam configuration was circular in cross section, with fixed diameters, selected to be Band shaped keratopathy was first described by between 1-0-5X0 mm. Dixon in 1848' and subsequently by his associate Bowman in 1849.2 It is a degenerative condition, characterised by the slow development of a grey SUBJECTS white opacity ofthe superficial cornea, usually in There were 97 patients (122 eyes) treated for on October 3, 2021 by guest. Protected copyright. the interpalpebral zone. band keratopathy. Although there was a large Patients may complain of glare and disturbed morphological spectrum these patients could be vision when the pathology extends over the separated into two broad groups: 'smooth' and visual axis. Provided the epithelial surface 'rough'. In smooth surfaced band deposition the Department of remains intact such eyes are comfortable, but epithelium was intact with the calcified material Ophthalmology, once it is breached there is considerable ocular lying at the level of Bowman's layer. These eyes St Thomas's Hospital, London irritation. were comfortable and usually had good visual D P S O'Brart The aim of surgical treatment is to remove the potential. In rough band keratopathy the D S Gartry opaque calcium deposits and/or restore the epithelium was unstable over calcified plaques. C P Lohmann agents were often blind The A L Patmore normal smooth corneal surface. Chelating These painful, eyes. M G Kerr Muir - for example, ethylenediaminetetra-acetic acid aetiology of all cases is shown in Table 1. J Marshall (EDTA),34 and superficial keratectomy have Smooth bands were treated in 78 eyes of 56 been advocated.5 6 However, the calcium deposi- patients. The average age was 66 years and the University Eye Clinic, Regensberg, Germany tion may be resistant to removal with EDTA and mean follow up was 10 months (range 3-54 C P Lohmann mechanical keratectomy may result in an months). In 18 cases the follow up was over 12 Correspondence to: irregular surface. months, while in nine it was over 2 years. Mr David O'Brart, was in Department of Clinical excimer lasers have become available Preoperatively, reduced vision reported Ophthalmology, St Thomas's since the mid 1980s and offer a new approach to 68 eyes and 48 had glare. Three eyes were treated Hospital, Lambeth Palace cataract Road, London SE1 7EH. the treatment of superficial corneal pathologies.7 to improve the peroperative view for Accepted for publicatisii The advantages of such lasers derive from two surgery. 22 June 1993 unique characteristics. The first is the ability to Rough band keratopathies were treated in 44 Treatmentofbandkeratopathy byexcimer laserphototherapeutic keratectomy 703 Table I Aetiologyfor band keratopathy in 97 patients trained to fixate on the target light for the Br J Ophthalmol: first published as 10.1136/bjo.77.11.702 on 1 November 1993. Downloaded from Nunber of predicted duration of the procedure. In bland Aetiological condition patiens eyes some patients were able to maintain fixation (i) Aetiology for smooth surfaced band deposition in 56 patients* using the fellow sighted eye. The noise associ- Primary (idiopathic) 17 ated with the laser was demonstrated to the Associated with glaucoma 15 Still'stchildhood uveitis 7 patients and they were warned to expect a smell Silicone oil 6 ofburning during treatment. A lid speculum was Sarcoid/hypercalcaemia 3t Other 8 inserted and the relevant procedure performed. (ii) Aetiology for rough band keratopathy in 41 patients* Postoperatively a mydriatic (homatropine 2%) Trauma (mainly penetrating) 8 and an antibiotic ointment (chloramphenicol Herpes zoster 7 1%) were instilled and the eye padded for 24 Herpes simplex keratitis 4 Silicone oil 4 hours. Oral analgesics were prescribed for the Glaucoma (blind eyes) 3 first 48 hours and chloramphenicol 0 5% Vernal plaques 2 eye Sarcoid/hypercalcaemia 2t drops were administered four times a day for 10 Uveitis (blind eyes) 2 days. The majority of patients were followed up Other 9 at 1 week and 1, 3, 6, 9, and 12 months and *Two patients had smooth calcium deposition in one eye and a annually thereafter. rough band in the other. tIn one patient rough calcified plaques eroded through the peripheral corneal epithelium, 18 months after successful treatment for a smooth band. SURGICAL TECHNIQUES Smooth band keratopathy eyes of41 patients. The average age was 56 years The axial opacification was removed using and the mean follow up was 16-3 months (range a single large ablation (4 0-5 0 mm) zone. 3-60 months). Follow up was greater than 12 In contrast to PRK the epithelium was not months in 21 cases and 24 months in 13. mechanically debrided. The intact epithelial Preoperatively ocular discomfort was reported in surface acted as a 'template' for the ablation 37 eyes, reduced vision in nine, and four patients procedure and no masking agents were required. were treated to allow cosmetic contact lenses to All laser pulses resulted in fluorescence in the be worn. target tissue but a brighter fluorescence occurred during ablation of the calcified deposits and the end point was determined by cessation of this ASSESSMENT AND EXAMINATION bright fluorescence. Usually less than 300 pulses Patients were fully counselled before surgery and were required to ablate through both the a detailed ocular examination performed. epithelium and the calcium to leave a clear Corneal topography was examined in selected circular 'window' over the visual axis (Fig 1). patients using a photokeratoscope (TMS-1 Topographic Modelling System, Computed Anatomy). Where possible, a full refraction was Rough band keratopathy http://bjo.bmj.com/ performed. In 17 patients with smooth band In eyes with a poor visual prognosis treatment keratopathy and Snellen visual acuities of6/18 or could be performed without the need to consider better visual contrast sensitivity and disability the refractive changes that might be induced. glare were measured preoperatively and 1 Multiple overlapping ablation zones were used to month after surgery using a specially designed smooth the irregular corneal surface. Any large computer program, which has been previously calcified plaques were removed with a scalpel described.'7 before PTK. These had a lower ablation rate per on October 3, 2021 by guest. Protected copyright. pulse than the surrounding corneal tissue and attempts to photoablate them directly may have THE PROCEDURE resulted in deep gutters being excised in the A local anaesthetic (amethocaine hydrochloride cornea around their edges. The troughs created 1%) was instilled. Where possible the patient was in the stroma by the removal ofthe plaques were Fig IA Fig IB Figure I Smooth surfaced band keratopathy. (A) The preoperative appearance. (B) The appearance 18 months after excimer ablation ofa single axial zone. The increased clarity ofthe ablated area is evident. The axial zone remains clear 36 months after surgery. 704 O'Brart, Gartry, Lohmann, Patmore, KerrMuir, Marshall PAIEiNT: >t- process. During the smoothing procedure it was often useful to slightly move the patient's eye, by 90 the surgeon gently moving the patient's head.
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