Corneal keloids are rare and typically reported following trauma (including post-surgical) and has been reported without any trauma or previous surgery. A corneal keloid differs from a hypertrophied scar in that it occurs months/years after the injury, enlarges over time and extends beyond the orders of the original traumatized tissue. They are typically solitary, firm, elevated and well-demarcated from the normal tissue. The authors report two cases with no trauma/surgical history. Case 1 was that of a 21 year old Caucasian man with a five year history of enlarging white opacity on the central cornea, OCT showed only anterior stromal involvement with a defined plane. His uncorrected visual acuity was 20/70 and BCVA 20/20. Superficial keratectomy (SK) was carried out followed by recurrence which was treated with two further SK and PTK with topical Mitomycin 0.02%. Further recurrence confined to the diameter of the excimer laser ablation required a DALK (Femto assisted). Eight months post-op his BCVA was 20/25. Histology showed irregular epithelium overlying anterior lamellar stromal scarring and thick collagen bundles associated with exuberant fibroblastic proliferation consistent with corneal keloid. Case 2 was that of a 24 year old African American man presenting with bilateral corneal opacities which were present since the age of seven and grew dramatically in the preceding two years. He underwent bilateral SK at the age of nine years with rapid recurrence. At the age of 13 he underwent PK in the left eye with dense recurrence two weeks post-operatively. He became legally blind for 11 years and developed sensory deprivation nystagmus and underwent Boston K pro type 1 (for blinking eye with no cicatrisation or lid abnormalities) including intra-operative lensectomy and vitrectomy. Three months post-operatively his uncorrected VA was 20/20 with recurrence to the edge of the keratoprosthesis titanium front plate. Histology showed coarse collagen bundles, granulation tissue and fibroblasts consistent with corneal keloid. Keloids have also been described congenitally in association with Lowe’s syndrome. The differentials are Salzmannoid nodular degeneration, Peter’s anamoly and fibrous hystiocytoma in addition to conditions causing diffuse corneal oedema. Histology usually shows a thickened corneal epithelium, overlying an anterior stroma with irregularly arranged collagen bundles, with activated fiboblasts and myofibobalsts which later become hyalinised collagen. Hypertrophied scar tissue involves subepithelial tissue and the collagen bundles are less haphazard and less hyalinized. Some have hypothesized that keloids and hypertrophic scars represent successive stages of the same condition driven by an inflammatory process. It is interesting to note that the front plate of the Boston K-pro type 1 appears to have halted the margin of recurrence in the second case and the authors comment that this should be considered as the primary corneal procedure in such cases. It would certainly be worth considering following recurrence after repeat SKs as an alternative to a penetrating or lamellar keratoplasty.
Corneal keloid: Report of natural history and Outcome of Surgical Management in Two Cases
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