Band Keratopathy

Author: Michael Taravella, MD; Chief Editor: Hampton Roy r, MD

!"Bac#$round
Band keratopathy is characterized by the appearance of a band across the central cornea, formed
by the precipitation of calcium salts on the corneal surface (directly under the epithelium).
[1]
This
form of corneal degeneration can result from a ariety of causes, either systemic or local, !ith
isual acuity decreasing in proportion to the density of the deposition (see the image belo!).
("ee #tiology.)
Band keratopathy. $ote the bandlike !hitish%grey lesion across the corneal surface, sparing the
superior and inferior cornea.
"uperficial debridement generally restores ision and comfort for most patients !ith band
keratopathy, although failure to manage the source of the condition often leads to recurrence.
("ee &rognosis, Treatment, and 'edication.)
%"Etiolo$y
Corneal depo&ition of calcium &alt
"erum and normal body fluids (eg, tears, a(ueous humor) contain calcium and phosphate in
concentrations that approach their solubility product. #aporation of tears tends to concentrate
solutes and to increase the tonicity of tears) this is especially true in the intrapalpebral area,
!here the greatest e*posure of the corneal surface to ambient air occurs. #leated serum calcium
or serum phosphate can tip the balance in faor of precipitation.
+n addition, eleation of the surface p, out of the physiologic range changes the solubility
product and faors precipitation. This type of tissue p, change can be seen in chronically
inflamed eyes and may e*plain, in part, !hy patients !ith ueitis are at risk for the deelopment
of band keratopathy.
[-, ., /]
#ndothelial function may also play a role in calcium deposition. 0ompromise of endothelial
function and corneal edema are sometimes seen in patients !ho hae silicone oil inside the eye,
!hen the oil comes into contact !ith the posterior cornea. The e*act reasons for this association
remain uncertain.
[1, 2]
Band keratopathy !as one of the main long%term complications (34 of patients) in a study of 15
ophthalmologic patients treated !ith silicone oil in !hom the oil remained inside the eye for an
unusually long period of time (median, .5 months).
[6]
y&temic ri&# factor&
The follo!ing conditions are associated !ith hypercalcemia, a risk factor for band keratopathy7

,yperparathyroidism

#*cessie itamin 8 intake

9enal failure
[3]

,ypophosphatasia

'ilk%alkali syndrome

&aget disease

"arcoidosis
8iscoid lupus erythematosus and tuberous sclerosis are other systemic conditions associated !ith
band keratopathy.
'ocal ocular ri&# factor&
:ocal ocular conditions associated !ith band keratopathy include the follo!ing7

0hronic ueitis

;uenile idiopathic arthritis !ith ueitis

&hthisis bulbi

#nd%stage glaucoma
[<]

=nterior mosaic dystrophy

Chemically a&&ociated ri&# factor&
8rug%associated calcium deposition can result from the follo!ing7

"teroid phosphate preparations (see the images belo!)

[15]

&ilocarpine%containing, mercury%based preseraties

>iscoelastic agents % 9are, early formulations) may be related to phosphate buffers

"ilicone oil

Topical medications containing phosphate buffers % #specially in the setting of chemical

eye burns
[11]
+ntraocular use of tissue plasminogen actiator
[1-]
0alcium deposition associated !ith the use of
de*amethasone phosphate. The calcium pla(ues appear as eleated !hite lesions at the edge of a
persistent epithelial defect

The image sho!n is of a patient !ho deeloped a calcium pla(ue follo!ing a corneal transplant
and the use of a topical steroid phosphate preparation.
0hemical fume related risk factors include the follo!ing7
'ercury apor
0alcium bichromate apor
Hi&tory and (hy&ical E)amination
Hi&tory
&atients !ith band keratopathy complain of the follo!ing7
8ecreased ision
?oreign body sensation
@cular irritation
9edness (occasionally)
(hy&ical e)amination
>isual acuity !ill be decreased in proportion !ith the density of deposition of calcium salts in
the central cornea. "lit lamp e*amination often reeals a grayish !hite, pla(uelike deposition
that occurs in a band across the cornea. The ery periphery of the cornea may be spared because
of the buffering effect of limbal blood essels. ,oles in the pla(ue may be apparent) these
represent spaces !here the corneal neres are traersing the Bo!man membrane to the epithelial
surface. ("ee the image belo!.)
Band keratopathy. $ote the bandlike !hitish%grey lesion across the corneal surface, sparing the
superior and inferior cornea.
The calcium deposition typically begins in the periphery and progresses centrally but,
occasionally, may begin centrally. The calcium may be ery fine or thick and pla(uelike. Ahen it
is thick, it may flake off, causing epithelial defects and painful symptoms.
'a*oratory tudie&
&atients !ho present !ith band keratopathy should hae a serum calcium and phosphate leel
dra!n unless the deposition has been documented preiously and the underlying cause is kno!n.
9enal function tests, such as blood urea nitrogen (BB$) and creatinine, should be performed as
!ell. 9enal failure and the need for dialysis can be associated !ith an eleation in serum
phosphate and calcific band keratopathy.
[1/, 11]
+f sarcoid is suspected, an angiotensin%conerting enzyme (=0#) should be obtained. +n
other!ise idiopathic cases, parathyroid hormone leels should be checked.
Hi&tolo$ic +indin$&
Band keratopathy is characterized by calcium deposition inoling the Bo!man layer and the
superficial stroma of the cornea. The earliest changes include basophilic staining of the Bo!man
layer. =morphous, eosinophilic connectie tissue and a fibrous pannus often are present bet!een
the calcium deposition and the oerlying epithelium in more adanced cases. ("ee the image
belo!.)
Total calcification of the cornea. 8eep and superficial layers of
the cornea are inoled !ith this process.
0alcium is deposited intracellularly !hen hypercalcemia is the cause) e*tracellular deposits are
characteristic of local ocular disease.
Approach Con&ideration&
"uperficial debridement in band keratopathy is usually effectie in restoring normal ision.
>arious aderse outcomes can result from the procedure, including corneal scarring and ision
loss, but the incidence of such complications is ery lo!.
=lthough medical therapy is ineffectie in treating band keratopathy, underlying conditions
associated !ith eleated leels of calcium or phosphate should be treated to preent deposition
from recurring.
Diet
=s noted, e*cessie itamin 8 intake has been associated !ith band keratopathy, as has milk%
alkali syndrome. #*cessie absorption and serum eleation of calcium is the conse(uence of
these - diet%related problems.
uperficial De*ridement
"uperficial debridement can be performed in a minor operating room under topical anesthesia.
&roparacaine or tetracaine drops can be used for this purpose. Bse of an operating microscope is
recommended.
(rocedure
&lace a lid speculum to hold open the eyelids, and debride the epithelium oerlying the calcium
!ith an ophthalmic surgical blade or spatula.
=pply 5.51 mol, 1.14 neutral disodium ethylenediaminetetra%acetic acid (#8T=) to the corneal
surface. Aeck%cel sponges soaked in this solution can be used for this purpose. =lternatiely, the
solution can be placed in a !ater bath oer the cornea to limit ocular e*posure.
0alcium deposits are then remoed !ith firm scraping of the corneal surface !ith a blunt spatula.
(= &aton spatula !orks !ell.) @ften, it is necessary to apply solution, follo!ed by scraping
seeral times to remoe the pla(ue. The primary goal is to clear the isual a*is. Thin calcium
deposits may come off in 1 minutes, !hile thick pla(ues may take .5%/1 minutes to dissole.
@nce the deposits hae been scraped, an assessment of the smoothness of the underlying stroma
can be made. +f the surface is ery irregular, phototherapeutic keratectomy !ith an e*cimer laser
can be performed to smooth the surface. +deally, this procedure is performed in the same setting.
$ote that the e*cimer laser should not be used to remoe calcium. =ttempting to remoe band
keratopathy !ith the e*cimer laser alone !ill result in significant irregular astigmatism, since the
cornea, not calcium, !ill be ablated preferentially. The role of the e*cimer is to polish the surface
after the pla(ue has been remoed.
[12]
+rrigate the eye thoroughly follo!ing the procedure to remoe #8T= solution from the
conCunctial surface and fornices.
&lace a bandage contact lens oer the cornea. =lternatiely, pressure patching or fre(uent
antibiotic ointment can be used.
(o&toperative care
&ostoperatie care includes the insertion of a bandage contact lens that is left in place until the
epithelium heals. Topical nonsteroidal agents are useful for pain control immediately follo!ing
the procedure and for the first fe! days after!ards.
=n antibiotic drop should be prescribed !ith the bandage contact lens in place. Bse of a topical
steroid drop (eg, prednisolone acetate [not phosphate]) is helpful for comfort and treatment of the
inflammation and corneal edema that are often present in the early postprocedure period. These
medications can be stopped !hen the epithelium is healed and the bandage contact lens is
remoed (usually !ithin the first 1%- !k).
Complication&
The main complications related to the remoal of calcium deposits on the corneal surface include
the follo!ing (it is also possible that additional procedures !ill be needed)7
&ain
9ecurrence of the calcium band
0orneal scarring
0orneal edema
+nfection
8ecreased ision or ision loss
@ccasionally, a mild subepithelial haze can be seen !eeks after #8T= chelation. This may
resole on its o!n. = mild topical steroid (eg, fluorometholone 5.14) may help to resole this
haze. +f there is significant damage to the Bo!man membrane, the haze may be permanent.
Medication ummary
The goals of pharmacotherapy are to reduce plasma calcium leels, to preent complications,
and to reduce morbidity. =s preiously mentioned, 5.1 mol, 1.14 neutral disodium #8T= is
applied to the corneal surface to aid in superficial debridement for band keratopathy. Aeck%cel
sponges soaked in this solution can be used for this purpose, or the solution can be placed in a
!ater bath oer the cornea to limit ocular e*posure. =fter debridement, the eye should be
thoroughly irrigated to remoe #8T= solution from the conCunctial surface and fornices.
Cla&& ummary
This is used to lo!er serum calcium leels.
Edetate calcium di&odium ,Calcium Di&odium -er&enate.

This compound chelates !ith many dialent and trialent metals. Because of its affinity for
calcium, it lo!ers serum calcium leels during intraenous (+>) infusion. "lo! infusion causes
mobilization of e*tracirculatory calcium stores. #detate calcium disodium also chelates !ith
other polyalent metals, therefore increasing urinary e*cretion of magnesium, zinc, and other
trace elements. =lthough it does not chelate !ith potassium, it may reduce the serum potassium
leel. 8o not use this medication for lead to*icity.
#dentate calcium disodium is indicated for the emergency treatment of hypercalcemia but is
rarely used, since ne!er drugs are no! aailable to treat this indication. +t must be specially
compounded and buffered for topical formulation.
Dia$no&tic Con&ideration&
0onditions to consider in the differential diagnosis of band keratopathy include the follo!ing7
Dout
+nterstitial keratitis
&rimary and secondary calcareous degeneration of the cornea
0alciphyla*is % =n ocular and systemic hypersensitiity reaction characterized by
calcium deposition in response to specific antigens or agents
"pheroidal degeneration % Bandlike deposition of hyaline
(ro$no&i&
&atients !ith band keratopathy may e*perience a decrease in ision as the deposition progresses
across the isual a*is. = foreign body sensation and irritation associated !ith an irregular surface
are common symptoms. The ocular discomfort may !orsen to the point of becoming disabling.
The pla(ue itself often is isible and of cosmetic concern to the patient and family members.
=s preiously mentioned, unless underlying conditions hae been addressed, remoing the
calcium deposits in band keratopathy !ill be associated !ith a high incidence of recurrence. +n
general, ho!eer, superficial debridement restores ision and comfort for most patients !ith
band keratopathy, !ith the incidence of aderse outcomes follo!ing this procedure being ery
lo!.
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