Pellucid marginal degeneration
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This document discusses the surgical management of Pellucid marginal degeneration (PMD), a non-inflammatory thinning of the cornea. It describes various surgical techniques used to treat PMD including INTACS inserts, eccentric penetrating keratoplasty, large diameter epikeratoplasty, lamellar crescentic keratoplasty, lamellar crescentic resection, and wedge resection. The goal of these surgeries is to reshape the cornea and reduce high astigmatism caused by PMD through techniques like inserting inserts, excising the thinned area, or using donor tissue grafts. Complications can include increased risk of rejection, vascularization, and long-term astigmatism changes.
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Pellucid marginal degeneration
- 1. Pellucid marginalPellucid marginal degenerationdegeneration With emphasis on surgicalWith emphasis on surgical managementmanagement PushParaj singh
- 2. Pellucid marginal degenerationPellucid marginal degeneration • Schalaeppi (1957) • Bilateral, noninflammotry, • Ectatic inferior cornea(crescentic) • Thinning extends from the 4-8 o’clock position, 1 mm from the limbus. • Epithelium intact, and the cornea above the thinned out area is ectatic
- 4. • The area between the limbus and thinning is 1. Clear, 2. NO Scarring 3. NO Lipid deposition, 4. NO vascularization. • Age group- 30-40 yr
- 5. • Flattening of the cornea along a vertical axis • Steepening of the inferior cornea peripheral to the site of the lesion (ATR)
- 11. MANAGEMENTMANAGEMENT • Spectacles:-small horizontal eye sizes, & high refractive index lenses with antireflective coating • Contact lenses:- RGP, Toric lenses, scleral lenses • Verisye/ Artisan phakic iol* *De verrien NE. cornea 2008;27:241-45
- 12. Acute hydropsAcute hydrops • Risk factor:- Ocular allergy,Eye rubbing,Down syndrome, • C/O:- blurred vision, irritation, pain, watering, photophobia • Mx:- conservative • Hypertonic agents, steroids, antibiotics, cycloplegics, hypotensive agents • Bandage Contact lens • BCL & Cyanoacrylate glue (in perfoation)
- 13. AIRAIR Miyata K et al .Miyata K et al .Am J Ophthalmol. 2002 Jun;133(6):750-2Am J Ophthalmol. 2002 Jun;133(6):750-2 • acts as temponade, stretches both ends of ruptured DM • 0.1 ml (1-4 times) • 4-24 days to resolve edema(2-4 mth in conservative mx) • Complication:- infection, IOP rise, pupillary block, endothelial cells damage
- 14. CC33FF8 &8 & SFSF66 • Acts as mechaical barrier, preventing aqueous humour into stroma & as temponade • *C3F8- 0.1-0.2 ml, 10-14 % nonexpansile conc • **SF6- 0.2ml, iso-expansile conc (18%) intracamerally *Shah SG et al.Am J Ophthalmol. 2005 Feb;139(2):368-7 **Vanathi M et al.Cont Lens Anterior Eye. 2008 Feb 19
- 15. SURGICAL MAMAGEMENTSURGICAL MAMAGEMENT •INTACS •Eccentric PKP •Full thickness wedge resection •Lamellar crescentic resection •Large diameter epikeratoplasty •lamellar crescentic keratoplasty •Comb. Of lamellar crescentic + PKP
- 16. INTACSINTACS Allsandro et al.ophthalomology 2005;112:660-66Allsandro et al.ophthalomology 2005;112:660-66 • Crescent shaped(PMMA), arc length of 150° • Inner diam.-6.8 mm,outer diam.- 8.1 mm • 0.25 superior, 0.45 inferior side • Inferior cornea thickness > 450μm(7mm optical zone) • Temporal 1.8 mm incision (70% depth) • FM lasers:- used to create intra stromal tunnel (Ertan A.JCRS,2006;32:1710-16)
- 17. principleprinciple • New optical zone, separates the ectatic area from central zone • Spherical equivalent, reduced by flattening action of 2 opposite ring • Inferior ring causes a barrier effect against high astigmatism induced by PMD towards central cornea • Stabilization & elimination of the progression of ectatic disease
- 18. Eccentric PKPEccentric PKP • Large graft required (9-10mm) with same recipient bed or 0.5 larger • Increased risk for vascularisation • High postop. Astigmatism • Increased rejection(64% > keratoconus) • In one study 7 out 11 eyes, endothelial rejection occurred* * Gary A. Am.J.Ophthalmol 1990,110:149
- 19. Large diameter epikeratoplasty*Large diameter epikeratoplasty* *Aldo Fronterre.Cornea 1991; 10(5):450-453*Aldo Fronterre.Cornea 1991; 10(5):450-453 • Commercially prepared tissue lens (KERATO-LENS) • Large graft (9-12mm) • Lenticules sutured as epikeratophakia • Comp.- neovascularisation, rejection
- 20. Lamellar crescentic keratoplastyLamellar crescentic keratoplasty schanzlin J.am jschanzlin J.am j ophthalmol.1983;96(2)253-254ophthalmol.1983;96(2)253-254 • Tectonic graft • Limited to thinned area • Sutured with nylon 10-0
- 21. Lamellar crescentic+ PKPLamellar crescentic+ PKP Robinwitz et al.ophthalomology 2000 oct.107(10)1836-40Robinwitz et al.ophthalomology 2000 oct.107(10)1836-40 • Simultaneous peripheral crescentic LK & central PKP • Tendency for increased WRA Noted in long term
- 22. Lamellar crescentic resectionLamellar crescentic resection Principle • Excise abnormal crescentic thinned stroma • Approximate normal thickness stroma to normal thickness stroma • Aim for overcorrection of astigmatism (WRA), Upto 50 % (Troutman) • Adv:- localised to abnormal area incision smaller no donor tissue- no rejection
- 23. Disadv:- visual acuity poor for 6Disadv:- visual acuity poor for 6 monthmonth long term astigmatism driftlong term astigmatism drift
- 25. WEDGE RESECTIONWEDGE RESECTION • PRINCIPLE:- same as crescentic resection • Inferior full thickness crescentic wedge (2mm) removed • Wound is approximated by 10-15 nylon or polypropylene 10-0 suture • LTAD monitored • Adv-disadv:- same as crescentic resection