What is the first line of treatment for leucoma (corneal opacity)?

First-Line Treatment for Leucoma (Corneal Opacity)

Phototherapeutic keratectomy (PTK) is the first-line treatment for leucoma when the corneal opacity is limited to the anterior 10-15% of stromal thickness. 1

Treatment Algorithm Based on Depth of Opacity

For Superficial Opacities (Anterior 10-15% of Cornea)

1. Phototherapeutic Keratectomy (PTK)

   • Most beneficial for anterior stromal scarring 1
   • Provides rapid visual rehabilitation with improvement in best-corrected visual acuity (BCVA) 1
   • Can be combined with refractive treatment to reduce astigmatism 1

2. Epithelial Debridement

   • For lesions anterior to Bowman layer 1
   • Performed with a lid speculum and microblade
   • Often followed by bandage contact lens and prophylactic antibiotics

3. Mitomycin-C Application

   • Used as adjunct to prevent recurrence of scarring 1
   • Typically applied at 0.02% concentration using a wet cellulose disk 1
   • Requires careful irrigation afterward to prevent toxicity

For Deeper Opacities

1. Superficial or Anterior Lamellar Keratectomy

   • For deeper but not full-thickness opacities
   • Can be combined with PTK for better outcomes 1
   • Best-corrected visual acuity significantly improves at 2,6, and 12 months 1

2. Keratoplasty (Corneal Transplantation)

   • For opacities involving mid and deep stroma 1
   • Options include:
     • Deep anterior lamellar keratoplasty (DALK)
     • Penetrating keratoplasty (PK)

Special Considerations

For Band Keratopathy

• Use disodium EDTA to facilitate calcium removal 1
• Apply using cellulose sponge or sterile cotton applicator soaked in 3-4% solution 1

For Cosmetic Concerns

• Corneal Tattooing can be considered for non-visual improvement 1
• Involves embedding sterile India ink or carbon particles in anterior/mid stroma 1
• Has shown satisfactory cosmetic results with minimal complications 2, 3

For Severe Cases with Poor Visual Potential

• Keratoprosthesis may be considered when traditional treatments fail 4
• Particularly useful in cases with:
  • Severe vascularization
  • Recurrent transplant rejections
  • Leucoma adherens

Potential Complications and Management

PTK Complications

• Post-treatment haze and hyperopia with deeper treatments
• Recurrence of underlying disease
• Surface irregularity
• Risk of infectious keratitis

Prevention of Complications

• Masking agents (methylcellulose or sodium hyaluronate) during PTK to create smooth surface 1
• Mitomycin-C to reduce haze and recurrence 1
• Bandage contact lenses and prophylactic antibiotics after procedures 1
• Antiviral prophylaxis if history of herpetic eye disease 1

Follow-up and Monitoring

• Assess visual acuity improvement
• Monitor for recurrence of opacity
• Evaluate corneal transparency, regularity, and optical quality 1
• Consider rigid gas permeable (RGP) contact lenses for residual surface irregularity 1

The treatment approach should be guided by the depth and extent of the leucoma, with PTK being the preferred first-line option for superficial opacities due to its effectiveness in improving visual outcomes while being less invasive than keratoplasty.