Medical and Surgical Management of Corneal Scarring

Overview

Corneal scarring from infection, inflammation, or trauma can significantly impair vision. Management ranges from medical therapies and scleral lenses to surgical interventions like keratectomy and keratoplasty, depending on scar depth and location.

Background

Corneal clarity is essential for optimal vision, but scarring can obstruct the visual axis. Treatment decisions hinge on the depth and location of scarring, with superficial scars often amenable to medical or minimally invasive treatments, while deeper scars may require surgical intervention. Alternatives to full-thickness corneal transplant exist to reduce risks such as graft rejection. Advances in imaging and surgical techniques have improved outcomes for patients with corneal scarring.

Data Highlights

Topical losartan dosage: 0.8 mg/mL, 6 times daily for 3-6 months.
Use of plasma rich in growth factors (PRGF): 4 times daily for 6 months.
Superficial keratectomy targets anterior 15-20% of corneal depth.
Phototherapeutic keratectomy (PTK) involves epithelial removal and laser ablation with mitomycin to prevent haze recurrence.
Risk reduction of graft rejection with anterior lamellar keratoplasty (ALK) and deep anterior lamellar keratoplasty (DALK) compared to full-thickness keratoplasty.

Key Findings

• Superficial anterior stromal scars can improve with time or medical management, including topical steroids and novel agents like recombinant human nerve growth factor (rhNGF) and topical losartan.
• Scleral contact lenses can improve vision by correcting irregular astigmatism and serve as a drug delivery platform for medications such as preservative-free dexamethasone and PRGF.
• Superficial keratectomy and phototherapeutic keratectomy (PTK) are effective surgical options for anterior corneal haze, with mitomycin used postoperatively to reduce haze recurrence.
• Deeper corneal scarring often requires keratoplasty; anterior lamellar keratoplasty (ALK) and deep anterior lamellar keratoplasty (DALK) reduce graft rejection risk compared to full-thickness penetrating keratoplasty (PKP).
• DALK techniques like the big bubble and grip-and-rip improve stromal removal precision, reducing interface haze and astigmatism but may still slightly reduce best corrected visual acuity (BCVA) and contrast.
• Full-thickness PKP remains necessary for cases with endothelial dysfunction or when lamellar techniques are insufficient.

Clinical Implications

Clinicians should assess scar depth and location to tailor management, starting with medical therapies and scleral lenses for superficial or irregular astigmatism-related vision loss. Surgical options should be reserved for deeper or dense scarring, with lamellar keratoplasty preferred to minimize rejection risk. Patient counseling on potential outcomes, including hyperopic shifts and visual acuity changes, is essential.

Conclusion

Effective management of corneal scarring requires a nuanced approach balancing medical and surgical options based on scar characteristics. Advances in medical therapies and surgical techniques offer improved visual rehabilitation while reducing complications associated with full-thickness transplantation.

References

1. Parra AS et al. 2018 -- Assessment of the Prosthetic Replacement of Ocular Surface Ecosystem (PROSE) scleral lens on visual acuity for corneal irregularity and ocular surface disease
2. Dutra BAL, Wilson SE. 2025 -- Topical Losartan in the Management of Corneal Scarring Fibrosis: Update on Dosage, Efficacy, and Potential Epithelial Toxicity
3. Rush SW et al. 2013 -- Optical coherence tomography-guided transepithelial phototherapeutic keratectomy for the treatment of anterior corneal scarring
4. Porges Y et al. 2003 -- Phototherapeutic keratectomy with mitomycin C for corneal haze following photorefractive keratectomy for myopia