Clinical Scorecard: Medical and Surgical Management of Corneal Scarring

At a Glance

Key Highlights

• Superficial anterior stromal scarring may improve with medical management or superficial keratectomy.
• Deeper or dense scarring often requires surgical intervention such as anterior lamellar keratoplasty or full-thickness keratoplasty.
• Scleral contact lenses can improve vision by correcting irregular astigmatism and serve as a drug delivery method.

Guideline-Based Recommendations

Diagnosis

• Assess depth and location of corneal scarring using anterior segment imaging.
• Evaluate visual impact, especially for central versus peripheral scarring.

Management

• Initiate medical management with topical steroids for active haze and control infection or inflammation.
• Use recombinant human nerve growth factor (cenegermin) for neurotrophic keratitis-related ulcers and haze.
• Consider topical losartan 0.8mg/mL six times daily for 3 to 6 months for haze improvement.
• Employ scleral lenses for visual rehabilitation and medication delivery (e.g., preservative-free dexamethasone, plasma rich growth factors).
• Perform superficial keratectomy or phototherapeutic keratectomy (PTK) with mitomycin C for anterior corneal haze.
• Use anterior lamellar keratoplasty (ALK) or deep anterior lamellar keratoplasty (DALK) for deeper scarring to reduce rejection risk.
• Reserve full-thickness penetrating keratoplasty (PKP) for cases with endothelial dysfunction or failed lamellar procedures.

Monitoring & Follow-up

• Monitor for recurrence of haze post-treatment, especially after keratectomy or PTK.
• Assess visual acuity and corneal clarity regularly.
• Watch for graft rejection signs after keratoplasty.

Risks

• Risk of graft rejection with full-thickness keratoplasty.
• Potential interface irregular astigmatism and haze after lamellar keratoplasty.
• Hyperopic shift due to corneal flattening after anterior corneal treatments.

Patient & Prescribing Data

Patients with anterior corneal scarring from infection, inflammation, trauma, or neurotrophic keratitis

Topical steroids and losartan can improve haze; scleral lenses enhance vision and medication delivery; surgical options depend on scar depth and location.

Clinical Best Practices

• Determine scar depth and location before selecting treatment modality.
• Start with medical management before surgical intervention when possible.
• Use anterior segment imaging to guide laser ablation depth in PTK.
• Apply mitomycin C after PTK to prevent haze recurrence.
• Consider scleral lenses for visual rehabilitation and as a drug delivery platform.
• Choose lamellar keratoplasty techniques to reduce rejection risk in appropriate patients.
• Educate patients about potential hyperopic shifts and risks associated with surgery.

References

• Parra AS et al. Assessment of PROSE scleral lens on visual acuity. Ocul Surf. 2018
• Dutra BAL, Wilson SE. Topical Losartan in Corneal Scarring. J Ocul Pharmacol Ther. 2025
• Rush SW et al. OCT-guided transepithelial PTK for anterior corneal scarring. Am J Ophthalmol. 2013
• Porges Y et al. PTK with mitomycin C for corneal haze post-PRK. J Refract Surg. 2003