A 64-yr-old female patient with calcified corneal lesions on the cornea was referred to Chung-Ang University Hospital. She had a history of extracapsular cataract extraction and intraocular lens (IOL) implantation in the left eye 20 yr ago. Recently, the patient's visual condition was aggravated in both eyes, after the first ocular surgery. Corneal opacity had continued to progress and foreign body sensation and blurring had developed in both eyes over the past 10 yr. Slit lamp examination revealed corneal opacity, and calcium plaque (Fig. 1A), but limbal deficiency was not observed. She had light perception vision and intraocular pressures, that were checked by Pro-view® (BAUSCH & LOMB, Tampa, FL, U.S.A.) were in normal ranges in both eyes. Serum levels of Ca⁺⁺, BUN, and creatinine were all normal (8.7, 13, and 0.9 mg/dL, respectively). The diagnosis of band keratopathy, pseudophakia and Vogt-Koyanaki-Harada syndrome was made.

The patient underwent surgery to remove the calcified band keratopathy. First, trephination to the anterior stromal layer was performed by using 6 mm size punch (Stortz, Denver, CO, U.S.A.) in both eyes. Then EDTA (0.125 M) was applied for 2.5 min until it adequately infiltrated the space between the destroyed stroma and dissolved the calcium impaction. Then, the superficial keratectomy with a round blade and #15-0 Bard-Parker blade was done and the transplantation of the basement membrane-containing thick amniotic membrane (preserved in DMEM and glycerol 2:1 mixed media, -70℃) was performed epithelial side up. Amniotic membrane was sutured into place using interrupted and continued bite secondary with #10-nylon for replacement of the defective stroma. Subsequently, the temporary amniotic membrane patch (TAMP) with epithelial side down was done to protect the ocular surface.

Postoperatively, the patient was treated with 20% autologous serum and ofloxacin (Tarivid®, Santen, Osaka, Japan) 4 times a day from the second day after the operation. On the 5th post-operative day, neomycin/polymixin-B/dexamethasone mixed eye drops (Maxitrol®, Alcon, Ft. Worth, TX, U.S.A.) were administered for 3 days and then changed to flouromethorone (Ocumethrone®, Shin-Il, Seoul, Korea) for 2 weeks. After removal of TAMP on the 5th day, the epithelium was healed to a pinpoint-like defect in the right eye and one-third part of a defect in the left eye upon slit lamp examination. The patient did not complain of any ocular pain, but only did foreign body sensation. Corneal epithelialization was confirmed on the 2nd postoperation day, and when completed, the ocular surface was stable in the both eyes on the 10th postoperation day. Pathologic findings of biopsy specimen revealed impacted calcium in the epithelium and anterior stroma. Destroyed basement membrane and superficial stromal degeneration were also observed in the electron micrographic figure (Fig. 1C). After discharge, during outpatient department follow up, the patient did not complain of ocular pain but only the condition of cornea remained stable. On the last follow up after 17 months, visual acuity had improved to finger count at 70 cm, and intraocular pressure was 10/12 torr in both eyes. Macular degenerations and hypertensive retinopathy (Keith-Wagener, grade 2) were observed in the both eyes. Because of these lesions, visual outcome was poor in spite of the removal of calcified lesions with stabilized corneal surface.

A 60-yr-old male patient visited our clinic because of ocular pain and severe foreign body sensation in the right eye. He had undergone intra-capsular cataract extraction and anterior chamber lens (ACL) implantation in the right eye under diagnosis of presenile cataract 19 yr ago. Severe pain and blurring had developed since the 8 yr after the operation; and symptoms had been increasingly exacerbated thereafter. Visual acuity was perceptive to hand motion in the involved right eye and 0.9 in the normal left eye. Slit lamp examination revealed corneal opacity and horizontal calcified corneal lesions in the palpebral fissure. Partial limbal deficiency and pseudopterygium with neovascularization were also seen at the 4 o'clock position (Fig. 2A). Because of calcified corneal lesions, it was impossible to examine full details, but a dislocated anterior chamber lens (ALC) and iridotomy hole on the peripheral iris in the anterior chamber. Intraocular pressures (IOP) were measured at the level of 33 torr in the right side and 20 torr in the left eye by Pro-view®. Serum levels of Ca⁺⁺, BUN, and creatinine were in normal ranges (8.5, 14 and 1.1 mg/dL, respectively) and no systemic disorders were found. We diagnosed him as ACL dislocation, secondary glaucoma, and possibly anterior uveitis and band keratopathy. Patient was given β-blocker and carbonic anhydrase inhibitor mixed eye drop (Cosopt®, MSD, Whitehouse Station, NJ, U.S.A.) twice a day, acetzolamide 250 mg (Diamox®, Wyeth, Madison, NJ, U.S.A.), twice a day, p.o. for IOP control. After confirming the normalized IOP, the patient underwent trephination with 6 mm size punch into the potent pathologic space beneath Bowman's layer to instill EDTA. After that, EDTA chelation (0.125 M) to dissolve the calcium plaque was performed for 2.5 min until enough had spread into the space. Then, superficial keratectomy with blunt spatula was done without any excision or scraping, because the instilled EDTA had already dissolved the calcium impaction and the space between the destroyed stroma and Bowman's membrane had separated clearly without any scar. After removal of pseudopterygium and ACL, AMT was performed with epithelial side up to replace the removed stromal matrix and enhance wound healing. Then, TAMP with epithelial side down was done under local anesthesia. Amniotic membrane graft was sutured in place interruptedly and continuously with #10-0 nylon after removal of the calcium-impacted epithelium and anterior stroma. IOL re-implantation was not done. Postoperatively, the patient was treated with the same drug regimen as described in case 1. On the 2nd day, corneal reepithelialization had started and was nearly completed after 9 days. When discharged on the 12th day, the visual outcome was noted at finger count of 60 cm and the IOP was 9 torr under aphakic conditions by Pro-view®. Pathologic findings of the cornea showed impacted calcium, broken basement membrane and separated Bowman's membrane due to calcium deposition with degenerative changes (Fig. 2C). The pain and severe inflammation were not revealed until the last follow up at 10 months after the operation. Final visual outcome was recorded as 0.06 in the right eye with aphakic state and the corrected visual acuity was 0.4.