OcuLearning › Cornea

Band Keratopathy

ROUTINE — Cornea

Symptoms

  • Decreased vision (if deposits cross the visual axis).
  • Foreign body sensation and irritation.
  • Visible whitening of the cornea (cosmetic concern).
  • Recurrent erosions if the calcium plaque fractures.
  • May be asymptomatic in early stages.

Clinical Findings

Morphology

  • Horizontal gray-white opaque band of calcium hydroxyapatite deposits.
  • Located at the level of the Bowman layer and anterior stroma.
  • Restricted to the interpalpebral fissure (CO₂ evaporation raises local pH, favoring precipitation).
  • "Swiss-cheese" appearance: Lucid round holes within the band representing corneal nerve penetration sites.

Progression

  • Begins as peripheral opacities at the 3 and 9 o'clock positions.
  • Spreads centripetally to form a complete horizontal band.
  • "Lucid interval": A thin strip of clear cornea separates the band from the limbus (limbal vessels buffer pH).

Ocular associations

  • Chronic uveitis: Especially JIA-associated uveitis (classic pediatric finding).
  • Chronic corneal edema / bullous keratopathy.
  • Silicone oil in the anterior chamber.
  • Phthisis bulbi and end-stage glaucoma.
  • Interstitial keratitis (ghost vessels).

Etiology

Ocular causes (most common)

  • Chronic inflammation (uveitis) or surface disease.
  • Chronic corneal edema.
  • Phthisis bulbi.
  • Silicone oil retention after retinal surgery.
  • Prolonged use of phosphate-buffered eye drops.

Systemic causes (hypercalcemia/hyperphosphatemia)

  • Hyperparathyroidism.
  • Vitamin D intoxication.
  • Sarcoidosis.
  • Renal failure (hyperphosphatemia).
  • Multiple myeloma and metastatic bone disease.
  • Milk-alkali syndrome.
  • Paget disease of bone.

Red Flags

  • Chronic uveitis (especially JIA): Inflammation must be controlled before surgical chelation.
  • Systemic hypercalcemia: Requires medical workup to address potentially serious underlying renal or parathyroid disease.
  • Rapidly progressive disease in young patients: Rule out toxic exposure or phosphate-drop overuse.

Investigations

Clinical exam

  • Slit-lamp biomicroscopy to document the extent of the plaque and identify associated ocular disease.
  • Assess both eyes (often bilateral in systemic disease).

Systemic workup (if no ocular cause)

  • Serum calcium (corrected for albumin), ionized calcium, and phosphate.
  • Parathyroid hormone (PTH) and 25-OH Vitamin D.
  • Renal function tests (BUN, creatinine).
  • ACE and lysozyme (if sarcoidosis suspected).
  • SPEP (if multiple myeloma suspected).

Treatment

Conservative management

  • Mild cases: Preservative-free artificial tears and ointments.
  • Recurrent erosions: Bandage soft contact lens and prophylactic topical antibiotics.

Surgical (EDTA chelation)

  • Indications: Visual obstruction or persistent foreign body sensation.
  • Procedure: Epithelial debridement followed by application of 3–4% disodium EDTA until calcium clears.
  • Post-op care: Antibiotic ointment, cycloplegics, and bandage contact lens until epithelialized.

Adjunctive therapy

  • Excimer laser PTK: Used for residual stromal scarring or to manage recurrent erosions.

Clinical Pearl

Calcium deposits in the Bowman layer point to either chronic intraocular inflammation (think JIA) or systemic hypercalcemia. Chelation with EDTA clears the cornea but does not address the underlying systemic or ocular trigger.

Differential Diagnosis

  • Salzmann nodular degeneration
  • Corneal scarring (trauma or infection)
  • Limbal dermoid
  • Anterior membrane dystrophy

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