7) Adherent Leucoma

LONG CASE- ADHERENT LEUCOMA
Date of Examination- ??/??/22
PATIENT PARTICULARS-
Name- Mr. ABC
Age- 52 years
Sex- Male
Religion- Hindu
Occupation- Farmer
Address-
Socioeconomic Status- Poor economic condition
Chief Complaints-
1) Cannot see clearly with the Left Eye (LE) for 8 months.
2) Whiteness of black portion of the LE for 6 months.
Diagrammatic depiction of corneal opacities- A, nebular; B, macular;
C, leucomatous; D, adherent leucoma.

Adherent leucoma due to perforating corneal injury
History of Present Illness-
The patient got a vegetable matter foreign body in his LE while working on his farm about 8 months ago.
Two weeks after the injury, he developed dimness of vision with redness, irritability, itching, watering and
intolerance to light in his LE. When the symptoms increased, he went for a consultation with the local
doctor who prescribed oral and topical medicines for a left corneal ulcer. The other symptoms resolved
after a sudden rush of fluid from the LE (likely due to perforation of the corneal ulcer) but the dimness of
vision persisted. This is when he presented to our hospital for further consultation.
Past Ocular History-
Nil significant.
General Medical History-
Hypertension (HTN) for 2 years and is on treatment.
Drug/ Medicines History-
Amlodipine 5 mg OD for HTN
History of any Allergies especially to Medicines-
Nil known.
Family History-
Nil significant.
Social History-
Not addicted to tobacco or alcohol.
General Physical and Systemic Examination-
Within normal limits (WNL). No anaemia, cyanosis or jaundice found.
Ocular Examination-
Right Eye (RE) Left Eye (LE)

Visual Acuity (VA) Unaided- 6/6p Unaided- Hand movements (HM)
Pinhole (PH) No improvement with inaccurate Projection of
(PHNI). Rays (inaccurate PR).
PHNI.
Eyelids & Eye lashes Position- Normal. Position- Normal.
No blepharitis/ Meibomian No blepharitis/ Meibomian Gland
Gland Disease (MGD)/ Disease (MGD)/ entropion/
entropion/ ectropion/ trichiasis. ectropion/ trichiasis.
Conjunctiva No congestion. No congestion.
Sclera WNL. WNL.
Cornea Clear. Corneal opacity type= Adherent
Leucoma. Position- It is present
inferiorly. Size- 3 mm diameter.
Shape- slightly oval.
Pigmentation present.
Vascularisation- absent.
Anterior Chamber Depth Normal. Variable- almost nil at the site of
adherence.
Pupils Pupil is round and reacts briskly Pupil is distorted and peaked
to light. towards the scar. Difficult to
assess pupil reaction.
Iris WNL. Adherent to the corneal scar.
Lens Clear. Difficult to see through the
corneal scar.
Purkinje’s Images P1- P4 are all visible. Just P1 is visible.
IOP Normal by digital tonometry. Normal by digital tonometry.
Extraocular muscle movements Normal and full. Normal and full.
Lacrimal Apparatus No regurgitation on lacrimal sac No regurgitation on lacrimal sac
pressure. pressure.
Case Summary-
A 52 year old hypertensive male presents with reduced vision in the left eye (LE) for 8 months and
whiteness of the black portion of the LE for 6 months. The patient got a vegetable matter foreign body in
his LE while working on his farm about 8 months ago. Two weeks after the injury, he developed dimness of
vision with redness, irritability, itching, watering and intolerance to light in his LE. When the symptoms
increased, he went for a consultation with the local doctor who prescribed oral and topical medicines for a
left corneal ulcer. The other symptoms resolved after a sudden rush of fluid from the LE (likely due to
perforation of the corneal ulcer) but the dimness of vision persisted. This is when he presented to our
hospital for further consultation.
On examination, his uncorrected vision in the RE is 6/6p which is not improving with the pinhole. His LE
vision is Hand movements (HM) with inaccurate Projection of Rays (inaccurate PR) which is not improving
with the pinhole.
The LE shows a Corneal opacity, type= Adherent Leucoma, position- It is present inferiorly, size- 3 mm
diameter and shape- slightly oval. Pigmentation present. Vascularisation- absent. The left anterior chamber
depth is variable and almost nil at the site of adherence. The left pupil is distorted and peaked towards the
scar. It is difficult to assess the left pupil reaction. The iris is adherent to the corneal scar and it difficult to
comment about the left lens because of the corneal scar. Only P1 is visible.
These findings indicate a likely diagnosis of Adherent Leucoma in the left eye.
Likely Questions-
1) What is an Adherent Leucoma?
Adherent Leucoma is a dense white or opaque corneal scar which has fibrous tissue adherent to its deeper
surface. It nearly always indicates a perforation (unless it is an adherent leucoma of congenital origin).
2) What does Leucoma mean?
It literally means a white tumour of the cornea (“leucos” means white and “oma” means tumour).
3) How will this patient be managed?
This patient can undergo penetrating keratoplasty or PK with a guarded visual prognosis (GVP) explained
before the surgery. The GVP must always be recorded on the prescription.
4) Why is there a guarded visual prognosis?
There is a guarded visual prognosis because of the vision which is Hand Movements with inaccurate
Projection of Rays and because of the diagnosis.
5) What is a penetrating keratoplasty? What are the indications?
Penetrating Keratoplasty (PK) is full-thickness corneal grafting.

The indications are-
a) Optical, i.e., to improve vision. Important indications are- corneal opacity, bullous keratopathy,
corneal dystrophies and advanced keratoconus.
b) Therapeutic, i.e., to replace inflamed cornea not responding to conventional therapy.
c) Tectonic graft, i.e., to restore integrity of the eyeball e.g. after corneal perforation and in marked
corneal thinning.
d) Cosmetic, i.e., to improve the appearance of the eye.
6) What are the steps of a Penetrating Keratoplasty? (If you are answering very well!)
Surgical technique of penetrating keratoplasty-

a) Excision of donor corneal button- The donor corneal button should be cut 0.25 mm larger than the
recipient, taking care not to damage the endothelium. Donor cornea is placed in a tephlon block and the
button is cut with the help of a trephine from the endothelial side.
b) Excision of recipient corneal button- With the help of a corneal trephine (7.5 mm to 8 mm in size) an
almost full thickness incision is made in the host cornea. Then, the anterior chamber is entered with the
help of a sharp instrument and the excision is completed using corneo-scleral scissors, aided by
maintaining the host button alignment with fine-toothed forceps.
c) Suturing of the corneal graft into the host bed is done with either continuous &/ or interrupted 10–0 nylon
sutures.
7) Be prepared for questions about Tobacco- Alcohol Amblyopia if you mention these addictions in
the Social History.

7) Adherent Leucoma

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LONG CASE- ADHERENT LEUCOMA

Date of Examination- ??/??/22

Name- Mr. ABC

Socioeconomic Status- Poor economic condition

2) Whiteness of black portion of the LE for 6 months.

Diagrammatic depiction of corneal opacities- A, nebular; B, macular;

C, leucomatous; D, adherent leucoma.

History of Present Illness-

Past Ocular History-

General Medical History-

Hypertension (HTN) for 2 years and is on treatment.

Drug/ Medicines History-

Amlodipine 5 mg OD for HTN

History of any Allergies especially to Medicines-

Not addicted to tobacco or alcohol.

General Physical and Systemic Examination-

Within normal limits (WNL). No anaemia, cyanosis or jaundice found.

Right Eye (RE) Left Eye (LE)

2) What does Leucoma mean?

3) How will this patient be managed?

4) Why is there a guarded visual prognosis?

5) What is a penetrating keratoplasty? What are the indications?

Penetrating Keratoplasty (PK) is full-thickness corneal grafting.

Surgical technique of penetrating keratoplasty-

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