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Sections Neovascularization, Corneal, CL-related
Overview
Presentation
- History
- Physical
- Causes
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DDx
Workup
Treatment
Medication
Follow-up
References

Overview

Background

The normal cornea is transparent and maintains itself as an immune privileged site, in part because it is avascular. Ocular insult and ocular hypoxia due to infectious keratitis, immunological conditions, corneal trauma, alkali injury, and contact lens (CL) wear^{[1, 2, 3, 4]}can encourage new blood vessels to grow from the limbus and, hence, neovascularization (NV).^{[5, 6]}NV is generally accompanied by an inflammatory response and always represents a state of disease.^[7]

With CL wear, superficial NV is more common than deep stromal vessels. It is speculated that deep stromal NV may reflect a more profound insult (hypoxia) compared to that which generates only superficial NV. Both superficial and deep stromal NV are reported with the use of hydrogel, hard (polymethyl methacrylate [PMMA]), rigid gas permeable CLs, and scleral lenses.^[8] This is especially present in patients with a history of aphakia, extended wear, poor compliance, low oxygen permeable CLs, long-term CL wear (many years), and poor follow-up care.^[9]Deep stromal NV is serious, possibly leading to loss of optical transparency of the tissue and hence decrease visual acuity through stromal hemorrhage, scarring, and lipid deposition.

Pathophysiology

NV is believed to result from an inflammatory or hypoxic disruption of an exquisitely balanced corneal immune system.^{[10, 11, 12]}Hydrogel, hard, rigid gas-permeable corneal CLs and scleral lenses stimulate NV by either mechanically irritating the limbal sulcus or by creating corneal hypoxia, which leads to limbal inflammation, epithelial erosion, or hypertrophy, and, hence, angiogenic mediator release.^{[1, 13, 14]}

Epithelial trauma^[15]and/or hypoxia^[16]may stimulate production of angiogenic factors by local epithelial cells, keratocytes, and infiltrating leukocytes^{[17, 18]}(eg, macrophages, neutrophils). Some of these factors (ie, acidic and basic fibroblast growth factors, interleukin 1 [IL-1], and vascular endothelial growth factor [VEGF]) have been identified and isolated from cornea and tears. Angiogenic factors^[19]stimulate a localized enzymatic degradation of the basement membrane of perilimbal vessels at the apex of a vascular loop. Vascular endothelial cells migrate and proliferate to form new blood vessels (eg angiogenesis) branching from pre-existing limbal vessels.^[20]

Frequency

United States

Prevalence among CL wearers ranges from 0.1-37%.^{[21, 22, 23]} Prevalence is lower in those who wear (rigid) corneal gas permeable lenses than in soft CL wearers because the diameter of soft CLs are larger and cover the entire cornea, limbus, and surrounding perilimbal conjunctiva, decreasing oxygen from the atmosphere.^{[24, 25, 4]}There is an increased risk for patients who have high myopia, dry eyes, or ocular surface disease (eg, idiopathic or associated with other diseases, such as acne rosacea, Sjögren syndrome, and immune dysfunction). There also is an increased risk in those who use extended wear hydrogel CLs and in those who use aphakic or therapeutic CLs.

Silicone hydrogel CLs with oxygen permeabilities approaching 100-200 Fatt Dk units have decreased the incidence of corneal NV among CL users.^[22]

Mortality/Morbidity

This condition is not associated with mortality. Symptoms can range from asymptomatic and mild to severe with loss of vision. NV in the cornea's visual axis can threaten visual function directly or through secondary hemorrhage,^[26]scarring, or lipid deposition.

Incidence of subsequent corneal graft rejection is estimated by one study to be 1.7 times higher in a setting of vascularized rather than nonvascularized host corneas. Risk and severity of a graft rejection is believed to depend on the depth and extent of NV; hence, deep stromal vessels incur more risk than superficial pannus, and the more quadrants involved, the higher the risk for rejection.^[27]

Race

No ethnic predilection exists.

Sex

No gender predilection exists.

Age

NV can occur and progress at any age.

Clinical Presentation

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Author

Barry A Weissman, OD, PhD, FAAO Retired Professor of Optometry, Southern California College of Optometry at Marshall B Ketchum University; Professor Emeritus of Ophthalmology, Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Barry A Weissman, OD, PhD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association, California Optometric Society, International Society for Contact Lens Research

Disclosure: Nothing to disclose.

Coauthor(s)

Karen K Yeung, OD, FAAO Senior Optometrist, UCLA Arthur Ashe Student Health and Wellness Center; Clinical Assistant Professor, College of Optometry, Western University of Health Sciences

Karen K Yeung, OD, FAAO is a member of the following medical societies: American Academy of Optometry

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Sidney Kimmel Medical College of Thomas Jefferson University; Director of the Cornea Service, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AAO; OMIC; American Society of Ophthalmic Trauma (ASOT); Avellino, Baxis; Bio-Tissue; Celularity; Dompe; Emmecell; Glaukos; Kala; Oyster Point; Tarsus; TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Dompe<br/>Received research grant from: Glaukos<br/>Received income in an amount equal to or greater than $250 from: AAO; OMIC; Baxis; Bio-Tissue; Cellularity; Dompe; Glaukos; Kala; TearLab<br/>stock options for: RPS, Fount Bio.

Chief Editor

Hampton Roy, Sr, MD † Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Andrew W Lawton, MD Neuro-Ophthalmology, Ochsner Health Services

Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, Southern Medical Association

Disclosure: Nothing to disclose.

Sections Neovascularization, Corneal, CL-related
Overview
Presentation
- History
- Physical
- Causes
- Show All
DDx
Workup
Treatment
Medication
Follow-up
References

Neovascularization, Corneal, CL-related

Background

Pathophysiology

Epidemiology

Frequency

Mortality/Morbidity

Race

Sex

Age

References

Tables

Contributor Information and Disclosures

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