Ultraviolet-induced corneal degenerative changes: Clinical spectrum and management decision making

We have noted four female patients, with the age ranging from 54 to 68 years, who worked in salt pans or brine fields for a prolonged period of time ranging from 18 to 32 years. Each patient reported spending 6 to 8 hours in day light with direct reflection of sunlight from salt crystals/brine surfaces without any protective glasses. Their clinical presentations ranged across the spectrum from mild central corneal haze [Fig. 1a] and epithelial irregularity [Fig. 1d] causing mild visual disturbances to moderate disease with corneal stromal thinning and vertical stress lines [Fig. 1a, b, and d] and causing significant anterior surface flattening with moderate to severe visual impairment. The severe disease constitutes; extreme thinning leads to descemetoceles and perforations [Fig. 1b and 1c]. These lesions are typically central or paracentral, extending up to the stroma, without vascularity, and corneal sensation was absent. Histopathology of the lesion demonstrated extreme epithelial/stromal thinning/degeneration and approximation to the thickened Descemet’s membrane. The follow-up ranged from 6 to 14 months. The eyes undergone Tenons patch achieved stable tectonic support with complete epithelial healing waiting to undergo optical graft. The patient after PKP had a clear graft with restoration of the anterior contour and a good best corrected visual acuity to 6/18. The patient who underwent DSEK did not achieve good vison postoperatively due to central flattening of the anterior stroma.Figure 1: (a) Image shows central stromal thinning with stress lines. (b) Image shows central extreme stromal thinning, with descemetocele. (c) Image shows another patient with descemetocele and stromal thinning. (d) Image shows epithelial thinning, defect, and stromal thinning with stress linesDiscussion The harmful effects of ultraviolet radiation (UVR) on the cornea are well known, including photo keratitis, pterygium, ocular surface neoplasia, cataract, Salzmann nodular degeneration, and climatic droplet keratopathy. Salt pan keratopathy (SPK) is a variant of corneal degeneration occurring in workers chronically exposed to high-intensity UVR, high ambient temperatures, and salt-laden environments, relevant in many parts of India, such as Tamil Nadu, Andhra Pradesh, and parts of Gujarat, where occupational UV exposure is high, and protective measures are minimal.[1–3] The stromal degradation occurs due to chronic direct oxidative damage to the epithelial DNA, formation of ROS, and cyclobutene pyrimidine dimers, with upregulation of matrix metalloproteinases, which in turn triggers cellular stress responses and degradation of the extracellular matrix.[4] The decision making for the management depends upon the stage of the disease ranging from tenon’s patch grafts [Fig. 2b] or fibrin-glue-assisted sealing for small descemetoceles or perforations to full-thickness penetrating keratoplasty [Fig. 2c], which remains the treatment of choice due to the extensive architectural distortion extending to Descemet’s level. In cases with relatively preserved stroma but irregular contour, scleral lenses may serve as a visual rehabilitation option.[5,6] However, in our experience, the endothelial keratoplasties such as DSEK [Fig. 2a] are insufficient as they fail to correct anterior surface flattening and irregularity. Long-term follow-up is imperative for understanding graft survival and recurrence risk. Across all stages, long-term prevention with UV-blocking eyewear, ocular surface protection, and occupational health interventions is paramount to reducing recurrence and disease burden among exposed workers.Figure 2: (a) Slit-lamp image shows post-DSEK, with central flattening, lost corneal contour, and clear graft. (b) Slit-lamp image shows tenons patch graft for descemetocele. (c) Slit lamp shows postoptical penetrating keratoplasty with retained cornea contourAuthors’ contributions Concept and Design: Anitha Venugopal, Rajesh Fogla; Intellectual Content: Revathi Rajaraman; Literature Search: Anitha Venugopal; Clinical studies and Patient care: Anitha Venugopal, Rajesh Fogla, Revathi R; Data Acquisition and manuscript preparation: Anitha Venugopal; Manuscript review: Meenakshi R. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, patient have given his consent for his images and other clinical information to be reported in the journal. The patient understand that their names and initials will not be published and due effort will be made to conceal their identity, but anonymity can not be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.