Management of Severe Exposure Keratopathy

Darmayanti Siswoyo

Dr. Darmayanti Siswoyo is currently consultant of Ophthalmic Plastic & Reconstructive Surgery, Jakarta Eye Center Hospital, Indonesia.

She is the past Head of Ophthalmic Plastic & Reconstructive Surgery, Sub Department, Department of Ophthalmology, Faculty of Medicine, University of Indonesia.

She is also the past Head of Indonesian Ophthalmic Plastic & Reconstructive & Eye Tumor Surgery Association. She graduated from Department of Ophthalmology University of Indonesia in 1987.

She underwent orbital reconstruction training at Cranio Facial Center, Department of Plastic surgery, Royal Adelaide Hospital, South Australia in 1987.

She also underwent Oculoplastic & Reconstructive Surgery training at Department of Plastic Surgery, Kansai Medical Faculty and Department of Ophthalmology, Hamamatsu Hospital, Japan in 1992.

She is also National Speaker, Didactic Course Instructor, Wet Lab Instructor in Oculoplastic and Reconstructive Surgery in Indonesia since 1988 and International Speaker in Oculoplastic & Reconstructive Surgery since 1996.



Tjahjono D. Gondhowiardjo

Dr. Tjahjono D. Gondhowiardjo is currently consultant of Refractive and Corneal surgery, Jakarta Eye Center Hospital, Indonesia.

His clinical expertise in corneal problems were derived from Prof. Gabriel van Rij and Prof. Hennie Volker-Dieben, the two best corneal surgeons in the Netherlands in that era.

He is the past Head of the Department of Ophthalmology Medical faculty University of Indonesia-Cipto Mangunkusumo National Hospital (1997–2004).

He is the past Vice Chairman of Indonesian Eye Bank (2005–2010).

He is also past APAO Asian Coordinator for Education (2009–2011) & then Vice President of APAO Asian Coordinator for Education (2010–2012).

His role was recognized by APAO Distinguish Service Award (2004) & the Arthur Liem’s Award for Leadership in 2010.

He is currently Chaiman of the Indonesian College of Ophthalmology (2010–now), and a life member of the Indonesian Academy of Sciences.

He plays the main role in the development and progress of the Indonesian Ophthalmology within the last decade.



Exposure keratopathy is seen in severe thyroid orbitopathy with proptosis caused by the drying of the ocular surface. Typically, this is caused by lagophthalmos. Progressive proptosis with eyelid retraction and meibomian gland inflammation may worsen corneal exposure and progress to corneal ulceration and perforation and can end with blindness if not managed properly [1].

The Interplay Within the Tear Film, the Ocular Surface, and the Eyelid in Tear Flow Dynamic

A proper focus of any visual object in the macula cannot be obtained without an optically smooth ocular surface, which can only be produced through the interplay within the tear film, the ocular surface (cornea and conjunctiva), and the dynamic tear flow pumping mechanism by blinking of eyelids. The eyelids play a crucial role in the secretion, distribution, and drainage processes of the tear fluid. Moreover, since the delicate mixture of the tear fluid is not secreted from a single source, the blinking serves to combine the various components of the tear film.

During blinking, the normal healthy eyelids push the tear film evenly across the ocular surface. Blinking also assists pumping of the tear lake into the proximal part of lacrimal drainage system. However, the time between each blinking is the critical period to have a stable and optimal tear film in order to obtain a smooth optical ocular surface. An optimal tear film quality and quantity could maintain its stability for a certain period before discontinuity (dry spots) of the tear film form. The tear film also has a buffering capacity to overcome any corneal or conjunctival surface irregularities.

In reverse, any abnormalities of either the lid function or ocular surface may in turn jeopardize the tear film quality, changing the volume of the tear lake, and its buffering capabilities. These conditions may subsequently decrease the “tear breakup time,” which clinically contributes to the so-called dry eye syndrome [3, 5, 8].

If the blinking mechanism is affected severely and reduced by lagophthalmos either due to proptosis as well as lid retraction as in thyroid eye disease, severe exposure keratopathy may occur (Fig. 29.1).


Fig. 29.1
Left eye severe keratopathy

Clinical Manifestations

Although Graves’ orbitopathy can present with a number of clinical signs, it is very unusual for patient to present with all of them.

The most frequent sign is upper eyelid retraction (Fig. 29.2a, b), which affects 90–98 % of patients at some stage [2].


Fig. 29.2
(a) Upper lid retraction on both eyelids. (b) Upper lid retraction on both eyelids

The contour of the retracted upper eyelid often shows lateral flare, an appearance that is almost pathognomonic for Graves’ ophthalmopathy (GO) [2]. Proptosis is a very frequent sign, and if associated with significant upper or lower lid retraction, then these patients are more likely to demonstrate incomplete eyelid closure or lagophthalmos.

Many such patients, especially those with eyelid retraction, will show punctate inferior corneal staining with fluorescein, sometimes with thinning and very occationally corneal perforation. Corneal ulceration can develop when normal corneal protection is lost. This occurs in those patients who not only cannot close their eyes but also whose cornea remains visible when the eyelids are closed due to poor Bell’s phenomenon, the normal protective upward movement of the eyeball (Fig. 29.3a). Although this reflex is absent in 10 % of individuals, it is more likely to be affected in GO due to a very tight and thickened inferior rectus limiting the upward excursion of the eyeball (Fig. 29.3b).


Fig. 29.3
(a) Poor Bell’s phenomenon, limiting upward movement of the left eyeball. (b) Thick left inferior rectus muscle

Corneal Examination

Corneal sensitivity is tested by applying soft cotton fibers to the unanesthetized cornea and comparing the blink reaction with that of the fellow eye. Conduct a slit-lamp exam that focuses on the presence of punctate epithelial erosions or abrasions highlighted with fluorescein staining, and pay particular attention to the inferior cornea where lid excursion ends. Also, record the tear breakup time. Any epithelial defects or corneal ulcers should be carefully documented [7].

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Oct 16, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Management of Severe Exposure Keratopathy

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