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Swiss cheese appearance of cornea

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Swiss Cheese Appearance of the Cornea = Band Keratopathy

The "Swiss cheese appearance" of the cornea is a classic sign of band keratopathy. It describes the lucid (clear) spaces present within an anterior corneal calcium plaque, which interrupt the white opaque deposit and give it a holey, Swiss cheese-like look.
Band keratopathy showing Swiss cheese appearance with lucid spaces in the calcium plaque
Figure: Band keratopathy. Note the white interpalpebral calcium plaque with dark lucid spaces creating the Swiss cheese pattern.

What Is Band Keratopathy?

Band keratopathy is a deposition of calcium (hydroxyapatite crystals) at the level of Bowman's membrane, in the superficial anterior corneal stroma. It is located within the interpalpebral fissure (horizontally across the cornea, between the eyelid apertures), and is characteristically separated from the limbus by a clear margin of cornea.

Key Signs (from The Wills Eye Manual)

FeatureDescription
LocationInterpalpebral zone, starting at 3 o'clock and 9 o'clock positions
Layer affectedBowman's membrane
AppearanceWhite/gray chalky plaque with lucid (clear) holes = Swiss cheese
Limbal sparingBand separated from limbus by a clear zone

Causes

More Common:
  • Chronic uveitis (especially juvenile idiopathic arthritis / JIA)
  • Interstitial keratitis
  • Corneal edema
  • Trauma / phthisis bulbi
  • Long-standing glaucoma
  • Dry eye
  • Post ocular surgery (especially retinal detachment repair with silicone oil)
  • Idiopathic
Less Common (systemic causes of hypercalcemia/hyperphosphatemia):
  • Hyperparathyroidism
  • Renal failure
  • Sarcoidosis
  • Multiple myeloma
  • Paget disease of bone
  • Vitamin D excess
  • Gout (hyperuricemia)
  • Long-term exposure to mercury fumes

Workup

  • History: chronic eye disease, prior surgery, systemic disease, environmental exposures
  • Slit lamp examination
  • If no obvious ocular cause: serum calcium, albumin, magnesium, phosphate, BUN, creatinine, and uric acid (if gout suspected)

Treatment

Mild (foreign body sensation):
  • Preservative-free artificial tears 4-6x/day
  • Lubricating ointment at bedtime
  • Antibiotic ointment if epithelial defects overlie the calcium
  • Bandage soft contact lens for comfort
Severe (vision obstruction, intractable irritation, cosmetic concern):
  • Chelation with disodium EDTA 3-4% - the definitive treatment
    1. Topical anesthesia + lid speculum
    2. Debride epithelium overlying calcium with sterile blade
    3. Apply EDTA-soaked sponge until calcium clears (10-60 minutes)
    4. Irrigate with saline, apply antibiotic ointment + cycloplegic
    5. Consider bandage contact lens and systemic analgesics
In summary: Swiss cheese appearance of the cornea = band keratopathy, due to calcific deposits at Bowman's membrane with lucid (clear) spaces interrupting the plaque. - The Wills Eye Manual, p. 195-197
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