Terrien marginal degeneration

Does Corneal Topography Using 3-Dimensional Optical Coherence Tomography Suggest Different Subtypes of Terrien Marginal Degeneration?

PURPOSE

The aim of this study was to analyze corneal topography relative to astigmatism, higher order aberrations, and corneal curvatures in Terrien marginal degeneration using 3-dimensional anterior-segment optical coherence tomography.

METHODS

Twenty-nine eyes of 15 Finnish patients from a tertiary referral center had topographic axial power maps classified into 4 patterns by visual grading: crab claw (CC), mixed (M), arcuate (A), and normal. Regular astigmatism, keratometry, higher order aberrations, maximal corneal thinning, apex thickness, and curvature changes relative to best fit sphere toward maximal peripheral thinning were compared.

RESULTS

Four, 9, and 12 eyes were classified as CC, M, and A, respectively; 1 as normal with clinical disease; and 3 as normal with unilateral disease. Median follow-up was 2.3 (range, 0-7.2) years. Three eyes changed pattern. Patients with the CC pattern were the youngest when diagnosed, progressed more rapidly, exhibited cavities in superior quadrants with anterior bulging, and had greater higher order posterior aberrations. Patients with the M pattern were older, progressed slower, and showed superonasal asymmetric corneal steepening extending centrally, often with asymmetric bow tie. Patients with pattern A showed little progression and were the oldest when diagnosed, with maximal corneal thinning equally in all quadrants. According to the Wang classification, the median stage was 4, 2, and 2 in CC, M, and A patterns, respectively, whereas it was always 2 by the Süveges classification.

CONCLUSIONS

Terrien marginal degeneration is characterized by distinct corneal topographic patterns that differ in tomographic features, suggesting existence of subtypes in addition to different stages of disease. Patients representing CC and M patterns might benefit from more frequent monitoring.

Replace or Regenerate? Diverse Approaches to Biomaterials for Treating Corneal Lesions

The inner structures of the eye are protected by the cornea, which is a transparent membrane exposed to the external environment and subjected to the risk of lesions and diseases, sometimes resulting in impaired vision and blindness. Several eye pathologies can be treated with a keratoplasty, a surgical procedure aimed at replacing the cornea with tissues from human donors. Even though the success rate is high (up to 90% for the first graft in low-risk patients at 5-year follow-up), this approach is limited by the insufficient number of donors and several clinically relevant drawbacks. Alternatively, keratoprosthesis can be applied in an attempt to restore minimal functions of the cornea: For this reason, it is used only for high-risk patients. Recently, many biomaterials of both natural and synthetic origin have been developed as corneal substitutes to restore and replace diseased or injured corneas in low-risk patients. After illustrating the traditional clinical approaches, the present paper aims to review the most innovative solutions that have been recently proposed to regenerate the cornea, avoiding the use of donor tissues. Finally, innovative approaches to biological tissue 3D printing and xenotransplantation will be mentioned.

Pseudopterygia in Fuchs Superficial Marginal Keratitis: Clinical Course and Surgical Outcome

PURPOSE

Surgery for pseudopterygia in Fuchs superficial marginal keratitis (FSMK) bears the risk of corneal perforation, as described in a few case reports. The aim of this case series was to understand the clinical course and surgical outcomes of pseudopterygia in FSMK.

METHODS

A retrospective case series included patients meeting FSMK criteria with pseudopterygia in at least 1 eye. The severity grading of pseudopterygia and peripheral infiltration events at follow-up were analyzed. Pseudopterygia involving corneal central 3 mm diameter (grade III) received surgery. Peripheral corneal infiltrate events within 1 week after surgery were recorded.

RESULTS

Thirty-three eyes of 19 patients (8 men, 11 women; age 40-85 years; mean, 65 years) were included, with an average 48.1-month follow-up (range 0-188.8 months). At presentation, 7 eyes (21%) had grade III pseudopterygia. One patient showed corneal perforation 3 days after "pterygium" surgery elsewhere. The contralateral eye met the diagnosis of FSMK. During follow-up, 16 eyes (49%) exhibited peripheral corneal infiltrates, and 7 eyes (21%) showed progression of pseudopterygia to higher grades before or without any surgery. Ten eyes with grade III pseudopterygia underwent surgery. The best-corrected visual acuity in Logarithm of the Minimum Angle of Resolution improved from 0.34 ± 0.18 (range 0.05-0.52) to 0.13 ± 0.11 (range 0.05-0.4) (P = 0.0023). Six eyes (60%) developed peripheral corneal infiltrates within 1 week after surgery, which responded well to topical corticosteroids.

CONCLUSIONS

Pseudopterygia in FSMK may progress to threaten visual acuity. Surgical excision can be safe and can effectively improve vision on the condition that the patients are closely followed in the early postoperative period to notice the corneal infiltrates.

Systemic treatment and surgical intervention in inflammatory Terrien disease

This case report presents a unique instance of a 55-year-old male patient exhibiting features of both Terrien marginal degeneration (TMD) and Fuchs' superficial marginal keratitis. Characterized by peripheral corneal thinning vascularization, and a pseudopterygium, the patient experienced recurrent photophobia, redness, and tearing over 15 years. This case challenges the traditional distinction between TMD and Fuchs' superficial marginal keratitis, suggesting a potential common underlying disorder. Mycophenolate mofetil provided a partial response, while pseudopterygium removal led to sustained remission, emphasizing its therapeutic significance. This case highlights the first documented use of mycophenolate in TMD and supports the notion of shared vasculitic origins between TMD and Fuchs' keratitis, raising intriguing questions about targeted therapeutic interventions.

Perforation in interstitial keratitis associated with hidradenitis suppurativa: medical and surgical management

We present a case of bilateral interstitial keratitis leading to perforation in a woman with hidradenitis suppurativa (HS). A woman in her mid-20s with a history of HS and Grave's disease was referred to the corneal service with loss of vision and pain in both eyes since childhood. She was found to have circumferential thinning and steepening affecting her peripheral cornea bilaterally. Corrected distance visual acuity with spectacles was in the right eye 6/7.5, and in the left 6/30, with local thinnest area of 209 and 217 µm in the right and left eyes, respectively. She experienced recurring episodes of redness and irritation, and perforation occurred. The corneal perforation was managed with cyanoacrylate glueing, followed by a local conjunctival flap. Systemic immunosuppression with mycophenolate mofetil and adalimumab was commenced, with improvement after 18 months of treatment. Dermatologists and ophthalmologists should be aware of this association given its potential severity.

Prosthetic Replacement of the Ocular Surface Ecosystem for Terrien Marginal Degeneration: A Case Series

OBJECTIVES

To assess outcomes of the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment in patients with advanced Terrien marginal degeneration (TMD).

METHODS

This is a retrospective case series of patients with advanced TMD who were assessed and fit with customized PROSE lenses. Data were collected on PROSE fitting details including visual acuity (VA) before and after PROSE, slit-lamp findings, and corneal tomography scans.

RESULTS

Six eyes in four patients were included. All patients attempted at least one other contact lens (CL) modality before PROSE. Some patients had corneal comorbidities such as pseudopterygium and pseudobleb that contributed to intolerance to previous lenses and warranted extra considerations in the fitting process. With PROSE, VA improved in all six eyes. Patients with structural corneal comorbidities achieved improved vision, comfort, and lens tolerance with PROSE. Two eyes had noncorneal ocular comorbidities that limited PROSE efficacy. Another eye discontinued PROSE wear because of limbal stem-cell disease progression necessitating a limbal stem-cell transplant.

CONCLUSIONS

PROSE treatment can be an effective option to improve vision and comfort for patients with advanced TMD who are intolerant to first-line therapeutic CL modalities, even in the presence of other corneal comorbidities.

Pseudopterygium: An Algorithm Approach Based on the Current Evidence

Pseudopterygium is a non-progressive conjunctival adhesion to the peripheral cornea secondary to a corneal-limbus damage. According to the literature, the main etiology is a previous eye trauma. Nevertheless, this could be biased by the existence of other underdiagnosed causes of pseudopterygium, some of which may have severe consequences for the integrity of the eye and patient’s life. This comprehensive literature review was performed based on a search on the PubMed and Google Scholar databases of relevant pseudopterygium published papers according to our current knowledge and seeks to gather the existing evidence about its diverse etiologies and clinical features, as well as to propose a diagnostic algorithm to simplify its correct approach.

Topographic changes in contralateral eye of a case of Terrien's marginal degeneration

A woman in her late twenties presented with blurring of vision in the right eye for 6 years. Retinoscopy showed a scissoring reflex in the right eye with best spectacle-corrected visual acuity of 20/40 in the right eye and 20/20 in the left eye. Slit-lamp examination of the right eye showed superior crescentic thinning with conjunctivalisation and lipid deposition while the left eye was normal. Corneal topography of the right eye showed inverse crab-claw pattern suggestive of Terrien's marginal degeneration (TMD) and the left eye showed inferior steepening with posterior elevation and thinning suggestive of keratoconus-like topography. This case shows that evaluation of the other apparently normal eye with 20/20 vision might show changes on topography in cases of unilateral TMD and needs follow-up to assess any further progression.

Corneal stromal deposits in connective tissue disease, a case series

Purpose

We report two cases of refractile, peripheral, corneal stromal deposition in two patients with arterial tortuosity syndrome (ATS) and Ehlers-Danlos syndrome (EDS), two closely related connective tissue diseases (CTDs).

Observations

Patient 1: A 21-year-old man with history of ATS and keratoectasia presented with bilateral peripheral corneal neovascularization with numerous whitish brown, refractile, deep stromal opacities that were circumferential along the inferotemporal cornea. After 3 years of follow-up, the corneal deposits did not progress, but the ectasia did, with significant bilateral corneal steepening and thinning for which the patient was recommended to undergo repeat corneal collagen cross linking. Patient 2: A 26-year-old man with presumed diagnosis of EDS presented with numerous whitish brown, refractile, deep stromal opacities that were circumferential along the temporal cornea in the right eye, and superiorly in the left eye. The left eye had a pseudopterygium involving 50% of the cornea. After 2 years of follow-up, the corneal opacities did not progress; however, the patient underwent primary excision of the pseudopterygium and subsequently had conjunctivalization of the entire cornea. The lesions in both cases resembled those seen in Terrien's marginal degeneration.

Conclusions and importance

Peripheral corneal stromal deposits have never been reported before in EDS or ATS or other connective tissue diseases. This case series may prompt further inquiry and characterization of these findings in patients with CTDs.

Necrotizing Anterior Scleritis in a Woman with Terrien’s Marginal Degeneration: A Case Report

Purpose:

The aim of the study was to report the first case of a patient with Terrien’s Marginal Degeneration (TMD) who developed necrotizing anterior scleritis without systemic disease association, requiring systemic immunosuppressive treatment.

Case Report:

A 32-year-old female consulted for bilateral ocular burning and hyperemia. Initially, she was diagnosed with conjunctivitis and treated with topical antibiotics and corticosteroids, with mild transitory improvement but the progression of the disease. Years later, she attended the ocular immunology consultation for a second opinion where TMD with ocular inflammatory component OU was diagnosed. Seven months later, she presented with severe pain, decreased visual acuity, and photophobia in OS. At the slit-lamp examination, necrotizing anterior scleritis with a high risk of perforation in OS was observed. The patient was referred to the rheumatologist and started treatment with systemic corticosteroids and cyclophosphamide, exhibiting a clinical improvement. The patient did not meet the criteria for any systemic illness associated with scleritis, such as autoimmune diseases or vasculitis. Thus, scleritis was related to the adjacent inflammatory process associated with TMD, as an atypical presentation of this disease.

Conclusion:

Although an inflammatory type of TMD has been proposed, it is essential to follow up closely these patients and consider necrotizing anterior scleritis, a severe ocular disease that requires prompt immunosuppressive management, as a possible atypical associated presentation of this disease.

Clinical profile and demographic distribution of Terrien's marginal degeneration in a multitier ophthalmology network in India

Purpose:

To describe the clinical profile and demographic distribution of Terrien’s marginal degeneration (TMD) in patients presenting to a multitier ophthalmology hospital network in India.

Methods:

This cross-sectional hospital-based study included 2,470,793 new patients presenting between September 2012 and September 2020 (~8 years period). Patients with a clinical diagnosis of TMD in at least one eye were included as cases. The data were collected using an electronic medical record system.

Results:

Overall, 184 (0.007%) new patients were diagnosed. Over half of patients were males (56.52%) with bilateral affliction (54.89%). The mean age of the patients was 38.63 ± 16.75 years. Majority (28.26%) of the patients were between 21 and 30 years of age bracket. The number of patients were from rural and urban districts were comparable (41.85% vs. 48.37%). The most common clinical signs were ectasia/thinning (50.53%), corneal scar (44.21%), and prominent nerves (5.26%). Associated ocular comorbidities included vernal keratoconjunctivitis in 6 (2.11%) eyes, meibomitis in 6 (9.7%) eyes, squamous blepharitis in 2 (3.2%) eyes, dry eye in 2 (3.2%) eyes, cataract in 46 (74.2%) eyes, and glaucoma in 6 (9.7%) eyes. Most of the eyes had mild or no visual impairment (43.86%). Two (0.7%) eyes had spontaneous perforation patients. None of patients had hydrops in the years of follow-up. Keratoplasty was performed in 3.86%.

Conclusion:

TMD is a rare disease affecting patients seeking eye care at the ophthalmology network. It commonly affects adult males and is predominantly bilateral. The disease progression is slow, and risk of spontaneous perforation was low. At initial presentation, visual impairment was mild to moderate in majority and the most common surgical intervention was cataract surgery during the study period.

Anterior Segment Ischemia After Peripheral Annular Lamellar Sclerokeratoplasty for Advanced Terrien Marginal Degeneration

ABSTRACT

A man with 360° bilateral peripheral thinning, peripheral vascularization, and lipid deposition diagnosed with Terrien marginal degeneration, underwent a 360° peripheral annular lamellar sclerokeratoplasty (PALK) (tuck-in) in the right eye for 90% peripheral thinning and high astigmatism. One-week postoperatively, a sudden drop in vision to counting fingers 1 m from 20/50 with circumciliary congestion, diffuse corneal edema, intense anterior chamber inflammation, keratic precipitates with fixed dilated pupil, and hypotony led to a diagnosis of suspected anterior segment ischemia. Anterior segment fluorescein angiography was suggestive of ischemia. After intensive topical and systemic steroids tapered over 6 months, his symptoms and signs improved. At the last follow-up 4 years later, his best contact lens-corrected visual acuity was 20/30. Anterior segment ischemia has not been reported after a PALK for advanced corneal ectatic disorders. Prompt diagnosis and commencement of intensive steroids was helpful in reversing this condition.

Corneal neovascularization

The optical clarity of the cornea is essential for maintaining good visual acuity. Corneal neovascularization, which is a major cause of vision loss worldwide, leads to corneal opacification and often contributes to a cycle of chronic inflammation. While numerous factors prevent angiogenesis within the cornea, infection, inflammation, hypoxia, trauma, corneal degeneration, and corneal transplantation can all disrupt these homeostatic safeguards to promote neovascularization. Here, we summarize its etiopathogenesis and discuss the molecular biology of angiogenesis within the cornea. We then review the clinical assessment and diagnostic evaluation of corneal neovascularization. Finally, we describe current and emerging therapies.