In Vivo Confocal Microscopy in Terrien Marginal Corneal Degeneration: A Case Report

Prospective In Vivo Confocal Microscopy of the Central Cornea in Terrien Marginal Degeneration

PURPOSE

To analyze central corneal in vivo confocal microscopy (IVCM) in Terrien marginal degeneration (TMD).

METHODS

An observational prospective case-control study. Ten Finnish patients with TMD from a tertiary referral center were compared with 10 age- and sex-matched healthy volunteers. Seven patients had bilateral TMD. Age, anterior segment optical coherence tomography, extent of thinning in clock hours, grade of microdots, and stage of TMD were analyzed.

RESULTS

According to Süveges and Wang classification, the median stage of TMD was 2 (range, 2-3) and 2 (range, 2-6), respectively. Twelve (71%) of 17 eyes with clinical TMD showed corneal thinning at all clock hours. The median age at the time of examination was 70 years (range, 28-81), and the median time from diagnosis 8.8 years (range, 6.0-15.2). By IVCM, the epithelium, subepithelial nerve plexus, and endothelium were intact in all eyes. The anterior stroma showed bilateral hyperreflective dots in the central cornea beneath the subepithelial nerve plexus in all eyes, and larger patches were detected in the posterior stroma anterior to Descemet membrane; both were invisible by anterior segment optical coherence tomography. As compared with controls, the grade of anterior microdots increased faster with age before the age of 65, and that of posterior stromal patches was higher. Two patients additionally had bilateral hyperreflective needle-like deposits in the anterior and midstroma.

CONCLUSIONS

By IVCM, TMD is characterized regardless of clinical laterality by bilateral microdots in the central corneal stroma. They might be a supporting diagnostic criterion and alone could suggest subclinical disease.

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.

Diagnostic Criteria for Terrien Marginal Degeneration: Nordic Terrien Degeneration Study

PURPOSE

To refine the diagnostic criteria for Terrien marginal degeneration (TMD) based on experience in 3 Nordic countries.

METHODS

This is a retrospective, multicenter, hospital-based cross-sectional study of 49 eyes of 29 white patients in tertiary referral centers in Finland, Sweden, and Denmark from 1998 to January 2018. The median follow-up was 3 years. Symptoms, best corrected visual acuity, astigmatism, corneal thickness, curvature and cavities, stage, and progression were analyzed.

RESULTS

TMD was diagnosed equally likely between 15 and 86 years of age (median, 47 years). Twenty patients (69%) had bilateral disease, and 62% were men. Seventeen patients (59%) had symptoms including blurred vision and ocular surface disease symptoms without inflammatory signs. Eight patients (28%) had slightly reduced corneal sensitivity. Median best corrected visual acuity was 20/25 (range, 20/16-20/200) and astigmatism was 2.6 diopters (D) (range, 0-10) with a mean progression of 0.41 D per year (range, 0-5.4). Age and astigmatism were not correlated. All eyes had peripheral vascularization, lipid deposits, and hyperreflectivity throughout thinned peripheral stroma and its anterior edge. The thinning progressed in 15 patients (52%). Of 26 patients, 8 (31%) had single or confluent paralimbal intrastromal cavities, most commonly superiorly. By Süveges classification, the stage was 2 (92%) or 3 (8%). Minimum corneal thickness and corneal curvature were loosely associated, leading to different stages in Wang classification in 34 eyes (69%).

CONCLUSIONS

TMD is defined by peripheral corneal thinning, superficial neovascularization, lipid deposition at the leading edge, absence of ulceration and inflammation, and frequently cavitation. The most sensitive way to follow its progression is anterior segment optical coherence tomography.

Peripheral hypertrophic subepithelial corneal degeneration: clinical aspects related to in vivo confocal microscopy and optical coherence tomography

Purpose

To report the findings of anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM) in two patients with peripheral hypertrophic subepithelial corneal degeneration (PHSD).

Methods

Case series by restrospective chart review and imaging analysis of AS-OCT and IVCM.

Results

Slit lamp examination of the two patients revealed a bilateral subepithelial-elevated fibrous tissue of the superior-nasal quadrant, as well as inferior-nasal in one of the patients. Best corrected visual acuity ranged from 20/25 to 20/15. AS-OCT showed continuous, homogenous, well-demarked hyperreflective subepithelial band associated with hyperreflectivity in the anterior stroma. IVCM demonstrated normal epithelial cell morphology and arrangement and a fibrous structure subepithelial and in the anterior stroma.

Conclusion

AS-OCT and IVCM can facilitate the diagnosis of PHSD and differentiate it from other corneal entities that present peripheral opacifications.

In Vivo Confocal Microscopy of Cornea in Patients with Terrien's Marginal Corneal Degeneration

This study was aimed at observing the morphological changes of the cornea with ocular in vivo confocal microscopy (IVCM) in patients with Terrien's marginal degeneration (TMD). Ten patients (20 eyes) with TMD treated in the Department of Ophthalmology, Xiangya Hospital, and 10 healthy controls (20 eyes) were included in the current study. A detailed slit lamp microscopy, anterior segment photography, and corneal IVCM examination were performed for each eye. The density of central and marginal corneal epithelial cells, stromal cells, and subepithelial nerve fibers was compared between the two groups using the Wilcoxon rank sum test. Compared with the control group, the corneal epithelial and endothelial cells in the TMD group showed granular highly reflective substances and thinner subepithelial nerve fibers. The uneven dot-like highly reflective substances without cell structures appeared in the stromal layer of the cornea. The density of central and marginal corneal epithelial cells, stromal cells, and subepithelial nerve fibers was lower in the TMD group (p < 0.05), and they were negatively correlated with severity of the disease (p < 0.05). Our study demonstrated that the density of corneal epithelial cells, stromal cells, and sensory plexus nerve fibers was significantly reduced in the TMD group. The pathological changes were more obvious in the marginal cornea, and it is correlated with severity of the disease.

High-Resolution Optical Coherence Tomography in the Differentiation of Inflammatory Versus Noninflammatory Peripheral Corneal Thinning

PURPOSE

To evaluate whether high-resolution optical coherence tomography (HR-OCT) can aid in differentiation of inflammatory versus noninflammatory causes of peripheral corneal thinning.

METHODS

Retrospective chart review of 10 patients with peripheral corneal thinning and their respective slit-lamp photographs and HR-OCT images.

RESULTS

Ten patients were identified who had peripheral corneal thinning and HR-OCT images. Five had a clinical history consistent with Terrien marginal degeneration (TMD), whereas 5 had thinning believed to be inflammatory in origin. In the eyes with presumed TMD, patients denied pain or inflammation. HR-OCT images demonstrated stromal thinning in the presence of an intact epithelium. The stroma underneath the epithelium in the area of thinning had a similar reflectivity pattern as the nonaffected cornea. There was epithelial marsupialization evident in 2 of the 5 images. In the 4 patients with a clinical history of inflammation (bulbar hyperemia and pain), and in the 1 patient with active inflammation at the time of HR-OCT imaging, HR-OCT also demonstrated thinning with an intact epithelium. In contrast to the TMD group, in the group with signs of inflammation, a dense hyperreflective band was noted in the stroma directly below the epithelium in the area of thinning, suggestive of scarring and/or cellular infiltration.

CONCLUSIONS

In patients with a clinical history of inflammation and corneal thinning, HR-OCT revealed a hyperreflective band directly under the epithelium in the area of thinning, which was not seen in patients with presumed noninflammatory melts and thinning.

Terrien Marginal Degeneration: Clinical Characteristics and Outcomes

PURPOSE

To describe outcomes of patients with Terrien marginal degeneration.

DESIGN

Retrospective case series.

METHODS

Database review of 25 patients (43 eyes) seen over 10 years (2004-2013) at Toronto Western Hospital cornea clinic. Outcome measures included demographics, location of disease, topographic astigmatism, visual acuity, coexisting ocular disease, and surgical management.

RESULTS

Mean age at presentation was 44 years (range, 20-82 years) and 54% were male. Eighteen patients (72%) had bilateral disease. Mean follow-up was 30.3 months. Mean topographic astigmatism was 4.02 diopters (D) at 5 degrees. Mean change in astigmatism 1 year from baseline was 0.75 D; at 2 years was 1.22 D; and at 3 years was 1.68 D. Mean best spectacle-corrected visual acuity (BSCVA) at presentation was 20/46 and 20/48 at last follow-up. Eyes requiring surgery (23.3%) had mean BSCVA of 20/81 at presentation and 20/106 after surgery. Five eyes perforated: 4 spontaneously, and 1 from trauma. Three eyes (6.9%) presented with pseudopterygium. Two eyes (4.7%) had intracorneal cysts. Fourteen patients (56%) presented with ocular surface inflammation.

CONCLUSIONS

Terrien marginal degeneration is a slow-progressing, bilateral but asymmetric degeneration of the peripheral cornea. Men over 40 are more commonly affected. Stromal thinning, vascularization, lipid deposition, and against-the-rule astigmatism are classic signs. Though typically noninflammatory, a variant form characterized by prominent inflammation exists. Surgery (lamellar graft) can preserve corneal integrity and is indicated when conventional options fail to maintain vision or if perforation is imminent. Perforations are rare but can result in significant vision loss.

Partial and Total Descemet's Detachments in a Patient with Severe Terrien's Marginal Degeneration and Juvenile Idiopathic Arthritis

A 16-year-old female with juvenile idiopathic arthritis presented with a one-month history of decreasing vision and increasing corneal edema in her left eye. Slit-lamp examination, keratometric measurements, and OCT evaluation led to a diagnosis of Terrien's marginal degeneration in both eyes along with a complete detachment of Descemet's membrane in the left eye and partial detachment in the right eye. She was treated with an intracameral injection of air and then topical betamethasone and chloramphenicol which lead to the resolution of symptoms. We further examine the pathophysiology of this disease based on current literature.

Terrien's marginal degeneration accompanied by latticed stromal opacities

Purpose

We report a case of Terrien’s marginal degeneration (TMD) with a unilaterally typical narrow band of peripheral corneal stroma thinning, accompanied by the presence of an unusual network of opacities diffusing throughout the anterior stroma layers.

Case Report

A 43-year-old woman presented with superior nasal peripheral corneal thinning and an unusual network of polygonal stromal opacities in the anterior corneal stroma of the right eye. Latticed corneal changes were unusually extensive and distributed diffusely in the stroma. No abnormalities were found in the corneal epithelium and in the basal epithelial cells. No noticeable changes were found in the left eye. Because of a progressively worse ocular irritation of the right eye, a diagnosis of TMD was made for this patient.

Conclusions

This case of TMD accompanied by keratopathy was unusual. The branching stromal lattice pattern of the corneal opacities was difficult to distinguish from lattice corneal dystrophy. In this case, the polygonal stromal opacities were located in the anterior corneal stroma and therefore were distinguished from a similar manifestation in posterior crocodile shagreen.