Indirect evaluation of corneal endothelial cell density

A review of the evidence for in vivo corneal endothelial regeneration

Human corneal endothelium has long been thought to be a nonmitotic cell layer with no endogenous reparative potential. Pathologies that damage endothelial function result in corneal decompensation and, if untreated, blindness. The mainstay of treatment involves partial or complete corneal replacement, amounting to 40% of all corneal transplants performed worldwide. We summarize the case reports describing complications postoperatively in the form of (sub)total graft detachment and those resulting in postoperative bare stroma. Complications during cataract and glaucoma surgeries leading to an uncovered posterior cornea are also included. We discuss the newer treatment strategies that are alternatives for current Descemet membrane endothelial keratoplasty and Descemet stripping automated endothelial keratoplasty, including partial grafts and stripping of the diseased cell layer. In more than half of the cases reviewed, corneal transparency returned despite incomplete or no corneal endothelial cell transplantation. We question the existing paradigm concerning corneal endothelial wound healing in vivo. The data support further clinical study to determine the safety of simple descemethorexis in central endothelial pathologies, such as Fuchs endothelial corneal dystrophy, where presence of healthy peripheral cells may allow successful corneal recompensation without the need for donor cells.

Endothelial morphology related to disease activity in human corneas

Twenty normal and four groups of pathological corneas with the diagnoses aphakia, macula after herpetic keratitis. Fuchs' endothelial dystrophy and graft rejection were stained with trypane blue and alizarin red. The morphology of the endothelium was described in terms of cell density, coefficient of variation for cell area, percentage of hexagonal cells, percentage of joint meetings of more than three cells, nuclei per cell and nuclear shape. The groups of aphakia, keratitis, Fuchs' dystrophy and graft rejection were considered to represent increasing degrees of endothelial disease activity at the time of evaluation. The only parameter showing consistent variation with disease activity was the percentage of joint meetings of more than three cells.

Urgent Need for Normalization of Corneal Graft Quality Controls in French Eye Banks

BACKGROUND

Assessment of corneal tissue quality before graft is mainly based upon the determination of endothelial cell density (ECD) by eye banks. These cells are responsible for corneal transparency, and ECD correlates with graft survival. In France and often elsewhere in Europe, ECD is measured using a "naked-eye" procedure under a light microscope. To measure objectively the reliability of ECD determination in France, we developed four test corneas with a known ECD.

METHODS

The test corneas consisted of 1 mm2 of human corneal endothelium with stained cell borders. The 64 technicians of the 21 French eye banks counted according to the protocol applied in their respective centers.

RESULTS

More than half of the 256 counts (152, 59%) deviated by more than 10% from actual ECD. Of the counts, 85 (33%) were over-estimated, and 67 (26%) were under-estimated. Deviation ranged between 42% under-estimation and 82% over-estimation. Eight banks (38%) constantly over-estimated, and nine (43%) under-estimated ECD. Half of the inter-technician gaps within an eye bank were more than 10%, with a maximum of 51%.

CONCLUSIONS

This audit highlights the unacceptable lack of reliability of manual ECD assessment in French eye banks. This surely indicates the delivery of poor quality corneas for graft in certain centers and wastage in others. We urgently advocate normalization of French counting methods. This may require upgrading to a computer-aided method.

The effects of corneal parameters on the assessment of endothelial cell density in the elderly eye

BACKGROUND

The possible impact of corneal thickness, curvature, and size on the measurement of endothelial cell density (ECD) has largely been ignored in the normal eye. The aim of this study was to investigate the possible impact of the main corneal parameters on the analysis of ECD values at the central, superior, and temporal parts of the corneal surface.

METHODS

All 75 participants (52 females, 23 males) were assessed as part of a pre-cataract surgery investigation. The mean age was 75.7 (SD 10.9) years. Confocal microscopy was used to measure ECD and the percentage of six sided cells at the central, superior, and temporal parts of the cornea. The Orbscan II topography system was used to measure corneal thickness, topography, and horizontal corneal diameter.

RESULTS

The mean central ECD measured was 2488 (SD 301) cells/mm(2), compared with 2525 (SD 505) cells/mm(2) in the temporal cornea and 2639 (SD 398) cells/mm(2) in the superior cornea. The regional differences in ECD were not significant (p>0.14). The central ECD was significantly correlated to the central (mean 0.593 (SD 0.039) mm, p = 0.021) as well as the temporal (0.628 (SD 0.039) mm, p<0.001) and the superior corneal thickness (SD 0.644 (SD 0.048) mm, p = 0.018). The mean corneal curvature at the centre (7.7 (SD 0.34) mm, p = 0.002) as well as 3 and 5 mm from the apex was significantly related to ECD (p = 0.008 and p = 0.009, respectively).

CONCLUSIONS

The study suggests that in an older population, lower ECD values would be expected in thinner and/or steeper corneas.

Is manual counting of corneal endothelial cell density in eye banks still acceptable? The French experience

AIM

To examine the differences in manual endothelial cell counting methods in French eye banks and to analyse whether these differences could explain some substantial discrepancies observed in endothelial cell density (ECD) for corneas made available for transplant.

METHODS

A questionnaire was sent to the 22 eye banks asking for details of the technical features of the light microscopes used, the microscope calibration, strategy for cell counting, the technical staff, and the method of presenting endothelial data.

RESULTS

All eye banks responded and 91% (20/22) used only manual counting methods, in real time, directly through a microscope, and 62 different technicians, with varying experience, were involved in such counting. Counting of cells within the borders of a grid that were in contact with two adjacent borders was the most common method (17/22, 77%). Of the eight banks (8/22, 36%) that did not calibrate their microscopes, six reported the highest ECD values. Of the 14 others (64%), six applied a "magnification correcting factor" to the initial cell counts. In five of these cases, the corrected ECD was lower than estimated on initial count. Most of the banks (12/22, 55%) counted 100 cells or less in one to six non-adjacent zones of the mosaic. 14 of the banks (14/22, 64%) also graded cell polymegethism while seven (7/22, 32%) also graded pleomorphism ("hexagonality").

CONCLUSIONS

Lack of microscope calibration appears to be the leading cause of variance in ECD estimates in French eye banks. Other factors such as differences in counting strategy, the evaluation of smaller numbers of cells, and the different extent of experience of the technicians may also contribute to intraobserver and interobserver variability. Further comparative studies, including cross checking and the outcome of repeated counts from manual methods, are clearly needed with cross calibration to a computer based image archiving and analysis system.

The resiliency of the corneal endothelium to refractive and intraocular surgery

PURPOSE

To describe stress factors (phenylephrine and contact lenses) from the corneal epithelium that can affect the corneal endothelium, and to describe the effects of refractive and intraocular surgery on the corneal endothelial structure and function.

METHODS

Significant clinical and experimental publications are reviewed and recent experiments conducted in the author's laboratory to describe the corneal endothelial stresses.

RESULTS

The corneal epithelium serves as a barrier to topical phenylephrine (2.5-10%). In a compromised epithelium, topical phenylephrine will cause drug-induced stromal edema and endothelial vacuolization. Contact lenses are capable of stimulating the epithelial arachidonic acid cascade to release 12(R)hydroxyeicosatetraenoic acid (12(R)HETE) and 8(R)hydroxy-hexadecatrienoic acid (8(R)HHDTrE) to cause endothelial Na+/K+ adenosine triphosphatase (ATPase)-inhibition and polymegethism. Specular microscopy of the corneal endothelial cells after refractive surgery (photorefractive keratectomy [PRK], laser in situ keratomileusis [LASIK], intrastromal rings [INTACs]) has shown that there is minimal effect. However, laser ablation of the stroma within 200 microm of the corneal endothelium will result in endothelial cell structural changes and the formation of the amorphous substance deposited onto Descemet's membrane. Phacoemulsification with a high flow of the irrigation solution can alter the endothelial surface glycoprotein layer. Lidocaine hydrochloride (1%) used as intracameral anesthesia readily diffuses through the corneal endothelium, resulting in stromal uptake and endothelial cell swelling. With phacoemulsification, however, the washout of lidocaine from the cornea (T1/2, 5 minutes) and iris (T1/2, 9 minutes) occurs quickly. Corneal endothelial wound healing after keratoplasty occurs in the following sequence: migration of endothelial cells, development of tight junctions, and the formation of Na+/K+ ATPase pump sites.

CONCLUSIONS

Corneal endothelial resiliency is due to the increased peripheral endothelial cell number for migration, the ability of endothelial cells to form tight junctions to maintain the endothelial barrier, the increase in endothelial Na+/K+ ATPase pump sites under stress, and the ability of the corneal endothelial cells to shift their metabolism of glucose to the hexose monophosphate shunt for the production of nicotinamide adenine dinucleotide phosphate (NADPH) and membrane repair. All of these factors are important, along with the aqueous humor sodium concentration, which establishes the osmotic gradient for corneal deturgescence and transparency.

The effect of contact lens wear on the central and peripheral corneal endothelium

PURPOSE

To compare central and peripheral corneal endothelial cell morphometry in normal subjects and long-term contact lens wearers.

METHODS

Endothelial cell density (ECD), coefficient of variation of cell area (CV), and percentage of six-sided cells were measured by contact specular microscopy in the corneal center and temporal periphery of both eyes of 43 long-term contact lens wearers and in 84 normal subjects who had never worn contact lenses. The latter group included 43 age- and sex-matched controls for the contact lens wearers. ECDs were corrected for magnification changes due to corneal thickness.

RESULTS

Central ECD (2,723+/-366 cells/mm2, mean +/- SD) was significantly higher than peripheral ECD (2,646+/-394 cells/mm2) for the normal group (p = 0.01) but not for the contact lens wear group (2,855+/-428 cells/mm2 central, 2,844+/-494 cells/mm2 peripheral, p = 0.84). Peripheral CV was significantly higher than central for normal subjects and contact lens wearers and was significantly higher in both center and periphery in contact lens wearers than in controls. Central percentage of six-sided cells was significantly higher than peripheral for normal subjects and contact lens wearers and was lower in both center and periphery in contact lens wearers than in controls.

CONCLUSIONS

Central ECD was significantly higher by 3% than peripheral ECD in normal subjects, but not in contact lens wearers. The results suggest that contact lens wear causes a mild redistribution of endothelial cells from the central to the peripheral cornea. A reversal of this redistribution after contact lens wear is discontinued for refractive surgery could mask mild central endothelial damage from the refractive procedure.

Quantitative analysis of wide-field endothelial specular photomicrographs

Samples from the center of a wide-field specular micrograph adequately assessed cell density and frequency distribution of cell areas. A preliminary analysis of the spread of values indicated whether an increased sample size was required. An algorithm determined how large a sample taken from the central photograph (three, five, or nine rectangles) was necessary to permit detection of a 10% change in cell area. This analysis of sample size also indicated that sampling by small-field specular microscopy was not representative of the surrounding square millimeter of corneal endothelium.

Fresh and cultured corneal grafts compared by post-operative thickness and endothelial cell density

Thirty-nine corneas were removed within 6 h post mortem and stored in a moist chamber at 4 degrees C before grafting. The mean donor age was 33 years and the average time between death and grafting was 11 h. Thirty cadaver corneas were selected after trypane blue staining and cultured at 31 degrees C for 24 h before grafting. The mean donor age was 61 years and the mean time between death and culture was 18 h. During the first 10 postoperative days fresh grafts were thinner than cultured grafts. One year after the transplantation the two groups did not differ significantly in regard to the clinical result, corneal thickness, or endothelial cell loss. This indicates that corneas from old donors with extended post mortem time can be used for transplantation after individual evaluation and corneal culture.

Shrinkage in preparatory steps for SEM. A study on rabbit corneal endothelium

Since specular microscopy of the cornea offers the opportunity to observe and measure cells in vivo without any outside interference this method forms an unrivalled basis for estimation of tissue shrinkage during various preparatory methods. Therefore a study was performed with the purpose of evaluating the degree of artifacts in each preparatory step from the living tissue "in vivo" to the final SEM specimen. The study was performed on rabbit corneas, the endothelium serving as measuring target. The in vivo state was recorded by specular microscopy. Unfixed corneas were studied by light microscopy unstained and stained by alizarin red S or silver nitrate. Fixation was performed intracamerally with 1.5% glutaraldehyde (Gla) by a pH, osmolarity, viscosity and intraocular pressure identical with the physiological values of rabbit eyes. Fixation was completed by immersion in 2.5% Gla for 1/2 h. Gla-fixed corneas were evaluated as above before osmification. Dehydration was performed either by graded acetone, by acetone in a gradient-free system, both followed by critical point drying (CPD). At all steps cells were counted using the same reference frame. The number of cells/mm2 was estimated and statistical analysis showed a shrinkage of 22 per cent (area) in unfixed tissue, 26 per cent (area) in normally dehydrated tissue and 37 per cent (area) in gradient free dehydrated tissue processed for SEM.

Endothelial cell density in donor corneas

In 68 pairs of donor corneas the endothelial cells were visualized by provoked swelling of the cell borders in isotonic saline. In cornea from donors below 50 years of age numerical cell density was correlated to age. This was not the case in corneas from older donors. The cell densities in paired corneas were correlated. The cell density in the second cornea of a pair was found to be within x +/- 10.97% (+/-1.98SD) of the first cornea. The precision of this estimate could only be improved insignificantly by correction for age, sex, mean cell density or variation of the mean.

Early morphological changes in organ cultured human corneal endothelium

Nineteen human cadaver corneas with few damaged endothelial cells were incubated under tissue culture conditions for time periods ranging from five min to 48 h. Morphological alterations of the endothelial cells were studied in whole wet mounts stained by alizarine red-alkohol-trypane blue and by scanning electron microscopy. Joint meetings of three cells are characteristic for normal corneal endothelium. After 15--60 min of incubation, damaged cells were expelled from the coherent cell sheet by expanding neighbouring cells. Joint meetings of 5--8 expanding cells were formed. After 24 h of incubation, joint meetings of four cells were the dominating morphological abnormality. Morphological changes during reduction of the numbers of cells in joint meetings are described.

The precision of unbiased estimates of numerical density of endothelial cells in donor cornea

The precision of estimates of central corneal endothelial density was studied in 16 human corneas stained by alizarine red and trypane blue. Estimates based on central counts and estimates based on peripheral counts were considered separately. The numerical density was estimated employing an unbiased sampling technique. From central counts estimates with an error of less than five per cent could be obtained. From peripheral counts a maximum precision of mean +/- 12.2 per cent could be obtained. The theoretical maximum precision was calculated by application of a variance component model. The precision of estimates was calculated for 1, 2 and 4 test areas of different sizes. Economy of sampling was evaluated by comparison of the actual precision to the theoretical maximum precision of estimates.