The Neuropeptide α-Melanocyte-Stimulating Hormone Prevents Persistent Corneal Edema following Injury

Corneal endothelial cells (CEnCs) regulate corneal hydration and maintain tissue transparency through their barrier and pump function. However, these cells exhibit limited regenerative capacity following injury. Currently, corneal transplantation is the only established therapy for restoring endothelial function, and there are no pharmacologic interventions available for restoring endothelial function. This study investigated the efficacy of the neuropeptide α-melanocyte-stimulating hormone (α-MSH) in promoting endothelial regeneration during the critical window between ocular injury and the onset of endothelial decompensation using an established murine model of injury using transcorneal freezing. Local administration of α-MSH following injury prevented corneal edema and opacity, reduced leukocyte infiltration, and limited CEnC apoptosis while promoting their proliferation. These results suggest that α-MSH has a proregenerative and cytoprotective function on CEnCs and shows promise as a therapy for the prevention and management of corneal endothelial dysfunction.

New Endothelial Corneal Dystrophy in a Chinese Family

PURPOSE

The aim of this study was to characterize the clinical presentation of atypical endothelial corneal dystrophy (ECD) and to identify possible associated genetic variants in a Chinese family.

METHODS

Six affected members, 4 unaffected first-degree relatives, and 3 spouses who were enrolled in this study underwent ophthalmic examinations. Genetic linkage analysis was performed for 4 affected and 2 unaffected members, and whole-exome sequencing (WES) was performed for 2 patients to identify disease-causing variants. Candidate causal variants were verified using Sanger sequencing in family members and 200 healthy controls.

RESULTS

The mean age at disease onset was 16.5 years. The early phenotype of this atypical ECD was characterized by multiple small white translucent spots located in Descemet membrane of the peripheral cornea. These spots coalesced to form opacities with variable shapes, and eventually merged along the limbus. Subsequently, translucent spots appeared in central Descemet membrane and accumulated, causing diffuse polymorphous opacities over time. Finally, significant endothelial decompensation led to diffuse corneal edema. A heterozygous missense variant in the KIAA1522 gene (c.1331G>A; p.R444Q) was identified by WES, which was present in all 6 patients but was absent in the unaffected members and healthy controls.

CONCLUSIONS

The clinical features of atypical ECD are unique compared with those of known corneal dystrophies. Moreover, genetic analysis identified the c.1331G>A variant in KIAA1522 , which may be responsible for the pathogenesis of this atypical ECD. Thus, we propose this is a new form of ECD based on our clinical findings.

Keratopathy in Noonan Syndrome

PURPOSE

Anterior segment abnormalities associated with Noonan syndrome are rare. We report our experience with 2 patients who developed keratopathy with significant visual sequelae.

METHODS

case series.

RESULTS

The first patient is a 9-year-old boy with genetically confirmed Noonan syndrome. At presentation, he was noted to have diffuse inferior epitheliopathy with vascularization and bilateral mild ptosis. Over 1 year, he developed focal areas of scarring with deterioration of vision and underwent superficial keratectomy in the left eye. However, over the following 2 years, he experienced recurrent corneal scarring and vascularization. The second patient is a 7-year-old boy with phenotypic Noonan syndrome. At presentation, he had an anterior subepithelial corneal scar inferiorly with epithelial defects in both eyes. He also had bilateral moderate ptosis and lagophthalmos. Despite lubrication, he developed recurrent bilateral corneal erosions with focal areas of scarring associated with vascularization and underwent superficial keratectomy for both eyes. Despite this, there was worsening corneal scarring and vascularization over time, eventually requiring deep anterior lamellar keratoplasty in the left eye. The host cornea showed a disturbed Bowman layer and an acellular mass of fibrous collagenous tissue between epithelium and stroma.

CONCLUSIONS

Noonan syndrome may be associated with visually significant keratopathy, manifesting as focal corneal scarring with vascularization. These changes may due to an excessive fibrotic response in Noonan syndrome. Early recognition and treatment can help to delay the progression of keratopathy and need for surgical intervention.

Implementation of the Corneal Sweep Test in the Diagnosis of Recurrent Corneal Erosion: A 2-Year Retrospective Study

PURPOSE

The purpose of this study was to evaluate the incidence and epidemiology of recurrent corneal erosion within a clinical population using standard diagnostic techniques and a new technique called the corneal sweep test (CST).

METHODS

A retrospective chart review was conducted on 58 eyes of 51 patients with the diagnosis of recurrent corneal erosion from July 2018 to June 2020. All underwent a thorough history and physical examination. The CST was performed as a confirmatory test and on any patient who lacked visible corneal pathology.

RESULTS

The CST was necessary on 49 of the 58 eyes to help confirm the diagnosis of a corneal erosion. Among them, 34 had an occult corneal erosion, which is defined as having a normal-appearing cornea on slitlamp examination but found to have loose corneal epithelium with the CST. Clear corneal cataract surgery (28 eyes, 48.2%) was the most common presumed mechanism of injury, with 20 (71.4%) developing symptoms only after cataract surgery. All 20 eyes had an erosion located directly over a clear corneal cataract incision.

CONCLUSIONS

The CST is a new and effective technique to help diagnose corneal erosions in the absence of visible corneal findings. Clear corneal cataract surgery is an under-recognized but important risk factor to consider because the incision can be the source for an erosion. Using the CST could lead to a paradigm shift in the way clinicians approach RCEs and patients with a persistent ocular pain syndrome.

Collagen fibril characteristics at the corneo‐scleral boundary and rabbit corneal stromal swelling

BACKGROUND

The aim of this investigation was to reassess the impact of the scleral rim on the swelling of the mammalian corneal stroma and to investigate the ultrastructural features of the scleral rim and corneal stromal tissues.

METHODS

The epithelium and endothelium were removed from corneas excised from three-month-old female rabbits. The resulting preparations consisted of the corneal stroma plus a surrounding scleral rim, excised corneal stroma or a nine-millimetre button of central corneal stroma. These preparations were immersed in a 35 mM bicarbonate-buffered mixed salt solution (equilibrated with five per cent CO2-air, pH 7.54 at 37 degrees Centigrade for nine hours. Some sclero-corneal preparations were fixed for light or transmission electron microscopy.

RESULTS

The initial rate of swelling of corneal stromal buttons was greatest at 127 +/- 8 per cent per hour, less for complete stromal preparations (118 +/- 9 per cent per hour) and least for sclero-stromal preparations (76 +/- 12 per cent per hour). The swelling continued over three to nine hours but sclera preparations swelled up to 40 per cent with no further swelling. Light microscopy demonstrated that the sclero-corneal rim tissue limited the swelling of the posterior corneal stroma. TEM sections of the episclera and sclera indicate that most fibril bundles show a radial orientation to the cornea. There are marked anterio-posterior differences in the collagen fibrils of the scleral surround that are distinctly different from previous reports. Average fibril diameters were 62.8 +/- 7.9 nm in the episclera, 122.4 +/- 18.9 nm, 133.5 +/- 51.9 nm and 56.5 +/- 11.2 nm in the anterior, mid- and posterior scleral stroma, compared to an average fibril diameter of 33.5 +/- 3.5 nm for the posterior corneal stroma.

CONCLUSIONS

When there is a scleral rim in place, the swelling of the corneal stroma is substantially less than for isolated corneal stroma. The effect can be attributed to the absence of a cut-edge effect for the sclero-corneal stromal preparation but the unique and largely radial arrangement of the collagen fibrils in the scleral rim plays a part in limiting the swelling of the adjacent corneal stroma. The heterogeneous nature of this sclero-corneal interface requires further investigation to define the mechanism of the effect.

[Evaluation of Iris Morphology Viewed through Stromal Edematous Corneas by Infrared Camera]

BACKGROUND

We reported that the application of infrared camera enables us to observe iris morphology in Peters' anomaly through edematous corneas.

PURPOSE

To observe the iris morphology in bullous keratopathy or failure grafts with an infrared camera.

SUBJECTS AND METHODS

Eleven bullous keratopathy or failure grafts subjects (6 men and 5 women, mean age ± SD; 72.7 ± 13.0 years old) were enrolled in this study. The iris morphology was observed by applying visible light mode and near infrared light mode of infrared camera (MeibomPen). The detectability of pupil shapes, iris patterns and presence of iridectomy was evaluated.

RESULTS

Infrared mode observation enabled us to detect the pupil shapes in 11 out of 11 cases, iris patterns in 3 out of 11 cases, and presence of iridetomy in 9 out of 11 cases although visible light mode observation could not detect any iris morphological changes.

CONCLUSION

Applying infrared optics was valuable for observation of the iris morphology through stromal edematous corneas.

Overnight corneal swelling with high and low powered silicone hydrogel lenses

PURPOSE

To compare central corneal swelling after eight hours of sleep in eyes wearing four different silicone hydrogel lenses with three different powers.

METHODS

Twenty-nine neophyte subjects wore lotrafilcon A (Dk, 140), balafilcon A (Dk, 91), galyfilcon A (Dk, 60) and senofilcon A (Dk, 103) lenses in powers -3.00, -10.00 and +6.00 D on separate nights, in random order, and on one eye only. The contra-lateral eye (no lens) served as the control. Central corneal thickness was measured using a digital optical pachometer before lens insertion and immediately after lens removal on waking.

RESULTS

For the +6.00 D and -10.00 D, lotrafilcon A induced the least swelling and galyfilcon A the most. The +6.00 D power, averaged across lens materials, induced significantly greater central swelling than the -10.00 and -3.00 D (Re-ANOVA, p<0.001), (7.7±2.9% vs. 6.8±2.8% and 6.5±2.5% respectively) but there was no difference between -10.00 and -3.00 D. Averaged for power, lotrafilcon A induced the least (6.2±2.8%) and galyfilcon A the most (7.6±3.0%) swelling at the center (Re-ANOVA, p<0.001). Central corneal swelling with +6.00 D was significantly greater than -10.00 D lens power despite similar levels of average lens transmissibility of these two lens powers.

CONCLUSIONS

The differences in corneal swelling of the lens wearing eyes are consistent with the differences in oxygen transmission of the silicone hydrogel lenses. In silicone hydrogel lenses central corneal swelling is mainly driven by central lens oxygen transmissibility.

Ozil® versus conventional ultrasound phacoemulsification: a randomized comparative study

The purpose of this study is to compare and assess the performance and the postoperative outcomes of torsional mode and ultrasound (US) mode performed in the phacoemulsification of cataract with different nuclear densities. This is a randomized comparative clinical study. Two groups of 75 eyes (the first operated by Ozil(®) and the second by US) were comparable in age, gender, cataract density, corneal incision size, and intraocular lens type. We assessed peroperative parameters: US time (UST) and cumulative dissipated energy (CDE). Postoperative outcome measures were corneal edema and final best-corrected visual acuity. The UST was significantly lower in the ozil(®) group for all nucleus grades (73.43 s ± 8.3 with US vs. 46.02 s ± 23 with Ozil(®)) (p = 0.0003). The CDE was lower in the Ozil(®) group for grade III and IV cataract (p = 0.005). However, no significant difference was noted for grade II cataract (p = 0.07). Immediate postoperative corneal edema was significantly harder in the US group (p = 0.00002). The mean one month postoperative visual acuity was 0.2 ± 0.03 logMAR and 0.15 ± 0.07 logMAR, respectively, in the US group and the Ozil(®) group (p = 0.06). Ozil(®) mode seems to dissipate less energy in the eye than US mode. The visual outcome at one month is comparable in the two groups.

Frog saliva-induced toxic keratopathy: a case report

Corneal toxicity due to exposure to many chemicals and medications have been described in the literature. We present a case of toxic keratopathy by corneal exposure to salivary secretion of a frog. A 40-year-old male patient reported a sudden splash of frog saliva in his right eye while he was examining it at a close distance. Corneal punctate epitheliopathy and stromal oedema and Descemet folds were the initial clinical findings, which completely recovered on the 2nd control day of topical dexamethasone and ofloxacin treatment. We aimed to show the toxic effects of animal-derived secretions on the cornea as a rare cause of toxic keratopathy.

Bilateral corneal edema secondary to amantadine in the pediatric population: a case report

PURPOSE

To report a case of amantadine induced corneal edema in a pediatric patient.

METHODS

A comprehensive ophthalmologic evaluation was performed to a 16-year-old female patient who presented with bilateral, painless loss of vision and corneal edema.

RESULTS

Review of the patient's medical information revealed the use of amantadine to alleviate extrapyramidal side effects secondary to psychiatric medications. Complete resolution of bilateral corneal edema was achieved one month after cessation of amantadine therapy.

CONCLUSION

Amantadine induced corneal edema should be considered in the differential diagnosis of bilateral corneal edema in all age groups. Review of the toxic side effects of systemic medications should be performed in every patient who presents with bilateral corneal edema.

[Structural analysis of normal corneas and diseased corneas by applying second harmonic generation]

We have established a second harmonic generation (SHG) microscopy system for imaging of the human cornea with a mode-locked femtosecond laser and a laser confocal microscope. This SHG microscopy system has allowed us to scan corneal tissue noninvasively ex vivo and to obtain three-dimensional images of corneal collagen lamellae. Such three-dimensional imaging of the normal anterior cornea revealed that collagen lamellae at the anterior stroma are inter-woven and adhere to Bowman membrane with these adherent lamellae being designated "sutural lamellae." Sutural lamellae adhere to Bowman membrane at an angle of approximately 19 degrees, whereas the angle of lamellae in the mid-stroma relative to Bowman membrane is smaller. We hypothesize that the structural unit consisting of both Bowman membrane and the sutural lamellae contributes to the rigidity and anterior curvature of the cornea. SHG imaging of keratoconic corneas revealed an either abnormal or a total lack of structure of the sutural lamellae, suggesting that this abnormality might be related to that of the corneal anterior curvature in such corneas. Furthermore, SHG imaging of corneas affected by stromal edema showed that the structure of the sutural lamellae was maintained, although abnormal collagen signals both above and below Bowman membrane were detected in corneas affected by clinical stromal edema for more than 12 months. SHG imaging of the structure of collagen lamellae in normal and diseased corneas thus has the potential to provide insight both into the mechanism for maintenance of corneal curvature as well as into the pathophysiology of corneal diseases.

[The value of anterior stromal puncture in the treatment of bullous keratopathy]

Results of anterior stromal puncture (ASP) in treatment of painful bullous keratopathy (PBK) are presented and its mechanism of action is hypothesized. ASP is an effective, simple, safe and low-cost procedure for symptomatic relief in patients with PBK.

Human graft cornea and laser incisions imaging with micrometer scale resolution full-field optical coherence tomography

Micrometer scale resolution full-field optical coherence tomography (FF-OCT) is developed for imaging human graft corneas. Three-dimensional (3-D) images with ultrahigh resolution (respectively, 1 and 1.5 μm in the axial and transverse directions), comparable to traditional histological sections, are obtained allowing the visualization of the cells and the precise structure of the different layers that compose the tissue. The sensitivity of our device enables imaging the entire thickness of the cornea, even in edematous corneas more than 800 μm thick. Furthermore, we provide tomographic 3-D images of laser incisions inside the tissue at various depths without slicing the studied corneas. The effects of laser ablations can be observed, along various optical sections, directly in the bulk of the sample with high accuracy, providing information on the interface quality and also imaging tiny changes of the tissue structure. FF-OCT appears to be a powerful tool for subcellular imaging of the corneal structure and pathologies on the entire thickness of the tissue as well as interface quality and changes in the collagen structure due to laser incisions on ex vivo human cornea.

Effect of corneal hydration on ultrasound velocity and backscatter

The cornea's acoustic properties (speed-of-sound, backscatter, attenuation) are related to its state of hydration. Our aim was to determine these properties as a function of corneal hydration using high-frequency ultrasound. Bovine corneas were suspended in a Dexsol-equivalent corneal preservation medium at 33 degrees C and then immersed successively in 75%, 50% and 25% medium and distilled water. Using a 38-MHz focused ultrasound transducer, we measured speed-of-sound and corneal thickness (n = 8) and stromal backscatter (n = 6) after 45-min immersion in each medium. Corneal speed-of-sound was modeled as a function of corneal thickness. We found the mean speed-of-sound to be 1605.4 +/- 2.9 m/s in normotensive medium. The maximum observed speed-of-sound was 1616 m/s. As we decreased medium tonicity, the cornea swelled and the speed-of-sound decreased, reaching 1563.0 +/- 2.2 m/s in water. Average corneal thickness increased from 969 +/- 93 microm in 100% medium to 1579 +/- 104 microm in water. Going from 100% medium to water, stromal backscatter (midband-fit) increased from -60.0 +/- 0.8 dBr to -52.5 +/- 3.5 dBr, spectral slope increased from -0.119 +/- 0.021 to -0.005 +/- 0.030 dB/MHz and attenuation coefficient decreased from 0.927 +/- 0.434 to 0.010 +/- 0.581 dB/cm-MHz. The observed correlation between acoustic backscatter and attenuation with the speed-of-sound offers a potential means for more accurate determination of speed-of-sound and, hence, thickness in edematous corneas.

[Influence of 3.0 mm incision coaxial phacoemulsification and microincision cataract surgery (MICS) on corneal thickness]

PURPOSE

To compare influence of two different cataract surgery methods on corneal thickness.

MATERIAL AND METHODS

Prospective, randomized clinical trial with 30 patients undergoing cataract surgery with use of AMO Sovereign Compact-WhiteStar System (15--standard coaxial, 15--microincisional). Central corneal thickness was evaluated by means of Visante OCT (Zeiss Meditec, USA) 1 day before, 1 day, 7 days and 4 weeks after surgery. Equivalent phaco time (EPT) and percentage of phaco power (AVG), was registered after each operation. Surgeons used phaco-chop phacoemulsification technique for nuclear removal.

RESULTS

Mean EPT and mean AVG were comparable in both groups. Mean EPT was 8.06 +/- 4.47 (s +/- SD), in standard coaxial-phaco group and 8.94 +/- 5.75 (s +/- SD) in MICS group. Mean AVG was 13.87 _ 5.12% in standard coaxial-phaco group and 12.96 +/- 5.73% in MICS group. Mean central corneal thickness increase 1 day, 7 days, 4 weeks after cataract surgery, was respectively: in standard coaxial-phaco group: 81.23 +/- 53.44 (microm +/- SD), 64.50 +/- 50.75 (microm +/- SD), 4.05 +/- 15.32 (microm +/- SD); in MICS group: 69.09 +/- 48.69 (microm +/- SD), 7.75 +/- 8.24 (microm +/- SD), 2.51 +/- 5.32 (microm +/- SD).

CONCLUSIONS

Microincision cataract surgery reduces risk of corneal edema when comparing to standard coaxial phacoemulsification. Visante OCT is a useful method of corneal thickness assessment after cataract surgery.

Descemet stripping automated endothelial keratoplasty in a 2-year-old child

Endothelial transplantation in the form of Descemet stripping endothelial keratoplasty (DSEK) or Descemet stripping automated endothelial keratoplasty (DSAEK) has rapidly become a popular, if not the preferred, method of treating endothelial failure. Although the need to perform corneal transplantation in children with endothelial dysfunction is relatively rare, this situation does arise, and in children still in the amblyogenic age group, rapid recovery from an essentially refractive-neutral corneal procedure carries significant advantages. We describe the use of DSAEK in a 2-year-old child who exhibited irreversible corneal edema from endothelial damage secondary to complicated cataract surgery. The rapid recovery and lack of induced astigmatism from DSAEK allowed for prompt institution of amblyopia therapy.

[Comparative study of endothelial changes in cataract surgery with phacoemulsification technique]

PURPOSE

The comparative analysis of the corneal endothelium modifications (density, pleiomorphism and poly-megetism) appeared as a result of the phacoemulsification through divide and conquer (D-C) respectively phaco-chop (P-C) technique.

MATERIAL AND METHOD

One year prospective, observational and interventional clinical study on 60 eyes with cataract surgery through phacoemulsification by the same surgeon. They were split in 2 groups of study according to the hardness of the cataract (Group A-30 eyes with the hardness of the cataract 3+ and Group B-30 eyes with the hardness of the cataract 4+). In both groups half of the patients were treated with P-C technique surgery and the other half with D-C technique surgery. The groups were homogeneous in relation to age, cataract density, and without associated systemic and ocular pathology.

RESULTS

In all cases the endothelial analysis was performed using the endothelial direct microscope and the ultrasonic pachymetry in presurgery, in the second postoperative day, at 14 days and 2 months. At the end of the study in Group A (3+) there were not noticed any significant modifications in loss of the endothelial cells through both technique surgery. In Group B (4 =) appeared significant modifications with much more losses in (D-C) technique surgeries. Ultrasonic pachymetry in the second day of postsurgery has shown temporary increase of corneal thickness compared to presurgery due to corneal edema, with recovery two months post surgery.

CONCLUSIONS

Regardless of the technique, phacoemulsification leads to endothelial modifications. In our study the P-C technique maintained a better endothelial structure homeostasis.

In situ monitoring of second-harmonic generation in human corneas to compensate for femtosecond laser pulse attenuation in keratoplasty

The application of femtosecond lasers in corneal transplant surgery requires high pulse energies to compensate for the strong optical scattering in pathological corneas. However, excessive energies deteriorate the quality of the incisions. The aim of this study is to demonstrate the dependence of side effects on local radiant exposure, numerical aperture, and tissue properties, to quantify the penetration depth of the laser for individual corneas, and to provide a method for optimizing the energy in the volume of the cornea. We examine histological and ultrastructural sections of clear and edematous corneas with perforating and lamellar incisions performed at different pulse energies. We demonstrate that the augmented energies in edematous corneas may result in unwanted side effects even when using high numerical apertures. The dependence of the laser beam penetration depth on pulse energy is evaluated by histology and an exponential decrease is observed. We show that the penetration length can be determined by evaluating the backscattered second-harmonic emission associated with the nonlinear optical properties of the tissue. This approach represents a noninvasive method for the in situ quantification of the laser beam attenuation, enabling us to adapt the pulse energy accordingly. Experiments using adapted energies show that the side effects are minimized.

The impact of silicone hydrogel materials on overnight corneal swelling

PURPOSE

To identify the corneal swelling response associated with silicone hydrogel contact lens wear.

METHODS

Twenty-five subjects were recruited to participate in this single-center, controlled, single-masked, clinical trial. The corneal swelling response was evaluated by central corneal pachymetry after overnight wear of balafilcon A, etafilcon A, lotrafilcon A, senofilcon A, and no lens wear. More specifically, after 8 hours of closed-eye wear of each material, corneal thickness was measured immediately on eye opening, in addition to the first 4 hours of open-eye wear. Paired t tests were used to compare the swelling response from each condition to that associated with senofilcon A, and given the numerous statistical comparisons, a P value of <or=0.01 was considered significant.

RESULTS

At eye opening, there was no difference in the swelling response when comparing balafilcon A (1.35%), lotrafilcon A (1.22%), or no lens wear (0.77%) to senofilcon A (1.40%), although the swelling response associated with etafilcon A was significantly greater (P<0.001) than that associated with senofilcon A. There were no differences between balafilcon A, lotrafilcon A, and no lens wear compared to senofilcon A during the open-eye deswelling period. However, 1 hour after eye opening, corneal swelling remained significantly greater with etafilcon A than with senofilcon A (1.76% vs. -0.51%, respectively, P=0.01), although no other time-specific comparisons differed.

CONCLUSIONS

Silicone hydrogel lenses, with high oxygen transmissibilities, are associated with very little corneal swelling after overnight wear of the lenses.

Interface Fluid Syndrome in Human Eye Bank Corneas after LASIK

PURPOSE

To evaluate the effects of corneal edema on human donor corneas that had previous LASIK using a laboratory model with histologic and ultrastructural correlations.

DESIGN

Experimental study.

PARTICIPANTS

Thirty human eye bank corneas from 15 donors (mean age +/- standard deviation, 49.9+/-8.9 years) who had had previous LASIK surgery (2-8 years before death).

METHODS

The corneas were mounted in an artificial anterior chamber and the corneal endothelium was perfused for up to 5.0 hours with 0.9% saline solution (endothelial cell damage group) or BSS Plus at a pressure of 15 mmHg (control group), or BSS Plus at a pressure of 55 mmHg (high-pressure group). The corneas were evaluated by confocal and specular microscopy before, during, and at the end of the experimental period. Subsequently, the specimens were evaluated by light and electron microscopy.

MAIN OUTCOME MEASURES

Corneal thickness, reflectivity, histology, and ultrastructure.

RESULTS

Endothelial cell damage resulted in an increased (141.5+/-38.8 microm) total corneal thickness relative to controls (52.3+/-33.7 microm), whereas high pressure resulted in a decreased thickness (24.8+/-14.1 microm) relative to controls. This ultimately was due to swelling of the LASIK interface in both groups and swelling of the residual stromal bed (RSB) in the endothelial cell damage group or compression of the RSB and, possibly, the flap in the high-pressure group. A significant increase in corneal reflectivity at the LASIK interface occurred in both groups, primarily due to varying degrees of fluid accumulation and associated hydropic keratocyte degeneration, as well as increased corneal reflectivity in the RSB only in the endothelial cell damage group.

CONCLUSIONS

After LASIK surgery, edematous corneas preferentially hydrate and swell in the paracentral and central interface wound, commonly resulting in a hazy corneal appearance primarily due to keratocyte hydropic degeneration. More severe corneal edema is characterized by the formation of an optically empty space corresponding to an interface fluid pocket. The spectrum of interface fluid syndrome can be described in 3 stages.

Argon laser iridotomy-induced bullous keratopathy a growing problem in Japan

AIMS

To describe the long-term risk of bullous keratopathy following argon laser iridotomy (ALI) in Japan and to compare it with other centres in the world.

METHODS

We retrospectively reviewed the case records of all patients with ALI-induced bullous keratopathy that underwent penetrating keratoplasty at Kyoto Prefectural University of Medicine (KPUM) from January 2001 to December 2004. The results were compared with the other representative centres in Singapore and the UK.

RESULTS

Thirty-nine eyes of 33 patients were included in the study. The mean age of patients was 73.3+/-6.9 years (range, 58 to 87 years). Patients developed bullous keratopathy at a mean duration of 6.9+/-4.9 years (range, 0.2 to 16 years) after the laser iridotomy procedure. The majority of eyes that developed bullous keratopathy (59.0%) occurred following prophylactic ALI. KPUM had the highest percentage of ALI-induced bullous keratopathy cases that underwent penetrating keratoplasties, as compared with other centres in Singapore and the UK (20.0%, 1.8% and 0%, respectively).

CONCLUSION

Bullous keratopathy may arise many years following ALI, and is a growing problem in Asian countries. This condition is a major cause of ocular morbidity in Japan, which has seen a worrying increase in the number of cases in recent years.

Interlamellar flap edema due to steroid-induced ocular hypertension after laser in situ keratomileusis

BACKGROUND

Several recent studies have reported post-laser in situ keratomileusis (LASIK) complications related to a steroid-induced increase in intraocular pressure, including interface fluid and elevated intraocular pressure-induced interlamellar stromal keratitis.

CASES

We examined two cases of interlamellar flap edema due to steroid-induced ocular hypertension after uneventful laser in situ keratomileusis.

OBSERVATIONS

Oral acetazolamide and discontinuance of topical steroids were effective for treating interlamellar stromal edema in both cases.

CONCLUSION

A rise in intraocular pressure should be considered a cause of interlamellar stromal edema after LASIK.

The effect of contact lens induced oedema on the accuracy of Goldmann tonometry in a mature population

AIM

To determine the effect of contact lens induced oedema on the accuracy of Goldmann tonometry measurements of intraocular pressure (IOP) in mature subjects.

METHODS

22 healthy subjects aged between 50 and 60 years were recruited. Corneal curvature, IOP, and central corneal thickness (CCT) were measured before and after two hours of monocular closed eye wear of a thick hydroxyethyl methacrylate (HEMA) contact lens. Measurements were then repeated at 20 minute intervals for one hour after lens removal.

RESULTS

Both CCT (+54.1 mum) and IOP (+2.7 mm Hg) increased significantly after lens wear (p<0.001, paired t test with Bonferroni correction). For the hour following lens removal, the measured IOP was correlated to the increase in CCT (r = 0.84, p<0.001), at a rate of 1.0 mm Hg/10 mum (95% confidence interval, 0.8 to 1.2 mm Hg/10 mum, linear mixed model analysis).

CONCLUSIONS

A relatively small increase in CCT from contact lens induced corneal oedema caused an overestimation error in Goldmann tonometry measurements of IOP in healthy mature subjects.

Long-term recovery of the human corneal endothelium after toxic injury by benzalkonium chloride

INTRODUCTION

The inadvertent intra-ocular administration of benzalkonium chloride-preserved hydroxypropyl methylcellulose during cataract surgery at another hospital in 1999 resulted in toxic corneal endothelial injury and profound postoperative corneal oedema as a result of endothelial decompensation. The long-term effect of this adverse event was assessed.

METHODS

All 19 patients were invited to return for examination including corneal endothelial specular microscopy and pachymetry seven years after the incident. Results were compared with data from one year after the incident.

RESULTS

Five patients attended for examination, one had received a penetrating keratoplasty and was, therefore, excluded. Ten patients had died and four had moved out of the region and were unable to attend. All four study patients were pain free and achieved 6/12 or better. Mean central corneal thickness reduced by 13% from 652.6 microm at one year to 563.4 microm. Mean central corneal endothelial cell density (n = 3) increased 28% from 663.7 cells/mm(2) at one year to 835.7 cells/mm(2) (p<0.05).

CONCLUSIONS

After toxic injury, corneal endothelial function may have a remarkable capacity for recovery even after the first postoperative year. The rise in central endothelial cell density may represent cell migration from less affected areas or cellular proliferation. Should this unfortunate event recur, clinicians may expect continued recovery beyond one year.

Interface fluid syndrome in laser in situ keratomileusis after complicated trabeculectomy

A 69-year-old man developed stromal edema and a pocket of fluid in the laser in situ keratomileusis (LASIK) interface wound in the left eye after acute endothelial cell loss from complicated trabeculectomy. He eventually required penetrating keratoplasty along with cataract surgery. Histologic examination of the corneal button showed an edematous 720 microm central residual stromal bed, a 54 microm empty space at the level of the central interface wound, and a 154 microm LASIK flap. The endothelial cell count was 0 to 2 cells per high-power field, corresponding to a cell density of 450 to 500 cells/mm(2). Four years after LASIK, the central interface wound was susceptible to forming a pocket of serous fluid after the corneal endothelial function was compromised.

Comparison of Conventional and Silicone Hydrogel Contact Lenses for Bullous Keratoplasty

PURPOSE

To compare the efficacy and safety of conventional lenses and silicone hydrogel lenses in the treatment of bullous keratopathy. The silicone hydrogel bandage contact lenses used were Focus NIGHT & DAY and PureVision. The conventional lens used was Sauflon 85%.

METHODS

This was a prospective, comparative study of 22 patients with painful bullous keratopathy in one eye. Patients visited a specialty contact lens department and were fitted with all three different lens types in their affected eye for 1 month each, for a total duration of 3 months. The main outcome measures were comfort and pain relief, which patients scored on a scale that ranged from 1 to 5, with 1 being very poor and 5 being excellent. Doctors assessed the fit of the lens, its movement, and any deposit buildup. The statistical tests applied were the Kruskal-Wallis test and the Mann-Whitney test.

RESULTS

Sixteen of the 22 patients (24 eyes) successfully completed 1 month's wear of all three bandage contact lenses. The median comfort score was 3.9 for PureVision, 3.8 for Focus NIGHT & DAY, and 2.8 for Sauflon 85%; there was a statistical significance among the three groups (P=0.031). Silicone hydrogel lenses performed better than conventional lenses for comfort. The Mann-Whitney test showed that there was no statistically significant difference for comfort scores of Focus NIGHT & DAY versus PureVision (P<0.782) or of Focus NIGHT & DAY versus Sauflon 85% (P<0.073). However, there was a statistically significant difference for comfort scores of PureVision versus Sauflon 85% (P<0.0136). The median pain relief score was 3.8 for PureVision, 3.7 for Focus NIGHT & DAY, and 3.2 for Sauflon 85%. There was no significant difference among the three lenses for pain relief score. All three lens types were similarly good with regard to contact lens fit, movement, and deposit buildup.

CONCLUSIONS

The use of silicone hydrogel lenses are a safe and effective alternative to conventional contact lenses for the treatment of bullous keratopathy.

Therapierefraktäre Bindehautchemosis

We saw a 62-year-old male with a conjunctival chemosis, which was resistant to local therapy. Excisional biopsy and histological work-up of the tissue were performed. Additional immunohistochemical staining using the Lyve-1 antibody (specific for lymphatic vascular endothelium) allowed the diagnosis of a lymphangioma of the conjunctiva to be made.

Severe Corneal Toxicity After Topical Fluoroquinolone Therapy

PURPOSE

To describe 2 cases of sterile corneal ulcers that persisted after several weeks of therapy with topical moxifloxacin 0.5% but that resolved when antibiotic therapy was changed.

METHODS

Small case series.

RESULTS

Both cases presented here describe corneal ulcers that persisted and showed signs of worsening during weeks of frequent topical dosing with moxifloxacin. Descemet folds and an atypically large amount of stromal edema were present in both cases, and there appeared to be possible endothelial dysfunction as well. There was no sign of bacterial, viral, or fungal infection in either case. In both cases, healing began a few days after moxifloxacin was discontinued, and topical gatifloxacin and corticosteroids were initiated.

CONCLUSION

These cases suggest that moxifloxacin may interfere with the healing of corneal ulcers.

Deep Lamellar Endothelial Keratoplasty Histopathology of Complications in Initial Cases

PURPOSE

To report complications encountered after 2 initial cases of deep lamellar endothelial keratoplasty.

METHODS

Review of clinical findings of 2 initial cases in which intraoperative and postoperative complications were encountered. Corneal buttons from the 2 cases were evaluated by light microscopy and transmission electron microscopy.

RESULTS

Complications encountered were related to the graft-recipient interface and the lamellar dissection of the recipient and donor corneas.

CONCLUSION

Deep lamellar endothelial keratoplasty is an evolving procedure that shows much promise. These 2 cases show that the procedure entails a separate skill set from penetrating keratoplasty and requires significant surgeon practice before being introduced into the individual's transplant practice.

Acute corneal hydrops: A case report including confocal and histopathological considerations

This is a case report of corneal hydrops associated with keratoconus with a review of current literature pertaining to diagnosis, histopathology, and treatment options. A 30-year-old African American male presented to the University Eye Institute with acute unilateral pain, redness, and visual impairment. His symptoms, clinical presentation and past diagnosis of keratoconus confirmed his condition to be acute corneal hydrops (CH). The condition was closely followed utilizing topical treatment including hyper-osmotic (Muro 128) and non-steroidal anti-inflammatory agents (Acular and Voltaren). After 4 months, the patient's condition resolved but subsequent corneal scarring resulted. Corneal ectasia in patients with keratoconus may progress into acute rupture of the posterior limiting lamina (PLL) and the endothelium, resulting in CH, which may manifest as an area of edematous and opacified cornea lasting up to 4 months in duration. Acute complications such as CH seldom occur. Histopathology and confocal microscopy can be used to help visualize and understand CH on a cellular level. After regeneration of the corneal structures, central scarring may limit visual acuity and necessitate a corneal transplant.

Validity of Pachymetric Measurements by Manipulating the Acoustic Factor of Orbscan II

PURPOSE

To assess the validity of pachymetric measurements by examining the constancy of the acoustic factor (AF) of the Orbscan II (Orbtek, Bausch & Lomb, Rochester, NY) after overnight rigid gas-permeable (RGP) contact lens wear.

METHODS

Twenty participants wore CRT (Paragon Vision Sciences, Mesa, AZ) HDS 100 contact lenses on one eye and control lenses on the contralateral eye for one night while sleeping. Another 24 participants wore CRT lenses on both eyes for one night. Central corneal thickness was measured using optical coherence tomography and Orbscan II on the night before lens use, immediately after lens removal on the following morning, and 1, 3, 6, and 12 hours later. By using optical coherence tomography as a reference, the adjusted AF was calculated by using a least squares method over time.

RESULTS

The adjusted AF depended on the corneal thickness in normally hydrated corneas. The adjusted AF and the percentage change of the adjusted AF varied before and after overnight lens wear. There was a strong and significant correlation between the corneal swelling and the percentage change of the adjusted AF (all r at least 0.91, P<0.05).

CONCLUSIONS

The adjusted AF is a variable, not a constant. The AF is a function of the corneal thickness and its alteration with, for example, corneal swelling. The validity of the adjusted Orbscan II pachymetric measures using a single AF is untenable.

Acute onset of halos and glare: Bilateral corneal epithelial edema with cystic eruptions—atypical presentation of amiodarone keratopathy

BACKGROUND

Amiodarone (Cordarone; Wyeth, Ayerst, New York) is a potassium channel blocking antiarrythmal medication indicated for recurrent ventricular fibrillation and recurrent hemodynamically unstable ventricular tachycardia. Chemically, it is classified as an iodinated benzofuran derivate antiarrythmal drug not chemically related to any other available antiarrhythmic drug. Documented side effects of amiodarone include neurologic, gastrointestinal, dermatologic, cardiovascular, and ophthalmic. The ophthalmic abnormalities include optic neuropathy, optic neuritis, papilledema, corneal deposits, photosensitivity, lens opacities, and macular degeneration. Corneal microdeposits are seen in virtually all patients who receive amiodarone for more than 6 months. Corneal microdeposits result secondary to the secretion of amiodarone by the lacrimal gland with accumulation on, and absorption by, the corneal epithelium. Approximately 10% of these patients become symptomatic with glare and halos; however, that alone is usually not enough to precipitate intervention.

CASE REPORT

A 69-year-old woman presented to our office with a 2-week history of halos and glare in both eyes (OU). Her ocular history was significant for occasional contact lens wear. Her systemic history was significant for atrial fibrillation, for which she was taking amiodarone daily for the last 6 years. Six weeks before the onset of her chief complaint, her daily amiodarone dosage was increased from 100 mg to 300 mg. Ophthalmic examination found decreased visual acuities OU, amiodarone keratopathy (subepithelial verticillata), and diffuse corneal epithelial edema with diffuse sodium fluorescein staining OU. The corneal compromise was treated in 2 ways: the source medication was discontinued, and the ocular signs were medicated with a prophylactic topical antibiotic along with supportive preparations (tears/lubricants) and monitored over 2 weeks until full elimination of the pathologic signs and their symptoms. Even after complete resolution of the acute keratitis, the infiltrative keratopathy persisted along with the initial complaints of halos and glare. The supportive treatments were maintained over the course of 2 months until full recovery.

CONCLUSION

By exclusion, it was determined that the subepithelial depositions and cystic formations were secondary to an acute amiodarone dosage increase by a new practitioner. Prompt communication resulted in the physician discontinuing that medicine.

Toxic anterior segment syndrome and possible association with ointment in the anterior chamber following cataract surgery

PURPOSE

To report clinical and laboratory findings of 8 cases of toxic anterior segment syndrome (TASS) related to an oily substance in the anterior chamber of patients following cataract surgery with intraocular lens (IOL) implantation.

SETTING

John Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.

METHODS

Eight patients had uneventful phacoemulsification by the same surgeon via clear corneal incisions with implantation of the same 3-piece silicone IOL design. Postoperative medications included antibiotic/steroid ointment and pilocarpine gel; each eye was firmly patched at the end of the procedure. On the first postoperative day, some patients presented with diffuse corneal edema, increased intraocular pressure, and an oily film-like material within the anterior chamber coating the corneal endothelium. The others presented with an oily bubble floating inside the anterior chamber, which was later seen coating the IOL. Additional surgical procedures required included penetrating keratoplasty, IOL explantation, and trabeculectomy. Two corneal buttons were analyzed histopathologically. Two explanted IOLs had gross and light microscopic analyses (as well as surface analyses of 1 of them), and 4 other explanted IOLs had gas chromatography-mass spectrometry.

RESULTS

Pathological examination of the corneas showed variable thinning of the epithelium with edema. The stroma was diffusely thickened and the endothelial cell layer was absent. Evaluation of the explanted IOLs confirmed the presence of an oily substance coating large areas of their anterior and posterior optic surfaces. Gas chromatography-mass spectrometry of the lens extracts identified a mixed chain hydrocarbon compound that was also found in the gas chromatography-mass spectrometry analyses of the ointment used postoperatively.

CONCLUSIONS

The results indicate that the ointment gained access to the eye, causing the postoperative complications described. These cases highlight the importance of appropriate wound construction and integrity, as well as the risks of tight eye patching following placement of ointment.

Successful conservative management of hydrops with perforation in pellucid marginal degeneration

CASE REPORT

Hydrops with perforation in the setting of pellucid marginal degeneration is a rare complication that is generally treated surgically. We report the first case of successful nonsurgical management using only a bandage contact lens.

COMMENTS

Hydrops with perforation in one eye is a risk factor for a similar event occurring in the other eye. Initial conservative management with a bandage contact lens should be considered to avoid the risk of surgery. After resolution of hydrops, flattening of the cornea and reduced astigmatism is also a potential benefit.

Corneal Keratocyte Apoptosis Following Topical Intraoperative Mitomycin C in Rabbits

PURPOSE

To determine the soaking duration and concentration effect of mitomycin C (MMC) on the corneal keratocyte following single intraoperative application.

METHODS

Two hundred ten pigmented rabbit eyes underwent mechanical epithelium debridement of the central 10-mm comea followed by soaking of six different solutions: MMC1A: 0.01% MMC x 1 minute; MMC1B: 0.01% MMC x 2 minutes; MMC2A: 0.02% MMC x 1 minute; MMC2B: 0.02% MMC x 2 minutes; BSS1: balanced salt solution (BSS) x 1 minute; and BSS2: BSS x 2 minutes. Thirty-five eyes were allocated into each group. Changes of the central comeal thickness, corneal clarity score, and keratocyte apoptosis were examined on days 0, 1, 2, 3, 5, 7, and 14.

RESULTS

A significant increase of central corneal thickness and corneal clarity score was noted in all MMC treated groups. The central corneal thickness recovered to its baseline level whereas the corneal clarity score remained increased at 2 weeks. The changes were more significant in MMC2 than in MMC1 corneas. However, changes of central corneal thickness and corneal clarity score were more significant in MMC1B than in MMC1A, whereas no difference was noted between MMC2A and MMC2B. Significantly higher stromal keratocyte loss and keratocyte apoptosis, from superficial to deep corneal stroma, was noted in MMC1 and MMC2 groups up to 14 days postoperatively, in a soaking duration and dose-dependent manner.

CONCLUSIONS

Single application of MMC on the corneal surface caused soaking concentration and duration dependent corneal edema and keratocyte apoptosis in this rabbit model.

Perforated corneal hydrops treated with sulfur hexafluoride (SF6) gas and tissue adhesive

PURPOSE

To report a case of a perforated acute hydrops in a mentally retarded patient that was successfully managed with intracameral sulfur hexafluoride gas and cyanoacrylate tissue adhesive.

METHODS

Interventional case report.

RESULTS

A 14-year-old mentally retarded male patient with keratoconus presented with a perforated acute hydrops. A bandage contact lens was applied. However, following a large emesis 2 days later, the aqueous leak worsened with shallowing of the anterior chamber. Under general anesthesia, sulfur hexafluoride was injected to reform the anterior chamber and cyanoacrylate tissue adhesive was applied to the perforated site and covered by a bandage contact lens and temporary tarsorrhaphy. A follow-up examination at 1 month showed a formed anterior chamber with tissue adhesive in situ and no aqueous leak.

CONCLUSIONS

The successful use of intracameral sulfur hexafluoride and tissue adhesive in the management of perforated acute hydrops may avoid emergency tectonic penetrating keratoplasty and reduce potential complications in the poorly cooperative patient.

Effect of different irrigating solutions on aqueous humour pH changes, intraocular pressure and histological findings after induced alkali burns

PURPOSE

To evaluate the effects of hypo-osmolar tap water and isotonic saline solution on the intracameral pH, intraocular pressure and histological changes in alkali burned rabbit eyes.

METHODS

Four groups of four rabbit corneas each were burned with 2 N sodium hydroxide, and then rinsed with 0.5 l or 1.5 l of saline solution or tap water, respectively. Changes in pH were monitored with an intracameral microelectrode. Intraocular pressure (IOP) was monitored by a transducer placed in the vitreous cavity. After enucleation, histology was performed.

RESULTS

The pH increased after 1.5 min following alkali application. Irrigation with different solutions affected the maximum pH levels reached. Following the tap water rinse, the maximum rise was significantly lower than after the saline solution rinse. The maximum rise following rinsing with 1.5 l of tap water showed a significant delay. The increase in IOP was 23 +/- 10 mmHg without differences between the groups; the original pressure was recovered after 18 +/- 9 min. Histology of the eyes revealed a significant oedema in all corneas. Other ocular structures appeared unchanged.

CONCLUSIONS

The hypo-osmolarity of tap water led to remarkable corneal oedema. Enlargement of the diffusion barrier and intracorneal dilution inhibit elevated intracameral pH levels. The difference in maximum pH levels reached may influence the degree of subsequent intraocular structure injury. Therefore, the use of iso-osmolar saline solution proves to be less efficacious than tap water as an irrigation agent for ocular burns.

Clinical manifestation and pathologic finding of unilateral acute hydrops after bilateral laser in situ keratomileusis

We present a case of unilateral acute hydrops that developed in 25-year-old man 6 years after bilateral laser in situ keratomileusis (LASIK) for the correction of 2.75 diopters (D) of myopia. Preoperative corneal thickness using ultrasound pachymetry were 556 microm in the right eye and 554 microm in the left eye. Preoperative corneal topography of both eyes showed an asymmetric bow-tie pattern with inferior steepening. Forty-seven months after LASIK, the left eye developed astigmatism and enhancement excimer ablation was performed. Sixteen months after enhancement, a definite sign of keratectasia was detected in the left eye. Twenty-six months after enhancement, acute hydrops occurred in the left eye. The interface of the LASIK wound was separated and filled with aqueous humor. Penetrating keratoplasty was performed to avoid perforation. The keratocytes at the edge between the peripheral flap and remaining stroma showed mixoid degeneration and edematous change suggesting dying cells.

A Morphologic Study of Fuchs Dystrophy and Bullous Keratopathy

PURPOSE

To describe the morphologic features of Fuchs corneal dystrophy and compare them with those of bullous keratopathy.

METHODS

This was an observational case series. The study group consisted of 32 corneal buttons with a diagnosis of Fuchs dystrophy and the comparison group consisted of 22 corneal buttons with bullous keratopathy. Morphologic analysis was performed of corneal buttons from patients with the clinical diagnosis of Fuchs dystrophy or bullous keratopathy by light and electron microscopy.

RESULTS

The main outcome measure was identification of degenerated keratocytes, granular material in and around keratocytes, and lipid keratopathy. The overall morphologic features of Fuchs dystrophy and bullous keratopathy are similar to those described in previous literature. A high proportion of keratocytes exhibited degenerative changes (78.9% in Fuchs dystrophy versus 50.5% in bullous keratopathy). Granular material was identified in and around variably degenerated keratocytes in all cases of Fuchs dystrophy and in 14 of 22 (64%) of the corneas with bullous keratopathy. The percentage of keratocytes with granular deposits was higher in Fuchs dystrophy corneas as compared with corneas with bullous keratopathy (51.7% versus 14.1%, P < 0.0005). Lipid keratopathy was a common occurrence in both Fuchs dystrophy and bullous keratopathy (23/32 [72%] versus 12/22 [55%]).

CONCLUSIONS

Histopathologic changes in the corneal stroma and keratocytes occur in Fuchs dystrophy. Secondary lipid keratopathy ensues and may contribute to corneal haze. A higher proportion of keratocytes in Fuchs dystrophy have granular deposit than in bullous keratopathy. That a high proportion of keratocytes had degenerative changes in both Fuchs dystrophy and bullous keratopathy suggests that keratocytes may degenerate secondary to altered stromal microenvironment because of endothelial cell loss.

Forty Years of Changing Indications in Penetrating Keratoplasty in Israel

PURPOSE

To examine the leading indications for keratoplasty and identify the changing trends in the past 40 years in Israel.

METHODS

Pathology reports of all penetrating keratoplasties (PKPs) performed at Hadassah-Hebrew University Hospital from 1961 to 2000 were reviewed. We evaluated the indications for keratoplasty in each decade between the years 1961 and 2000.

RESULTS

During the 40-year period, a total of 1681 PKPs were performed. Keratoconus (n = 478, 28.4%) was the most common indication, followed by graft failure (n = 226, 13.4%), pseudophakic corneal edema (PCE) (n = 142, 8.4%), herpetic infections (n = 125, 7.4%), nonherpetic infections (n = 114, 6.8%), scarring (n = 113, 6.7%), and trauma (n = 110, 6.5%). The 7 groups account for approximately 77.5% of all keratoplasties performed. Ocular infections were the most common indications before 1970 and have been declining ever since. Keratoconus became the leading indication in the past 30 years. In the past decade, of 663 keratoplasties, keratoconus was the most common indication (56, 38.6%) followed by graft failures/rejections and PCE (the second most common indication between the years 1981 and 1990).

CONCLUSIONS

Keratoconus was the leading indication for keratoplasty in our series. There was a decreasing trend in PK for ocular herpetic infections during the decades. The rate of PCE decreased while failed graft became the second most common indication for PKP during the past decade.

Features of the Iridocorneal Endothelial Syndrome on Confocal Microscopy

PURPOSE

To present a subtle case of iridocorneal endothelial (ICE) syndrome and discuss the utility of in vivo confocal microscopy in the evaluation of this disorder. Previous reports of the confocal microscopic features of ICE syndrome are reviewed.

METHODS

A 32-year-old man presented with decreased vision and halos. Slit-lamp biomicroscopy and in vivo confocal microscopy were used to evaluate the etiology of his complaints. Clinical photographs and confocal micrographs were analyzed.

RESULTS

In vivo confocal microscopy revealed marked asymmetry between the right and left corneal endothelial layers with pleomorphic epithelioid cells on the right, some with hyperreflective nuclei. A transition between cells with uniform appearance and dark nuclei and a highly irregular cellular arrangement with hyperreflective nuclei was present.

CONCLUSIONS

This report supports the clinical utility of in vivo confocal microscopy in the evaluation of ICE syndrome. It demonstrates that the histopathologic features of ICE syndrome on scanning electron microscopy may be shown clinically using high-resolution confocal microscopy.