Transcript A Case of Beauveria Bassiana Keratitis Confirmed by Gene

Surgically removed Epithelial membrane ingrowth
after clear cornea incision cataract surgery
Jae-Wook Jung, M.D, Sung-Dong Chang, M.D, Ph.D,
Department of Ophthalmology, School of Medicine,
Dongsan Medical Center,
Keimyung University, Daegu, Korea
Authors have no financial interest
INTRODUCTION
Epithelial membrane ingrowth is one of the rare complications where the corneal or conjunctival
epithelium invades the anterior chamber due to the ocular trauma during the procedures of ECCE,
ICCE, glaucoma filtration surgery and corneal transplantation. Its prevalence has been reported to
be approximately 0.06-0.11% in patients who underwent intraocular surgery. Cases in which the
corneal and conjunctival ingrowth can occur include the intraocular surgery, an incomplete or
delayed wound healing, wound fistula, iris incarceration and suture site leakage. With the recent
advancement of cataract surgery, the environment that can provide the trauma for cornea and eye
ball during the cataract surgery has been diminished. Various treatment regimens include
irradiation,
cycloablation,
Argon
laser
photocoagulation,
surgical
removal
and
using
of
antimetabolite. But these methods have been reported to have a high failure rate and they can
damage the eye ball itself. We experienced a case of epithelial membrane ingrowth which was
developed at the site of clear corneal incision following the cataract surgery, for which we
successfully treated surgically without complications.
CASE
•
A 55-year-old man visited us with a chief complaint
of a 6-month-history of gradually progressing visual
disturbance in the left eye. The patient underwent
cataract surgery using sutureless phacoemulsification
with clear corneal incision four years ago. At the time of
admission,
the
visual
intraocular
pressure
acuity
was
was
20/25
13mmHg.
A
and
slit
the
lamp
microscopy showed that the epithelial membrane grew
A
AA
from 12:30 to 6:00 O/C at an approximately 4 . 5 mm
width
to
the
center
along
the
incision
area
in
retrocorneal surface. The anterior chamber angle was
also invaded. ectropion uvea was also concurrently
present (Figure A).
•
In the superior area of the clear corneal incision
site, there
were findings which were suspected to be
the fistula (Figure B).
B
CASE
•
About 1.5mm sized nasal corneal incision was
made. Pressed and grinded , flat, blunt modified
spatula was used to carefully dissect retrocorneal
membrane and endothelium.(Figure C)
C
•
Through the paracentesis, viscoelastics were
gradually infused by a 27G anterior chamber
needle and thereby the epithelial membrane was
dissected up to the anterior chamber angle.
(Figure D)
D
B
CASE
•
The
area
with
a
severe
adhesion
was
delaminated with using of micro-scissior. Using
forceps, the periphery of epithelial membrane was
carefully
retracted.
membrane
was
Meanwhile,
isolated
from
the
the
epithelial
anterior
chamber angle (Figure E).
•
E
After the fistula was confirmed at the site of
corneal incision, the epithelium lining the fistula
was curretaged from inside of the anterior
chamber to outside of the cornea. Then, the
suture was tightly performed (Figure F).
F
CASE
•
Next
day
on
surgery,
the
cornea
was
edematous. The visual acuity in the left eye was
20/60
and
the
intraocular
pressure
was
14mmHg.(Figure G)
G
•
1 month after surgery, the focally detached
Descemet’s
membrane
was
observed
in
the
superior area to the site of corneal incision.(Figure
H) The visual acuity in the left eye was 20/30, the
BCVA was 20/20 and the intraocular pressure was
11mmHg. In the center, the endothelial cell density
was 2433 cells/mm2.
H
CASE
•
6 months after surgery, the visual acuity in the
left eye was 20/20. In the center, the endothelial cell
density was 2132cell/mm2 and intraocular pressure
was 10mmHg. Meanwhile, there were no findings
which were suggestive of the recurrence and
complications.(Figure I)
•
I
Surgically removed tissues had histopathological
findings
of
nonkeratinized,
stratified
squamous
epithelial cells(Figure J), which were confirmed to
have an epithelial ingrowth.
J
DICUSSION
It has been reported that such surgical treatments as iridectomy, cycloablation and en bloc resection
caused a higher recurrence rate, the disturbance of corneal function, corneal transplantation, vitreal
bleeding, glaucoma and enucleation. In the surgical treatment, Naumann GOH and Rummelt V
performed enblock excision and anterior vitrectomy including the dissection of cornea, sclera and iris in
cases of cystic formation and diffuse sheet-like epithelial proliferation. According to them, the most
severe postsurgical complication was corneal endothelial decompensation. In addition, there were
secondary complications including glaucoma and globe atrophy. According to some authors, such
medical teatments as the application of potassum chloride, 5-fluorouracil and mitomycin-C, steroid and
antibiotics in the treatment of epithelial ingrowth could cause such complications as glaucoma. In
addition, other treatment methods include transcorneal cryotherapy. It has been reported that due to
the cryoablation effect, however, it can cause a damage to the adjacent tissue. Argon laser
photocoagulation is less invasive than cryotherapy and it can reduce the occurrence of trauma and
inflammation for the adjacent tissue. Moreover, using of photocoagulation in the retrocornea would
cause the corneal opacity due to heat injury in the corneal endothelium.
DICUSSION
The epithelial membrane ingrowth, which occurred following the implantation of IOL after
sutureless phacoemulsification through scleral tunnel incision, was first reported by Holliday JN in
1993. Argon laser therapy was performed for iris. The treatment was performed with a penetrating
sclerokeratoplasty. Following the removal of corneoscleral button, the iridectomy was performed
and a cryoablation was synchronously performed. The epithelial membrane ingrowth which was
developed following sutureless corneal incision phacoemulsification was first reported by Knauf
HP in 1997. Its pattern was a cystic epithelial membrane ingrowth. The lesions were removed by
en bloc resection as well as iridectomy including the dissection of cornea, sclera and iris with a
corneal incision. Thereafter, a sheet form of epithelial membrane ingrowth was reported by BL.Lee
et al. They reported it is possible that there was an unappreciated gaping of an unsutured corneal
wound that contributed to the development of the abnormality. Valgas LG. et al. treated the
epithelial membrane ingrowth with the surgical technique of an eccentric corneal and scleral
transplantation
DICUSSION
In regard to the epithelial membrane ingrowth which was developed following the cataract surgery, the
fistula provided the route for the ingrowth of epithelial membrane. Edward Maumenee et al. reported
that the fistula was formed in the anterior chamber in 19 cases of a total of 40 cases in association with
the ingrowth of epithelial membrane following cataract surgery. Schaeffer AR. reported that the route for
fistula formation was created at the site of incision wound, where the capsular remnant was incarcerated,
in association with the epithelial membrane ingrowth following ECCE. Besides, Soong HK et al. reported
that the fistula could be formed due to a leakage which was generated via a scleral incision at the site of
corneal limb. As described herein, to make sure that the epithelial membrane ingrowth should be
persistent, the cornea and epithelium must provide the stem cells everlastingly. This must be
accompanied by the formation of fistula which provides the tract. Cell-to-cell interaction and other
various growth factors can persist the epithelial membrane ingrowth. The normal uninflammed arqueous
can maintain the epithelial membrane, but it cannot proliferate it. In accordance with the experimental
models, the background of epithelial ingrowth must have wick of conunctival tissue within the surgical
margin of a hypotonus, imflamed eye, or the use of carcinogens.
Conclusion
Accordingly, the simple removal of epithelial membrane for the treatment of epithelial ingrowth is
insignificant. The fistula, providing the route for proliferation, and its lining epithelium must also be
removed. In the current case, through a clear corneal incision, the epithelial membrane ingrowth
into the retrocornea, iris and anterior chamber angle was dissected. Thus, the lesions were
surgically removed and removal of fistula which was intraoperatively identified had to be also
performed.
In diagnosis of epithelial ingrowth, argon laser photocoagulation was not performed. This is
because the dissection would be difficult due to the occurrence of the adhesion of epithelial
membrane and iris following argon laser photocoagulation. In our case, a diagnosis was established
based on histopathologic findings of the excised specimen. There were no postoperative
complications or findings which were suggestive of the recurrence. Six months postoperatively, the
visual acuity was 20/20.
References
1. Theobald GD, Haas JS. Epithelial invasion of the anterior chamber following cataract extraction.
Trans Am Acad Ophthal Otolaryngol. 1948;52:470.
2. Maumenee AE. Treatment of epithelial downgrowth and intraocular fistula following cataract extraction.
Trans Am Ophthalmol Soc. 1964;62:153-166.
3. Naumann GOH, Rummelt V. Block excision of cystic and diffuse epithelial ingrowth of the anterior chamber;
report on 3 consecutive patients. Arch Ophthalmol. 1992; 110:223-227.
4.Maumenee AE, Paton D, Morse PH, et al. Review of 40 histologically proven cases of epithelial downgrowth following
cataract extraction and suggested surgical management. Am J Ophthalmol. 1970;69:598-603.
5. Scholz RT, Kelley JS. Argon laser photocoagulation treatment of iris cysts following penetrating keratoplasty.
Arch Ophthalmol. 1982;100:926-927.
6. Schaeffer AR, Nalbandian RM, Bringham DW, O’Donnell FE Jr. Epithelial downgrowth following wound dehiscence
after extracapsular cataract extraction and posterior chamber lens implantation: Surgical management J cataract Refract Surg.
1989;15:437-41.
7. Scholz RT, Kelley JS. Argon laser photocoagulation treatment of iris cysts following penetrating keratoplasty.
Arch Ophthalmol. 1982;100:926-927.
8. Vargas LG, Vroman DT, Solomon KD, et al. Epithelial downgrowth after clear cornea phacoemulsification;
report of two cases and review of the literature. Ophthalmology. 2002;109:2331-2335.
9. Lee BL, Gaton DD, Weinreb RN. Epithelial downgrowth following phacoemulsification through a clear cornea[photo essay].
Arch Ophthalmol. 1999; 117:283.