Transcript Visualization of Epithelial Downgrowth of Inferior Angle, Iris, and

Visualization of Epithelial Downgrowth of Inferior
Angle, Iris, and Corneal Endothelium With Means of
Endolaser Probe
Mahmoud A. Khaimi, MD
J. Matthew Rouse, MD
Rhea Siatkowski, MD
Dean McGee Eye Institute
Oklahoma City, Oklahoma
The authors have no financial interest in this
subject matter.
Purpose
• To evaluate a unique approach to
visualize and treat epithelial downgrowth
using ocular endoscopic technology in a
64 year old post-penetrating keratoplasty
patient who developed signs of this
surgical complication.
Introduction
• Epithelial downgrowth is a sight and eye-threatening
complication that may occur after ocular surgery or
trauma.
• Clinical prevalence has been reported at 0.09-0.12%1
• Risk factors include prolonged inflammation, wound
dehiscence, delayed wound closure and Descemet’s
membrane tears.
• Pathologically, the downgrowth consists of nonkeratinized, stratified squamous epithelium with
avascular subepithelial connective tissue1
Introduction
• Epithelial downgrowth should be treated as it can have devastating
effects on underlying tissues with development of secondary
glaucoma, decreased vision, inflammation and destruction of ocular
tissue. Greater than 95% of untreated cases result in enucleation.2
• Multiple treatment methods have been attempted with varying
success. En bloc excision of areas involved with epithelial
downgrowth has been associated with variable rates of recurrence
and complications.3
• Transcorneal cryotherapy has been a successful adjunct, but can
cause heat damage to adjacent tissue4
• There has been limited report of endoscopic treatment of epithelial
downgrowth with diode laser.3
Case Study
• A 63 year old male underwent uneventful penetrating
keratoplasty (PK) of his left eye in November of 2009
after developing a corneal ulcer in his prior graft. He had
also previously undergone pars plana vitrectomy,
anterior chamber lens placement and tube shunt
placement in the eye.
• Six weeks after the PK, he presented with a membrane
over the corneal endothelium inferiorly. This membrane
was consistent with the appearance of epithelial
downgrowth and progressed towards the center of the
cornea over the next week.
Presentation 6 weeks after PK
A distinct line of endothelial membrane can be noted on the corneal
button.
Extending
line of
epithelial
downgrowth
Extension of Epithelial Downgrowth
The line of endothelial membrane extended in the first week after
presentation. This prompted the decision to return to surgery for
treatment of the presumed epithelial downgrowth.
Surgical Technique
• Intraoperatively, a corneal graft suture was removed and Healon
viscoelastic was placed into the anterior chamber.
• The endoscopic handpiece of the diode photocoagulation laser was
used to apply laser to the endothelial surface, iris surface, inferior
chamber angle and location of the epithelial downgrowth through the
graft-host junction. Whitening was noticed throughout the areas
covered with membrane. A whitish membrane was then peeled off
of the iris surface and pupillary margin.
• The laser was also used underneath the iris and around the
pupillary margin.
• The borders of the downgrowth were noted to be from approximately
3 o’clock to 7 o’clock
Surgical Technique
• After extensive use of the endophotocoagulation
handpiece, a cryotherapy probe was applied transclerally
at the limbus in the clock hours of 7 to 9 o’clock.
• The affected corneal button and the anterior chamber
intraocular lens were removed. Anterior vitrectomy was
performed. A new PK corneal button was then sewn to
the eye.
• Intraocular injection of Decadron as well as
subconjunctival injections of Fortaz and Kenalog were
given at the end of the case.
Results
• Pathologic analysis of the removed corneal button
revealed a focal area of nonkeratinized stratified
squamous epithelium on the posterior surface of
Descemet’s membrane which is consistent with the
diagnosis of epithelial downgrowth.
• Eleven months after surgery, there has been no sign of
recurrence in the operative eye.
• Best corrected visual acuity is 20/150. This vision is
limited due to cystoid macular edema in the eye.
Discussion
• Epithelial downgrowth is an eye-threatening complication
in which treatment is difficult.
• Various excisional and laser treatments have been used
in treatment of this complication.
• Endoscopic photocoagulation is a safe and effective tool
to be used in treatment of epithelial downgrowth. It may
prove even more useful in settings where visualization is
compromised through the cornea or downgrowth has
occurred in locations where other treatments may not be
able to reach.
References
1. Yanoff M, Sassani JW. Ocular Pathology. 6th edition
China: Elsevier, 2009.
2. Vargas LG, Vroman DT, Solomon KD, et al. Epithelial
downgrowth after clear cornea phacoemulsifcation:
report of two cases and review of the literature.
Ophthalmology. 2002: 109: 2331-2335.
3. Jadav et al. Endoscopic Photocoagulation in the
Management of Epithelial Downgrowth. Cornea. 2008:
27: 5 : 601-604
4. Zavala EY, Binder PS. The pathologic findings of
epithelial ingrowth. Arch Ophthalmol. 1980:98: 20072014.