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Research Letters |

Cystic Epithelial Ingrowth in a Case of Deep Anterior Lamellar Keratoplasty FREE

Jayangshu Sengupta, MS; Archana Khetan, MS
[+] Author Affiliations

Author Affiliations: Cornea and Refractive Services, Priyamvada Birla Aravind Eye Hospital, Kolkata, India.


Arch Ophthalmol. 2012;130(11):1476-1478. doi:10.1001/archophthalmol.2012.509.
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In deep anterior lamellar keratoplasty (DALK), complications related to baring of the Descemet membrane such as incomplete exposure or perforations are well known.1 Epithelial ingrowth, on the other hand, is rare following anterior lamellar keratoplasty and usually occurs as a sheet of cells across the interface.2 Herein, we report the first case, to our knowledge, of a cystic pattern of epithelial downgrowth in a case of DALK and its subsequent management.

A 29-year-old man had a translucent, cystic growth in the anterior chamber (approximately 6 × 8 mm) of the right eye extending from the 6- to 9-o’clock positions with encroachment of the pupillary margin 2 years after DALK for corneal scar after fungal keratitis, followed 6 months later by phacoemulsification and toric intraocular lens implantation through a superior scleral tunnel (Figure 1A and B). Records of this case demonstrated a needle entry through the Descemet membrane while passing the inferior secondary sutures ( ). At the initial visit, best-corrected visual acuity was 20/30. The graft was clear with an unaltered interface.

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Figure 1. Characteristics of epithelial ingrowth following deep anterior lamellar keratoplasty. A, Diffuse illumination view in slitlamp biomicroscopy demonstrating a cystic structure in the anterior chamber. B, Slitlamp section view demonstrating translucence of the cyst and clear graft interface. C, Ultrasound biomicroscopy demonstrating the thin cyst wall with attachment to the graft-host junction. D, Histopathological section showing the squamous lining of the cyst wall (hematoxylin-eosin, original magnification ×10).

Ultrasound biomicroscopic examination revealed an echolucent, thin-walled cystic structure attached to the graft-host junction while pressing on the underlying iris tissue with resultant iris atrophy. The cyst was free from the angle, ciliary body, and intraocular lens–capsular bag complex (Figure 1C).

Surgery consisted of decompression of the cyst followed by 23-gauge endocautery of the adjacent iris tissue and en bloc excision with the help of 23-gauge vitrectomy scissors. Subsequently, pupillary reconstruction was done with 10-0 Prolene sutures. The area of cyst attached to the graft-host junction was additionally cauterized ( ). Histopathological examination of the excised tissue showed multilayered stratified squamous epithelium (Figure 1D). Postoperatively, best-corrected visual acuity improved to 20/20 and the graft remained clear with no evidence of recurrence at the 1-year follow-up (Figure 2).

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Figure 2. Postoperative clinical picture. A, Diffuse illumination. B, Slitlamp section view showing the clear graft and interface.

Epithelial ingrowth following lamellar corneal procedures occurs in a diffuse pattern across the ocular structures and through the potential space of the lamellar interface as observed in laser-assisted in situ keratomileusis, Descemet-stripping endothelial keratoplasty, or anterior lamellar keratoplasty.3,4 A cystic pattern, on the other hand, commonly complicates penetrating trauma or intraocular surgery.5

We hypothesize that surface cells migrated across the graft-host junction or through the needle tract to form a nest of cells at the microperforation site that subsequently progressed to a cystic proliferation into the anterior chamber along the path of least resistance. This is evident by the attachment of the cyst to the perforation site at the graft-host junction away from the scleral tunnel and the nature of cells in histopathological sections. Together, fluid turbulence in the anterior chamber precludes a possibility of cell implantation during phacoemulsification. Thus, intraoperative Descemet membrane perforation during DALK can predispose to subsequent epithelial downgrowth, apart from the known consequences of double anterior chamber and enhanced endothelial cell loss.

Epithelial cysts have been treated with a variety of techniques. However, no particular procedure has established its superiority. The primary challenges in this case were to preserve the functioning of the graft as well as provide the advantages of a lamellar keratoplasty. A traditional aggressive approach to epithelial ingrowth may not be practical for a cystic form, where delineation of the cyst margin allows for a more complete excision. Early conservative surgery can preserve the greater integrity of ocular structures as shown in this case and prevent complications associated with progressive ingrowth. A similar observation was obtained by Haller et al6 in a different subset of patients. Our approach seems to have successfully prevented recurrence of downgrowth without jeopardizing the graft until the last follow-up at 12 months.

To conclude, cystic epithelial downgrowth is a rare complication of intraoperative Descemet membrane perforation in DALK, which is amenable to conservative surgical treatment.

Correspondence: Dr Sengupta, Cornea and Refractive Services, Priyamvada Birla Aravind Eye Hospital, 10 Loudon St, Kolkata 700017, West Bengal, India (jayansu@hotmail.com).

Conflict of Interest Disclosures: None reported.

Reinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty: a report by the American Academy of Ophthalmology.  Ophthalmology. 2011;118(1):209-218
PubMed   |  Link to Article
Shousha MA, Yoo SH, Kymionis GD,  et al.  Long-term results of femtosecond laser-assisted sutureless anterior lamellar keratoplasty.  Ophthalmology. 2011;118(2):315-323
PubMed   |  Link to Article
Shih CY, Ritterband DC, Rubino S,  et al.  Visually significant and nonsignificant complications arising from Descemet stripping automated endothelial keratoplasty.  Am J Ophthalmol. 2009;148(6):837-843
PubMed   |  Link to Article
Fournié PR, Gordon GM, Dawson DG, Malecaze FJ, Edelhauser HF, Fini ME. Correlation between epithelial ingrowth and basement membrane remodeling in human corneas after laser-assisted in situ keratomileusis.  Arch Ophthalmol. 2010;128(4):426-436
PubMed   |  Link to Article
Naumann GO, Rummelt V. Block excision of cystic and diffuse epithelial ingrowth of the anterior chamber: report on 32 consecutive patients.  Arch Ophthalmol. 1992;110(2):223-227
PubMed   |  Link to Article
Haller JA, Stark WJ, Azab A, Thomsen RW, Gottsch JD. Surgical approaches to the management of epithelial cysts.  Trans Am Ophthalmol Soc. 2002;100:79-84
PubMed

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Characteristics of epithelial ingrowth following deep anterior lamellar keratoplasty. A, Diffuse illumination view in slitlamp biomicroscopy demonstrating a cystic structure in the anterior chamber. B, Slitlamp section view demonstrating translucence of the cyst and clear graft interface. C, Ultrasound biomicroscopy demonstrating the thin cyst wall with attachment to the graft-host junction. D, Histopathological section showing the squamous lining of the cyst wall (hematoxylin-eosin, original magnification ×10).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Postoperative clinical picture. A, Diffuse illumination. B, Slitlamp section view showing the clear graft and interface.

Tables

References

Reinhart WJ, Musch DC, Jacobs DS, Lee WB, Kaufman SC, Shtein RM. Deep anterior lamellar keratoplasty as an alternative to penetrating keratoplasty: a report by the American Academy of Ophthalmology.  Ophthalmology. 2011;118(1):209-218
PubMed   |  Link to Article
Shousha MA, Yoo SH, Kymionis GD,  et al.  Long-term results of femtosecond laser-assisted sutureless anterior lamellar keratoplasty.  Ophthalmology. 2011;118(2):315-323
PubMed   |  Link to Article
Shih CY, Ritterband DC, Rubino S,  et al.  Visually significant and nonsignificant complications arising from Descemet stripping automated endothelial keratoplasty.  Am J Ophthalmol. 2009;148(6):837-843
PubMed   |  Link to Article
Fournié PR, Gordon GM, Dawson DG, Malecaze FJ, Edelhauser HF, Fini ME. Correlation between epithelial ingrowth and basement membrane remodeling in human corneas after laser-assisted in situ keratomileusis.  Arch Ophthalmol. 2010;128(4):426-436
PubMed   |  Link to Article
Naumann GO, Rummelt V. Block excision of cystic and diffuse epithelial ingrowth of the anterior chamber: report on 32 consecutive patients.  Arch Ophthalmol. 1992;110(2):223-227
PubMed   |  Link to Article
Haller JA, Stark WJ, Azab A, Thomsen RW, Gottsch JD. Surgical approaches to the management of epithelial cysts.  Trans Am Ophthalmol Soc. 2002;100:79-84
PubMed

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