In Vivo Confocal Microscopy of Fuchs Endothelial Dystrophy Before and After Endothelial Keratoplasty

Figure 1. In vivo confocal microscopic images of anterior corneal pathology in Fuchs endothelial dystrophy before endothelial keratoplasty demonstrate various changes contributing to increased anterior reflectivity (haze). A, The basal epithelial cells were easily visible in all corneas, with brighter than normal cell borders. C and E, Brightly reflective reticular networks of cells, presumably subepithelial fibroblasts, were often visible deep in the basal epithelium; occasionally, the nuclei of these cells were visible and appeared oval and distinct from keratocyte nuclei (Figure 3). B and D, The most anterior discernible stromal cell nuclei in Fuchs dystrophy were frequently sparse, brightly reflective, fragmented, and associated with increased background (extracellular matrix) reflectivity. F, The most anterior stromal cells of a normal cornea in a 65-year-old patient show the normal morphology and high density of nuclei in this region. All images represent areas with dimensions of 428 × 325 μm.

Figure 2. In vivo confocal microscopic images of posterior and midstromal corneal pathology in Fuchs endothelial dystrophy before endothelial keratoplasty. A, Typical appearance of guttae, which were visible in all corneas by definition; endothelial cell borders were often visible underlying the guttae. B, Midstromal cell nuclei with normal morphology and multiple, diffuse, punctate (2-3 μm) bright reflections, which were abnormal and visible throughout the stroma. Punctate opacities were visible in 6 corneas before endothelial keratoplasty, and they markedly, but not completely, improved after endothelial keratoplasty in all cases. C, Oblique section through the Descemet membrane shows linear elements traversing the membrane from the posterior stroma (stromal cells visible on the right side of the image) to the endothelium (guttae visible on the left side of the image). This appearance was noted in 3 corneas, although oblique sections were not routinely recorded in all corneas. D, Bodies of midstromal cells were sometimes visible, preventing the quantitative analysis of cells in 4 eyes. E, En face section of the Descemet membrane shows a brightly reflective honeycomb appearance anterior to the guttae, visible in 2 eyes. F, Midstromal cells of a normal cornea of a 65-year-old patient show the normal morphology and density of nuclei in this region. All images represent areas with dimensions of 428 × 325 μm.

Figure 3. Anterior corneal and interface pathology after Descemet stripping endothelial keratoplasty (DSEK) for Fuchs endothelial dystrophy. Subepithelial cells, presumably fibroblasts (A, C, and E), and the most anterior stromal cells (B, D, and F) are shown at 12 (A and B), 24 (C and D), and 36 (E and F) months after endothelial keratoplasty for Fuchs dystrophy. The subepithelial cells persisted through 3 years in some eyes. The appearance of this cell layer varied from distinct oval cell nuclei (A and B) to a reticular network of cell processes (C through F) and was not specific to any postoperative time. The most anterior stromal cells remained sparse and background reflectivity remained increased through 3 years compared with normal cells, contributing to anterior corneal haze. The DSEK surgical interface was easily identified in most eyes by small bright reflections (interface particles) and few cells. The interface images are of the same eye at 12 (G) and 36 (H) months after DSEK and demonstrate an improvement in background reflectivity with time after surgery. All images represent areas with dimensions of 428 × 325 μm.