0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Clinical Sciences |

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

Sanjay V. Patel, MD; Jay W. McLaren, PhD
JAMA Ophthalmol. 2013;131(5):611-618. doi:10.1001/jamaophthalmol.2013.799.
Text Size: A A A
Published online

Importance This study reveals significant changes of the anterior cornea in Fuchs endothelial dystrophy that probably affect the visual outcomes of endothelial keratoplasty for the disease.

Objective To determine whether abnormalities of corneal stromal and subepithelial cells in Fuchs endothelial dystrophy resolve after Descemet stripping endothelial keratoplasty (DSEK).

Design Prospective observational study of 49 corneas of 42 patients with Fuchs dystrophy before DSEK and during 3 years of postoperative follow-up. None of the preoperative corneas were vascularized or had pronounced subepithelial fibrosis on results of slitlamp examination. Corneas were examined using in vivo confocal microscopy to determine stromal cell density and the presence of abnormal subepithelial cells (presumed fibroblasts).

Setting The cornea service at Mayo Clinic, Rochester, Minnesota.

Participants Forty-nine corneas of 42 patients.

Intervention Descemet stripping endothelial keratoplasty.

Main Outcome Measures Stromal cell density and presence of subepithelial cells.

Results Subnormal cell density in the most anterior 10% of the host stroma in Fuchs dystrophy before DSEK (mean [SD], 22 030 [6479] cells/mm3 [n = 41]) remained unchanged at 2 (20 433 [4993] cells/mm3 [n = 35]; P = .36) and 3 years (20 925 [5433] cells/mm3 [n = 23]; P = .99) after DSEK. Abnormal subepithelial cells, which formed reticular networks deep to the basal epithelial cells, were visible in 33 eyes (67%) and remained present at 3 years after DSEK. Mean preoperative central corneal thicknesses when these subepithelial cells were and were not visible were 652 (45) and 668 (56) μm, respectively (P = .75).

Conclusions and Relevance The reduced cellularity of the anterior stroma in Fuchs dystrophy does not recover 3 years after restoring endothelial function. Abnormal subepithelial cells, presumably fibroblasts, are present in most corneas with Fuchs dystrophy requiring DSEK, even in cases with mild edema and in the absence of clinically obvious preoperative subepithelial fibrosis. Anterior corneal structural abnormalities might be related to visual outcomes after DSEK.

Figures in this Article

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Figures

Place holder to copy figure label and caption
Graphic Jump Location

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.

Place holder to copy figure label and caption
Graphic Jump Location

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.

Place holder to copy figure label and caption
Graphic Jump Location

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.

Tables

References

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Sign in

Create a free personal account to sign up for alerts, share articles, and more.

Purchase Options

• Buy this article
• Subscribe to the journal

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
Jobs
brightcove.createExperiences();