Peripheral Corneal Edema Research Articles

Contact lens‐related complications

The use of contact lens is very popular and its global market is growing. They have numerous applications, some well‐established and others still not consensual but which have been gaining more and more approval, namely refractive errors, dry eye management, post refractive surgery rehabilitation, persistent epithelial defects, cosmetic approaches and drug delivery systems. Unfortunately, there are some complications caused by their use, some of them sight threatening. The purpose of this presentation is to review these problems and to provide a better understanding of them.The major mechanisms implicated are numerous: trauma, decreased corneal oxygenation, reduced corneal and conjunctival lubrication, allergic and inflammatory responses and infection. However, depending on the complication we are talking about, there are other factors involved, such as contact lens‐related factors (material, design, fit and wearing schedule) and environmental factors (ocular surface condition, external environment, occupational factors, medications and compliance).The symptomatology experienced by patients ranges from hypoesthesia and mild conjunctival hyperemia to photophobia, contact lens intolerance and even decreased visual acuity.Many complications have been described. The most important (most common or most serious) are contact lens discomfort (CLD), dry eye, corneal deepithelialization (CD), sterile infiltrates (SI), corneal neovascularization (CNV), infectious keratitis (IK) and giant papillary conjunctivitis (GPC). Superior epithelial arcuate lesion, contact lens‐related peripheral ulcer, corneal distortion, hypoesthesia, ptosis, pinguecula, corneal edema, allergy aggravation, herpes reactivation and endothelial changes have also been described.CLD is an episodic or persistent adverse ocular sensation related to lens wear with a variable incidence in the literature, ranging from 23% to 94% in different series, being less common with soft lenses. Dry eye plays its role acting as a risk factor for CLD and/or as a consequence of contact lens use. CD manifests as punctate epithelial keratopathy, epithelial abrasions, foreign body tracks, corneal dellen, microcysts, vacuoles, mucin balls and dimple veiling. GPC is one of the most common adverse effects of contact lenses and the papillary reaction of the upper tarsal conjunctiva is the main feature of this entity. CNV is the formation of new vessels basically found in capillaries and venules of the pericorneal plexus, which may progress to the corneal stroma. They are much more associated with soft contact lenses, especially in extended wearers. Of note, contact lens use is one of the most common causes of CNV usually highlighted. SI are the result of an immunological reaction, often do not contain overlying epithelial defect or anterior chamber reaction and may manifest as stromal deep opacities. IK may be caused by bacteria, viruses, fungus or parasites and prompt immediate care and close revaluations to anticipate disastrous outcomes.Conservative measures play a role in almost all complications and their prevention, such as patient education, lubrication, contact lens exchange when applicable and modification of environmental factors. Addressing and learning how to prevent or quickly diagnose all these complications is crucial to prevent serious consequences.

Case Report of Brown McLean Syndrome

Purpose: To report two rare cases of Brown McLean syndrome after cataract surgery in a patient with aphakia.Case summary: (Case 1) A 54-year-old woman with Marfan’s syndrome who had aphakia and peripheral corneal edema after left eye cataract surgery 4 years ago. The patient had an elevated lesion in the peripheral cornea without involving the central cornea, and had symptoms of pain, irritation and tearing. Specular microscopy showed normal endothelial cell density and morphology in the edematous cornea. The peripheral corneal edema improved after use of antibiotics, autoserum eyedrops and 5% NaCl eyedrops. (Case 2) A 61-year-old woman with aphakia in her left eye after bilateral cataract surgery 11 years ago, underwent surgery for a macular hole in both eyes. The patient developed peripheral corneal erosions and edema in the left eye 2 months after the surgery. Specular microscopy showed normal endothelial cell density and morphology. The peripheral corneal edema was static over the years while using 5% NaCl eyedrops and artificial tears, and did not progress to involve the central cornea.Conclusions: Brown McLean syndrome is a rare disease but the possibility should be considered if a patient with aphakia after cataract surgery has peripheral corneal edema for several years.

Burr-Assisted Peripheral Superficial Keratectomy for the Treatment of Persistent Symptomatic Peripheral Corneal Edema.

PurposeTo describe a simple technique of diamond burr-assisted superficial keratectomy for the treatment of peripheral corneal edema. Cases PresentationTwo patients with persistent symptomatic peripheral corneal edema underwent superficial keratectomy with the use of a diamond ophthalmic burr. The efficacy of the treatment was evaluated clinically as well as with anterior segment optical coherence tomography. During the postoperative follow-up period, no adverse events were observed and corneal edema reduced significantly. The patients were asymptomatic, no epithelial cysts could be identified clinically, and visual acuity remained unchanged.ConclusionPeripheral superficial keratectomy could be an effective alternative for the treatment of peripheral, symptomatic corneal edema.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-021-00370-1.

Long-Term Outcome of Descemet Membrane Endothelial Keratoplasty in Eyes With Fuchs Endothelial Corneal Dystrophy Versus Pseudophakic Bullous Keratopathy.

The aim of this study was to compare the long-term outcome of Descemet membrane endothelial keratoplasty (DMEK) in patients with Fuchs endothelial corneal dystrophy (FECD) and pseudophakic bullous keratopathy (PBK). Records of consecutive DMEK surgeries performed between 2015 and 2016 at the Department of Ophthalmology, Cologne, Germany, were retrospectively reviewed from the prospective Cologne DMEK Database. Eyes with either PBK or FECD with a complete 3-year follow-up were enrolled. Main outcome parameters included central corneal thickness (CCT), peripheral corneal thickness (PCT), best spectacle-corrected visual acuity (BSCVA, logarithm of the Minimum Angle of Resolution), and endothelial cell count (ECC) before and after DMEK. Four hundred two eyes from 402 patients were included (FECD n = 371, PBK n = 31). Preoperatively, CCT (FECD: 681.91 ± 146.78 μm; PBK: 932.25 ± 319.84 μm) and PCT (FECD: 732.26 ± 98.22 μm; PBK: 867.54 ± 88.72 μm) were significantly higher in the PBK group (P < 0.01). Three years after DMEK, CCT (FECD: 526.56 ± 27.94 μm; PBK 663.71 ± 132.36 μm) was significantly lower in both groups compared with the preoperative values (P < 0.01), whereas PCT showed no significant difference. PCT increased during the course in the PBK group from month 12 after DMEK (12 mo: 783.73 ± 127.73 μm; 24 mo: 837.50 ± 110.19 μm; 36 mo: 857.79 ± 140.76 μm). The increase in PCT correlated with an accelerated ECC loss starting 12 months after DMEK (P = 0.036). Before DMEK, BSCVA in FECD was significantly higher (P < 0.001) compared with that in PBK. After 3 years, BSCVA improved in FECD and PBK eyes without significant difference (P = 0.239). Visual acuity after DMEK in PBK and FECD seems to be comparable during the long-term follow-up. Peripheral and central corneal edema seems to recur faster in eyes with PBK than in those with FECD. Therefore, using a donor graft with higher ECC or possibly a larger graft could be a promising approach for PBK patients.

Limbal Metabolic Support Reduces Peripheral Corneal Edema with Contact-Lens Wear.

PurposeTo assess the influence of limbal metabolic support on corneal edema during scleral-lens (SL) and soft-contact-lens (SCL) wear for healthy lens wearers.MethodsA two-dimensional (2D) model of the cornea and sclera was designed on Comsol Multiphysics 5.4 along with SL and SCL architectures to mimic lens-wear induced hypoxia. The cornea is suffused with oxygen and metabolites from the limbus and aqueous humor. Air oxygen is supplied from and carbon dioxide is expelled to the atmosphere. Lens-oxygen permeability (Dk) was adjusted to investigate lens-wear safety against edema in different wear conditions. The 2D concentrations of oxygen, carbon dioxide, bicarbonate, lactate, sodium, chloride, glucose, and pH are quantified. Central-to-peripheral swelling of the cornea is determined by the change in stromal hydration caused by changing metabolite concentrations at the endothelium during hypoxia.ResultsThe metabolic model assesses central-to-peripheral corneal swelling with different types of lenses, and oxygen Dks. Limbal metabolic support reduces edema from the periphery to approximately 1 mm away from the central cornea. Despite thicker lens designs, the peripheral cornea exhibits practically zero swelling due to limbal metabolic support.ConclusionsThe metabolic model accurately predicts central-to-peripheral corneal edema with various contact-lens designs, post-lens tear-film thicknesses, and lens oxygen Dk values. Despite the thicker periphery of most contact-lens designs, lactate and bicarbonate support from the limbus significantly reduces peripheral and mid-peripheral corneal edema, whereas oxygen has a lesser effect.Translational RelevanceBy utilizing metabolic kinetics, we provide a 2D computational tool to predict oxygenation safety across the entire cornea with various types and designs of contact lenses.

Bullous Keratopathy Secondary to Anterior Chamber Angle Foreign Body.

BACKGROUND:Penetrating ocular trauma with intraocular foreign body is a serious injury often resulting in loss of vision. Anterior chamber foreign bodies account for a considerable portion of all cases of all intraocular foreign bodies (up to 15%); however, they can be missed due to inconspicuous location.CASE REPORT:We report two cases of retained intraocular foreign bodies in the iridocorneal angle that was missed at the first ophthalmic examination. They were only discovered when complications occurred, such as corneal edema and increased intraocular pressure. In the case whereby the foreign body was taken out early, corneal damages were reversible. However, in the case whereby the foreign body was taken out late, endothelial damage was irreversible and endothelial transplantation was needed.CONCLUSION:Regarding trauma patients, a careful examination should be performed to discover foreign bodies in the iridocorneal angle. If local peripheral corneal edema occurred, attention should be paid to the trauma history and to timely discovery of the foreign body. This will prevent any irreversible corneal damages.

Corona sign: manifestation of peripheral corneal epithelial edema as a possible marker of the progression of corneal endothelial dysfunction.

To describe a characteristic form of the corona sign and its clinical relevance to the degree of corneal endothelial decompensation and investigate the underlying mechanism using a rabbit model. These observational cases include 31 patients undergoing penetrating keratoplasty (PKP) and 15 patients undergoing Descemet stripping automated endothelial keratoplasty (DSAEK) with special attention to the circumferentially developed corneal epithelial edema. We also conducted a laboratory observation of horizontal water flow in the rabbit cornea. We consistently observed the corona sign at the superior periphery during the initial stage of corneal endothelial decompensation after PKP. With progressive corneal endothelial cellular loss, the epithelial edema gradually expanded circumferentially in the periphery. The endothelial cellular density associated with the corona sign significantly (P<0.01) decreased compared with that without the sign. The endothelial cellular density decreased significantly (P<0.05) in cases with a circumferential corona sign compared with a superior corona sign. After DSAEK, however, the corneal epithelial edema subsided from the center but persisted peripherally as a corona sign in all cases. By 3months postoperatively, the epithelial edema was confined to the superior periphery along with uneventful corneal endothelial healing. Rabbit experiments showed that total corneal endothelial decompensation decreased the horizontal intracorneal water migration (Inoue-Ohashi phenomenon) in the corneal periphery and induced peripheral corneal edema. The slit-lamp microscopic findings of the corona-like epithelial edema in the peripheral cornea are associated with the stage of corneal endothelial function. To support this, the developmental mechanism of the corona sign was demonstrated experimentally.

The combined use of surgical debulking and diode laser photocoagulation for limbal melanoma treatment: a retrospective study of 21 dogs.

To evaluate effectiveness and safety of debulking and diode laser photocoagulation (DPC) for the treatment of limbal melanoma (LM). Retrospective multi-institutional case series. Medical records of animals diagnosed with LM at the Centro Veterinario Specialistico (CVS) and at the Long Island Veterinary Specialists from 1994 to 2014 were retrieved. Signalment, location, extent of tumors, recurrence rate, and early and late complications were reported. Patient follow-up information was obtained from veterinary ophthalmologists, primary care veterinarians, and where appropriate, owners. Twenty-one eyes of 21 dogs (13 females and 8 males) were included in this study. The dogs' average age was 6 years (range: 7 months-11 years). The follow-up period ranged from 1-108 months (median 48 months) after the last DPC procedure. Long-term follow-up was obtained by telephone interviews in 6 of 20 cases and by clinical re-evaluations in 14 of 20 cases. The most common early complications were a moderate anterior uveitis and peripheral corneal edema (21/21 eyes). Late complications included corneal fibrosis and/or pigmentation (20/21). In one case, a severe bullous keratopathy associated with extensive corneal fibrosis was observed (1/21). One case was blind due to concurrent Sudden Acquired Retinal Degeneration (SARD). However, after surgery 2 of 20 eyes lost vision and one of these was enucleated. Debulking, in addition to diode laser photocoagulation, was technically straightforward to perform, minimally invasive, well tolerated, and highly successful in this case series.

Scleral tunnel phacoemulsification: Approach for eyes with severe microcornea.

Cataract surgery in eyes with microcornea is associated with frequent complications such as corneal edema, posterior capsular rent, and risk of unplanned aphakia. We describe an improved surgical technique for the creation of surgical incisions during phacoemulsification in eyes with cataract associated with microcornea. A retrospective analysis of eight patients (8 eyes) operated at our center was undertaken. The mean age of the patients was 29.5 ± 10.9 years. All eyes were operated using the scleral pocket incision for phacoemulsification. This scleral pocket incision was tangential to the limbus and created approximately 2.5 mm behind limbus through which phacoemulsification probe was inserted. Because of the posterior placement of incision, the anterior chamber crowding was minimized. There was no incidence of port-site peripheral corneal edema. Fifty percent eyes developed transient central corneal edema, the intraocular lens in bag was implanted in 5/8 eyes, and none developed Descemet's membrane detachment. Mean best-corrected visual acuity improved from 1.85 ± 0.38 logarithm of minimum angle of resolution (LogMAR) to 1.26 ± 0.70 LogMAR postoperatively (P = 0.01; paired t-test). Posterior incision placement during phacoemulsification in microcornea helps achieve favorable postoperative outcomes in contrast to outcomes using clear corneal approach described in literature.

Larger Descemetorhexis to Improve Graft Adhesion in Descemet Membrane Endothelial Keratoplasty Does Not Cause Postoperative Peripheral Corneal Edema.

To evaluate the incidence of peripheral corneal edema after Descemet membrane endothelial keratoplasty (DMEK) with respect to the size of the descemetorhexis. A single-center retrospective review of data of 200 consecutive DMEK surgeries for Fuchs endothelial dystrophy was performed. Forty-eight eyes of 47 patients were enrolled in this study based on the presence of a peripheral zone of free denuded stroma between the margin of the graft and the host's Descemet membrane (DM) (group A) or a peripheral overlap between the graft and the host's DM (group B). In group A (n=26 eyes), the diameter of the descemetorhexis was approximately 10 mm, whereas in group B (n=22 eyes), the diameter was approximately 6 mm. Both groups received an 8-mm graft. Main outcome measures included peripheral corneal thickness (PCT) at 4 mm from the center, central corneal thickness (CCT), central-to-peripheral thickness ratio (CPTR), and endothelial cell density (ECD). Mean preoperative PCT±SD in group A was 728±52 μm and in group B was 708±49 μm (P=0.192). Four weeks after DMEK, mean PCT±SD was 703±43 μm in group A and 691±59 μm in group B (P=0.368). Mean preoperative CCT±SD was 642±53 μm and 627±58 μm in groups A and B, respectively (P=0.306). There was no significant difference in CCT between groups A and B 4 weeks after surgery (P=0.268). Mean preoperative CPTR±SD in group A was 0.88±0.05 and in group B was 0.89±0.05 (P=0.934). Four weeks after DMEK, CPTR was not significantly different between groups A and B (P=0.893). There was no significant difference in ECD between groups A and B, before and at 4 weeks after DMEK (P=0.093 and P=0.831, respectively). A larger descemetorhexis in DMEK resulting in a peripheral small zone of denuded stroma does not increase the incidence of peripheral corneal edema as compared with a small descemetorhexis with overlapping DMs.

Anterior stromal puncture for the treatment of Brown–McLean syndrome

Case reportThe Brown–McLean syndrome is defined by peripheral corneal edema sparing the central cornea. We report a patient with bullous annular keratopathy following phacoemulsification and implantation of posterior chamber intraocular lens. The uncorrected and best corrected visual acuity was 20/30. The patient required the use of a bandage contact lens for almost 5 years to relieve the ocular discomfort. DiscussionAnterior stromal puncture was performed using a cystotome. Two weeks after the procedure the ocular discomfort disappeared and the use of bandage contact lens was no longer required. Anterior stromal puncture is a simple procedure that is performed under the slit lamp, and can alleviate the symptoms in patients with Brown–McLean syndrome.

Micropunción estromal anterior como tratamiento del síndrome de Brown-McLean

Case reportThe Brown-McLean syndrome is defined by peripheral corneal edema sparing the central cornea. We report a patient with bullous annular keratopathy following phacoemulsification and implantation of posterior chamber intraocular lens. The uncorrected and best corrected visual acuity was 20/30. The patient required the use of a bandage contact lens for almost 5 years to relieve the ocular discomfort. DiscussionAnterior stromal puncture was performed using a cystotome. Two weeks after the procedure the ocular discomfort disappeared and the use of bandage contact lens was no longer required. Anterior stromal puncture is a simple procedure that is performed under the slit lamp, and can alleviate the symptoms in patients with Brown-McLean syndrome.

Transient peripheral edema following displaced corneal graft after descemet stripping automated endothelial keratoplasty (DSAEK): case presentation

BackgroundDescemet's Stripping with Automated Endothelial Keratoplasty (DSAEK) is constantly gaining popularity in the management of endothelial dysfunctions such as bullous keratopathy or Fuchs' dystrophy.Case PresentationA 36 year - old man with Fuchs' dystrophy underwent combined phacoemulsification and DSAEK of the right eye. Immediately postoperatively, corneal graft displacement and peripheral corneal edema which remained stable during the first postoperative month were evident on slit lamp examination. Three months after the procedure the peripheral edema had completely resolved and the patients' subjective symptoms were improved.ConclusionsThe purpose of this case presentation is to demonstrate that corneal graft displacement after DSAEK can lead to peripheral corneal edema that can resolve without further intervention such as graft repositioning or replacement.

Corneal ectasia secondary to peripheral endotheliopathy in a patient with classic pars planitis

PurposeTo report a case of corneal ectasia secondary to pars planitis corneal endotheliopathyMethodsClinical case description and proposed hypothesis regarding development of corneal ectasiaResultsEight-year-old male presented with 360° peripheral corneal endotheliopathy and edema, granulomatous keratic precipitates, and mild iritis OD. A progressive corneal ectasia then developed. Twenty months later, OS presented similarly and anterior chamber inflammatory cells, vitreous snowballs, and retinal vasculitis were observed OU. Classic pars planitis was diagnosedConclusionThis is the first case of endotheliopathy as the first manifestation of pars planitis and as a cause of a secondary central cornea ectasia developed

Post-LASIK Corneal Flap Displacement Following Penetrating Keratoplasty for Bullous Keratopathy

To report 3 patients who experienced late flap dislocation after laser in situ keratomileusis (LASIK) in eyes that had undergone prior penetrating keratoplasty (PKP) for bullous keratopathy. Retrospective chart review of 2 referral corneal and refractive surgery practices, case reports, and literature review. Three patients (mean age 58.3 years, 2 male, 1 female), all status post-corneal transplant for bullous keratopathy, had residual myopic astigmatism and underwent LASIK for correction of their significant anisometropia. Flap dislocation occurred at a mean of 7 days (range 3 to 14 days) following the LASIK procedure. All patients had peripheral corneal edema in their recipient bed. All 3 patients required an additional surgical procedure for visual rehabilitation. Flap displacement may occur following LASIK in patients who have undergone PKP for bullous keratopathy. The endothelial pump function, which is vital to maintaining flap adherence, may be compromised in these patients. We suggest that patients with a history of PKP and endothelial compromise who undergo LASIK wear protective shields for a longer than normal period and be followed closely to reduce the risk of flap slippage.

Atypical presentation and review of the ICE syndrome

The different variants of the iridocorneal endothelial (ICE) syndrome were separately described in the early to mid-1900's and were eventually linked to a common etiology of an abnormal corneal endothelium. The ICE syndrome typically manifests in early to middle adulthood, usually occurs in women, and is almost always unilateral. Management of patients with any variant of the ICE syndrome challenges even the best clinicians. We present a 52-year-old patient with Chandler's syndrome. Our patient shared many of the classic characteristics of Chandler's syndrome, including peripheral anterior synechiae and corneal edema, with one unusual aspect--the patient was male. Details regarding the subsets of the ICE syndrome, differential diagnosis, and current understanding of the pathophysiology are also reviewed. The ICE syndrome is a progressive anterior segment disease that is quite difficult to manage. Corneal edema, increased IOP, and glaucoma are all sequelae of these conditions and, even in the best hands, are extremely challenging to manage. Today, nearly 100 years after Harms described the first patient with an ICE syndrome, we still do not know the exact mechanism for the corneal endothelial changes. Many investigations have been made into the causative agent or stimulus for abnormal endothelial growth in the ICE syndrome. No definitive proof has been established, but a relationship may exist with the Herpes Simplex and Epstein-Barr viruses. Further investigation is needed to determine the most-appropriate treatment and management of the ICE syndrome.

In vivo confocal microstructural analysis and surgical management of brown-mclean syndrome associated with spontaneous crystalline lens luxation

We report 3 members of an extended family who presented with bilateral peripheral corneal edema consistent with Brown-McLean syndrome. On clinical examination, all eyes demonstrated normal central corneas and marked peripheral edema. In vivo confocal microscopy of the peripheral cornea highlighted similar observations in the 6 eyes including endothelial pigmentation, masked stromal structure due to edema, prominent nerves, and localized basal epithelial edema. In the central cornea, in vivo confocal microscopic observations highlighted large cellular structures with prominent nuclei in groups consisting of several cells of similar appearance. In vivo confocal microscopy may enhance the diagnosis of Brown-McLean syndrome and may be used for dynamic evaluation and postoperative follow-up of the structural corneal changes.

Spontaneous corneal perforation in a patient with unusual unilateral pellucid marginal degeneration

A 56-year-old man presented with acute loss of vision and tearing in his left eye. Slitlamp examination demonstrated peripheral corneal edema extending between the 2 and 6 o’clock positions as well as a perforation located inferiorly. The right eye was unremarkable. An emergent crescentic lamellar keratoplasty was performed. The patch graft remained clear during the 30-month follow-up, and visual acuity improved significantly. No changes occurred in the right eye. This case represents an unusual, unilateral corneal ectatic disorder, most likely pellucid marginal degeneration.

Cataract surgery in a patient with Brown-McLean syndrome

The Brown-McLean syndrome is defined by corneal edema that involves the peripheral 2.0 to 3.0 mm of cornea, sparing the central cornea. This syndrome is usually associated with previous cataract surgery but has been reported rarely in patients with other predisposing factors such as angle-closure glaucoma or spontaneous lens absorption with iridodonesis. We describe the clinical course of a 50-year-old man with myotonic dystrophy who had Brown-McLean syndrome with no identifiable predisposition for peripheral corneal edema. Although this syndrome appears to be the result of peripheral endothelial dysfunction, this patient was able to tolerate cataract extraction without developing central corneal edema.

Peripheral corneal edema following excision of a corneal keloid

A 49-year-old man presented with the rare finding of corneal keloid after corneal penetrating injury. The keloid was totally excised by lamellar keratectomy and was disconnected from a stromal scar, probably the perforation site. Symptomatic peripheral corneal edema developed postoperatively, extending 180°. The keloid had an effect similar to an avascular pannus in chronic bullous keratopathy. As long as the keloid was under the epithelium, the patient remained asymptomatic.