Surgically removed Epithelial membrane

ingrowth after clear cornea incision

cataract surgery

Surgically removed Epithelial membrane

ingrowth after clear cornea incision

cataract surgery

Jae-Wook Jung, M.D, Sung-Dong Chang, M.D, Ph.D, Jae-Wook Jung, M.D, Sung-Dong Chang, M.D, Ph.D,

Department of Ophthalmology, School of

Medicine,

Dongsan Medical Center,

Keimyung University, Daegu, Korea Authors have no financial interestAuthors have no financial interest

INTRODUCTIOINTRODUCTIONN

Epithelial membrane ingrowth is one of the rare complications where the corneal or

conjunctival epithelium invades the anterior chamber due to the ocular trauma during

the procedures of ECCE, ICCE, glaucoma filtration surgery and corneal transplantation.

Its prevalence has been reported to be approximately 0.06-0.11% in patients who

underwent intraocular surgery. Cases in which the corneal and conjunctival ingrowth

can occur include the intraocular surgery, an incomplete or delayed wound healing,

wound fistula, iris incarceration and suture site leakage. With the recent advancement

of cataract surgery, the environment that can provide the trauma for cornea and eye

ball during the cataract surgery has been diminished. Various treatment regimens

include irradiation, cycloablation, Argon laser photocoagulation, surgical removal and

using of antimetabolite. But these methods have been reported to have a high failure

rate and they can damage the eye ball itself. We experienced a case of epithelial

membrane ingrowth which was developed at the site of clear corneal incision following

the cataract surgery, for which we successfully treated surgically without complications.

• A 55-year-old man visited us with a chief

complaint of a 6-month-history of gradually

progressing visual disturbance in the left eye. The

patient underwent cataract surgery using

sutureless phacoemulsification with clear corneal

incision four years ago. At the time of admission,

the visual acuity was 20/25 and the intraocular

pressure was 13mmHg. A slit lamp microscopy

showed that the epithelial membrane grew from

12:30 to 6:00 O/C at an approximately 4.5mm

width to the center along the incision area in

retrocorneal surface. The anterior chamber angle

was also invaded. ectropion uvea was also

concurrently present (Figure A).

• In the superior area of the clear corneal incision

site, there were findings which were suspected to

be the fistula (Figure B).

CASECASE

AA

B

A

• About 1.5mm sized nasal corneal incision

was made. Pressed and grinded , flat,

blunt modified spatula was used to

carefully dissect retrocorneal membrane

and endothelium.(Figure C)

• Through the paracentesis, viscoelastics

were gradually infused by a 27G anterior

chamber needle and thereby the

epithelial membrane was dissected up to

the anterior chamber angle.

(Figure D)

CASECASE

B

C

D

• The area with a severe adhesion was

delaminated with using of micro-scissior.

Using forceps, the periphery of epithelial

membrane was carefully retracted.

Meanwhile, the epithelial membrane was

isolated from the anterior chamber angle

(Figure E).

• After the fistula was confirmed at the site of

corneal incision, the epithelium lining the

fistula was curretaged from inside of the

anterior chamber to outside of the cornea.

Then, the suture was tightly performed

(Figure F).

CASECASE

E

F

• Next day on surgery, the cornea was

edematous. The visual acuity in the left

eye was 20/60 and the intraocular pressure

was 14mmHg.(Figure G)

• 1 month after surgery, the focally detached

Descemet’s membrane was observed in

the superior area to the site of corneal

incision.(Figure H) The visual acuity in the

left eye was 20/30, the BCVA was 20/20

and the intraocular pressure was 11mmHg.

In the center, the endothelial cell density

was 2433 cells/mm2.

CASECASE

G

H

• 6 months after surgery, the visual acuity in

the left eye was 20/20. In the center, the

endothelial cell density was 2132cell/mm2

and intraocular pressure was 10mmHg.

Meanwhile, there were no findings which

were suggestive of the recurrence and

complications.(Figure I)

• Surgically removed tissues had

histopathological findings of nonkeratinized,

stratified squamous epithelial cells(Figure J),

which were confirmed to have an epithelial

ingrowth.

CASECASE

I

J

DICUSSIONDICUSSION

It has been reported that such surgical treatments as iridectomy, cycloablation and en bloc

resection caused a higher recurrence rate, the disturbance of corneal function, corneal

transplantation, vitreal bleeding, glaucoma and enucleation. In the surgical treatment, Naumann

GOH and Rummelt V performed enblock excision and anterior vitrectomy including the

dissection of cornea, sclera and iris in cases of cystic formation and diffuse sheet-like epithelial

proliferation. According to them, the most severe postsurgical complication was corneal

endothelial decompensation. In addition, there were secondary complications including

glaucoma and globe atrophy. According to some authors, such medical teatments as the

application of potassum chloride, 5-fluorouracil and mitomycin-C, steroid and antibiotics in the

treatment of epithelial ingrowth could cause such complications as glaucoma. In addition, other

treatment methods include transcorneal cryotherapy. It has been reported that due to the

cryoablation effect, however, it can cause a damage to the adjacent tissue. Argon laser

photocoagulation is less invasive than cryotherapy and it can reduce the occurrence of trauma

and inflammation for the adjacent tissue. Moreover, using of photocoagulation in the

retrocornea would cause the corneal opacity due to heat injury in the corneal endothelium.

DICUSSIONDICUSSION

The epithelial membrane ingrowth, which occurred following the implantation of IOL after

sutureless phacoemulsification through scleral tunnel incision, was first reported by

Holliday JN in 1993. Argon laser therapy was performed for iris. The treatment was

performed with a penetrating sclerokeratoplasty. Following the removal of

corneoscleral button, the iridectomy was performed and a cryoablation was

synchronously performed. The epithelial membrane ingrowth which was developed

following sutureless corneal incision phacoemulsification was first reported by Knauf

HP in 1997. Its pattern was a cystic epithelial membrane ingrowth. The lesions were

removed by en bloc resection as well as iridectomy including the dissection of cornea,

sclera and iris with a corneal incision. Thereafter, a sheet form of epithelial membrane

ingrowth was reported by BL.Lee et al. They reported it is possible that there was an

unappreciated gaping of an unsutured corneal wound that contributed to the

development of the abnormality. Valgas LG. et al. treated the epithelial membrane

ingrowth with the surgical technique of an eccentric corneal and scleral transplantation

In regard to the epithelial membrane ingrowth which was developed following the cataract surgery,

the fistula provided the route for the ingrowth of epithelial membrane. Edward Maumenee et al.

reported that the fistula was formed in the anterior chamber in 19 cases of a total of 40 cases in

association with the ingrowth of epithelial membrane following cataract surgery. Schaeffer AR.

reported that the route for fistula formation was created at the site of incision wound, where the

capsular remnant was incarcerated, in association with the epithelial membrane ingrowth

following ECCE. Besides, Soong HK et al. reported that the fistula could be formed due to a

leakage which was generated via a scleral incision at the site of corneal limb. As described

herein, to make sure that the epithelial membrane ingrowth should be persistent, the cornea

and epithelium must provide the stem cells everlastingly. This must be accompanied by the

formation of fistula which provides the tract. Cell-to-cell interaction and other various growth

factors can persist the epithelial membrane ingrowth. The normal uninflammed arqueous can

maintain the epithelial membrane, but it cannot proliferate it. In accordance with the

experimental models, the background of epithelial ingrowth must have wick of conunctival

tissue within the surgical margin of a hypotonus, imflamed eye, or the use of carcinogens.

DICUSSIONDICUSSION

ConclusioConclusionn

Accordingly, the simple removal of epithelial membrane for the treatment of epithelial

ingrowth is insignificant. The fistula, providing the route for proliferation, and its lining

epithelium must also be removed. In the current case, through a clear corneal incision,

the epithelial membrane ingrowth into the retrocornea, iris and anterior chamber

angle was dissected. Thus, the lesions were surgically removed and removal of fistula

which was intraoperatively identified had to be also performed.

In diagnosis of epithelial ingrowth, argon laser photocoagulation was not performed. This

is because the dissection would be difficult due to the occurrence of the adhesion of

epithelial membrane and iris following argon laser photocoagulation. In our case, a

diagnosis was established based on histopathologic findings of the excised specimen.

There were no postoperative complications or findings which were suggestive of the

recurrence. Six months postoperatively, the visual acuity was 20/20.

 

ReferenceReferencess

1. Theobald GD, Haas JS. Epithelial invasion of the anterior chamber following cataract extraction.

Trans Am Acad Ophthal Otolaryngol. 1948;52:470.

2. Maumenee AE. Treatment of epithelial downgrowth and intraocular fistula following cataract extraction.

Trans Am Ophthalmol Soc. 1964;62:153-166.

3. Naumann GOH, Rummelt V. Block excision of cystic and diffuse epithelial ingrowth of the anterior chamber;

report on 3 consecutive patients. Arch Ophthalmol. 1992; 110:223-227.

4.Maumenee AE, Paton D, Morse PH, et al. Review of 40 histologically proven cases of epithelial downgrowth following

cataract extraction and suggested surgical management. Am J Ophthalmol. 1970;69:598-603.

5. Scholz RT, Kelley JS. Argon laser photocoagulation treatment of iris cysts following penetrating keratoplasty.

Arch Ophthalmol. 1982;100:926-927.

6. Schaeffer AR, Nalbandian RM, Bringham DW, O’Donnell FE Jr. Epithelial downgrowth following wound dehiscence

after extracapsular cataract extraction and posterior chamber lens implantation: Surgical management J cataract Refract Surg.

1989;15:437-41.

7. Scholz RT, Kelley JS. Argon laser photocoagulation treatment of iris cysts following penetrating keratoplasty.

Arch Ophthalmol. 1982;100:926-927.

8. Vargas LG, Vroman DT, Solomon KD, et al. Epithelial downgrowth after clear cornea phacoemulsification;

report of two cases and review of the literature. Ophthalmology. 2002;109:2331-2335.

9. Lee BL, Gaton DD, Weinreb RN. Epithelial downgrowth following phacoemulsification through a clear cornea[photo essay].

Arch Ophthalmol. 1999; 117:283.