Epithelial ingrowth of anterior chamber and anterior surface of vitreous

This study is a case report of the histopathologic findings of the anterior chamber epithelial ingrowth in a patient who had penetrating injury in the right eye from an arrow approximately 20 years ago. The patient underwent the enucleation in the right eye due to pthisis bulbi and was fitted with a prosthetic eye. Specimens were prepared from the enucleated right eye for histopathologic observation using hematoxyllin-eosin to be observed under light microscopy. Epithelial ingrowth in the anterior chamber was noted in one layer or multi-layered epithelial cell growth. The ingrowth had spread to the posterior surface of the cornea to the anterior chamber angle, to the iris surface, and to the anterior surface of the vitreous. The finding suggests that epithelial ingrowth could invade even through a perforation site and spread wherever the cells could reach.     

Surgical management of anterior chamber epithelial cysts

PURPOSE: To review management strategies for treatment of anterior chamber epithelial cysts. DESIGN: Retrospective review of consecutive interventional case series. METHODS: Charts of patients treated for epithelial ingrowth over a 10-year period by a single surgeon were reviewed. Cases of anterior chamber epithelial cysts were identified and recorded, including details of ocular history, preoperative and postoperative acuity, intraocular pressure (IOP), and ocular examination, type of surgical intervention, and details of further procedures performed. RESULTS: Seven eyes with epithelial cysts were identified. Patient age ranged from 1.5 to 53 years at presentation. Four patients were children. In four eyes, cysts were secondary to trauma, one case was presumably congenital, one case developed after corneal perforation in an eye with Terrien's marginal degeneration, and one case developed after penetrating keratoplasty (PK). Three eyes were treated with vitrectomy, en bloc resection of the cyst and associated tissue, fluid-air exchange and cryotherapy. The last four eyes were treated with a new conservative strategy of cyst aspiration (three cases) or local excision (one keratin "pearl" cyst), and endolaser photocoagulation of the collapsed cyst wall/base. All epithelial tissue was successfully eradicated by clinical criteria; one case required repeat excision (follow-up, 9 to 78 months, mean 45). Two eyes required later surgery for elevated IOP, two for cataract extraction and one for repeat PK. Final visual acuity ranged from 20/20 to hand motions, depending on associated ocular damage. Best-corrected visual results were obtained in the more conservatively managed eyes. CONCLUSIONS: Anterior chamber epithelial cysts can be managed conservatively in selected cases with good results. This strategy may be particularly useful in children's eyes, where preservation of the lens, iris, and other structures may facilitate amblyopia management.     

Primary iris stromal cyst with unusual symptoms in an adult

BACKGROUND: Most epithelial cysts of the anterior chamber ("iris stromal cysts") occur after penetrating ocular injuries and represent secondary epithelial ingrowth. Primary iris stromal cysts are less common and mostly congenital. Acquired primary iris stromal cysts in adults are extremely rare and cause less often symptoms than congenital cysts. PATIENT: A 41-year old patient presented with sudden loss of visual acuity, epiphora and photophobia of his right eye. A large iris cyst was found in the nasal lower quadrant of the anterior chamber. It had not been present 3 years before when the patient was last seen by an ophthalmologist. There was no history of trauma and no signs of preceding ocular injury at slit-lamp examination. The cyst was surgically removed by iridocyclectomy. Postoperatively the patient developed cataract and macular edema. A phacoemulsification with posterior chamber lens implantation as well as a systemic treatment with steroids and acetazolamide were necessary. Until now, two years after surgery, the cyst did not recur. CONCLUSIONS: Primary iris stromal cysts also occur in adults. In contrast to previous reports the cyst of our patient has caused acute symptoms.     

Transformation of cystic into diffuse epithelial ingrowth caused by laser-puncture. Report on four patients

BACKGROUND: Epithelial ingrowth to the anterior chamber is a rare event after ocular injury or intraocular surgery. We report on four patients with primary cystic epithelial ingrowth (with primary curative cystic formation when treated with block excision) who underwent Nd:YAG-laser puncture of the cysts elsewhere. This treatment led to a change from a cystic to a diffuse form with a poor prognosis for the eye. PATIENTS: Three women and one man were seen in our outpatient department. Cystic epithelial ingrowth happened after intraocular surgery (1 x goniotomy, 2 x cataract surgery) or perforating injury (1 x). All four patients were treated elsewhere with puncture of the cysts (by Nd:YAG-laser). At first presentation in our department a change of cystic to diffuse epithelial ingrowth was noticed. Curative treatment by block excision was no longer possible. Diffuse epithelialisation of the anterior chamber resulted in secondary glaucoma with a poor prognosis. CONCLUSIONS: In our experience puncture of intraocular epithelial cysts may lead to a transformation to diffuse epithelial ingrowth with possible loss of the eye. Surgical opening of the cyst or subtotal excision is therefore contraindicated from our point of view. In case of cystic epithelial ingrowth of less than 5 hours of the limbal circumference, block excision in toto is indicated.     

Diagnosis of epithelial ingrowth after penetrating keratoplasty with confocal microscopy

PURPOSE: To report confocal microscopy use in the clinical diagnosis of epithelial ingrowth after penetrating keratoplasty (PKP). METHODS: A 36-year-old female patient with keratoconus developed a well-delimited posterior hazy membrane covering the inferior two thirds of the cornea 3 months after an uneventful PKP. A posterior corneal line was present resembling an endothelial graft rejection line, but with no keratic precipitates or corneal edema. Ocular hypertension was not observed. Confocal microscopy was performed to elucidate the diagnosis. RESULTS: Confocal microscopy showed epithelium and stroma with normal findings. Two distinct cellular types were presented at the endothelium layer. Enlarged endothelial cells were observed in the superior part of the cornea up to the leading edge of the hazy membrane. In the middle and inferior part of the graft, the cells were larger, with polygonal shape and easily recognizable hyperreflective nuclei, suggestive of epithelial cells. With these confocal microscopy findings, the patient was promptly submitted to another PKP. Histologic analysis confirmed the diagnosis of epithelial ingrowth. CONCLUSION: Confocal microscopy imaging technique seems to be a useful tool in the early diagnosis of epithelial ingrowth after PKP.     

Resolution of epithelial ingrowth in a patient treated with 5-fluorouracil

PURPOSE: To report the effect of 5-fluorouracil on the outcome of a single case of epithelial ingrowth secondary to a wound leak after a complicated penetrating keratoplasty. DESIGN: Case report. METHODS: A 44-year-old man with extensive epithelial ingrowth after trauma and a penetrating keratoplasty received a fluid-gas exchange followed by two injections of 500 microg of 5-fluorouracil into the anterior chamber. RESULTS: Two weeks after receiving the 5-fluorouracil injections, complete disappearance of the epithelial ingrowth from the anterior chamber occurred. No evidence of recurrence was detectable at 5 months. CONCLUSION: Use of 5-fluorouracil is a potentially effective treatment of epithelial ingrowth, particularly in eyes with extensive involvement, in which the risks of traditional ablative therapeutic modalities are considerable.     

Epithelial ingrowth in a phakic corneal transplant patient after traumatic wound dehiscence

PURPOSE: To report a case of epithelial ingrowth (downgrowth) occurring in a phakic corneal transplant patient after traumatic wound dehiscence with iris prolapse that was successfully eradicated with early surgical intervention. METHODS: Interventional case report of a 70-year-old monocular, phakic patient who developed epithelial ingrowth within 1 week of repair of a traumatic penetrating keratoplasty wound dehiscence, with reposition of the iris that had been prolapsed for 36 hours. A gradually expanding membrane developed from the surface of the reposited iris, across the anterior lens capsule. Argon laser photocoagulation applied to the surface of the iris confirmed the diagnosis and outlined the extent of the epithelial tissue on the iris. RESULTS: Intraoperative peeling of the epithelial membrane from the surface of the lens and excision of the involved iris were performed combined with extracapsular cataract extraction and insertion of a posterior chamber intraocular lens via an open-sky technique through a repeat penetrating keratoplasty opening in the cornea. This resulted in complete resolution of the intraocular epithelialization. Histopathologic examination of the excised tissue confirmed the diagnosis of epithelial ingrowth. CONCLUSIONS: Reposition of traumatically prolapsed iris tissue can result in epithelial ingrowth. Early aggressive surgical intervention can successfully remove all the epithelial tissue from within the anterior segment.     

Results of excision of advanced epithelial downgrowth

Advanced epithelial downgrowth was excised in 14 patients. The technique involved excision under direct observation of the epithelium found as bands in the anterior chamber and as membranes in the front and back of the iris, over the ciliary body, on the front and back surfaces of intraocular lenses, and over the vitreous face. In the first nine cases, cryoapplication was used to destroy the epithelium on the back of the cornea. In three patients, in spite of repeated applications, the epithelium was unaffected by freezing. In these cases the epithelial downgrowth was excised by scraping it free from the back of the cornea. In four eyes the whole cornea was removed both for visualization of the extent of the growth of the epithelium throughout the anterior and posterior chamber and to scrape the epithelium free. Thereafter the cornea was replaced. Eleven of the 14 eyes have remained free of epithelial downgrowth from 18 months to eight years postoperatively. Penetrating corneal transplantations were performed in six eyes because of corneal edema; these have remained transparent. Although two eyes have vision better than 20/40, the majority have 20/200.     

A re-appraisal of the development of the anterior chamber

The development of the anterior chamber passes through distinct well orchestrated phases. It is a dynamic transition from an embryonic cleft to the adult anterior chamber. The cornea, lens, tunica vasculosa lentis, the iris, the ciliary epithelium, and the trabecular meshwork all play important roles in the development of the anterior chamber. Apart from these morphological changes that occur, the hydrodynamics of the transudate (from the tunica vasculosa lentis) and the aqueous humor from the ciliary epithelium appear to be essential components in the maintenance of the integrity of the anterior and posterior chambers.     

The cornea in cataract and intraocular lens surgery

Advances in cataract surgery and intraocular lens implantation techniques continue to allow improved safety for the cornea. Complications can include mechanical or toxic injury of the endothelium, stripped Descemet's membrane, epithelial toxicity and disruption, infectious keratitis, or epithelial ingrowth. Most of the recent work has addressed endothelial cell survival after cataract extraction and lens implantation or in cases following secondary lens implantation. A great deal of controversy has been raised over the past year as to whether flexible open-loop anterior chamber lenses, iris-fixated posterior chamber lenses, or transsclerally sutured posterior chamber lenses are safest for the cornea. Even with additional data accumulating, it still is not clear which type of implant provides the best degree of safety in cases requiring secondary implantation. Certainly, both flexible open-loop anterior chamber lenses and bag-fixated posterior chamber lenses placed at the time of cataract surgery have a good record of safety for the cornea. Patients with keratoconjunctivitis sicca require extra lubrication to prevent epithelial toxicity at the time of surgery and also postoperatively. Methylcellulose-containing lubricants appear to be most protective of the corneal epithelium. Overall, cataract surgery and intraocular lens implantation is extremely safe with modern techniques.     

Korneale Neuroparalyse nach Blockexzision im Bereich des 3- und 9-Uhr-Meridians

PURPOSE: Corneal innervation is mainly supported by the long posterior ciliary nerves. Anatomically, the long ciliary nerves run with the long ciliary arteries at 3 and 9 o'clock. The aim of this retrospective study was to find out if block excision of anterior uveal tumors or epithelial ingrowth located at the 3 or 9 o'clock position of the limbal circumference causes corneal neuroparalysis. PATIENTS AND METHODS: Between 1980 and May 1999, a total of 151 block excisions were performed in our department (92 block excisions because of anterior uveal tumors and 59 because of cystic epithelial ingrowth to the anterior chamber). In 27 patients, anterior uveal tumors or cystic epithelial ingrowth were located at the 3 or 9 o'clock position of the limbal circumference (14 patients with cystic epithelial ingrowth and 13 patients with anterior uveal tumors). Mean age of all patients was 54.4 +/- 15.7 years at the time of surgery. Mean diameter of the block excision was 10.7 +/- 4.5 mm for tumor-patients and 9.0 +/- 1.2 mm for patients with anterior chamber cysts. Mean follow-up time was 93.6 +/- 43 months. RESULTS: Only 1 of 27 patients exhibited a moderate neuroparalytic corneal ulcer during the follow-up time. In the remaining 26 patients, no signs of clinically relevant corneal neuroparalysis such as epithelial disorders or neuroparalytic ulcers were found. CONCLUSION: Block excision of tumors or cystic epithelial ingrowth located at the 3 or 9 o'clock position of the limbal circumference did not lead to severe neuroparalytic disorders of the host cornea. This may be an important factor in postoperative management of patients undergoing block excision and corneoscleral grafting.     

Lamellar corneal dissection for visualization of the anterior chamber before triple procedure

PURPOSE: Open-sky cataract extraction during triple procedure can be associated with higher risk of complications owing to the missing counterbalance by the cornea. Herein, we present a fast and easy technique for visualization of the anterior chamber and the lens in eyes with opaque corneas planed for triple procedure. MATERIALS AND METHODS: Four patients with corneal oedema due to Fuchs' endothelial dystrophy and cataract underwent triple procedure. As the anterior chamber view was limited, the central 7.0 mm of the cornea was marked. Then, 60-80% of the corneal thickness was removed by lamellar dissection and filled with hydroxypropylmethylcellulose. Continuous curvilinear capsulorhexis (CCC) and phacoemulsification with intraocular lens implantation through a corneoscleral tunnel were then performed and at the end the remaining corneal tissue was excised and the donor tissue fixed with a single running continuous suture. RESULTS: Lamellar corneal dissection enhances the anterior chamber view and CCC can be performed under stable anterior chamber condition. Phacoemulsification via sclerocorneal tunnel could be easily performed under good anterior chamber view in all cases. The operation time was 60-75 min in all cases. CONCLUSION: Lamellar corneal dissection in opaque corneas before cataract extraction is a useful technique for enhancing anterior chamber view in cases of triple procedure.     

Corneal imaging with anterior segment optical coherence tomography for lamellar keratoplasty procedures

PURPOSE: To assess and describe the uses of anterior segment optical coherence tomography (OCT) in the evaluation of the cornea before and after lamellar corneal transplantation procedures. DESIGN: Prospective, noncomparative, observational case series. METHODS: Seven eyes of seven patients undergoing anterior and posterior lamellar corneal transplantation procedures at the Singapore National Eye Centre were included in the study. High-resolution anterior segment OCT scans of the cornea and anterior segment were performed both before and after lamellar transplantation procedures on the cornea with the Visante anterior segment OCT system (Visante OCT; Carl Zeiss Meditec, Inc, Dublin, California, USA), and the imaging findings were correlated with the clinical picture. Measurements of lamella thickness were performed with the software provided. RESULTS: Anterior segment OCT images were able to provide valuable information on donor apposition, Descemet membrane detachment after deep anterior lamellar keratoplasty (DALK), posterior lamellar dislocation, primary graft failure, and anterior chamber crowding with consequent chamber angle encroachment and pupillary block after Descemet stripping automated endothelial keratoplasty (DSAEK). CONCLUSIONS: Anterior segment OCT is a valuable imaging tool for assessing the feasibility of lamellar transplantation surgery in the diseased cornea and in the management of surgical complications after such procedures.     

前房穿刺术在内眼手术中应用的临床观察

目的：探讨前房穿刺术在内眼手术中的实用性及其优越性。方法：在青光眼小梁切除术、虹膜嵌顿术、白内障摘除及人工晶状体植入术、瞳孔成形术、角膜穿通伤合并虹膜脱出修复术等337例内眼手术中应用前房穿刺术，观察术中及术后并发症的发生。结果：术后浅前房占6．3％，角膜内皮水肿占5．2％，虹膜炎占10．7％，瞳孔不圆占6．6％，后囊破裂者占8．3％，无其它并发症。结论：前房穿刺术应用在内眼手术中是预防术后浅前房的有效措施，也便于手术操作、减少术中及术后并发症、促进前房形成等优点，可挽救某些濒临失败的手术。     

Surgical management of epithelial ingrowth

In ten consecutive cases of epithelial ingrowth operated on during the past 33 months, therapy included photocoagulation of the iris followed by excision of involved iris tissue and vitreous gel by means of instruments designed for vitreous surgery. Epithelium remaining on the posterior surface of the cornea, ciliary body, and in the anterior chamber was destroyed by controlled transcorneal and transscleral cryotherapy. An intraocular air bubble was used to provide an insulating effect and a more effective, controllable freeze. All patients except two had improved vision postoperatively, and four of the ten patients had postoperative visual acuity of 6/12 (20/40) or better.     

Free-floating cyst in the anterior chamber: ultrasound biomicroscopic reports

PURPOSE: To report a free-floating dislodged pigmented cyst in the anterior chamber and to describe the ultrasound biomicroscopic (UBM) features of the lesion. METHODS: Case report. RESULTS: A 26-year-old man presented with noise in his left eye in the prone position. Slit-lamp examination revealed a small pigmented mass lesion at the 6 o'clock position in the anterior chamber, slowly moving with changing head postures. UBM revealed an unfixed dislodged pigmented cyst with a thin wall and no internal reflectivity, changing its shape from ovoid to circular. Five years later, the anterior segment does not show any modification and the cyst has not changed in size or appearance. CONCLUSIONS: Cysts of the iris pigment epithelium arise in the posterior iris layer. They may be central, midzonal, peripheral, or dislodged. Dislodged cysts may be repositioned and fixed or free-floating in the vitreous or in the anterior chamber. Surgical removal must be considered only for a rapid enlargement or significant reduction in endothelial cell count. UBM can distinguish solid from cystic lesions, giving detailed information on internal structure, reflectivity, shape, and thickness.     

Epithelial cyst in the anterior chamber after penetrating keratoplasty: a rare complication.

We report the case of a 25-year-old man who had a penetrating keratoplasty for keratoconus. A year and a half after surgery a cyst was noted in the anterior chamber, which was observed to enlarge over six months. Because of anxiety about endothelial touch, it was removed surgically. Histologically the cyst was composed of stratified, non-keratinized squamous epithelium attached to loose fibrovascular tissue including islands of melanin-containing epithelial cells. This was interpreted as an epithelial implantation cyst of the anterior chamber of corneal origin attached to iris tissue.     

Scleral cyst formation following extracapsular cataract extraction.

Two patients who underwent extracapsular cataract surgery through corneal incisions developed scleral cysts 2 and 6 years later, respectively. The cysts involved the sclera without extension into the cornea or anterior chamber. To prevent further thinning of the sclera, only the anterior walls were excised and the posterior walls were mechanically debrided using alcohol and sponges. Histopathologic examination supported the clinical diagnosis of scleral cysts. No recurrence was seen. Scleral cyst formation may be encountered as a late complication of cataract surgery. Excision of the anterior wall coupled with removal of the epithelial lining of the posterior wall with alcohol may considerably lessen the likelihood of recurrence.     

经角巩膜缘入路玻璃体切割手术治疗永存原始玻璃体增生症合并前房消失及角膜混浊的疗效观察

目的 观察经角巩膜缘入路玻璃体切割手术治疗永存原始玻璃体增生症（PHPV）合并前房消失、角膜混浊的临床效果。方法 临床确诊为PHPV且合并前房消失、角膜混浊的16例患儿16只眼纳入研究。所有患眼均为混合型PHPV,其中央角膜混浊、前房消失、瞳孔闭锁前粘连、晶状体混浊。患眼中,视力为跟随运动1只眼,强光刺激反应15只眼。合并有小眼球7只眼,视网膜全脱离4只眼,视盘发育不良3只眼,局限视网膜皱襞1只眼,高眼压4只眼。所有患眼行经角巩膜缘入路玻璃体切割手术,手术中分离房角、瞳孔成形,切除晶状体组织及其后增生膜,切除或切断晶状体后原始玻璃体增生条索;视网膜脱离者于玻璃体切割手术后注入长效气体。手术后随访时间为9~21个月,平均随访时间15.8个月。观察患眼视力、眼压和眼前后节结构。结果 手术中所有患儿均未出现玻璃体积血、医源性视网膜裂孔等并发症。末次随访时,所有患眼前房深度正常,瞳孔圆形,视轴中心区暴露,角膜混浊程度较手术前减轻。视力强光刺激8只眼,不配合视力检查但有注视跟随运动者6只眼,最佳矫正视力为20/940者1只眼,最佳矫正视力为20/500者1只眼。4只视网膜脱离眼中,视网膜复位3只眼,占75%;视网膜未复位1只眼,呈视网膜部分展开。手术前高眼压的4只眼中,手术后眼压降至正常3只眼,占75%;手术后眼压控制不理想1只眼,占25%。 结论 经角巩膜缘入路玻璃体切割手术能有效控制PHPV合并前房消失、角膜混浊患眼的病变发展,改善眼球外观,提高视力。     

曲安奈德前房内注射在外伤性白内障术中的应用

目的:探讨前房内注射曲安奈德(triamcinolone acetonide,TA)在外伤性白内障术中的安全性和有效性.方法:收集2013-01/2016-05的31例31眼外伤性白内障患者,行小切口非超声乳化白内障摘除手术,术中联合前房内注入TA,以帮助辨识是否有玻璃体脱出以及玻璃体所在位置.13例13眼被证实后囊膜完整,无玻璃体脱入前房患者,行小切口非超声乳化白内障摘除手术.18例18眼被证实伴有后囊膜破裂,玻璃体脱出患者行小切口非超声乳化白内障摘除联合前部玻璃体切除手术.术后随访6~12 mo.结果:所有病例均顺利完成手术.Ⅱ期角膜穿通伤患者均顺利植入人工晶状体.18例前房内注入TA证实伴有后囊膜破裂、玻璃体脱出者,在TA辅助下,明显改善了术中玻璃体皮质的辨识度,均彻底切除了前房的玻璃体.术后随访28例患者术后最佳矫正视力大于4.5.所有患者术后眼内炎症反应轻微,均未出现持续1 wk以上的高眼压及角膜水肿,人工晶状体位置居中,瞳孔位置居中.结论:曲安奈德前房内注射使得外伤性白内障手术更安全,术中后囊破裂及玻璃体脱出的处理更容易,同时可以抑制术后炎症反应.