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PHOTO ESSAY
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 409-411

Changing perspectives: Objective monitoring of corneal health in granulomatous uveitis by mapping the keratic precipitates through a Scheimpflug imaging system with calipers in inverse contrast


1 Medical Officer, Department of Glaucoma and Research, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
2 Medical Officer, Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
3 Head of Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
4 Chief Medical Officer, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India

Date of Submission07-Sep-2020
Date of Acceptance29-Jan-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Prasanna V Ramesh
Mahathma Eye Hospital Private Limited, No 6, Tennur, Seshapuram, Trichy, Tamil Nadu - 620 017
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2871_20

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  Abstract 


Keywords: Granulomatous uveitis, Imaging the KPs, Scheimpflug imaging


How to cite this article:
Ramesh PV, Ramesh SV, Ramesh MK, Rajasekaran R. Changing perspectives: Objective monitoring of corneal health in granulomatous uveitis by mapping the keratic precipitates through a Scheimpflug imaging system with calipers in inverse contrast. Indian J Ophthalmol Case Rep 2021;1:409-11

How to cite this URL:
Ramesh PV, Ramesh SV, Ramesh MK, Rajasekaran R. Changing perspectives: Objective monitoring of corneal health in granulomatous uveitis by mapping the keratic precipitates through a Scheimpflug imaging system with calipers in inverse contrast. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:409-11. Available from: https://www.ijoreports.in/text.asp?2021/1/3/409/320021



The corneal involvement in uveitis remains understudied even today, though cornea may be the most probable target of intraocular inflammation in uveitis.[1],[2] In this report, the application of the novel measuring tool, using the calipers of Scheimpflug imaging system in inverse contrast is highlighted for accurate mapping of granulomatous keratic precipitates (KPs), as a objective structural corneal health monitoring tool.

A 70-year-old man presented with mild ocular pain and decreased visual acuity in the left eye. On evaluation, visual acuity was 20/60 with quiet anterior segment, and fresh greasy grey granulomatous keratic precipitates were present at the back of the cornea. Intraocular pressure was 44 mm Hg. Fundus examination revealed a clear media, with no vitreous disturbance and a normal posterior pole. Mantoux test and Computerized Tomography chest revealed findings suggestive of tuberculosis (TB). In addition, there was also a positive family history of TB in the spinal cord of the patient's mother. Thus the patient was started on anti-tubercular therapy and anti-inflammatory therapy with hypotensive agents for managing his uveitis with secondary glaucoma. The posterior corneal surface was screened with 360-degree Scheimpflug imaging system for mapping the inflammatory retro-corneal granulomatous keratic deposits and its dimensions were measured with calipers, for evaluating response to therapy and providing an objective basis for better patient counseling.

In this scenario, TB manifested as acute anterior uveitis (AAU) which is the most common type of intraocular inflammation.[1] Inflammation of the anterior segment causes changes in the endothelium and, if severe, can compromise the integrity of the cornea.[3]

In clinical practice, imaging the corneal inflammatory lesions in AAU has traditionally been carried out with slit lamp biomicroscopy [Figure 1], gonioscopy [Figure 2], specular microscopy [Figure 3]a and anterior segment optical coherence tomography [Figure 3]b and [Figure 3]c. However, objective quantitative assessment such as 360-degree imaging of the posterior cornea, and measuring the dimensions of KPs in all frames is limited and not possible with them. But with Scheimpflug imaging (Sirius, CSO, Italy) which images the anterior segment of the eye from the front of the cornea to the back of the lens in coronal plane by capturing the slices through the anterior chamber with high resolution, fills in this void.[4] It also provides objective documentation of the anterior segment with good three-dimensional posterior corneal assessment in a fast and accurate way.
Figure 1: Slit lamp examination revealing granulomatous keratic precipitates (red arrows) on the corneal endothelium. (a) Low magnification. (b) High Magnification

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Figure 2: Gonioscopy revealing granulomatous keratic precipitates on the corneal endothelium in all the four mirrors when focussed on the endothelium

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Figure 3: (a) Specular microscope (Konan Medical USA, Inc) reveals glistening dense white keratic precipitates (red arrow) scattered over the endothelium. (b and c). AS-OCT (Heidelberg Engineering, Germany) reveals hyper-reflective spots (red arrows) of keratic precipitates on the endothelium

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  Discussion Top


Scheimpflug system in this patient reveals hyper-reflective keratic precipitates on the corneal endothelium [Figure 4]a. With application of the inverse contrast, the granulomatous keratic precipitates were appreciated much better and were more distinct than the default picture [Figure 4]b. Hence Scheimpflug analysis with calipers was done in the inverse contrast image [Figure 5], for enabling to quantify the corneal inflammatory changes and gauge response to treatment. Granulomatous keratic precipitates as small as 0.03 mm were measured in the 0- to 180-degree plane and 86- to 266-degree plane [Figure 5]e and [Figure 5]f. The largest keratic precipitate was measured in the 29- to 209-degree plane [Figure 5]g.
Figure 4: (a) Scheimpflug system (Sirius, CSO, Italy) reveals hyper-reflective keratic precipitates (red arrow) on the endothelium. (b) In the same picture with inversion of contrast, hypo-reflective keratic precipitates (red arrow) are appreciated on the endothelium

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Figure 5: (a-d) Multiple imaging sections of posterior cornea with Scheimpflug system revealing the hypo-reflective keratic precipitates on the endothelium. (e-h). Magnified view of the same imaging sections with keratic precipitates marked with calipers to determine their dimensions. The dimensions of the granulomatous KPs ranged from 0.03 to 0.08 mm

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Scheimpflug imaging is a rapidly evolving tool in ophthalmology especially for uveitic evaluation. By incorporating it with various anterior segment modalities for a holistic evaluation, it will make a significant impact during prognosis and follow-up of corneal health in AAU.[4] To our knowledge, there are no literatures reported on the role of Scheimpflug imaging in posterior cornea assessment and its calipers in monitoring corneal health in AAU. This is the first time that the calipers with Scheimpflug imaging were reported to measure the dimensions of the keratic precipitates for monitoring corneal health in a uveitic patient.

Though Scheimpflug imaging has left its footprint in the field of cornea, its application for anterior chamber inflammation such as uveitic KPs remains untapped. Our observation suggests that calipers with Scheimpflug imaging are available to measure the dimensions of keratic precipitates in cases of granulomatous uveitis and it is envisaged that the 360-degree posterior corneal imaging with the Scheimpflug imaging system could well be the start of a new era for monitoring corneal health in anterior uveitis management. Another major advantage of this device is the non-contact modality of examination, ease of image acquisition, repeatability, and the range of quantitative and qualitative information they provide. With the usage of digital calipers, objective measurement of KP size is possible, which is not the case with specular microscopy and slit-lamp examination. It takes 25 radial scans of anterior chamber, hence providing us with enough data for a three-dimensional mind's eye view. On the flip side, a potential limitation with these devices are their cost. Newer technologies are nearly always expensive, but a part of their expenses are typically balanced by their accompanied increase in accuracy of diagnosis and prognosis as reported in this scenario. Additionally, there is often a trend for reduction in cost with increasing availability of latest instruments in due course of time.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Agrawal RV, Murthy S, Sangwan V, Biswas J. Current approach in diagnosis and management of anterior uveitis. Indian J Ophthalmol 2010;58:11-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Oliveira F, Motta AC, Muccioli C. Corneal specular microscopy in infectious and noninfectious uveitis. Arq Bras Oftalmol 2009;72:457-61.  Back to cited text no. 2
    
3.
Pillai CT, Dua HS, Azuara-Blanco A, Sarhan AR. Evaluation of corneal endothelium and keratic precipitates by specular microscopy in anterior uveitis. Br J Ophthalmol 2000;84:1367-71.  Back to cited text no. 3
    
4.
Konstantopoulos A, Hossain P, Anderson DF. Recent advances in ophthalmic anterior segment imaging: A new era for ophthalmic diagnosis. Br J Ophthalmol 2007;91:551-7.  Back to cited text no. 4
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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