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Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 263-264

Descemet's stripping endothelial keratoplasty in corneal epithelial hyperplasia with endothelial decompensation

1 Department of Cornea, Sudarshan Netralaya, Bhopal, Madhya Pradesh, India
2 Department of Cornea and Refractive Surgery, Sankara Nethralaya, Medical Research Foundation, 41, College Road, Chennai, Tamil Nadu, India

Date of Submission08-May-2021
Date of Acceptance18-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Prateek Gujar
Department of Cornea, Sudarshan Netralaya, Plot No 61, Old MLA Quarters, Jawahar Chowk, Bhopal - 462 003, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1149_21

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Keywords: Corneal decompensation, corneal epithelial hyperplasia, Descemet's stripping endothelial keratoplasty

How to cite this article:
Gujar P, Natarajan R. Descemet's stripping endothelial keratoplasty in corneal epithelial hyperplasia with endothelial decompensation. Indian J Ophthalmol Case Rep 2022;2:263-4

How to cite this URL:
Gujar P, Natarajan R. Descemet's stripping endothelial keratoplasty in corneal epithelial hyperplasia with endothelial decompensation. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:263-4. Available from: https://www.ijoreports.in/text.asp?2022/2/1/263/334857

Corneal epithelial hyperplasia (CEH) is a focal to diffuse change characterized by increased epithelial cell layers. CEH is often accompanied by epithelial hyperkeratosis and is whitish and spongy in appearance. It is usually associated with stromal inflammation and neovascularization. Eyelid closure may be a major driving force in epithelial cell migration and turnover.[1],[2] The relative lack of protection against eyelid-induced cellular exfoliation caused by irregular areas of the anterior stroma may be an extremely important factor in the genesis of CEH.[3] Long-standing corneal decompensation with bullae might trigger CEH because of irregular surface and prolonged inflammation. Imbibition of fluid due to faulty endothelium gives it a pale color and sponge-like texture.

Cases of corneal decompensation associated with CEH can pose a management dilemma for the corneal surgeon to choose between full-thickness penetrating keratoplasty (PKP) and Descemet's stripping endothelial keratoplasty (DSEK), lack of intraoperative visibility, and failure of the endothelial graft to clear the cornea completely.

Anterior segment optical coherence tomography (AS-OCT) helps identify CEH as multiple layers of the spongy and opaque epithelium with increased reflectivity and clear demarcation from the underlying cornea.

We describe three cases where long-standing corneal decompensation associated with CEH was successfully managed with DSEK [Figure 1] and [Figure 2]. In all the cases, the thickened corneal epithelium was peeled off in toto, with an easy plane of cleavage, using a crescent knife and Lim's forceps. The epithelial tissue was sent for histopathological examination [Figure 3]. DSEK was then performed using the 30-gauge cystotome push technique. All the cases had a follow-up of more than 1 year with clear and compact cornea [Figure 1] and [Figure 2].
Figure 1: (a-f) Preoperative and postoperative clinical images of three patients, managed successfully with in toto removal of CEH with DSEK

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Figure 2: (a-f) Preoperative AS-OCT (anterior segment optical coherence tomography) images showing multiple layers of the spongy and hyperreflective epithelium with clear demarcation from the underlying cornea and post-DSEK compact corneas

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Figure 3: Histopathology examination showing surface epithelial cells with hyperkeratosis with loss of normal cell structure and degenerative changes. The lowermost layer of basal cells are seen with multiple layers of wing/polygonal cells above it. Basement membrane invaded by thick fibrovascular proliferation with myofibroblasts and lumen of blood vessels are seen (Figure courtesy: SV Diagnostics)

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  Discussion Top

It is important to distinguish CEH from fibrous stromal dysplasia, as the former can be peeled off in toto, giving a clear view of the anterior chamber during surgery. Apart from slit-lamp examination, AS-OCT plays a pivotal role in decision making.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Thoft RA, Friend J. The X, Y, Z hypothesis of corneal epithelial maintenance. Invest Ophthalmol Vis Sci 1983;24:1442-3.  Back to cited text no. 1
Lemp MA, Mathers WD. Renewal of the corneal epithelium. Eye Contact Lens 1991;17:258-66.  Back to cited text no. 2
Lemp MA. The surface of the corneal graft: In vivo color specular microscopic study in the human. Trans Am Ophthalmol Soc 1989;87:619-57.  Back to cited text no. 3


  [Figure 1], [Figure 2], [Figure 3]


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