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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 3-5

Objective Scheimpflug imaging of the healing cascade and repair process of striate keratopathy with the concept of optical blooming


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 Optometrist, Department of Optometry and Visual Science, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
4 Head of the Department of Cataract and Refractive Surgery, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India
5 Chief Medical Officer, Mahathma Eye Hospital Private Limited, Trichy, Tamil Nadu, India

Date of Submission20-Apr-2021
Date of Acceptance24-Aug-2021
Date of Web Publication07-Jan-2022

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


DOI: 10.4103/ijo.IJO_933_21

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  Abstract 


To our knowledge, assessment of striate keratopathy (SK) is subjectively done with slit-lamp bio-microscopic examination, which is the most common practice. In this manuscript, we have reported the role of objective scheimpflug imaging modality, in decoding the healing and repair process of SK, post prolonged cataract surgery. The quantitative and qualitative framing of this pathology with hyperreflective and hyporeflective hot spots (optical blooming) has never been reported in the literature before. In addition to the imaging of the cascadic events of SK in default colour, the role of digital calipers in the measurement of corneal thickness in SK (in inverse colour) is also highlighted. This manuscript throws light on the unique features of scheimpflug imaging technology, for the possible consideration of it as a routine post-operative investigation in patients undergoing prolonged or complicated cataract surgery, in quantifying their SK.

Keywords: Digital Calipers; Healing Cascade; Optical Blooming; Scheimpflug Imaging; Striate Keratopathy


How to cite this article:
Ramesh PV, Ramesh SV, Aji K, Ray P, Ramesh MK, Rajasekaran R. Objective Scheimpflug imaging of the healing cascade and repair process of striate keratopathy with the concept of optical blooming. Indian J Ophthalmol Case Rep 2022;2:3-5

How to cite this URL:
Ramesh PV, Ramesh SV, Aji K, Ray P, Ramesh MK, Rajasekaran R. Objective Scheimpflug imaging of the healing cascade and repair process of striate keratopathy with the concept of optical blooming. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jun 29];2:3-5. Available from: https://www.ijoreports.in/text.asp?2022/2/1/3/334994



Striate keratopathy (SK) is characterized by the presence of stromal edema with radiating Descemet membrane (DM) folds located close to the incision, or more centrally in the cornea after prolonged or complicated cataract surgery.[1],[2],[3] It is commonly diagnosed and followed up clinically by subjective slit-lamp examination. In this manuscript, we have highlighted the cascade of events involved in the healing process of SK with objective Scheimpflug imaging using digital calipers. It is a novel imaging modality that has recently shown promise beyond the field of cataract to objectively evaluate pathologies such as pseudo-bleb, uveitis, and asteroid hyalosis in the anterior chamber (AC).[4],[5],[6],[7],[8]


  Case Report Top


In a 70-year-old female patient who underwent prolonged cataract surgery, the innate postoperative healing of SK was followed up with serial photographs of slit-lamp [Figure 1], anterior segment optical coherence tomography [Figure 2], and Scheimpflug imaging after instillation of 5% sodium chloride eyedrops four times a day, along with topical antibiotic and steroids. The type of surgery performed was small incision cataract surgery (SICS). The surgical time was approximately 25 minutes. Due to the brown nature of the mature cataract, and the floppy nature of the iris, the surgical time was prolonged. The surgery was otherwise uneventful. The corresponding author was the surgeon, with 5 years of experience post completion of his advanced SICS/Phacoemulsification training.
Figure 1: (a) One-week postoperative slit-lamp photograph in diffuse illumination showing corneal edema of OD. (b) One-week postoperative slit-lamp photograph in slit-beam illumination showing corneal edema and multiple Descemet membrane (DM) folds (yellow arrows). (c) Slit-lamp photograph in slit-beam illumination showing partial reduction of corneal edema and DM folds (yellow arrow) at two-week postoperative follow-up, with features suggestive of iritis with cells in the pupillary region. (d) Slit-lamp photograph revealing clear cornea at three-week follow-up

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Figure 2: (a) Anterior segment optical coherence tomography (AS-OCT) of OD cornea, showing multiple measurement sections of the corneal edema (1054, 957, 871, and 692 μm) and multiple Descemet membrane (DM) folds at one-week follow-up. (b) AS-OCT of the cornea showing a partial reduction in corneal edema (777 and 603 μm) and fewer DM folds at the two-week follow-up period. (c) AS-OCT image showing the resolved clear cornea with normal thickness (574 μm) at the three-week follow-up period.

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  Discussion Top


The utility of both default and inverse color Scheimpflug images has been highlighted with respect to optical blooming in this scenario.[9] Stromal examination in default color image revealed multiple hyperreflective hotspots produced by edematous stroma, which subsequently hindered the view of structures beneath them [Figure 3]a, whereas the same image in zoomed inverse color revealed hyporeflective corneal epithelial edema with increased corneal thickness [Figure 3]b during the first week of follow-up. On subsequent visits, there was a reduction in hyperreflective stromal hotspots, with subsequent unmasking of hyperreflective fumes in AC, suggestive of postoperative iritis [Figure 3]c and [Figure 3]d. Usually, SK is not necessarily associated with iritis, but in this scenario, the SK was associated with iritis, which has been documented both clinically [Figure 3]c and with the Scheimpflug imaging system, revealing as reflective fumes in AC [Figure 3]c and [Figure 3]d. It is well documented by Ramesh et al.[10] that these fumes are a feature of active inflammation (uveitis) of the anterior segment and not artifacts due to corneal edema. On further follow-up at 3 weeks, both hyperreflective hot spots (corneal edema) and hyperreflective fumes (iritis) resolved [Figure 3]e, with inverse color revealing simultaneous resolution of the hyporeflective epithelial edema [Figure 3]f. Considering such unique features, the Scheimpflug imaging system can be considered as an adjuvant postoperative investigation tool to objectively assess and quantify SK.
Figure 3: (a) OD Scheimpflug image revealing multiple hyperreflective hotspots (red asterisks) in the cornea suggestive of stromal edema and Descemet membrane folds with an increased corneal thickness (950 μm; red line) in default color at one-week follow-up. (b) Same image in zoomed inverse color view, revealing hyporeflective epithelium (yellow asterisk) and corneal thickness measurement (950 μm; red line), respectively. (c) OD Scheimpflug default image revealing hyperreflective fumes (red arrow) of the postoperative iritis reaction in the anterior chamber with partially reducing corneal edema (670 μm; red line), at two-week follow-up. (d) Same image in inverse color, revealing resolving corneal edema with reduction in corneal thickness (670 μm; red line) and epithelium thickness (yellow asterisk), respectively. (e and f) OD Scheimpflug image revealing the clear cornea (580 μm; red line) with normal epithelium (green asterisk) and resolved iritis in default and inverse color, respectively, at three-week follow-up.

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  Conclusion Top


In patients with striate keratopathy, both tools are indispensable, because AS-OCT will reveal any associated Descemet membrane folds or Descemet membrane detachment along with corneal edema, whereas the Scheimpflug imaging technology will quantify the healing cascade and repair process of striate keratopathy, with its digital calipers and highlight the different layers of cornea, with hyperreflective or hyporeflective hotspots, in both default and inverse color images. In addition, hyperreflective fumes in AC, suggestive of postoperative iritis, are also picked up with Scheimpflug imaging, which is not possible with AS-OCT. Scheimpflug imaging technology can act as an adjuvant to slit lamp and AS-OCT in the diagnosis of striate keratopathy, but cannot replace or substitute it.

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.
Singh P, Tripathy K. Keratopathy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 [cited 2021 Aug 17]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK562153/.  Back to cited text no. 1
    
2.
Sharma N, Singhal D, Nair SP, Sahay P, Sreeshankar S, Maharana PK. Corneal edema after phacoemulsification. Indian J Ophthalmol 2017;65:1381-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Hoovayya KS, Kumar A. A prospective study on corneal complications of small incision cataract surgery conducted in rural hospital. Trop J Ophthalmol Otolaryngol 2019;4:92-9.  Back to cited text no. 3
    
4.
Ramesh PV, Ramesh SV, Rajasekaran R, Ramesh MK. Clinical application of Scheimpflug imaging in congenital lamellar cataract-An objective preoperative densitometry museum. Indian J Ophthalmol Case Rep 2021;1:167.  Back to cited text no. 4
    
5.
Ramesh PV, Ramesh SV, Ramesh MK, Rajasekaran R. The mirage of a perfect bleb – Studying morphological appearance of a pseudobleb using anterior segment optical coherence tomography and Scheimpflug imaging. Indian J Ophthalmol Case Rep 2021;1:172.  Back to cited text no. 5
  [Full text]  
6.
Ramesh PV, Ramesh SV, Rajasekaran R, Ramesh MK. Vitreous asteroid hyalosis prolapse into the anterior chamber simulating masquerade syndrome: Imaging its dynamicity with anterior segment examination tools. Indian J Ophthalmol Case Rep 2021; 1:169.  Back to cited text no. 6
  [Full text]  
7.
Ramesh SV, Ramesh PV, Ramesh MK, Rajasekaran R. Scheimpflug imaging system: Opening up the black box of iris bombe. J Clin Ophthalmol Res 2021;9:46-7.  Back to cited text no. 7
  [Full text]  
8.
Ramesh PV, Ramesh SV. Foreign body through the looking glass: Scheimpflug imaging in inverse contrast. Kerala J Ophthalmol 2021;33:83-6.  Back to cited text no. 8
  [Full text]  
9.
Ramesh SV, Ramesh PV, Ramesh MK, Rajasekaran R. Fungal corneal ulcer: Through the eyes of a Scheimpflug camera. Indian J Ophthalmol Case Rep 2021;1:445.  Back to cited text no. 9
  [Full text]  
10.
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.  Back to cited text no. 10
  [Full text]  


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  [Figure 1], [Figure 2], [Figure 3]



 

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