Persistent loss of marginal corneal arcades after chemical injury
Abstract
Changes in the limbal microvasculature following a chemical eye injury are essential for prognosis and management. At the slit lamp, it can be difficult to assess, here using fluorescein and indocyanine green angiography we show that anterior segment angiography may be informative to assess objectively the limbal microvascular changes over the follow-up period. Chemical injury to the ocular surface is an ophthalmic emergency that may result in damage to the marginal corneal arcades (MCA), limbal microvasculature, and limbal epithelial stem cell niche.Accurate evaluation and monitoring of this microvasculature is essential for prognosis and management, if assessed at the slit lamp it can be challenging.Fluorescein and indocyanine green angiography (FA and ICGA), and to a lesser extent optical coherence tomography angiography (OCTA), have been shown to be informative in the diagnosis of these vascular changes. There is little information, however, on long term longitudinal changes to the MCA and limbal vasculature following a chemical injury, which may be of importance in planning clinical and surgical interventions that depend on a healthy supportive peri-limbal microvasculature. We report the vascular changes that occur in a patient over a 6-year time period following a chemical injury.
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November2020 CaseReports 2543 Persistent loss of marginal corneal arcades after chemical injury Carlos Rocha de Lossada1,2, Luca Pagano1,3, Kunal A Gadhvi1, Davide Borroni2,4, Gustavo Figueiredo1, Stephen Kaye1,4, Vito Romano1,4 Changes in the limbal microvasculature following a chemical eyeinjuryareessentialforprognosisandmanagement.Atthe slitlamp,itcanbedifficulttoassess,hereusingfluoresceinand indocyaninegreenangiographyweshowthatanteriorsegment angiographymaybeinformativetoassessobjectivelythelimbal microvascularchangesoverthefollow-upperiod. Key words:AnteriorsegmentOCT,anteriorsegmentangiography, limbalischemia,marginalcornealarcades,ocularchemicalburn Chemicalinjurytotheocularsurfaceisanophthalmicemergency thatmayresultindamagetothemarginalcornealarcades(MCA), limbalmicrovasculature,andlimbalepithelialstemcellniche.[1-3] Accurateevaluationandmonitoringofthismicrovasculature isessentialforprognosisandmanagement,ifassessedatthe slitlampitcanbechallenging.[1,2]Fluoresceinandindocyanine greenangiography(FAandICGA),andtoalesserextentoptical coherencetomographyangiography(OCTA),havebeenshown tobeinformativeinthediagnosisofthesevascularchanges.[4-6] Thereislittleinformation,however,onlongterm longitudinalchangestotheMCAandlimbalvasculature followingachemicalinjury,whichmaybeofimportancein planningclinicalandsurgicalinterventionsthatdependona healthysupportiveperi-limbalmicrovasculature.Wereport thevascularchangesthatoccurinapatientovera6-yeartime periodfollowingachemicalinjury. Case Report A57-year-oldladypresentedwithastageII(Roper-Hall classification[7])alkalinechemicalinjurytoherrighteye.At 1DepartmentofOphthalmology,RoyalLiverpoolUniversityHospital, Liverpool,UK,2DepartmentofOphthalmology,HospitalCostadel Sol,Marbella,Spain,3DepartmentofBiomedicalSciences,Humanitas University,Milan,Italy,4DepartmentofEyeandVisionScience, UniversityofLiverpool,Liverpool,UnitedKingdom Correspondenceto:Dr.CarlosRochadeLossada,Departmentof CornealandExternalEyeDiseases,StPaul’sEyeUnit,RoyalLiverpool UniversityHospital,PrescotSt,L78XP,Liverpool,UnitedKingdom. E-mail:[email protected] Received:25-Jun-2020 Revision:07-Sep-2020 Accepted:03-Oct-2020 Published:26-Oct-2020 Cite this article as: Rocha de Lossada C, Pagano L, Gadhvi KA, Borroni D, Figueiredo G, Kaye S, et al. Persistent loss of marginal corneal arcades after chemical injury. Indian J Ophthalmol 2020;68:2543-4. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: [email protected] Access this article online Quick Response Code: Website: www.ijo.in DOI: 10.4103/ijo.IJO_2056_20 PMID: ***** presentation,herbest-correctedvisualacuity(BCVA)was20/30 Snellen.Shehadaninferonasalepithelialdefectcrossingthe limbuswithcornealstromalhazeandaclinicalappearance oflimbalischemiaoverfourclockhours[Fig.1a].Shewas treatedwithabundantirrigation,followedbytopicalsteroids, antimicrobials,ascorbicacid,andsystemictetracycline.The patientwasfollowedupwithregularslit-lampbiomicroscopy, ICGA,andFAusingascanninglaserophthalmo-scope(HRA2; HeidelbergEngineering,Heidelberg,Germany)toquantifythe areaoflimbalischemiaandvascularchanges.Atdays1and7 afterpresentation,therewasevidentinferonasallimbalischemia withextensivelossoftheMCA,accompaniedbybothearlyand latefluoresceinandindocyaninegreenleakage[Fig.2]. Threemonthsaftertheinjury,althoughtherewasapartial recoveryoftheperi-limbalvasculature,areasoflossofvascularity, especiallytheMCAremained,evidentonICGA[Fig.2].Recovery oftheperi-limbalvasculatureandMCAcontinued,however, evenaftersixyears,therewerestillareasofcapillarylossand earlierfluoresceinleakageincomparisontotheunaffected fellow eye [Fig.2].BCVAremainedat20/20andclinicallythere wasresidualcornealscarringwithlipiddeposition,theocular surfaceremainedstablewithnoepithelialbreakdown[Fig.1b]. Discussion Clinicalassessmentoflimbalischemiaafterchemicalinjury ischallengingandstudieshavedemonstratedlowclinical agreementandinter-observerconsistency.[1]FAandICGAare usefultoolsinidentifying,quantifying,andmonitoringtheMCA andlimbalvasculature.[2,4,5]Ourcaseofchemicalinjuryhighlights thelimitsofclinicalcolorphotographyindetectingthesevascular abnormalities.Itisofnotethatthevascularabnormalities remainedovera6-yearperiodandwerenotapparentonslit-lamp biomicroscopyorcolorphotography.AlthoughOCTAisan alternativeandlessinvasiveprocedurethanFAandICGA, itprovideslimitedinformationaboutvesselmaturity.Early fluoresceinleakageisamakerofvesselimmaturityandorvessel damage.ICGdoesnotleakfromhealthyvesselsandtheleakage presentinthiscaseindicatestheextentofthevasculardamage. Thisindicatesthateveninthoseareaswherethevasculature waspresent,thevesselsweredamagedandunlikelytoprovide adequatesupporttothelimbaltissue.ThisisimportantasHuang et al.reportedthatlimbalepithelialstemcellscannotmaintain theirstemnessorproliferationwithoutthesupportofthelimbal microvasculaturenetmicroenvironment.[8] Conclusion MonitoringthechangesintheMCAandlimbalvasculature followingachemicalinjuryusingFAandICGAisimportant toassessthevascularinjuryandtheextentofitsrecovery. Downloaded from http://journals.lww.com/ijo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWn YQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 05/09/2023
2544 Indian Journal of Ophthalmology Volume68Issue11 b a Figure 1: Color anterior segment photographs of the patient’s right eye, showing (a) six clock hours of nasal limbal ischemia with five clock hours of associated corneal opacity, (b) resolved limbal ischemia and clear cornea 6 years post‑injury Figure2: Serial fluorescein and indocyanine green angiographs early and late phase at different time points. Images of the fellow eye to compare the pattern and the restored peri‑limbal vasculature post‑injury. Green arrows show leakage. Orange arrows show loss of marginal corneal arcade. Yellow lines show the ischemic area Declaration of patient consent Theauthorscertifythattheyhaveobtainedallappropriate patientconsentforms.Intheformthepatient(s)has/have givenhis/her/theirconsentforhis/her/theirimagesandother clinicalinformationtobereportedinthejournal.Thepatients understandthattheirnamesandinitialswillnotbepublished anddueeffortswillbemadetoconcealtheiridentity,but anonymitycannotbeguaranteed. Financial support and sponsorship Nil. Conflicts of interest Therearenoconflictsofinterest. References 1. KamKW,PatelCN,NikpoorN,YuM,BasuS.Limbalischemia: Reliabilityofclinicalassessmentandimplicationsinthe managementofocularburns.IndianJOphthalmol2019;67:32-6. 2. FungSSM,StewartRMK,DhalluSK,SimDA,KeanePA,WilkinsMR, et al.Anteriorsegmentopticalcoherencetomographicangiography assessmentofacutechemicalinjury.AmJOphthalmol2019;205:165-74. 3. NowellCS,RadtkeF.Cornealepithelialstemcellsandtheirniche ataglance.JCellSci2017;130:1021-5. 4. ZhengY,KayeAE,BokerA,StewartRK,TeyA,AhmadS,et al.Marginal cornealvasculararcades.InvestigOphthalmolVisSci2013;54:7470-7. 5. BrunnerM,RomanoV,StegerB,VinciguerraR,LawmanS, WilliamsB,et al.Imagingofcornealneovascularization: Opticalcoherencetomographyangiographyandfluorescence angiography.InvestigOphthalmolVisSci2018;59:1263-9. 6. AnijeetDR,ZhengY,TeyA,HodsonM,SuekeH,KayeSB.Imagingand evaluationofcornealvascularizationusingfluoresceinandindocyanine greenangiography.InvestigOphthalmolVisSci2012;53:650-8. 7. Roper-HallMJ.Thermalandchemicalburns.TransOphthalmol SocUK1965;85:631-3. 8. HuangM,WangB,WanP,LiangX,WangX,LiuY,et al.Rolesoflimbal microvascularnetandlimbalstromainregulatingmaintenanceof limbalepithelialstemcells.CellTissueRes2015;359:547-63. Downloaded from http://journals.lww.com/ijo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWn YQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 05/09/2023