Epithelial ingrowth in the cornea is a rare but potentially vision-threatening complication of penetrating ocular trauma and ocular surgery, including refractive surgery. Epithelial ingrowth can be assessed biomicroscopically, demonstrating epithelial cells in the corneal stroma or endothelium. It can also be confirmed by histology and immunohistochemistry. Fibrous ingrowth tends to be slower and is often self-limited. It generally does not require treatment, whereas epithelial ingrowth tends to be more aggressive and may require fairly extensive surgery.
This case describes an unusual association between fibrous ingrowth and a limbal stay suture used during strabismus surgery.
A 12-year-old girl presented after her parents noted a white lesion on her left cornea. She had no visual symptoms. Ocular history included strabismus surgery for exotropia 2 years prior, which involved recession of the left lateral rectus and resection of the left medial rectus muscles. The surgery was performed at another center for pediatric ophthalmology, and operation reports were reviewed. The operation involved use of a limbal stay suture (6.0 silk; Ethicon, Somerville, NJ), which was placed at approximately the 5- to 6-o’clock positions at the limbus. Surgery and recovery proceeded uneventfully. The patient had also sustained previous minor trauma to the same eye and eyelid after flicking a pencil. Following this incident, the child was asymptomatic, with no pain, redness, or visual disturbance. Examination performed on the same day demonstrated no epithelial defect, no conjunctival laceration or hemorrhage, and no other evidence of ocular injury.
Examination showed best corrected visual acuity to be 6/6 bilaterally. Slit-lamp examination demonstrated a fan-shaped intrastromal white lesion at the 5- to 6-o’clock position of the left corneal periphery, with a slightly scalloped leading edge containing areas of pearly thickening (Figure 1 ). Gonioscopy was normal. Anterior segment optical coherence tomography confirmed the stromal lesion arising from the limbus (Figure 2 ).
Figure 1. Color photographs demonstrating (A) a white fan-shaped lesion arising near the limbus, (B) a biomicroscopic appearance of a lesion with a slightly scalloped edge, and (C) a biomicroscopic cross-sectional appearance of a lesion.
Figure 2. Anterior segment optical coherence tomography (OCT) demonstrating an intrastromal lesion. (A) Cross-sectional vertical anterior segment OCT of scalloped edge, and (B) cross-sectional horizontal anterior segment OCT of peripheral edge.
Corneal specialist opinion was sought, and the lesion was thought to represent epithelial ingrowth. The only possible cause was deemed to be the limbal stay suture used during strabismus surgery. The patient is currently being monitored clinically for lesion advancement with slit-lamp photographs and optical coherence tomography at 6-month intervals. The patient’s vision is not affected and no intervention is currently planned.
This case presents epithelial ingrowth as an unusual complication of strabismus surgery. Epithelial ingrowth is rare, but can be vision-threatening and can complicate intraocular surgery and trauma.1,2 It commonly presents as membranous growth on the endothelial surface, but can occur intrastromally, especially after refractive surgery. Epithelial ingrowth has been reported to complicate Descement stripping automated endothelial keratoplasty,3 radial keratotomy,4 and laser in situ keratomileusis.5
It has been described to be associated with penetrating trauma, with one case describing a latency period of 48 years between the penetrating trauma and resulting epithelial ingrowth.6 In children, epithelial ingrowth has been reported to complicate surgery for congenital glaucoma.7
Histologically, epithelial ingrowth consists of epithelial cells at the endothelial level, which can be seen as round, hyperreflective nuclei of epithelial cells with microscopy.8 Immunohistochemical assessment of epithelial ingrowth is traditionally performed with cytokeratin AE1/AE3,9 but one study has shown that antibodies for MUC16 and cytokeratic are equally sensitive for epithelial ingrowth.10 Furthermore, this study showed that although all three antibodies are equally sensitive (100%), MUC16 antibody showed superior specificity.
Fibrous ingrowth is a differential diagnosis to be considered. Its origin appears to be keratocytes activated during corneal injury. Although fibrous ingrowth tends to be only slowly progressive or stable, it often demonstrates vascularity and an irregular edge.
To the best of our knowledge, epithelial ingrowth has not been described as a complication following strabismus surgery. Database searches including MEDLINE, PubMed, Scopus, and The Cochrane Library were performed. Search terms included “strabismus surgery,” “complication,” “limbal (± stay) suture,” “epithelial ingrowth,” and “epithelial downgrowth” in various combinations and no restrictions on language and timeframe were set. No report of previous epithelial ingrowth caused by limbal stay suture was found.
We report a case of epithelial ingrowth most likely caused by a limbal stay suture used during strabismus surgery. This potential complication in mostly young patients undergoing strabismus surgery could possibly be avoided by using Moody’s locking forceps intraoperatively for fixation of the globe instead of limbal stay sutures.
- Chen SH, Pineda R 2nd, . Epithelial and fibrous downgrowth: mechanisms of disease. Ophthalmol Clin North Am. 2002;15:41–48 doi:10.1016/S0896-1549(01)00013-X [CrossRef] .
- Bangert A, Bialasiewicz AA, Engelmann K, Schafer HJ, Domarus DV. Intraocular epithelial downgrowth: report on 14 cases from 1986 to 2000 [article in German]. Klin Monbl Augenheilkd. 2004;221:197–203.
- Gorovoy MS, Ratanasit A. Epithelial downgrowth after Descemet stripping automated endothelial keratoplasty. Cornea. 2010;29:1192–1194 doi:10.1097/ICO.0b013e3181d25fe8 [CrossRef] .
- Nemi A, Bahadur RP, Randleman JB. Traumatic epithelial downgrowth after radial keratotomy. J Cataract Refract Surg. 2008;34:327–329 doi:10.1016/j.jcrs.2007.09.018 [CrossRef] .
- Wang MY, Maloney RK. Epithelial ingrowth after laser in situ keratomileusis. Am J Ophthalmol. 2000;129:746–751 doi:10.1016/S0002-9394(00)00357-3 [CrossRef] .
- Rosentreter A, Schild AM, Wedemeyer I, Dietlein TS. Epithelial downgrowth 48 years after penetrating eye trauma [article in German]. Ophthalmologe. 2010;107:753–756 doi:10.1007/s00347-009-2121-z [CrossRef] .
- Giaconi JA, Coleman AL, Aldave AJ. Epithelial downgrowth following surgery for congenital glaucoma. Am J Ophthalmol. 2004;138:1075–1077 doi:10.1016/j.ajo.2004.06.073 [CrossRef] .
- Lenhart PD, Randleman JB, Grossniklaus HE, Stulting RD. Confocal microscopic diagnosis of epithelial downgrowth. Cornea. 2008;27:1138–1141 doi:10.1097/ICO.0b013e3181815959 [CrossRef] .
- Rodrigues MM, Krachmer JH, Sun TT. Clinical, electron microscopic, and monoclonal antibody studies of intraocular epithelial downgrowth. Trans Am Ophthalmol Soc. 1986;84:146–169.
- Pai VC, Glasgow BC. MUC16 as a sensitive and specific marker for epithelial downgrowth. Arch Ophthalmol. 2010;128:1407–1412 doi:10.1001/archophthalmol.2010.268 [CrossRef] .