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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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Year : 2011  |  Volume : 18  |  Issue : 4  |  Page : 317-319  

Histopathologic findings in two cases with history of intrastromal corneal ring segments insertion

1 Anterior Segment Division and Emergency Room, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
2 Department of Pathology and Laboratory Medicine, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia

Date of Web Publication23-Nov-2011

Correspondence Address:
Hind M Alkatan
Department of Pathology and Laboratory Medicine, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh 11462
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-9233.90136

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Intrastromal corneal ring segments (INTACS) implantation for mild myopia or keratoconus is simple and effective in most cases. Rarely, major complications can occur due to implantation. In this case report, we present two examples of possible intraoperative and postoperative complications of INTACS. The first case had histopathologic documentation of Descemet's membrane perforation as an intraoperative complication and the second case had accumulation of foamy histiocytes along the lamellar channels which has not been previously reported. These complications suggest further study is required on the long term effect of INTACS implantation on corneal tissue.

Keywords: Histiocytes, Intrastromal Corneal Ring Segments, Keratoconus

How to cite this article:
Al-Amry M, Alkatan HM. Histopathologic findings in two cases with history of intrastromal corneal ring segments insertion. Middle East Afr J Ophthalmol 2011;18:317-9

How to cite this URL:
Al-Amry M, Alkatan HM. Histopathologic findings in two cases with history of intrastromal corneal ring segments insertion. Middle East Afr J Ophthalmol [serial online] 2011 [cited 2022 May 16];18:317-9. Available from: http://www.meajo.org/text.asp?2011/18/4/317/90136

   Introduction Top

Intrastromal corneal ring segments (INTACS, Addition Technologies Inc., Des Plaines, IL, USA) are approved for the treatment of simple myopia and more recently for keratoconus and post-refractive surgery ectasia. [1] The procedure is considered a simple and safe intervention; however it can still be associated with complications. Complications such as corneal perforation can occur intraoperatively or postoperative complications can occur. In this case report, we present two examples of INTACs complications in keratoconus. One of the cases had an accumulation of foamy histiocytes along the lamellar channels, a finding that has not been previously reported in the peer-reviewed literature.

   Case Reports Top

Case 1

A 21-year-old male with keratoconus presented with a history of successful INTACS implantation in the left eye. INTACS implantation was aborted in the right eye because of intra-operative anterior chamber perforation. The vision in the right eye was 20/200 that improved to 20/50 with pinhole. Slit lamp examination of the right eye showed a focal corneal scar at the 12 o'clock position. The anterior chamber was deep with a clear lens. Posterior segment examination was unremarkable. Fifteen months after presentation, the patient underwent penetrating keratoplasty (PKP). The histopathologic appearance of the right corneal button that was removed during PKP was consistent with keratoconus. We were able to document the focal area of perforation on histopathologic examination of the right corneal button. Migrating endothelial cells with an underlying thin basement membrane were observed outlining the stroma around the area of attempted ring segment insertion [Figure 1]. The endothelium along the remaining Descemet's membrane away from the perforation was slightly attenuated.
Figure 1: Case 1 histopathologic documentation of a ruptured Descemet's membrane with migrating endothelial cells (arrows) outlining the stroma around the area of attempted ring segment insertion (Periodic acid schiff, ×200)

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Case 2

A 27-year-old male with keratoconus presented to us with hard contact lens intolerance in both eyes. He underwent INTACS implantation in both eyes without intraoperative complications. The INTACS segments were 450 μm thick (Addition Technology, Inc. Ref # ISK-450-150). His vision in his first post-operative visit was hazy with a complaint of diplopia, 3 weeks following the procedure. The second post-operative visit, 4 months post surgery showed a best corrected visual acuity (BCVA) of 20/60 in the right and 20/70 in the left eye. His corneas remained clear around the segments for 4 months and subsequently developed whitish intrastromal deposits along the INTACS tunnels with clear central cornea and no effect on BCVA [Figure 2]a. These were first noted on his third post-operative visit, 5 months following the ring segments insertion.
Figure 2: (a)The clinical appearance of the intrastromal deposits around the ring segment (right eye) which was identical in both eyes
Figure 2b: The left eye clinical appearance following penetrating keratoplasty
Figure 2c: The histopathologic appearance of foamy histiocytes (arrows) in the same area (Periodic acid schiff, ×200)
Figure 2d: Immunohistochemical staining of the cells (CD68, ×200)

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Penetrating keratoplasty (PKP) was performed for optical correction of the left eye vision in the fourth post-operative visit 8 months following the procedure. PKP was then performed after a total period of 16 months post-INTACS implantation on the left [Figure 2]b. The cornea was sent for histopathologic examination after the removal of INTACS. Histopathologic examination showed features consistent with keratoconus and revealed the presence of intrastromal foamy histiocytes around the INTACS channels [Figure 2]c, d.

   Discussion Top

INTACS are used in the management of simple myopia, keratoconus, and post-refractive surgery ectasia. They consist of two hexagonal semi-circular segments measuring 150° in arc length, with an inner diameter of 6.80 mm and an outer diameter of 8.10 mm. INTACS are made of poly(methyl methacrylate) or (PMMA) and are available in various thicknesses. [1] Complications of INTACS may seen in the intraoperative period and includeanterior chamber perforation and Descemet's membrane detachment in cases where the femtosecond laser (Intralase, Abbott Laboratories Inc., Abbott Park, IL, USA) is used to create channels. [2] Popstoperative complications include segment extrusion, keratitis, neovascularization, and collection of abnormal deposits along the lamellar channels. [1],[2]

The procedure in our first case was performed with mechanical insertion of the ring segment. The scar at the perforation site was identified clinically at the 12 o'clock position which was opposite the thinnest part of the cornea (inferonasally). Hence, we believe the intraoperative perforation occurred due to inaccurate pachymetry.

In the second case, deposits along the lamellar channels appeared less than 6 months postoperatively. Ruckhofer and colleagues [1] reported that deposits occur clinically in up to 74% of cases within the first 2 years, peaking within the first 6 months. The incidence and density of the deposits were higher with increasing segment thickness and duration of implantation. [1] Our second patient underwent implantation of thick segments (0.45 mm) which might have been a predisposing factor. Central crystalline deposits and similar deposits along the channels have been clinically observed 4 years following INTACS implantation with no effect on vision. [3]

Histologic stromal changes in response to corneal inserts in rabbits include keratocyte activation, intracellular lipid accumulation, and new collagen formation. [4] Based on animal models, some authors believed that keratocytes can produce lipid as a nonspecific response to mechanical or metabolic factors. [5] In humans, corneal implants may also precipitate intracellular and extracellular production of lipids as a result of stress by degenerating cells. [6] This lipid production presents clinically as crystalline deposits and has been even reported to occur at site other than the ring segment insertion. [3] A recent theory using histopatholgic studies suggests accumulation of fibrotic extracellular matrix components and proteinases due to keratocyte apoptosis. [7],[8] However, there was no evidence of an inflammatory response or foreign-body granuloma in any of these reports. The presence of foamy histiocytes in case 2 is a new unexplained histopathologic finding. The long term effect of INTACS-induced tissue reactions needs to be determined with specific attention directed toward the possible keratoconus progression and acceleration of corneal thinning. [5]

   References Top

1.Ruckhofer J, Twa MD, Schanzlin DJ. Clinical characteristic of lamellar channel deposits after implantation of intacs. J Cataract Refract Surg 2000;26:1473-9.  Back to cited text no. 1
2.Gharjarnia M, Moshirfar M, Mifflin MD. Descemet detachment after femtosecond-laser-assisted placement of intrastromal ring segments in pellucid marginal degeneration. J Cataract Refract Surg 2008;34:2174-6.  Back to cited text no. 2
3.Katsoulis K, Sarra GM, Schittny JC, Frueh BE. Bilateral central crystalline corneal deposits four years after intacs for myopia. J Refract Surg 2006;22:910-3.  Back to cited text no. 3
4.Twa MD, Ruckhofer J, Kash RL, Costello M, Schanzlin DJ. Histologic evaluation of corneal stroma in rabbits after intrastromal corneal ring implantation. Cornea 2003;22:146-52.  Back to cited text no. 4
5.Twa MD, Kash RL, Costello M, Schanzlin DJ. Morphologic characteristics of lamellar channel deposits in the human eye: A case report. Cornea 2004;23:412-20.   Back to cited text no. 5
6.Parks RA, McCarey BE, Knight PM, Storie BR. Intrastromal crystalline deposits following hydrogel keratophakia in monkeys. Cornea 1993;12:29-34.  Back to cited text no. 6
7.Samimi S, Leger F, Touboul D, Colin J. Histopathological findings after intracorneal ring segment implantation in keratoconic human corneas. J Cataract Refract Surg 2007;33:247-53.  Back to cited text no. 7
8.Maguen E, Rabinowitz YS, Regev L, Saghizadeh M, Sasaki T, Ljubimov AV. Alteration of extracellular matrix components and proteinases in human corneal buttons with INTACS for post-laser in situ keratomileusis keratectasia and keratoconus. Cornea 2008;27:565-73.  Back to cited text no. 8


  [Figure 1], [Figure 2]

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