Journal of EuCornea 3 (2019) 1–4

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Journal of EuCornea

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Columnar keratopathy: An early manifestation of limbal deficiency T Veronica Mas Tura,b, Amna AlMaazmia,b, Ahmed AlSaadic, Mario Nubiled, Dalia G. Saida,b, ⁎ Leonardo Mastropasquad, Harminder S. Duaa,b, a Section of Academic Ophthalmology, Larry A Donoso Laboratory for Research, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK b Department of Ophthalmology, Nottingham University Hospitals NHS Trust, UK c Department of Ophthalmology, Zayed Military Hospital, Abu Dhabi, United Arab Emirates d Ophthalmology Clinic, National Centre of High Technology (CNAT) in Ophthalmology, University of “G d'Annunzio”, Chieti-Pescara, Italy

ARTICLE INFO ABSTRACT

Keywords: Background/Purpose: Stem cells of the reside in the limbal palisades and associated limbal Columnar keratopathy epithelial crypts. The limbus constitutes a barrier between the conjunctival and corneal phenotype of cells. When Limbus the limbal barrier is breached, stem cell deficiency (LSCD) results with conjunctivalisation of the . The fi Stem cell de ciency purpose of this study was to document an early manifestation of LSCD which is consistent and distinct across several causes of LSCD. Methods: Seventeen of 11 consecutive patients with diverse known causes of LSCD were included. Patients were examined clinically with the slit lamp and fluorescein staining, and by in vivo confocal microscopy. All were photographed with a slit lamp camera. Seven patients underwent in vivo confocal microscopy examination. Results: There were 6 males and 5 females. Six cases had bilateral involvement and the other 5 were unilateral. All patients showed predominantly superior loss of limbal anatomy with effacement of the palisades of Vogt, superficial vascularization encroaching on the peripheral cornea and alternating columns, 6–20 in number, of late fluorescein staining conjunctivalised and normal epithelium extending for a variable distance towards the corneal centre. These were related to prolonged contact wear, atopic keratoconjunctivitis, superficial ocular surface burns, ocular cicatricial pemphigoid, rosacea keratoconjunctivitis, old trachoma and neurotrophic ker- atopathy. In vivo confocal microscopy confirmed features of LSCD. Conclusion: Alternating columns of conjunctivalized and normal epithelia encroaching on the cornea from the superior limbus is a distinct manifestation of early LSCD across a diverse range of causes. The reason for this manifestation is unclear but could be related to the random dysfunction or loss of the palisade architecture.

1. Introduction manifesting as irregular epithelium with late fluorescein staining [5,7]. We report a series of cases where columns of late fluorescein The palisades of Vogt and the inter-palisade rete ridges that are staining cells alternating with columns of normal cells were seen in the distributed along the sclero-corneal limbus serve as repositories of the superior limbus and cornea. The condition has been termed ‘Columnar limbal stem cells (SC) [1]. The palisades of Vogt together with the keratopathy’ and is an early sign of LSCD. limbal epithelial crypts provide the anatomical and physiological basis for the niche [2–4]. The palisades are better defined in 2. Methods the superior and inferior limbus. Several diseases of the ocular surface can lead to limbal SC deficiency (LSCD) [5]. When the insult is acute Consecutive case series of 17 eyes of 11 patients, 6 males and 5 with extensive destruction of the limbus, the signs of LSCD manifest in females, presenting with ocular surface discomfort and signs of altered the form of a thick fibrovascular pannus or persistent epithelial defect limbal anatomy and conjunctivalisation of the cornea were studied. The [6]. When the underlying pathology or injury is mild, chronic and patients presented with one or more of the following symptoms; dry slowly progressive; subtle signs of LSCD appear in the form of con- eye, irritation and blurred vision. History of ocular and systemic health junctivalisation of the cornea with or without vascularization was elicited, visual acuity was recorded and slit lamp examination

⁎ Corresponding author. E-mail address: [email protected] (H.S. Dua). https://doi.org/10.1016/j.xjec.2019.10.001 Received 25 April 2019; Accepted 16 October 2019 Available online 18 October 2019 2452-4034/ © 2019 Published by Elsevier Inc. on behalf of European Society of Cornea & Ocular Surface Disease Specialists. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/). V. Mas Tur, et al. Journal of EuCornea 3 (2019) 1–4 carried out without and with fluorescein (one drop of 2% fluorescein symptoms of dry eyes and blurred vision. Both wore lenses for 10–12 h minims, Bausch & Lomb, Laboratoire Chauvin, Aubenas, France); fol- a day. Visual acuity with contact lenses in situ was 6/9 and 6/7.5 (RE), lowed 5 s later with 2 drops of normal saline minims (Bausch & Lomb). and 6/9 and 6/6 (LE) respectively. Patients were advised to stop Slit lamp clinical findings were recorded. Anterior segment images were wearing contact lenses and treated with lubricant eye drops and a taken with the Topcon slit lamp camera (Topcon SL-7F slit lamp, course of topical preservative free prednisolone 0.5% starting at four Topcon 4059). The Heidelberg Tomograph II Rostock Corneal times a day and tapering to once a day. Corneal findings are illustrated Module (Heidelberg Engineering GmBH, Dossenheim, Germany) was in Fig. 1(a-b) [8]. used to perform in vivo confocal microscopy (IVCM) examination in 7 Two males and one female aged 53, 41 and 40 years had bilateral cases. chronic atopic keratoconjunctivitis with eczema and history of asthma. Ocular symptoms were present over a duration 15 to 36 months. They complained of intermittent blurred vision but maintained visual acuity 3. Results between 6/6 and 6/12. The eyes had received treatment with different medications over the duration of the condition. These included car- Six cases had bilateral involvement and the other 5 were unilateral. mellose 0.5% lubricant drops, steroids (prednisolone phosphate 0.5% Two cases, one bilateral, were related to contact lens wear; three cases, and dexamethasone 0.1%) and tacrolimus skin cream (protopic 0.03%) two bilateral, had atopic keratoconjunctivitis; two cases were secondary to the lid margins. Two patients showed corneal signs in both eyes and fi to super cial ocular surface burns and one each had ocular cicatricial one in the right eye only as illustrated in Fig. 1(c, d). pemphigoid (bilateral), rosacea keratoconjunctivitis (bilateral), old A 45 years old female with old history of chemical injury with hy- trachoma (bilateral) and neurotrophic keratopathy. All had the drogen peroxide on the right eye 18 months previously. Best corrected fi fl common corneal ndings of uorescein staining and non-staining al- visual acuity with RGP contact lens was 6/12 on the right eye and 6/6 fi ternating columns of cells from the superior limbus. Corneal ndings on the left eye. She had chronic symptoms of irritation and photophobia are collectively described below after the patient demographics, with in the affected eye. illustrations in Fig. 1. A 45 years old male had suffered from superficial ocular surface Two females aged 56 and 32 years who had been using soft contact burn in the left eye with household cleaning liquid one year prior to lenses for correction of myopia for over 5 years presented with bilateral

Fig. 1. Clinical presentation of Columnar Keratopathy, manifesting as alternating columns of fluorescein stained and unstained columns of epithelial cells of varying width and length extending from the superior limbus towards the . (a,b) Contact lens related limbal stem cell deficiency (LSCD) demonstrating curvilinear extensions of stained epithelium from the limbus to the centre. The central cornea shows extensive punctate erosions. (c,d) LSCD secondary to atopic kerato- conjunctivitis showing parallel alternating columns of fluorescein stained and unstained epithelium. (e) LSCD secondary to chemical injury with multiple columns of fluorescein stained epithelial cells. The inferior cornea shows a segment of conjunctivalisation. (f) LSCD secondary to herpes simplex keratitis with a central persistent epithelial defect and alternating fluorescein stained and unstained columns superiorly. (g) LSCD secondary to rosacea with superior ‘columnar keratopathy’ asso- ciated with superficial vascularization of the cornea (h) LSCD secondary to old trachoma with columns of fluorescein stained and unstained epithelium at the superior limbus. These columns are relatively shorter in length than in the other examples. (i) LSCD secondary to ocular cicatricial pemphigoid with visible broad columns of fluorescein staining at the base and trapper to a fine line centrally. There was peripheral and associated central vascularization. (some figures are from the authors own previous publications that are referenced in the text).

2 V. Mas Tur, et al. Journal of EuCornea 3 (2019) 1–4 presentation. He showed evidence of conjunctivalisation of the cornea reflective metaplastic cells and normal cells in the remainder (Fig. 2 e, inferiorly and superonasally with superficial vascularization (Fig. 1e). f). An 87 years old male with a central persistent epithelial defect and corneal melt in the right eye secondary to Herpes Simplex 4. Discussion and severe/stage 3 neurotrophic keratopathy [9]. Best-corrected visual acuity was 6/36 pinhole 6/24 on the affected eye and 6/6 on the left Limbal stem cell deficiency has a range of clinical manifestations eye (Fig. 1f). The patient was known to have rheumatoid arthritis and and can occur from a variety of causes. is the most common was being treated with Methotrexate 10 mg a week. congenital cause and chronic ocular surface inflammatory diseases such A 58 years old male with bilateral rosacea related keratoconjuncti- as OCP, Stevens Johnson syndrome (SJS), trachoma, atopic kerato- vitis presented with blurred vision and symptoms of dry eye. Best- conjunctivitis (AKC) and infections; chemical burns, prolonged contact corrected visual acuity was 6/18 on the right eye and 6/12 on the left lens wear, ocular surface squamous neoplasia and multiple surgeries are eye. He was on oral doxycycline tablets 100 mg a day for two months common acquired causes [18–20]. All the underlying diseases in the and topical carmellose 0.5% 4–6 times a day. In the past he had in- eleven patients studied are known to be associated with LSCD. termittently been treated with topical steroid medication. Clinical manifestation can vary depending on the nature and Conjunctivalisation of the cornea as described below, was seen super- chronicity of the insult. Acute disease or injury lead to a greater and iorly extending to the pupil area (Fig. 1g). He underwent alcohol de- rapid loss of SC with an exaggerated and abnormal wound healing re- lamination on the central corneal epithelium on the right eye followed sponse wherein part or all the cornea is covered by an opaque fi- by sequential sector conjunctival epitheliectomy to prevent con- brovascular pannus. Mild injury or low grade slowly progressive disease junctivalisation extending to the visual axis.[7,10–13] Visual acuity on can lead to subtle signs that can progress over time. The changes range the right eye improved to 6/6. from loss of limbal anatomy, vascularization, conjunctivalisation of the A 76 years old man had bilateral signs of old trachoma in the form of cornea, persistent epithelial defects, scarring and calcification of the Herbert’s pits, and superior tarsal scarring. He complained of dry eyes cornea. Early changes can affect part of the limbus, sparing other parts. and was comfortable with topical use of carmellose 0.5% 6 times a day. Conjunctivalisation of the cornea, indicated by the presence of meta- In the past he had used moist heat treatment with ‘Blephasteam’ (Thea plastic, late staining epithelial cells with goblets cells is the hallmark of Pharmaceuticals) [14]. He presented with bilateral cataracts when the LSCD. Conjunctivalised areas are often but not always associated with corneal signs, as described below, were noted (Fig. 1h). superficial vessels. The conjunctivalised area is usually thinner than the A 57 years old female with bilateral ocular cicatricial pemphigoid adjacent corneal epithelium but when conjunctivalisation occurs as part (OCP) presented with right cataract and left pseudophakia. Best cor- of a fibrovascular growth on the cornea the abnormal tissue is quite rected visual acuity was 6/9 in the right eye and 6/6 in the left. She was thick. In mild and early LSCD the palisade architecture is lost. This being managed with oral dapsone 100 mg a day, topical ciclosporin would disrupt the limbal barrier allowing conjunctival cells to migrate 1 mg/ml twice a day to both eyes and carbomer gel as and when re- on to the cornea [21]. Such ingrowth of cells between normal palisades quired. She had also received intermittent courses of oral and topical would enable streaming of both conjunctival and normal cells in a steroids during periods of flare up (Fig. 1i). linear or curvilinear manner from the limbus towards the central cornea. Why this appearance is more evident from the superior limbus 3.1. Corneal features is unclear. Normally palisades are well defined both superiorly and inferiorly hence such growth from the inferior limbus could also occur. At slit-lamp examination the corneal epithelium had a lack lustre Observations made on patients undergoing auto limbal grafts or appearance, which in some cases involved the visual axis. There was living related allo-limbal grafts have demonstrated that the upper two loss of limbal anatomy with disruption of the palisade architecture in all thirds of the cornea can be covered by cells derived from the superior but one case (Fig. 1d). On fluorescein staining, columns of stained cells explant and the lower one third from the lower explant [22]. Similar of varying width and length could be seen extending from the limbus observations were made from in-vitro studies where corneal epithelial towards the pupil. These were broader at the limbus and tapered to a cells were cultured on slides placed vertically in a trough of culture fine line centrally. In 12 of the 17 eyes the lines were slightly curved medium. Cells form the limbal explant migrated predominantly in- close to the limbus. The stained columns alternated with unstained feriorly with limited superior migration. As the cornea is normally or- columns of normal looking corneal epithelial cells. Clinically there was iented vertically in the coronal plane, the same considerations may a clear demarcation between the stained and unstained columns. Su- apply here [23]. Evidence is also provided by the Hudson-Stahli line perficial vessels were seen extending across the limbus encroaching into which occurs at the junction of the upper two thirds with the lower one the peripheral cornea in 15 of the 17 eyes. These vessels did not extend third of the cornea. In keeping with this, the vertically oriented columns along length of the fluorescein stained columns. The patient with OCP were noted to extend from the limbus to cover no more than the upper had the most extensive manifestation of the condition and the patient two thirds of the cornea. with trachoma had the mildest, with very short and few columns. Late The first description of such alternating columns of conjunctivalised fluorescein staining is a well described feature of conjunctival/meta- epithelium and corneal (limbal) epithelium was provided by Dua et al plastic epithelium on the cornea. This was a feature in all cases pre- in 1994 with conjunctivalised epithelium on the cornea representing sented here and reported in the literature.[15–18] The total number of loss of limbal barrier effect provided by the limbal stem cells [1]. fluorescein staining columns ranged from 6 to 20. In the patient with Fig. 1d and 1g are reproduced (with permission) from that publication OCP adjacent columns appeared to have merged to give broader col- [1]. The term ‘columnar keratopathy’ with illustrations has appeared in umns. This columnar pattern of involvement prompted us to term this their subsequent publications as book chapters [8,24,25]. Several si- appearance ‘Columnar keratopathy’. The central and inferior cornea milar descriptions have followed, reporting the same clinical condition showed superficial punctate keratitis in 7 eyes. with subtle variations. D’Aversa et al in a compelling publication IVCM showed hyper-reflective metaplastic cells with ill-defined cell termed the clinical picture ‘Advancing wave like epitheliopathy (AWE) borders in the area corresponding to the fluorescein stained columns. [26]. They described waves of coarse and irregular epithelium advan- Occasional goblet cells, cystic spaces and blood vessels were seen cing centripetally from the superior limbus in relation to inflammation, (Fig. 2). The intervening unstained columns showed normal phenotype contact lens wear and surgery. They reported an associated mild sub- of corneal epithelial cells with no goblet cells. The junction between the epithelial haze and significantly, no changes along the adjacent limbus. stained and unstained columns was clearly defined in 6 of the 17 eyes Kim et al reported a series of similar cases attributed to limbal niche (Fig. 2d) and was irregular with inter-digitating projections of hyper- dysfunction and emphasized that the signs could be reversed by medical

3 V. Mas Tur, et al. Journal of EuCornea 3 (2019) 1–4

Fig. 2. In vivo confocal microscopy images of columnar keratopathy showing features within the late staining columns and the adjacent non-staining epithelium. (a, b) Hyper reflective stroma with vasculariza- tion and altered palisade morphology. (c) Metaplastic, hyper reflective epithelial cells with ill-defined cell margins, cystic spaces and goblet cells, all of which are indicative features of LSCD. (d) Illustrates the hyper reflective conjunctivalised epithelium and cystic spaces in the stained column, sepa- rated distinctly from the adjacent non- staining column with normal looking epi- thelial cells that are hypo reflective with bright defined borders. (e, f) The demarca- tion between the staining and non staining columns was not always clearly defined. Extensions of hyper reflective con- junctivalised epithelium into the adjacent ‘normal’ epithelial cells are seen indicating that ‘conjunctivalisation’ was spreading lat- erally as well.

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