Clinical Insights and Examination Techniques in Ophthalmology by Thomas Kuriakose

Author:Thomas Kuriakose
Language: eng
Format: epub
ISBN: 9789811528903
Publisher: Springer Singapore

9.3.5.4 Examination of the Corneal Endothelium

Corneal endothelial dysfunction causes oedema of the cornea with eventual loss of transparency. Early signs of corneal endothelial function loss may only be an increase in the corneal thickness compared to the other eye. Even before the signs appear, patients with endothelial dysfunction may complain of early morning blurring of vision which clears after the eye gets dehydrated when exposed to the atmosphere. The evaporation caused by the open eye and better oxygenation of the cornea removes the excess fluid collected overnight. Corneal oedema causes flattening of the posterior corneal curvature as that part of the cornea is less rigid and moves backward. The backward movement of the endothelial surface is associated with a reduced surface area causing it to produce folds. These posterior folds are best made out on indirect illumination or retro-illumination. Epithelial oedema if present too is best seen with indirect or retro-illumination. They appear as fine droplets on the corneal surface. To observe the endothelium clinically, one should do the specular reflection described in Chap. 6. Low endothelial density, loss of the hexagonal shape of the cells and wart-like projections on the endothelium are all suggestive of poor endothelial function. In Fuchs endothelial dystrophy, there are small warty lesions on the endothelium that project into the anterior chamber called corneal guttata. In these patients, slit lamp examination with a thick slit will show copper beaten appearance of the endothelial surface with pigment deposition.

If one sees patients suspected with endothelial dysfunction and an area of localised corneal oedema inferiorly, one should suspect a corneal foreign body in the angle causing trauma to the endothelium. A gonioscopy should be done in these cases.

When cornea is examined with a thin slit light, the endothelial layer of the cornea should also be examined. White blood cells due to inflammation in the anterior chamber gets deposited on the endothelial surface and is called keratic precipitates (KP). In granulomatous uveitis, there will be a collection of cells forming one KP and is called mutton fat KP. In cases of suspected disciform keratitis with viral endotheliitis, one should look for KPs on the endothelium underlying the oedema. In suspected corneal graft rejections, one should look for KPs arranged in a row (rejection line) called Khodadoust line. On the endothelium, one should look for pigment dusting more concentrated in the vertical meridian like a cigar (seen in pigmentary glaucoma).

Breaks in endothelium should be looked for in congenital glaucoma, non-resolving corneal oedema after surgery, trauma, etc. Haab’s striae are breaks seen in the endothelium in cases of congenital glaucoma. Retro-illumination is the best way to look for endothelial breaks. Breaks will appear like a rail track on retro-illumination.

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