Mechanical removal of epithelial hyperplasia leads to successful treatment of irregular astigmatism

BACKGROUND: Corneal epithelium remodeling in response to changes in the anterior corneal surface (keratoconus, corneal refractive surgery) is well-documented in the literature. However, several conditions may induce a different behavior of the epithelium, in which focal areas of epithelial thickening induce irregular astigmatism. This case report presents a highly unusual case of irregular astigmatism induced by an epithelial hyperplasia of unknown etiology, which was treated by the mechanical removal of only the epithelium. CASE PRESENTATION: A 29-year-old woman underwent implantable collamer lens implantation to correct myopia. The patient provided written informed consent. The procedure was uneventful in both eyes. Twenty months later, she complained of decreased visual acuity in the left eye (uncorrected distance visual acuity (UCDVA) was 20/30; corrected distance visual acuity was 20/20 with + 1.00 -2.25 × 170). Corneal topography revealed a nasal steepening in the left eye. Although the corneal thickness map was normal, epithelial thickness mapping revealed a localized nasal area of epithelial hyperplasia in the left eye that matched the area of steepest curvature. Slit lamp examination showed a total clear cornea with no signs of abnormality. The patient´s medical history was unremarkable and a case of epithelial hyperplasia of unknown etiology, without active inflammation, was considered. The decision was made to perform a mechanical removal of the corneal epithelium after application of diluted alcohol. One month after the procedure, the topography of the epithelized cornea showed a regular bow tie pattern and UCDVA improved to 20/20. No recurrence of the epithelial hyperplasia was detected after twenty-one months. CONCLUSIONS: Focal epithelial hyperplasia may induce irregular astigmatism. Epithelial thickness mapping is a very helpful technological tool to assess cases with irregular topography. De-epithelization as an isolated procedure may be useful for the successful management of these cases. Further research is required to understand the mechanism that triggers the spontaneous development of a focal epithelial hyperplasia.