Intraocular Epithelial Downgrowth Following Multiple Ocular Surgeries: A Case Report

Purpose: We report a case of epithelial downgrowth following multiple intraocular surgeries, successfully managed with en-bloc excision and cryotherapy during a third penetrating keratoplasty.Case summary: A 60-year-old male with a history of corneal edema, ectasia, and a mature cataract underwent extracapsular cataract extraction 10 years ago, followed by penetrating keratoplasty, scleral fixation of intraocular lens (IOL), and conjunctival advancement. Eight years after the initial surgery, a second penetrating keratoplasty was performed. Two years later, a whitish membrane was observed over the iris, accompanied by elevated intraocular pressure (IOP). Biopsy was performed, and 3 months later, due to persistent corneal edema and uncontrolled IOP, glaucoma drainage device implantation was carried out. However, the patient developed progressive shallowing of the anterior chamber and refractory IOP elevation. Consequently, a third penetrating keratoplasty was performed, including en-bloc excision of the affected iris tissue and adjunctive cryotherapy. Intraoperatively, a dense, sheet-like whitish epithelial membrane was observed covering the iris. Epithelial debris was seen displacing the iris and glaucoma valve tip anteriorly and extending over the IOL surface. Histopathological analysis confirmed epithelial downgrowth. The patient remained free of recurrence for 7 months postoperatively.Conclusions: In patients with a history of multiple intraocular surgeries, meticulous wound closure and precise suturing—ensuring avoidance of full-thickness corneal perforation—are essential to prevent epithelial downgrowth. This rare but potentially sight-threatening complication results from the migration of corneal or conjunctival epithelial cells into the anterior chamber.