Fig. 2.1
(a–c) Fingerprint lines (arrows), in places crossing (a, right arrow). (c) additionally shows a fine granular pattern (arrowhead)
Case 2. Edematous Area, Fingerprint Lines and Blebs
Case Report
A 58-year-old man with spontaneous recurrent pain in the right eye on awakening for 2 weeks. At presentation, the paracentral inferior cornea showed an edematous, slightly elevated but not disrupted epithelial area, a few cysts, fingerprint lines and blebs. The left cornea showed discrete fingerprint lines. After a week’s treatment with NaCl ointment 5 %, the edema disappeared and only a few small cysts were left. The photographs of the right cornea were taken at presentation.
Fig. 2.2
Variously shaped fingerprint lines (arrows), blebs (a, arrowhead; cf. Fig. 1.12), cysts (b, c, black arrowheads), smooth rounded structures (b, bowed arrow) and a fine granular pattern (grey arrowheads)
Case 3. Recurrent Erosion and KCS (1)
Case Report
A 73-year-old woman with KCS and pain in the left eye on awakening for 2 months. At presentation, the left cornea showed a small lesion and many cysts and the right one fingerprint lines and a few cyst; there were no KCS-relatable changes. The symptoms subsided rapidly with lubricating eye drops and NaCl ointment 5 % at bedtime for a couple of weeks. Two years later, the same problem started in the right eye despite lubricating eye drops. The right cornea showed two lager lesions, cysts and fingerprint lines and the left one fingerprint lines and one small cyst. A lubricating ointment at bedtime was added. She was followed for a further 6 months. The symptoms in the right eye recurred but always subsided after an application of NaCl 5 % ointment at bedtime. When last seen, she was symptom-free.
The photographs of the symptomatic cornea were taken at respective presentation and of the right one also 1 month later.
Fig. 2.3
Survey. (a) The deranged surface of the left cornea shows a small lesion (arrow) and many cysts (arrowhead). (b) The strong light reflection from the lesion (arrow) precludes the visibility in white light of the green fluorescein staining; many but not all cysts (arrowheads) stain green; fluorescein is still present in the tear film. (c) The same area visualised with fluorescein and blue filter. (The markers are placed in corresponding locations.) Some details of this area are shown in Fig. 2.4
Fig. 2.4
(a) In retroillumination, fluorescein staining of the lesion (arrow) appears yellow-brown (cf. Fig. 2.5, overleaf). (b) A short epithelial line (arrow) between two small enlargements; in (d), the same line is stained green with fluorescein (right arrow). (c) Epithelial lines (arrows) and cystic spaces (arrowheads) staining (d) green with fluorescein. (e) Another cystic space (arrowhead) staining (f) green with fluorescein (the markers are placed in corresponding locations in each pair of photographs)
Comment
Epithelial lines and pear-shaped cystic spaces imply remnants of a recently present lesion (like that shown in Fig. 2.5, overleaf).
Fig. 2.5
(a–c) A large lesion (long arrow) present in the right cornea. (a) Fluorescein staining shows various shades of green. The dashed arrow indicates a circular area within the lesion (cf. Figs. 1.33 and 1.34). (b) In retroillumination, fluorescein staining appears yellow-brown. (c) The circular area (dashed arrow) and some other spots within the lesion stain red with rose bengal. (d–e) Both the upper (d) and the lower (e) part of the lesion (arrow) contain rounded bodies (white arrowheads). The cyst (d, black arrowhead) adjacent to the lesion does not stain with fluorescein (cf. a, b) (the arrows are placed in corresponding locations)
Fig. 2.6
(a–b) Another lesion (long arrows) captured in the right cornea at the same occasion as that in Fig. 2.5. The short plain arrows indicate a curved edge, the dashed arrows an epithelial line, the double arrowhead an area stained red with rose bengal and the black arrowheads a group of cysts. In (b) various hues of the green fluorescein staining of the lesion and green staining of some but not all cysts (arrowhead) are visible (cf. Fig. 2.23) (the arrows are placed in corresponding locations)
Fig. 2.7
(a) Fingerprint lines (arrow), (a–c) cysts (black arrowheads), and rounded bodies (white arrowheads) captured in the right cornea 1 month later
Case 4. Recurrent Erosion and KCS (2)
Case Report
A 53-year-old woman with recurrent pain in the right eye on awakening for several years, treated elsewhere with lubricating eye drops and ointment at bedtime, was referred for dry eye investigation. At presentation, the right cornea showed larger and smaller epithelial lesions and both corneae many small cysts. KCS tests supported the diagnosis, but the corneae showed no KCS-relatable changes. She was treated with lubricating eye drops and NaCl ointment 5 % at bedtime. One month later, she reported improvement although she had stopped the ointment after 2 weeks. After that, she was using lubricating eye drops and ointment sporadically. Three months after presentation, the cornea showed a larger lesion, but the symptoms were slight. During the follow-up, twice a year, the corneae either showed a few small epithelial cysts or appeared normal. When last seen, 6 years after the first visit, she had been symptom-free for 3 years.
The photographs of the right cornea were taken at presentation (day 1) and 1 month, 3 months and 16 months later.
Fig. 2.8
(a) Survey of a deranged area containing a larger (left arrow) and a smaller (right arrow) lesion, which (b) contains many rounded bodies (arrowhead). (c–d) The area indicated by round frame in (a) shows approaching tips of epithelial sheets (arrows) and (e–g) that in rectangular frame two small adjacent lesions (double arrowheads) which stain (e) brownish and (f) green with fluorescein and (g) red with rose bengal; additionally are visible cysts (black arrowheads) and a line implying a small tip of an epithelial sheet (arrow). (The markers are placed in corresponding locations in each set of photographs.) For the dynamics of the green fluorescein staining, see Fig. 2.9
Fig. 2.9
(a) The large lesion (long arrow) stains (b) partly and after a while (c) completely green with fluorescein (cf. Fig. 2.11). (b, c) The green fluorescein staining indicated in (b) by short arrow has (c) disappeared. (c, d) Some surface elements stain red with rose bengal. The double arrowheads indicate the same small lesions as in Fig. 2.8e–g. The photographs are shown in the order as taken. (b) is a composed photograph
Fig. 2.10
(a) Small cysts that appear confluent (double arrowhead) but only the upper one stains (b) green with fluorescein. The arrowhead indicates a pear-shaped cyst (the markers are placed in corresponding locations)
Fig. 2.11
(a–c) Two lesions (arrows) in apposition. The upper lesion stains (b) partly and (c) entirely green with fluorescein; the lower one does not stain (cf. Figs. 2.19, 2.21 and 3.2). The surroundings show cysts (arrowheads) of which some (b, c) stain green. (The photographs are shown in the order as taken. The markers are placed in corresponding locations.) (d) At this occasion, the cornea showed only a few small cysts (black arrowhead) and rounded bodies (white arrowhead)
Case 5. Recurrent Erosion and KCS (3)
Case Report
A 57-year-old woman under investigation for Sjögren’s syndrome with grittiness in both eyes on awakening for many years but no symptoms during daytime. Lubricating eye drops had no effect. At presentation, KCS tests supported the diagnosis. The conjunctivae showed pronounced rose bengal staining but none was present on the corneae. Both corneae showed many epithelial cysts, fingerprint lines and greyish membranes (‘maps’) and the right cornea additionally an epithelial lesion. A lubricating ointment at bedtime was added; the symptoms persisted but were relieved by NaCl ointment 5 % at bedtime. During the observation period of almost 2 years, KCS tests showed the same results and both corneae showed the same changes as before, but no new epithelial lesions were observed.
The photographs of the right eye were taken at presentation (day 1) and 15 months later.
Fig. 2.12
(a, b) A lesion (arrows), cysts (black arrowheads) and rounded bodies (white arrowhead); in (b), the visibility of fluorescein staining is hampered by a strong light reflection from the lesion; the cyst (arrowhead) does not stain ((b) blue filter). (c, d) Rose bengal staining of diseased conjunctival cells (arrowheads). (e, f) Cysts (black arrowheads) and rounded bodies (white arrowheads) in (e) retroillumination and (f) focal illumination (not the same areas)
Case 6. Recurrent Erosions or KCS Symptoms?
Case Report
A 62-year-old woman with hypothyreosis after thyreoiditis, psoriasis, joint pain and foreign body sensation or pain in either eye on awakening for 6 years was treated for (presumed) dry eye with lubricating eye drops and topical cortisone. At presentation, KCS test values were well within normal range. The right cornea showed a larger epithelial lesion and the left one many small cysts. She was treated with lubricating eye drops and NaCl ointment 5 % at bedtime. Within 11 days, her symptoms had disappeared, but both corneae showed small cysts; 6 weeks after presentation, the right cornea additionally showed a small epithelial lesion. Five months after presentation both corneae showed small cysts.
The photographs of the right cornea were taken at presentation (day 1) and 11 days, 6 weeks, 10 weeks and 5 months later.
Fig. 2.13
A large lesion with bizarre shape and chaotic appearance and a small one in apposition (arrow). (a, b) The large lesion seems to consist of variously large and variously shaped compartments; the arrowheads indicate rounded bodies. (c) Early after the application of fluorescein, the large lesion shows various shades of green; its upper right part appears mottled, and in places such as at the arrowhead there is a brownish component. (c) Some parts of the lesion stain red with rose bengal; the small lesion does not. (The markers are placed in corresponding locations. See also Fig. 1.36e–d). For dynamics of the green fluorescein staining, see Figs. 2.14 and 2.15
Fig. 2.14
(a–c) Brilliantly green staining of the small lesion (white arrow) and of the left part of the large one; its right upper part appears mottled and the lower one contains an oval area (dashed arrow; see also Fig. 2.25, d2). (d) After rose bengal staining, fluorescein has disappeared from the tear film but not from the lesions. (The photographs are shown in the order as taken.) (e) The green stained parts appear yellow in retroillumination. (f) Some parts of the lesion stain red with rose bengal. (g) A few cysts (arrowhead) and light-reflecting (greyish) structures adjacent to the upper part of the large lesion. (h) Only a few small cysts (black arrowhead) and rounded bodies (white arrowhead) were present at this occasion
Fig. 2.15
(a) A small lesion (arrow), a cyst (black arrowhead), grouped cysts and rounded bodies (double arrowhead) and a rounded body (white arrowhead). (b–d, f) Sequential photographs of fluorescein staining. In (d), the tear film was refreshed after a blink. (e) shows the brownish hue of fluorescein in retroillumination (the markers are placed in corresponding locations)
Fig. 2.16
(a, b) A lesion (long arrows) showing many rounded bodies (white arrowhead) and an epithelial line (dashed arrows), both (b) staining green with fluorescein. The surroundings show many light-reflecting rounded bodies (white arrowheads) and cyst-like structures (black arrowheads) that do not stain. (The markers are placed in corresponding locations.) (c) At this occasion were present several cysts (black arrowhead) and rounded bodies (white arrowhead) but no lesions
Addendum
Although symptom-free, the patient continued using NaCl ointment 5 % at night. Nine and 15 months after presentation, both corneae showed small epithelial cysts; 1 and 2 years later, when last seen, both corneae appeared normal.
Case 7. Recurrent Erosion or Herpes Simplex?
Case Report
A-48-year-old man with difficulties of verbal communication reported recurrent grittiness in the right eye on awakening for about 1 year; he had been repeatedly treated elsewhere with acyclovir because of a (presumed) virus infection. At presentation, both lower corneae showed small cysts and fingerprint lines. He was treated with NaCl ointment 5 % at bedtime, and within 1 month the pain and the cysts disappeared. Seven years later he presented again with the same symptoms, this time in both eyes. The right cornea showed small cysts and fingerprint lines and the left one additionally epithelial lesions. After 2 weeks treatment with NaCl ointment 5 % the symptoms had almost disappeared, but the corneae showed changes as before. After a further 8 weeks, the symptoms were gone; both corneae showed only cysts and fingerprint lines. When last seen, 15 months after presentation, the left cornea again showed an epithelial lesion in addition to cysts and fingerprint lines, present in both corneae; the patient’s symptoms were, however, minimal and he was using the ointment only sporadically.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
