FIGURE 5-1. Epithelial basement membrane (EBM) dystrophy. A. Reduplicated EBM causing map-like changes is readily visible centrally. B. Large map-like opacities are present throughout the central cornea, causing complaints of monocular “diplopia,” better described as “shadow vision.”

FIGURE 5-1. (continued) C. Map-like changes in this eye are almost confluent centrally, resulting in significant visual distortion. D. The map-like changes here are often referred to as a “mare’s tail” pattern.

FIGURE 5-1. (continued) E. Fluorescein stain and the cobalt blue light view of the cornea shown in D. Significant “negative staining” is evident because of areas of elevated epithelium. These elevated areas can cause foreign-body sensation and/or decreased vision. F. Dot changes of EBM dystrophy. These creamy white Cogan microcysts are tiny pockets of surface epithelial cells trapped beneath an abnormal EBM.

FIGURE 5-1. (continued) G. A large area of epithelial microcysts is seen superiorly. H. Retroillumination view of the same eye seen in G highlights the epithelial microcysts.

FIGURE 5-1. (continued) I. Fingerprint-like changes of EBM dystrophy in retroillumination. These parallel lines and bleblike changes are a result of irregularities in the EBM. They are causing irregular astigmatism and decreased vision. J. Fingerprint lines in a “mare’s tail” pattern are seen centrally in this eye with EBM dystrophy.

FIGURE 5-1. (continued) K. Chronic severe map-like changes have caused underlying anterior stromal scarring in this eye with EBM dystrophy, resulting in poor vision. Owing to the presence of anterior stromal scarring, this eye was treated with excimer laser PTK and not a diamond burr polishing procedure. L. Seven weeks after excimer laser PTK of the eye seen in K, the map-like changes and most of the anterior stromal scarring are gone, with significant improvement in the patient’s vision. PTK: phototherapeutic keratectomy.

FIGURE 5-2. Meesmann dystrophy. A. Multiple tiny, translucent, epithelial cysts are apparent in retroillumination. They tend to be more prominent in the interpalpebral zone. B. On direct illumination, the microcysts are gray in color but are difficult to see. On illumination of the iris, at the 3 o’clock edge of the pupil, myriad microcysts are visible.

FIGURE 5-3. Lisch corneal dystrophy. A. A large paracentral area of gray-white epithelial opacity with flameshaped edges is seen in this left eye of a 60-year-old patient with Lisch corneal dystrophy. B. The areas of abnormal epithelium of the left eye of the patient with Lisch corneal dystrophy seen in A are highlighted using retroillumination off the retina.

FIGURE 5-4. Reis-Bücklers dystrophy. A. A slight reticular pattern can be seen mainly in the central cornea in this eye with relatively mild Reis-Bücklers dystrophy. B. This eye has moderate changes of Reis-Bücklers dystrophy. It primarily involves the central cornea, but the opacity approaches the limbus inferiorly.

FIGURE 5-4. (continued) C. This eye with advanced Reis-Bücklers dystrophy has diffuse, reticular, limbus-to-limbus subepithelial, and anterior stromal opacity. There are few if any clear spaces. D. This eye also has advanced Reis-Bücklers dystrophy. Fortunately, the vision improved significantly after excimer laser PTK.

FIGURE 5-4. (continued) E. Central reticular, honeycomb-shaped opacity is present in the left eye of this 22-yearold patient with Reis-Bücklers corneal dystrophy. F. An anterior segment OCT of the eye seen in E demonstrating significant opacity of Reis-Bücklers corneal dystrophy at the level of Bowman layer. G. A high-resolution anterior segment OCT of the cornea seen in E and F highlights the opacity of Reis-Bücklers at the level of Bowman layer.

FIGURE 5-4. (continued) H. Recurrent Reis-Bücklers a few years after a penetrating keratoplasty. Unfortunately, Reis-Bücklers recurs relatively rapidly after corneal transplantation. I. This eye also has recurrent Reis-Bücklers dystrophy several years after penetrating keratoplasty. Note the honeycomb opacity centrally and involvement of the entire corneal periphery.

FIGURE 5-4. (continued) J. Significant recurrence of the dystrophy can be seen many years after a corneal transplant for Reis-Bücklers corneal dystrophy in this 44-year-old patient. The patient underwent subsequent excimer laser PTK. K. One month after excimer laser PTK of the eye with recurrent Reis-Bücklers corneal dystrophy seen in J, the central cornea is essentially clear, with tremendous improvement in the patient’s vision. OCT: optical coherence tomography; PTK: phototherapeutic keratectomy.