Fig. 1.1
(a) Normal precorneal tear film stained evenly green with fluorescein. (b–c) Surface elevations (arrows) appear dark. (d–e) show abnormal epithelial structures (white arrows) located below an elevated (dark, black arrows) but not disrupted surface (cf. Chap. 3, Case 1). (f) Fluorescein diffusion (green) around a surface disruption (arrow); its centre is indicated by (asterisk). (g) Fluorescein diffusion (upper arrow) into the surroundings captured in a narrow light beam (lower arrow)
Fluorescein Staining (2) Pooling of the Dye
Fig. 1.2
Fluorescein pooling in: (a–b) a sharply delineated space (arrows); (c–d) epithelial lines (arrows) and variously shaped spaces (arrowheads); (e–f) a sharply delineated space (arrows) in which fluorescein visibility is partly hampered by a strong light reflection; (g) a relative surface depression (arrow); (h–i) a complex lesion (arrows). (The markers are placed in corresponding locations in each pair of photographs. a, c, e and h: before staining.) For dynamics of the green staining see Figs. 2.9, 2.11 and 2.14
Signs of Pathology
Rounded Bodies and Small Rounded Cysts (1)
Fig. 1.3
(a–k) Rounded bodies (white arrowheads), individual or grouped, and small rounded cysts (black arrowheads) of which many contain rounded bodies (g–i, white arrowheads) and some a smooth rounded structure (h, arrow). (j–k) Many of the rounded bodies (white arrowheads) and cysts (black arrowheads) are light-reflecting (not the same area). (l) Of the two rounded cysts (black arrowheads) only the upper one stains green with fluorescein (for additional examples of fluorescein staining of rounded cysts, see Figs. 1.14, 1.32, 2.6 and 2.45)
Rounded Bodies and Small Rounded Cysts (2)
Fig. 1.4
(a–c) Epithelial cysts (black arrowheads), in apposition or merging (for fluorescein staining of similar cysts cf. Fig. 1.14). Rounded bodies (white arrowheads) are visible within the cysts and in the surroundings. (d) Also this light-reflecting cyst implies the result of confluence
Fig. 1.5
(a–c) Rounded bodies (arrowheads) captured in different illumination modes. (d) A lesion the whitish appearance of which is partly due to (e) many light-reflecting rounded bodies (arrowheads) that (f) are difficult to discern after fluorescein staining. (g) Many rounded bodies (arrowheads) in (h) appearing as dark dots in the green stained fluid. (i) Rounded bodies (arrowhead) present in a fusiform expansion between approaching edges (arrows) of epithelial sheets (the arrowheads are placed in corresponding locations in each set of photographs)
Signs of Pathology Opaque Cysts (1)
Fig. 1.6
(a) Rounded, variously large and strongly light-reflecting opaque cysts (arrowheads) that appear (b) dense (dark) in retroillumination. (c–e) Similar cysts, rounded (arrowheads) or variously shaped (double arrowheads) (cf. Fig. 1.7, opposite page). (d) The cysts do not (e) stain with fluorescein; the surrounding epithelium shows surface elevations (dark in the green stained tear film, arrow). See also Chap. 5, Case 3. (The arrowheads in (a, b) and (d, e) are placed in corresponding locations)
Comment
The photographs shown in Fig. 1.6 were captured in three patients with EBMD:
(a, b)
In a 52-year-old myopic (−7.0) woman with fluctuating vision and glare for 7 months; both corneae showed centrally located light-reflecting opaque cysts and irregular astigmatism.
(c)
As accidental finding in the upper cornea in a 60-year-old woman presenting with iridocyclitis.
(d, e)
In a 46-year-old woman with a 6-month history of fluctuating vision in the right eye; the right cornea showed centrally located opaque cysts and irregular astigmatism and the left one similar cysts out of the visual axis.
In all three patients, both corneae additionally showed lines and maps. None of them had recurrent erosion symptoms.
Opaque Cysts (2)
Fig. 1.7
(a–d) Rounded (black arrowheads) and variously shaped (double arrowheads) cysts in many of which is discernible granular material (rounded bodies and/or cell debris, white arrowheads). In (d), the bizarre shapes of the cysts seem to be the result of confluence (black arrowheads) (in focal illumination, such cysts appear greyish-white, cf. Fig. 1.6)
Signs of Pathology Lines (1)
Fig. 1.8
(a) Survey. In low magnification, the distribution of the fine lines gives an impression of a fingerprint. (b–f) show variously thick lines (arrows) suggestive of ridges. The same cornea showed also small cysts (not shown)
Lines (2)
Signs of Pathology Lines and ‘Maps’ (1)
Fig. 1.10
(a–e) The edges of greyish membranes (‘maps’) (asterisks) often show brighter lines (plain arrows). In (d) a darker ‘hole’ (dashed arrow) in the membrane and a small light-reflecting cyst (arrowhead) are additionally visible. (e–f) show the same area 3 weeks later; the cyst has disappeared. In retroillumination (f), the light-reflecting line (plain arrow) appears thick. In (f), the dashed arrow indicates a faintly visible edge of the dark ‘hole’. (The arrows in (d–f) are placed in corresponding locations; see also Chap. 2, Case 13)
Lines and ‘Maps’ (2)
Fig. 1.11
(a, b) Two different areas of the same cornea. In (a) a greyish membrane (asterisk) and in (a, b) variously thick light-reflecting lines (arrows) are visible. (c, d) Light-reflecting thick lines (arrows) (c) in focal illumination and (d) in retroillumination. (e, f) show the same phenomena (arrows) in the same area 5 months later
Signs of Pathology Blebs (1)
Fig. 1.12
(a–e) Variously large vesicle-like rounded structures (blebs, arrowheads) and (e) lines (arrow; cf. Fig. 2.2a). (f) Large blebs may occasionally cause surface elevations (arrowhead) visible as dark spots in the tear film stained green with fluorescein
Blebs (2)
Fig. 1.13
(a–c) Variously large vesicle-like rounded structures (blebs, arrowheads). In (d) the blebs (arrowhead) seem partly confluent
Signs of Pathology Various Cysts and Lines in Combination (1)
Fig. 1.14
(a, b) Survey of an area showing cysts, lines and surface elevations (a) before and (b) after the application of fluorescein. (c) In the green stained tear film, the area of surface elevation (arrow) appears dark; within this area, one of the opaque cysts (grey arrowheads) appears as a greyish not staining fleck (lower grey arrowhead), three rounded cysts in apposition stain brilliantly green (left black arrowhead) and another rounded cyst does not stain with the dye (right black arrowhead). (d–g) Several cysts, the opaque ones dense and granular (grey arrowheads), others round and apparently clear (black arrowheads). The arrows indicate lines, straight in (d) and bowed in (e, g) (the arrowheads are placed in corresponding locations)
Various Cysts and Lines in Combination (2)
Fig. 1.16
A pear-shaped clear cyst (black arrowhead) the lower part of which contains rounded bodies/cell debris (white arrowhead). The cyst seems to have a surface connection (arrow) (cf. Fig. 2.52)
Signs of Repair
Epithelial Sheets (1)
Fig. 1.17
(a) A curved tip (arrow) of an epithelial sheet pointing to a seemingly smooth surface (asterisk). (b) A similar tip (arrow) pointing to a deranged area (asterisk)
Fig. 1.18
(a) A small curved tip (white arrows) of an epithelial sheet. The grey arrows indicate areas of its merging with the surroundings. (b) In front of the tip, the green fluorescein pooling (bowed arrow) indicates a relative surface depression in which rounded structures (asterisks) are protruding (dark) (the markers are placed in corresponding locations)