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April consultation #4
CONSULTATION SECTION
more useful to us than we were to them. In other words, these almost artistic ring opacities might just be a rare coincidental finding not requiring medical attention.1,A,B (The reduced visual acuity in the left eye in this case is probably explained by the macular hole.) That being said, this case and earlier similar cases could still be of great scientific interest for ophthalmology. Such rings could be the result of an anatomic stromal defect or of refractive surgery; however, these possibilities are less likely because the corneal tissue did not show defects and all patients denied a history of corneal surgery or trauma. It would stand to reason that the rings relate to some type of gradient across the cornea that entails symmetry (thus producing perfect circles) as well as demarcation properties from the limbus to apex (cornea clear both centrally and peripherally from the depositions). If so, this observation could inform our understanding of the corneal physiology and its associated disorders. Gerrit R.J. Melles, MD, PhD Rotterdam, the Netherlands Financial Disclosure: Dr. Melles is a consultant to D.O.R.C. International BV/Dutch Ophthalmic USA and Surgicube International.
some thoughts regarding the description, etiology, additional testing, and management. There is a perfectly circular ring opacity with a small linear opacity extending superotemporally and a mild, diffuse, anterior corneal haze central and peripheral to the ring. Because of the perfectly circular shape and the apparent normal examination previously, it is extremely unlikely that the ring opacity is caused by an inherent or purely biological condition. One could look at family members to explore this possibility further. The ring's shape suggests some type of lightor laser-induced opacity; however, the uniformity of the opacity over its entire depth argues against this suggestion. Another possibility is that it is a lesion caused in some way by the tonometer tip. A final option is that it is a self-inflicted lesion. Additional testing could help in understanding the nature of these rings. In performing corneal topography and tomography, one should see central steepening if the lesion is thermal. Specular micrography could determine whether there is evidence of injury to the endothelium that could cause these opacities. In managing the case, I would observe and then perform a follow-up examination in 1 to 2 months. Douglas D. Koch, MD Houston, Texas, USA
REFERENCES ra JP, Eggink CA, Cruysberg JRM, Binder PS. 1. Melles GRJ, de Se Bilateral, anterior stromal ring opacity of the cornea. Br J Ophthalmol 1998; 82:522–525. Available at: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1722592/pdf/v082p00522.pdf. Accessed February 23, 2015 2. Bron AJ. Peripheral ring opacity of the cornea. Br J Ophthalmol 1969; 53:270–273. Available at: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1207311/pdf/brjopthal00328-0056.pdf. Accessed February 23, 2015 3. Caroline PJ, Melles GRJ. Two cases of bilateral, stromal ring opacity of the cornea. Cornea 2001; 20:237–238
OTHER CITED MATERIAL A. Winnick J, “Bilateral Corneal Ring Opacity Found in Long-Term Contact Lens Wearer,” poster presented at the annual meeting of the American Academy of Optometry, San Francisco, California, USA, December 1998. Abstract available at: http://www.aaopt. org/bilateral-corneal-ring-opacity-found-long-term-contact-lenswearer. Accessed February 23, 2015 B. Barnes D, Volkert T, Dunphy R, Selvin G, Lambert N, “Bilateral Ring-Shaped Corneal Opacities,” poster presented at the annual meeting of the American Academy of Optometry, San Diego, California, USA, December 2002. Abstract available at: http:// www.aaopt.org/bilateral-ring-shaped-corneal-opacities. Accessed February 23, 2015
- First, I want to acknowledge that I am fairly clueless. I have never seen anything like this (nor have 4 of my colleagues at Baylor University). Here are
897
- This 63-year-old woman presented with decreased vision in the left eye, which was referred for evaluation of bilateral corneal opacities noted by a retinal surgeon. The slitlamp photographs show bilateral white rings that are remarkably thin, circular, and symmetric between the 2 eyes and approximately 4.0 mm in diameter. The left eye otherwise appears uninflamed and to have a smooth contour and a clear central cornea. The thin-beam slitlamp and AS-OCT images confirm the full-thickness stromal location and the absence of significant corneal thickening or previous surgical scars. The rings likely have minimum clinical significance because they are symmetric and the vision in the right eye is correctable to 20/20, confirming to a retinal surgeon that the origin of the vision limitation is largely retinal, not corneal. The differential diagnosis can be broadly any disorder that can lead to opacification; however these thin, symmetric, midperipheral, circular lesions are characteristic of a presumably idiopathic corneal dystrophy that has been described periodically since it was first reported in 1964.1 Melles et al.2 reviewed a collection of 6 cases that shared the same appearance but varied from patient to patient in terms of size and age at presentation (20s to elderly). Over the years, these opacities have presented as an incidental
J CATARACT REFRACT SURG - VOL 41, APRIL 2015
more useful to us than we were to them. In other words, these almost artistic ring opacities might just be a rare coincidental finding not requiring medical attention.1,A,B (The reduced visual acuity in the left eye in this case is probably explained by the macular hole.) That being said, this case and earlier similar cases could still be of great scientific interest for ophthalmology. Such rings could be the result of an anatomic stromal defect or of refractive surgery; however, these possibilities are less likely because the corneal tissue did not show defects and all patients denied a history of corneal surgery or trauma. It would stand to reason that the rings relate to some type of gradient across the cornea that entails symmetry (thus producing perfect circles) as well as demarcation properties from the limbus to apex (cornea clear both centrally and peripherally from the depositions). If so, this observation could inform our understanding of the corneal physiology and its associated disorders. Gerrit R.J. Melles, MD, PhD Rotterdam, the Netherlands Financial Disclosure: Dr. Melles is a consultant to D.O.R.C. International BV/Dutch Ophthalmic USA and Surgicube International.
some thoughts regarding the description, etiology, additional testing, and management. There is a perfectly circular ring opacity with a small linear opacity extending superotemporally and a mild, diffuse, anterior corneal haze central and peripheral to the ring. Because of the perfectly circular shape and the apparent normal examination previously, it is extremely unlikely that the ring opacity is caused by an inherent or purely biological condition. One could look at family members to explore this possibility further. The ring's shape suggests some type of lightor laser-induced opacity; however, the uniformity of the opacity over its entire depth argues against this suggestion. Another possibility is that it is a lesion caused in some way by the tonometer tip. A final option is that it is a self-inflicted lesion. Additional testing could help in understanding the nature of these rings. In performing corneal topography and tomography, one should see central steepening if the lesion is thermal. Specular micrography could determine whether there is evidence of injury to the endothelium that could cause these opacities. In managing the case, I would observe and then perform a follow-up examination in 1 to 2 months. Douglas D. Koch, MD Houston, Texas, USA
REFERENCES ra JP, Eggink CA, Cruysberg JRM, Binder PS. 1. Melles GRJ, de Se Bilateral, anterior stromal ring opacity of the cornea. Br J Ophthalmol 1998; 82:522–525. Available at: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1722592/pdf/v082p00522.pdf. Accessed February 23, 2015 2. Bron AJ. Peripheral ring opacity of the cornea. Br J Ophthalmol 1969; 53:270–273. Available at: http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1207311/pdf/brjopthal00328-0056.pdf. Accessed February 23, 2015 3. Caroline PJ, Melles GRJ. Two cases of bilateral, stromal ring opacity of the cornea. Cornea 2001; 20:237–238
OTHER CITED MATERIAL A. Winnick J, “Bilateral Corneal Ring Opacity Found in Long-Term Contact Lens Wearer,” poster presented at the annual meeting of the American Academy of Optometry, San Francisco, California, USA, December 1998. Abstract available at: http://www.aaopt. org/bilateral-corneal-ring-opacity-found-long-term-contact-lenswearer. Accessed February 23, 2015 B. Barnes D, Volkert T, Dunphy R, Selvin G, Lambert N, “Bilateral Ring-Shaped Corneal Opacities,” poster presented at the annual meeting of the American Academy of Optometry, San Diego, California, USA, December 2002. Abstract available at: http:// www.aaopt.org/bilateral-ring-shaped-corneal-opacities. Accessed February 23, 2015
- First, I want to acknowledge that I am fairly clueless. I have never seen anything like this (nor have 4 of my colleagues at Baylor University). Here are
897
- This 63-year-old woman presented with decreased vision in the left eye, which was referred for evaluation of bilateral corneal opacities noted by a retinal surgeon. The slitlamp photographs show bilateral white rings that are remarkably thin, circular, and symmetric between the 2 eyes and approximately 4.0 mm in diameter. The left eye otherwise appears uninflamed and to have a smooth contour and a clear central cornea. The thin-beam slitlamp and AS-OCT images confirm the full-thickness stromal location and the absence of significant corneal thickening or previous surgical scars. The rings likely have minimum clinical significance because they are symmetric and the vision in the right eye is correctable to 20/20, confirming to a retinal surgeon that the origin of the vision limitation is largely retinal, not corneal. The differential diagnosis can be broadly any disorder that can lead to opacification; however these thin, symmetric, midperipheral, circular lesions are characteristic of a presumably idiopathic corneal dystrophy that has been described periodically since it was first reported in 1964.1 Melles et al.2 reviewed a collection of 6 cases that shared the same appearance but varied from patient to patient in terms of size and age at presentation (20s to elderly). Over the years, these opacities have presented as an incidental
J CATARACT REFRACT SURG - VOL 41, APRIL 2015