Article

NOVEMBER 2017 ONLINE PHOTO DIAGNOSIS

The lesion in this photo was noted in the left eye of a 7-year-old male who presented for a routine eye examination. He had no specific complaints, nor did he report any issues with vision. His best-corrected visual acuities were OD 20/20 and OS 20/30. Examination of his anterior segment revealed a linear lesion passing diagonally across the visual axis of the left eye. Further evaluation showed that the anomaly was isolated to the endothelium. The margins of the area in question were slightly irregular and showed highly reflective dots. All findings in the right eye were unremarkable.

Our initial evaluation was primarily focused on potential traumatic corneal injury secondary to forceps delivery. The patient’s father initially stated that the patient was born via forceps delivery; however, we later learned from his mother that this was not the case. The only other endothelial condition that presents with this appearance is posterior corneal vesicles (PCVs). This diagnosis was confirmed by a corneal consult.

PCVs are an uncommon presentation. They were initially reported by Schnyder in 1924, and at the time they were believed to be herpetic in nature.1 Corneal vesicles are a non-inherited, unilateral disorder of the corneal endothelium and Descemet’s membrane. In many cases, they are asymptomatic and are detected only upon biomicroscopy of the anterior segment.

The appearance of this condition is unique, typically presenting as one or more linear vesicular lesions located at the level of Descemet’s membrane. They are best viewed with biomicroscopy using retroillumination. In vivo microscopic evaluation of corneal vesicles shows reduced density of corneal endothelial cells compared to the fellow eye. The corneal epithelium is unaffected, showing characteristics similar to the fellow eye. The endothelial cells in the affected areas were irregular in size and shape.

PCVs are in some ways similar in appearance to posterior polymorphous dystrophy (PPMD); however, PCVs are unilateral and non-inheritable whereas PPMD is a bilateral, autosomal-dominant, progressive condition that presents in the first decade.

PCV management includes patient and/or parent education and correction of any refractive error.

References

  1. Schnyder W. Herpetiforme Erkrankung der Hornhautrückfl\che [Herpes corneae posterior] Klin Mbl Augenheilk. 1924;73:385-390.