Optometry & Vision Science:
doi: 10.1097/OPX.0000000000000202
CLINICAL COMMUNICATIONS: Clinical Pearls

Clinical Pearls

Alexander, Larry J.

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OD, FAAO

This month, “Clinical Pearls,” under the clinical editorship of Editorial Board member Larry J. Alexander, OD, FAAO, includes color image content and optional supplementary digital content, with no cost to our authors.

Each article in this section is followed by a clinical comment by our clinical editor, emphasizing the clinical take-home message. We provide these “Clinical Pearls” of the publication following the article’s title, authors, and abstract. The full text and illustrations are found online with the colored images and any video clips.

Dr. Larry J. Alexander provides all of the clinical comments (“clinical pearls”) on each article in “Clinical Pearls.” This is all part of our Optometry and Vision Science (OVS) program to enrich the clinical content of OVS and make it very accessible, in color and motion, to clinicians, readers, and authors alike.

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CLINICAL CASES

Inadvertent Use of Cornea with Previous LASIK in Deep Lamellar Keratoplasty

Prafulla Maharana, Vishal Jhanji, and Rasik B. Vajpayee

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Purpose. To report transplantation of a post-laser in situ keratomileusis (LASIK) donor cornea in a deep anterior lamellar keratoplasty (DALK).

Methods. An 18-year-old male patient with bilateral keratoconus underwent DALK in his right eye. One week postoperatively, the uncorrected visual acuity was 6/24 and the keratometry readings were 36.4/48.6 D in the operated eye. On slit-lamp examination, two interfaces were observed in the corneal stroma. An anterior segment optical coherence tomography (ASOCT; Visante) scan was performed on the operated eye. The ASOCT showed two distinct interfaces, one in the deep corneal stroma close to the Descemet membrane and another interface in the anterior corneal stroma, 225 µm below the surface of the cornea representing the LASIK flap. The central corneal thickness was 498 µm and the residual stromal thickness was between 45 and 52 µm. The records of the 57-year-old male donor who had died of a road traffic accident did not reveal any history of refractive surgery in the past. The patient was informed about the presence of a LASIK flap on his cornea. Because the patient is asymptomatic, a decision was taken to observe instead of exchanging the graft.

Conclusion. Our case report highlights transplantation of a donor cornea with previous refractive surgery. With refractive surgery being performed commonly, a careful and specific history should be obtained from the relatives of the deceased. We recommend the incorporation of standard imaging protocols in eye banks for detection of previous refractive surgery in donor corneas.

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Granular Corneal Dystrophy: A Novel Approach to Classification and Treatment

David P. Roncone

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Purpose. The purpose of this case report is to review granular corneal dystrophy (GCD) and examine the new paradigm in its classification and treatment.

Case Report. A 49-year-old white male patient reported yearly for monitoring of GCD. He had an ocular surgical history in the left eye for penetrating keratoplasty in 1989 and phototherapeutic keratectomy with mitomycin C for graft recurrence of stromal bread-crumb opacities 17+ years later in 2002. At his last examination, the patient’s vision and comfort was stable in each eye, with minimal recurrence of granular opacities in the left surgical eye, stable granular opacities in the right eye, no recurrent corneal erosion symptoms in either eye, and best spectacle-corrected vision of 20/40 OD and 20/30 OS.

Conclusions. GCD is a Category 1, Stromal, TGFBI-associated corneal dystrophy. Although it is classified as a stromal dystrophy, research suggests the possibility that the granular opacities have an origination to the corneal epithelium with a migratory effect to the corneal stroma. Patients with Groenouw I, like the one in this report, usually do not have severely compromised vision. When vision is significantly affected or recurrent corneal erosion occurs, despite first- and second-line treatments, viable management options thereafter include photokeratectomy and other new surgical treatments such as femtosecond deep anterior lamellar keratoplasty and femtosecond laser-assisted keratoplasty. Future advancements in diagnostic technology, immunohistologic and genetic testing, medications, and surgery will allow for advancements in treating and managing patients with GCD.

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Sebaceous Carcinoma of Lacrimal Caruncle in a Chinese Patient

Zhengwei Zhang and Song Sun

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Purpose. To describe a case of sebaceous carcinoma of the caruncle and review relevant literature to raise awareness about this rare disease.

Case Report. A 63-year-old Chinese man presented with a nontender mass that had developed within the right lacrimal caruncle more than 3 years previously and had been growing in size. The patient was admitted to the hospital, and no systemic diseases were noted on physical and instrumental examinations. The mass was removed intact, and 10 small map biopsies of the surrounding conjunctiva and deeper tissues were performed. Thereafter, 0.04% mitomycin C was applied to the surgical defect for 5 minutes before repair by conjunctival autografting. The gross specimen was observed to be firm and yellow. Microscopic examination revealed that the tumor consisted of lobules, composed of pleomorphic vacuolated cells with central necrosis. The pathologic diagnosis was a well-differentiated sebaceous cell carcinoma of the caruncle that did not extend to the deep surgical margins. Moreover, no tumor recurrence was noted 12 months after surgery.

Conclusions. The occurrence of sebaceous cell carcinoma in the caruncle is rare. In general, this neoplasm is often both clinically and histopathologically misdiagnosed as a benign condition, resulting in both a delay in correct diagnosis and increased morbidity and mortality. Therefore, this malignancy should be considered in the differential diagnosis of caruncular lesions. The suspected neoplasm should be removed by margins that are as wide as possible; map biopsies are considered to be useful to rule out the subclinical spread of the tumor.

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Delayed Recurrence of Intracranial Chordoma

Brooks R. Alldredge and George W. Meers

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Purpose. Although a chordoma is extremely rare, it commonly presents with ocular symptoms, often impacting one or more cranial nerves.

Case Report. The authors describe a unique case of rapidly developing intracranial chordoma that recurred 9 years after the original mass was successfully diagnosed and treated. It is noteworthy that, although the tumor originated within the cranium at the base of the skull, it presented primarily with clinical signs of a unilateral orbital mass because of tumor extension.

Conclusions. The lifetime recurrence rate for chordoma is high after treatment; therefore, a high level of suspicion is warranted in any patient with new symptoms and a history of intracranial chordoma.

Copyright © 2014 American Academy of Optometry

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