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Clinical Pearls

Alexander, Larry J. OD, FAAO

Author Information
doi: 10.1097/OPX.0000000000000142
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This month, “Clinical Communications,” under the clinical editorship of Editorial Board member Larry 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 Alexander provides all of the clinical comments (“Clinical Pearls”) on each article in “Clinical Communications.” This is all part of our OVS program to enrich the clinical content of OVS and make it very accessible, in color and motion, to clinicians, readers, and authors alike.

Tony Adams, OD, PhD, FAAO

Editor in Chief

Clinical Cases

The “Double-Layer Sign”: In Vivo Imaging of Polypoidal Choroidal Vasculopathy

Jamie M. St. Martin, Julie Rodman, Joseph J. Pizzimenti, and Eva Duchnowski


Purpose. Polypoidal choroidal vasculopathy (PCV), a disease of the choroidal vascular network, presents clinically with polyp-like reddish orange lesions, as well as retinal pigment epithelial (RPE) and/or neurosensory retinal detachments. Optical coherence tomography (OCT) is a useful diagnostic tool that provides cross-sectional and volumetric imaging of posterior segment microstructure. Typical OCT findings in PCV may reveal a classic hyperreflectivity in the choroidal layers known as the “double-layer” sign. This sign is indicative of an abnormal choroidal vascular network. Indocyanine green angiography is also useful for the diagnosis of PCV and clearly identifies the polyp-like lesions arising from the choroidal vasculature.

Case Report. A 53-year-old African American woman presented with complaints of gradually decreasing vision in the left eye (OS). Clinical examination revealed moderately reduced acuity OS with a small central scotoma found on Amsler grid testing. Dilated fundus examination revealed a hemorrhagic RPE detachment with suspicion of a choroidal neovascular membrane in the foveal region of the OS. Exudative leakage appeared circumferentially around the macula OS. Optical coherence tomography of the OS also revealed two highly reflective layers: one at the level of the RPE and another beneath the RPE (“double-layer” sign). The patient was referred to a retina subspecialist for angiography and treatment consideration.

Conclusions. It is important to distinguish PCV from other variants of choroidal neovascularization. The polyp-like lesions found in the PCV are a unique and classic characteristic. Proper diagnostic workup includes stereoscopic posterior fundus evaluation and imaging studies, including OCT and indocyanine green angiography.

A Case of Schnyder Corneal Dystrophy with Crystals

Trennda L. Rittenbach


Purpose. To report a rare corneal dystrophy and its common findings to help aid others in proper and early diagnosis and management.

Case Report. A 56-year-old male patient presented with the concern of blurry vision in both eyes that has progressed over the last 10 years. Anterior segment examination revealed arcus with a central haze in both eyes and crystalline deposition in the right eye. A diagnosis of Schnyder corneal dystrophy was made based on clinical presentation.

Conclusions. Schnyder corneal dystrophy is rare but has different presentations and may actually be misdiagnosed. The clinical signs change as the patient ages causing a decrease in vision, which may necessitate referral for phototherapeutic keratectomy, penetrating keratoplasty or deep anterior lamellar keratoplasty. The patient’s systemic findings that correlate with the dystrophy need to be assessed and managed appropriately.

© 2013 American Academy of Optometry