This Week's Eye-Openers

AAO

A retained contact lens masquerading as corneal melanoma

Before diagnosing the cornea, make sure the lesion is actually on the cornea. A 55-year-old man presented with progressive vision loss in the right eye. Best-corrected visual acuity was 20/400 OD and 20/20 OS. Anterior segment examination revealed numerous superficial, centrally located brown deposits, raising concern for a pigmented corneal lesion (A).

Fluorescein staining revealed deposits on a retained contact lens (B), which was then removed. Microscopy revealed lightly pigmented, reflective fungi on the lens surface and penetrating the lens material (C), with associated pigmentation of the lens. Periodic acid–Schiff staining highlighted the fungal elements (D).

This case demonstrates pigmented fungal colonization of a retained contact lens masquerading as a corneal melanocytic lesion and highlights the importance of confirming the anatomic origin of an apparent corneal lesion before pursuing further workup.

By: Gautam Ramanathan

A 78-year-old female with a history of HTN, coronary artery disease, prior CVA, and CKD presents with a new, painless central blind spot in the left eye, first noticed several weeks earlier and has been stationary since onset. She denies flashes, curtain-like visual field defect, headache, or trauma, though she does report a recent bout of constipation with straining around the time her symptoms began. She also reports that her systolic blood pressure was in the 180s around symptom onset.

Visual acuity is 20/30 OD and count fingers at 1 foot OS. Dilated fundus examination of the left eye reveals trace vitreous hemorrhage along with a raised area of subretinal hemorrhage near the fovea, extending inferiorly. The retinal periphery is flat, retinal vessels appear of normal caliber, and the optic nerve appears healthy. The right eye is unremarkable aside from a few peripheral drusen.

Over the following weeks, serial examinations show the hemorrhage gradually organizing into fibrosis that continues to extend toward the fovea despite conservative monitoring. Follow-up exams also reveal mild arteriolar tortuosity, vascular nicking, and a streak of hemorrhage tracking along a retinal arteriole adjacent to the area of blood. OCT of the left eye is shown below.

What is the most likely diagnosis?

A.  Ruptured retinal arterial macroaneurysm

B.  Valsalva retinopathy

C.  Neovascular age-related macular degeneration (wet AMD)

D.  Retinal vein occlusion

E.  Proliferative diabetic retinopathy with vitreous hemorrhage

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