![]() ![]() ![]() No decrease in corneal sensation was observed in tested patients, and fundoscopy was unremarkable. ![]() Some of the patients demonstrated a “fractal pattern” wherein smaller lesions were grouped to form a larger Landolt ring. Vesicular changes can be seen, but there is no apparent inflammation. The shape (i.e., the location of the gap in the “C”), number, and size of the ring lesions varied from patient to patient and from visit to visit, eventually resolving with disease remission. Figure 1 is a slit lamp photo of a patient with Landolt ring-shaped lesions. Slit lamp exam shows randomly dispersed Landolt-shaped rings in the corneal epithelium, which can be enhanced with fluorescein staining. Prior history of similar symptoms may also be present, as all patients who were followed for at least a year had recurrence of their symptoms. Symptoms became clinical in the winter months, especially around changes in the weather (e.g., 90% of patients became clinical in either December or March). Patients most often complain of insidious bilateral foreign-body sensation, photophobia, ocular pain, or blurred vision one patient reported increased glare. Though, it should be noted that further work is needed to understand the underlying pathophysiology of this process fully. This theory proposes that centripetal regeneration of epithelium from the limbus and proliferation of basal epithelial cells maintain epithelium from cells lost at the surface. This idea of limbal cell dysfunction is supported by Thoft and Friend’s X,Y,Z hypothesis of corneal regeneration. It has been proposed that the pathology may be associated with regional limbal stem cell dysfunction in a few clock hours, and reduced cell turnover in the area corresponding to the lesions may be the cause of the characteristic lesions. This disease is likely not limited to Japanese individuals and may be seen in other ethnicities. Superficial ballooning and swelling also contributed to disruption of the epithelial junction, as seen on fluorescein staining. Additionally, on slit lamp exam, the anterior chamber was unremarkable. ![]() The bowman layer (including subbasal nerve plexus and long nerve fibers), stromal layer, and endothelial layer were intact. The deep basal cell layer contains the Landolt shaped-ring structures and abnormal hyperreflective precipitates. Conversely, wing cells showed hyperreflective nuclear and cell membrane changes. In a case report, the anterior superficial layer displayed cellular ballooning with hyporeflective cytoplasmic changes. In vivo confocal microscopy of the corneal epithelium shows differing morphologic characteristics in the superficial cell layer, wing cell layer, and basal cell layer of the cornea. While the pathophysiology is still unknown, some ocular changes give a clue for the underlying pathology. Landolt ring-shaped lesions in the cornea with Fluorescein staining. Finally, a genetic factor may also contribute as all published cases have been reported in Japanese individuals that are not related and came from different parts of the country. Age may also play a role as 64% of cases have occurred in patients 41-52 years old. It is hypothesized that weather affects the disease as lesions tend to develop in the winter months (i.e., all cases were diagnosed between November and March). Landolt Ring–Shaped Epithelial KeratopathyĪt present, the Landolt ring-shaped epithelial keratopathy is a sporadic and chronic process. There are eleven known cases first published in a case study in 2015 Disease Landolt ring–shaped epithelial keratopathy describes a condition in which focal lesions in the basal layer of the corneal epithelium that resemble a Landolt ring, or the letter “C” develop insidiously. ![]()
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