SD-OCT images were obtained from 19 patients. Ten patients were diagnosed as having AWE (a total of 18 eyes, male:female = 2:8, eight patients had bilateral disease and two patients had unilateral disease). Nine patients were diagnosed as having phlyctenular keratitis/ocular rosacea (a total of 15 eyes, male:female = 2:7, six patients had bilateral disease and three patients had unilateral disease). The mean age of patients with AWE and those with phlyctenular keratitis/ ocular rosacea was 48.7 ± 14.0 (range: 33–73) years and 30.3 ± 18.2 (range: 9–62) years, respectively. Table 1 summarizes the age, sex, laterality, and quadrants of limbal involvement observed through slit-lamp biomicroscopy of all patients. Of the 18 eyes of patients with AWE (case 1-10), 14 (77.8%) exhibited isolated superior quadrant involvement and 4 (22.2%) had limbal involvement in at least one quadrant, in addition to the involvement of both superior and inferior quadrants. In patients with phlyctenular keratitis/ocular rosacea (cases 11–19), subepithelial infiltration was frequently observed at the leading area of advancing corneal neovascularization in superior or inferior quadrants. Furthermore, of the 15 eyes, 6 (40.0%) showed isolated superior quadrant involvement, 4 (26.7%) showed isolated inferior quadrant involvement, 3 (20.0%) showed combined superior and other quadrant involvement, and 2 (13.3%) showed the involvement of at least one quadrant, in addition to both superior and inferior quadrants.
Table 1: Demographic data, disease patterns, and quadrants showing limbal involvement
|
Diagnosis
|
No.
|
Age
|
Gender
|
Involved eye
|
Involved quadrant
OD
|
Involved quadrant
OS
|
Advancing wavelike epitheliopathy
(AWE)
|
1
|
44
|
F
|
OU
|
superior
|
superior
|
2
|
57
|
F
|
OD
|
superior
|
-
|
3
|
36
|
M
|
OU
|
superior
|
superior
|
4
|
34
|
M
|
OU
|
superior
|
superior
|
5
|
33
|
F
|
OU
|
superior
|
superior
|
6
|
41
|
F
|
OU
|
superior
|
superior
|
7
|
73
|
F
|
OU
|
superior, inferior
nasal, temporal
|
superior, inferior
nasal, temporal
|
8
|
62
|
F
|
OU
|
superior, inferior
nasal, temporal
|
superior
|
9
|
44
|
F
|
OU
|
superior
|
superior
|
10
|
63
|
F
|
OD
|
superior, inferior
nasal, temporal
|
-
|
Phlyctenular keratitis/
Ocular rosacea
|
11
|
20
|
F
|
OD
|
superior, inferior
nasal, temporal
|
-
|
12
|
22
|
F
|
OU
|
inferior
|
inferior
|
13
|
24
|
M
|
OU
|
superior, nasal
|
superior, temporal
|
14
|
21
|
F
|
OD
|
superior
|
-
|
15
|
60
|
M
|
OS
|
-
|
superior, inferior,
nasal
|
16
|
27
|
F
|
OU
|
superior, temporal
|
superior
|
17
|
28
|
F
|
OU
|
superior
|
superior
|
18
|
9
|
F
|
OU
|
superior
|
superior
|
19
|
62
|
F
|
OU
|
inferior
|
inferior
|
M=male, F=female. No: case number. OD; right eye. OS: left eye. OU: both eyes.
|
Abnormal POV was detected through SD-OCT at the lesion sites of the diseased eyes diagnosed by slit-lamp biomicroscopy.
Table 2 summarizes the presentation of the POV in lesion sites according to the parameters defined in this study (Figure 1). A decreased epithelial thickness of the POV, loss of the sharp stromal tip of the POV, loss of the smooth epithelial–stromal interface of the POV, dilated limbal vessels, and a decreased density of the POV were observed in 44.4%, 11.1%, 77.8%, 66.7%, and 72.2% of patients with AWE, respectively, and 46.7%, 0%, 40.0%, 86.7%, and 60.0% of patients with phlyctenular keratitis/ocular rosacea, respectively. These SD-OCT findings indicated that limbal involvement in patients with AWE and phlyctenular keratitis/ocular rosacea was not only restricted to the epithelial layer but also involved the limbal stroma and vessels of the POV.
Table 2 : Presentations of the abnormal POV at the most severe lesion sites of the diseased eyes evaluated through SD-OCT
|
Ocular surface disorders
|
Presentation of abnormal POV (number of eyes)
|
Percentage
|
Advancing wavelike epitheliopathy (AWE)
|
Decreased epithelial thickness (8/18)
Loss of sharp stromal tip of POV (2/18)
Loss of smooth epithelial–stromal interface (14/18)
Dilated stromal vessels (12/18)
Decrease density of POV (13/18)
|
44.4%
11.1%
77.8%
66.7%
72.2%
|
Phlyctenular keratitis/ Ocular rosacea
|
Decreased epithelial thickness (7/15)
Loss of sharp stromal tip of POV (0/15)
Loss of smooth epithelial–stromal interface (6/15)
Dilated stromal vessels (13/15)
Decrease density of POV (9/15)
|
46.7%
0.0%
40.0%
86.7%
60.0%
|
POV= Palisades of Vogt. SD-OCT=Spectral-domain optical coherence tomography.
|
Abnormal POV was detected through SD-OCT at the presumed-healthy sites of the diseased eyes diagnosed by slit-lamp biomicroscopy.
Slit-lamp biomicroscopy findings revealed that 14 of the 18 eyes of patients with AWE and 14 of the 15 eyes of patients with phlyctenular keratitis/ocular rosacea exhibited a presumed-healthy limbus in at least one quadrant. Table 3 lists the percentage of the abnormal POV detected through SD-OCT in the lesion and presumed-healthy sites of the limbus. In the AWE group, 100% and 88.9% of the eyes demonstrated at least one and two abnormal findings in the lesion site, respectively, whereas 100% and 64.3% of the eyes exhibited at least one and two abnormal findings in the presumed-healthy sites, respectively. In the phlyctenular keratitis/ocular rosacea group, 100% and 93.3% of the eyes exhibited at least one and two abnormal findings in the lesion site, respectively, whereas 100% and 85.7% of the eyes showed at least one and two abnormal findings in the presumed-healthy site, respectively. Table 4 provides the detailed regional presentations of the abnormal POV detected through slit-lamp biomicroscopy and SD-OCT.
Table 3: Percentage of the abnormal POV detected through SD-OCT in the most severe lesion and presumed-healthy sites of the diseased eyes
|
Ocular surface diseases
|
Abnormal POV detected by SD-OCT
(number of eyes)
|
Percentage
|
Advancing wavelike epitheliopathy (AWE)
|
Lesion site (18 eyes)
≥1 abnormal finding : 18/18
≥2 abnormal findings: 16/18
≥3 abnormal findings: 9/18
≥4 abnormal findings: 3/18
5 abnomral findings: 0/18
Presumed-healthy site (14 eyes)
≥1 abnormal finding : 14/14
≥2 abnormal findings: 9/14
≥3 abnormal findings: 7/14
≥4 abnormal findings: 3/14
5 abnomral findings: 0/14
|
100.0%
88.9%
50.0%
16.7%
0%
100.0%
64.3%
50.0%
21.4%
0%
|
Phlyctenular keratitis/ Ocular rosacea
|
Lesion site (15 eyes)
≥1 abnormal finding: 15/15
≥2 abnormal finding: 14/15
≥3 abnormal finding: 7/15
≥4 abnormal finding: 3/15
5 abnomral findings: 0/15
Presumed-healthy site (14 eyes)
≥1 abnormal finding: 14/14
≥2 abnormal finding: 12/14
≥3 abnormal finding: 7/14
≥4 abnormal finding: 3/14
5 abnomral findings: 0/14
|
100.0%
93.3%
46.7%
20.0%
0%
100.0%
85.7%
50.0%
21.4%
0%
|
In total, 4 of the 18 eyes in the AWE group and 1 of the 15 eyes in the phlyctenular keratitis/ocular rosacea group showed limbal involvement in all the four quadrants of the limbal area. Accordingly, only 14 eyes in both groups have considered the presumed-healthy sites of the limbus in the disease eyes.
POV= Palisades of Vogt. SD-OCT=Spectral-domain optical coherence tomography.
|
Table 4: Percentage of different abnormal POV patterns in the four quadrants in diseased eyes detected through SD-OCT
|
Group
|
Lesion or presumed-healthy site
|
Quadrant
|
No.
|
Decreased epithelial thickness
No (%)
|
Loss of sharp stromal tips
No (%)
|
Loss of smooth epithelial–stromal interface
No (%)
|
Dilated stromal vessels
No (%)
|
Decrease
density of
POV
No(%)
|
AWE
|
Lesion site
|
S
|
18
|
6 (33%)
|
2 (11%)
|
14 (78%)
|
10 (56%)
|
13 (72%)
|
I
|
4
|
1 (25%)
|
0 (0%)
|
2 (50%)
|
3 (75%)
|
2 (50%)
|
N
|
4
|
1 (25%)
|
0 (0%)
|
4 (100%)
|
3 (75%)
|
3 (75%)
|
T
|
4
|
2 (50%)
|
0 (0%)
|
4 (100%)
|
2 (50%)
|
3 (75%)
|
Presumed-healthy site
|
S
|
0
|
-
|
-
|
-
|
-
|
-
|
I
|
14
|
4 (29%)
|
0 (0%)
|
7 (50%)
|
8 (57%)
|
3 (21%)
|
N
|
14
|
8 (57%)
|
0 (0%)
|
5 (36%)
|
7 (50%)
|
3 (21%)
|
T
|
14
|
5 (36%)
|
0 (0%)
|
6 (43%)
|
6 (43%)
|
4 (29%)
|
Ocular rosacea/ phylectenulosis
|
Lesion site
|
S
|
11
|
1 (9%)
|
0 (0%)
|
8 (73%)
|
10 (91%)
|
6 (55%)
|
I
|
6
|
5 (83%)
|
0 (0%)
|
2 (33%)
|
4( 67%)
|
2 (33%)
|
N
|
3
|
1 (33%)
|
0 (0%)
|
3 (100%)
|
2 (67%)
|
2 (67%)
|
T
|
3
|
2 (67%)
|
0 (0%)
|
3 (100%)
|
3 (100%)
|
3 (100%)
|
Presumed-healthy site
|
S
|
4
|
2 (50%)
|
0 (0%)
|
1 (25%)
|
2 (50%)
|
0 (0%)
|
I
|
9
|
5 (56%)
|
2 (22%)
|
2 (22%)
|
7 (78%)
|
2 (22%)
|
N
|
12
|
3 (25%)
|
0 (0%)
|
6 (50%)
|
10 (83%)
|
5 (42%)
|
T
|
12
|
6 (50%)
|
1 (8%)
|
9 (75%)
|
9 (75%)
|
5 (42%)
|
No: case number. S= superior limbus, I= inferior limbus, N= nasal limbus, T= temporal limbus.
|
Abnormal POV was detected through SD-OCT in the presumed-healthy fellow eyes diagnosed by slit-lamp biomicroscopy.
Five patients were found to have unilateral ocular surface disease, which was diagnosed by slit-lamp biomicroscopy (AWE group, cases 2 and 10; phlyctenular keratitis or ocular rosacea group, cases 11, 14, and 15). SD-OCT findings revealed abnormal POV in at least one quadrant in the presumed-healthy fellow eyes of four patients. In patients with unilateral AWE, a decreased epithelial thickness of the POV (case 2), loss of the smooth epithelial–stromal interface of the POV (case 2), dilated limbal vessels (case 2), and a decreased density of the POV (case 2) were detected through SD-OCT. In patients with unilateral phlyctenular keratitis/ocular rosacea, a decreased epithelial thickness of the POV (cases 11, 14, and 15), loss of the smooth epithelial–stromal interface of the POV (case 14), dilated limbal vessels (cases 14 and 15), and a decreased density of the POV (case 14) were detected through SD-OCT. These findings were similar to the abnormal pattern of the POV observed in the presumed-healthy sites of the contralateral diseased eyes.
Case presentation of AWE.
Figure 2 (a-j) shows the external eye photos, impression cytology findings, and SD-OCT scans of a 44-year-old woman with bilateral AWE in the superior limbus (case 1). The external eye photos and impression cytology findings demonstrated the typical advancing waves of conjunctival epithelial and goblet cells migrating onto the corneal surface at the superior quadrant. The radial cross-sectional OCT scan of the superior limbus in both the eyes showed loss of the smooth epithelial–stromal interface and dilated stromal vessels of the POV. Although no evidence of limbal involvement diagnosed by slit-lamp biomicroscopy was observed in other quadrants, a decreased epithelial thickness and dilated stromal vessels of the POV were observed in the inferior limbus (presumed-healthy sites) in both the eyes through SD-OCT. Figure 2 (k-m) demonstrates another representative case of AWE who was a 36-year-old man (case 3) with pathology at the superior limbus in both the eyes. The tangential cross-sectional scan demonstrated a decreased density of the POV in the superior limbus.
Case presentation of phlyctenular keratitis or ocular rosacea.
Figure 3 (a-k)) shows the eye photos of a 27-year-old woman with bilateral ocular rosacea (case 16). Typical findings of ocular rosacea, including facial erythema and bilateral meibomian gland obstruction, were found. Corneal neovascularization and infiltration in the superior and temporal limbus extending to the cornea were detected through slit-lamp biomicroscopy. The involved area also exhibited an unsmooth corneal surface, as observed through fluorescein staining. However, slit-lamp biomicroscopy showed no pathological change in the inferior limbus. Furthermore, SD-OCT findings revealed loss of the smooth interface between the epithelium and stroma and dilated stromal vessels of the POV in the superior limbus in both the eyes. A decreased epithelial thickness and dilated stromal vessels of the POV were also observed in the inferior limbus, and these were diagnosed as presumed-healthy sites through slit-lamp biomicroscopy. Figure 3 (l-s) demonstrates another case of unilateral ocular rosacea (case 11, a 20-year-old woman). In this patient, slit-lamp biomicroscopy showed prominent meibomian gland obstruction and diffuse corneal neovascularization with subepithelial infiltration in the right eye mainly in the lower half of the cornea. No corneal pathology was noted in the left eye (presumed-healthy eye) through slit-lamp biomicroscopy. However, some abnormal patterns of the POV were found in the left eye, including decreased epithelial thickness and decreased density of POV