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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 35-36

Unusual “fish bone pattern” epitheliopathy

1 The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
2 Jasti V Ramanamma Children's Eye Care Center, L V Prasad Eye Institute, Hyderabad, India
3 The Centre of Excellence for Rare Eye Diseases, L V Prasad Eye Institute, Hyderabad, India

Date of Submission13-May-2020
Date of Acceptance28-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Muralidhar Ramappa
Head, Centre of Excellence for Rare Eye Diseases, Consultant, the Cornea Institute and Jasti V Ramanamma Children's Eye Care Center, L V Prasad Eye Institute, Kallam Anji Reddy Campus, Banjara Hills, Hyderabad - 500 034, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1461_20

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Keywords: Alcohol kerato-epitheliectomy, hypertrophic epithelium, neurotropic keratopathy

How to cite this article:
Rajarajan M, Muthukumar B, Kapoor R, Ramappa M. Unusual “fish bone pattern” epitheliopathy. Indian J Ophthalmol Case Rep 2021;1:35-6

How to cite this URL:
Rajarajan M, Muthukumar B, Kapoor R, Ramappa M. Unusual “fish bone pattern” epitheliopathy. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Mar 2];1:35-6. Available from: https://www.ijoreports.in/text.asp?2021/1/1/35/305485

A 13-year-old female presented with the history of whitish discoloration and decreased vision in both eyes since 3 years, more-so in the right eye (RE). She denied antecedent history of fall of foreign body (FB) or trauma. Best corrected visual acuity was 20/80 and 20/40 in the right and left eye (LE), respectively. Slit-lamp examination of RE showed the presence of central corneal nebulo-macular opacity at the mid-stromal level with an overlying irregular epithelial hyperplasia in an unusual pattern [Figure 1]a. Upper and lower tarsal plate inspection did not reveal any retained FB, focal subtarsal scarring, or conjunctival concretions. Corneal sensations were absent. The LE cornea revealed a faint anterior mid-stromal scar. The Schirmer's test 1 reading was 14 and 16 mm in RE and LE, respectively, at 5 min. Child was diagnosed to have hereditary sensory autonomic neuropathy (HSAN) type 4, isolated trigeminal anesthesia. Gentle epithelial debridement using dilute isopropyl alcohol (20%) in the RE with bilateral two-third width permanent tarsorrhaphy was done. Post alcohol kerato-epitheliectomy, a bandage contact lens was placed and the patient was started on topical antibiotics and lubricants. This intervention resulted in the resolution of corneal lesions [Figure 1]b along with scar remodeling, the same can be appreciated on the postoperative anterior segment OCT image of the RE [Figure 2].
Figure 1: (a) Digital photo graft of the right eye captured through a slit-lamp bioscope discerning the central anterior stromal scarring with an epithelial hypertrophy “Fish bone” pattern. (b) Postoperative 1-month picture of the right eye after alcohol kerato-epitheliectomy and lateral paramedian tarsorrhaphy

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Figure 2: Postoperative anterior segment OCT image of the RE showing scarring at the anterior-mid stromal level

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  Discussion Top

Neurotrophic keratitis (NK) is a degenerative corneal condition where the trigeminal nerve impairment results in epithelial breakdown, persistent epithelial erosions, and sterile corneal ulceration resulting in visual axis destruction or perforation due to progressive stromal melt.[1] Mackie classified NK into three clinical stages. In Stage I, there occurs geographic dry spot formation with a confluent punctate epithelial keratopathy, if left untreated, it may lead to varying degrees of epithelial hyperplasia with stromal scarring. Stage 2 presents with persistent nonhealing epithelial defect, and in Stage 3, sterile ulceration ensues.[2] The patient's clinical history should be scrutinized to identify regional/systemic causes for corneal anesthesia.[3] In our patient, the aim was to prevent epithelial breakdown and improve ocular surface stability, which was accomplished by performing epithelial debridement and expedited two-third width permanent tarsorrhaphy. In this photoessay, we highlight an unusual “fish bone pattern” of epithelial hyperplasia in a case of NK perhaps due to HSAN.


We thank our diagnostic and photographic teams of L V Prasad Eye Institute, Hyderabad KAR Campus, for their support in patient management and documentation of the clinical pictures and investigations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None of the authors have any commercial interests related to materials or techniques described to disclose.

Conflicts of interest

There are no conflicts of interest.

  References Top

Sacchetti M, Lambiase A. Diagnosis and management of neurotrophic keratitis. Clin Ophthalmol 2014;8:571-9.  Back to cited text no. 1
Mackie IA. Role of the corneal nerves in destructive disease of the cornea. Trans Ophthalmol Soc U K 1978;98:343-7.  Back to cited text no. 2
Versura P, Giannaccare G, Pellegrini M, Sebastiani S, Campos EC. Neurotrophic keratitis: Current challenges and prospects. Eye Brain 2018;10:37-45.  Back to cited text no. 3


  [Figure 1], [Figure 2]


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