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A 54-year-old man with bilateral symmetrical circular corneal opacities
Digital Journal of Ophthalmology 2020
Volume 26, Number 2
June 21, 2020
DOI: 10.5693/djo.03.2019.12.001
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Colm McAlinden, MD, MB BCh, BSc (Hons), MSc, PhD, MRCOphth | Department of Ophthalmology, Princess of Wales Hospital, Bridgend, United Kingdom
Christopher P. R. Williams, BSc (Hons), MB BCh (Hons), MRCP, FRCOphth | Department of Ophthalmology, Princess of Wales Hospital, Bridgend, United Kingdom
Diagnosis and Discussion
This unusual presentation of circular stromal opacities was comprehensively investigated, and no identifiable cause was found. Only a small number of similar idiopathic cases have been reported in the literature,(1) the first being described by Ascher in 1963.(2)

The absence of corneal vascularization and symmetrical appearance may point more toward a degeneration or dystrophy, such as a phenotypic variation of a stromal dystrophy, with perhaps the most similar being Schnyder corneal dystrophy.(7) The degenerations of crocodile shagreen and Vogt’s limbal girdle differ in appearance, as does the Hudson-Stähli line in iron deposition, Stocker’s line in keratoconus, and posterior embryotoxon.

Other alternative considerations are immunological and infective responses such as Coats white ring, Wessely immune ring, Gram-negative rods, fungi, herpes simplex/zoster, and Acanthamoeba. However, none of these fit the history and clinical features of the present case. Other differentials include immunoglobulin deposition as part of a multiple myeloma, which was excluded in our case.(8)

Corneal opacities may be secondary to a wide array of etiologies, including trauma, infection, or inflammation. They may also result from drug deposition, metabolic disorders, and corneal dystrophies or degenerations. It is important in such rare presentations to take an accurate history and to arrange appropriate investigations. The perfect circular shape and isolation in the midperipheral cornea suggest that this case likely represents deposition from an unknown material.