Rings around Cones

Abstract

A 65 year old Caucasian male was referred for reduced vision related to suspected keratoconus in both eyes. His son was recently diagnosed to have keratoconus. Slit lamp examination revealed bilateral paracentral golden brown pigment arranged in a semicircle along the base of the cones, suggestive of Fleischer's rings. Although corneal topography confirmed bilateral keratoconus close examination of the Fleischer ring showed the pigment line to be made up of fine granules with an atypical vortex configuration at the nasal and temporal ends. The patient was on amiodarone for one year. Hence amiodarone related Vortex keratopathy was considered in the differential diagnosis. In vivo confocal microscopy (IVCM) revealed deposits within the epithelial and stromal layers consistent with amiodarone related keratopathy and not with a Fleischer ring. This case reinforces the clinical observation that any induced 'angulation' of the cornea; i.e abrupt change in steepness, influences the deposition/accumulation of pigment such as iron and even of other deposits such as those related to drugs.