Ophthalmic Images in Diverse Patient Populations

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Ambar Faridi, MD

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Ambar Faridi, MD

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Currently, a disproportionate number of textbook figures and photographs are of eye conditions in white patients. Many ocular conditions can appear differently in individuals of color or those with darker skin. The purpose of this page is to share images of both common and rare pathology of the external, anterior, and posterior segments in patients of color. The American Academy of Ophthalmology's Committee for Resident Education’s DEI workgroup initiated this image collection to serve as a source for education and future versions of the Basic and Clinical Science Course (BCSC) and other texts.

Visit the Academy website to learn more about its commitment to diversity, equity, and inclusion in the ophthalmic community and review educational resources related to DEI in ophthalmology.

A-C

Acanthamoeba keratitis

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  Classic clinical signs of Acanthamoeba keratitis. Ring-shaped infiltrate

Age-related macular degeneration

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  Fundus photographs (A, C, D) and fluorescein (B) and indocyanine green (E) angiographies of typical nAMD (A, B), nnAMD (C), and PCV (D, E) in Japanese patients. nAMD neovascular AMD; nnAMD non-neovascular AMD; PCV polypoidal choroidal vasculopathy.

Amblyopia

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  Strabismus. Strabismus is the most common underlying cause of amblyopia.With constant deviation of one eye, reduced vision occurs. Amblyopia is less likely when the deviation is intermittent or when the two eyes alternate fixation.

Amblyogenic ptosis

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  Amblyogenic ptosis, left eye.

Aniridia-associated keratopathy and nystagmus

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  Pars Planar Tube Surgery for Aniridia-Associated Keratopathy

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  Pars Planar Tube Surgery for Aniridia-Associated Keratopathy

Arlt's line

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  Arlt’s line: a horizontal linear scar found in the watershed area between the marginal and peripheral conjunctival vasculature.

Asteroid hyalosis

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  Asteroid hyalosis. Yellowish-white viterous opacities in Pakistani patient.

Bacterial orbital cellulitis with proptosis

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  Bacterial orbital cellulitis with proptosis (A) secondary to sinusitis (B) in a Black patient

Bardet-biedl syndrome

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  This infant with nystagmus related to retinal dystrophy also had polydactyly (arrow), which led to the diagnosis of Bardet-Biedl syndrome. Systemic features such as renal impairment emerge in later childhood.

Basal cell carcinoma (eyelid)

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  Basal cell carcinoma in Black patient.

Bilateral inferior oblique muscle overaction

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  Bilateral inferior oblique muscle overaction. Overelevation in adduction, seen best in the upper fields.

Bilateral scleral thinning

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  Bilateral nonspecific orbital inflammation (orbital pseudotumor) in an 11-year old Asian boy with a 1-week history of eye pain. Ocular rotation was markedly limited in all directions. CT confirmed proptosis and showed enlargement of all extraocular muscles. Laboratory workup was negative for thyroid disease and rheumatologic disorders. Complete resolution occurred after 1 month of corticosteroid treatment.

Blepharophimosis–ptosis–epicanthus inversus syndrome

• 

  Blepharophimosis–ptosis–epicanthus inversus syndrome (blepharophimosis syndrome) in Asian patient

Blue nevi

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  Images from a 71-year-old white Hispanic man. A, Slit-lamp photograph showing moderately pigmented lesions in the forniceal and adjacent palpebral and bulbar conjunctiva (arrow). B, Photomicrograph revealing densely pigmented spindled melanocytes containing copious intracytoplasmic pigment, consistent with blue nevus (arrow; stain, hematoxylin–eosin; original magnification, ×200). C, Photomicrograph demonstrating removal of melanin pigment with bleach and morphologically benign dendritic cells lacking prominent nucleoli (stain, permanganate bleach; original magnification, ×200). D, Photomicrograph demonstrating SOX10 staining (arrows) within the dendritic pigmented melanocytes (stain, SOX10 immunostain with red Chromagen; original magnification, ×400) E, Photomicrograph demonstrating CD68-positive melanophages (arrow) interspersed with the dendritic melanocytes (stain, CD68 immunostain with red Chromagen; original magnification, ×400).

Blue dot cataract

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  Blue dot cataract. Congenital dot-like opacities in the lens.

Blunt trauma and ruptured globe

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  Blunt trauma with orbital and eyelid edema

Brown syndrome

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  Brown syndrome. a. Child with left Brown syndrome has a hypotropia that is present with gaze up and to the right due to superior oblique restriction in the left eye. b. Eye movements and alignment are normal with gaze up and to the left.

Buphthalmos

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  Buphthalmos in the case of late presenting congenital glaucoma.

Carcinoma in situ

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  Carcinoma in situ

Cavernous hemangioma

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  Cavernous hemangioma. a. Normal exam and appearance. b, c. Axial MRI images demonstrate a well encapsulated, heterogeneously enhancing intraconal tumor in the right orbit. MRI findings of T1 hypointensity, and T2 hyperintensity, are useful in the differential diagnosis from neurofibroma, neurilemmoma, or hemangiopericytomas (these tumors share similar imaging characteristics on CT)

Chalazion

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  Chalazion.

Choroidal metastasis

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  A 65-year-old Asian woman (patient 4) presented with choroidal metastasis (A) from breast carcinoma of 3.1-mm thickness on B-scan ultrasonography (B). After photodynamic therapy, tumor regression was seen clinically (C) and ultrasonographically (D).

Cicatricial trachoma

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  Cicatricial trachoma (TS): presence of scarring in the upper tarsal conjunctiva.

CMV retinitis

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  Active CMV retinitis with adjacent toxoplasmic retinochoroidal scar in Brazilian patient.

Congenital glaucoma, buphthalmos

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  Newborn with congenital glaucoma (right eye), buphthalmos.

Congenital coloboma

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  True coloboma of the upper eyelid.

Congenital lacrimal–cutaneous fistula

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  Congenital lacrimal–cutaneous fistula draining to the skin surface.

Congenital nevocellular nevus

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  Congenital nevocellular nevus of the eyelid, present since birth.

Conjunctival granulomas

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  A 33-year-old African American female patient with conjunctival granulomas. Arrow, biopsy site. The insert shows the conjunctival biopsy that revealed nonnecrotizing granuloma.

Conjunctival papillomas

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  Conjunctival papillomas.

Conjunctival melanoma

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  Photographs showing conjunctival melanoma in various races. A, White man with (B) conjunctival melanoma resulting from nevus. C, African American woman with (D) conjunctival melanoma from primary acquired melanosis. E, Hispanic woman with (F) conjunctival melanoma de novo.

• 

  Conjunctival melanoma of mixed pigmentation. Slit-lamp photograph of a 41-year-old Hispanic man with a nodular, thickened conjunctival mass with amelanotic and melanotic areas and a prominent feeder vessel superotemporally. Systemic workup revealed distant metastases.

Conjunctival nevus

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  Conjunctival nevi are congenital hamartomas that consist of nests of modified melanocytes (nevus cells).

Corneal arcus

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  Corneal arcus.

Corneal dellen

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  Corneal dellen. The exposed end of vicryl suture produced dellen on the adjacent portion of the cornea.

Corneal ulcer

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  Central bacterial corneal ulcer in a patient with severe conjunctival and corneal scarring from trachoma. Streptococcus pneumoniae was cultured.

CRAO (dark choroid)

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  Fundus photograph of right eye showing severe whitening of retina and cherry-red spot at fovea (A 17-year-old female patient of Asian origin)

Crawford tube

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  A single Crawford tube is passed through both upper punctum and recovered from the right and left nares. The tube is then tied in a square knot between the nares.

Crosslinking surgical technique

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  Measurement of corneal pachymetry to ensure 400 μm thickness prior to UVA irradiation.

D-F

Dermoid cyst

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  Patient at São Tomé and Príncipe in Africa with dermoid cyst

Descematocele

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  Descematocele. Descement membrane is not disintegrated by the bacterial enzymes and so survives the destructive phase of corneal ulceration.

Diabetic retinopathy

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  Figure 1. Color fundus photograph of the left eye in case 1 in 1995 showing lipid exudates (arrow), cotton wool spots, and intraretinal hemorrhages of diabetic retinopathy as well as multiple refractile intraretinal crystals (arrowhead). Figure 2. Color fundus photograph of the left eye in case 1 in 2001 after focal photocoagulation for diabetic macular edema. The edema has completely resolved, and there are fewer intraretinal crystals, which are arranged in a pattern different from that in 1995. Figure 3. Color fundus photograph of the right eye in case 2 showing a frond of retinal neovascularization and many iridescent intraretinal crystals within the foveal avascular zone. Figure 4. Mid-phase fluorescein angiogram of the right eye in case 2 showing the perfused retinal neovascularization and the absence of any fluorescein angiographic sign of the crystals. Figure 5. Color fundus photograph of the right eye in case 2 one year after panretinal laser photocoagulation. Most of the crystals have resolved. Figure 6. Color fundus photograph of the right eye in case 3. The distribution of the intraretinal crystals follows the pattern of the distribution of intraretinal lipid from diabetic macular edema. The diabetic lipid exudates (arrow) can be distinguished from the refractile crystals (arrowhead).

Direct carotid–cavernous fistula (CCF).

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  Direct carotid–cavernous fistula (CCF). a. Untreated CCF with severe conjunctival chemosis and bilateral oculomotor nerve III palsy. b. Coronal CT images of the orbit demonstrate bilateral dilated superior ophthalmic veins, and enlargement of extraocular muscles. c. Coronal CT images of the cavernous sinus demonstrate convex bowing of the lateral wall. Carotid angiography provides definitive diagnosis. Doppler ultrasound may demonstrate retrograde blood flow in the superior and inferior ophthalmic veins.

Distensible venous malformation

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  Distensible venous malformation. A, Mild proptosis resulting from venous malformation of the right orbit. B, Fullness of the right superior orbit (arrow). Note the absence of dilated corkscrew conjunctival vessels. C, After Valsalva maneuver, proptosis of the right globe increases (arrow). D, T1-weighted axial MRI shows a venous malformation of the superior ophthalmic vein.

Dystopia canthorum

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  Dystopia canthorum in a patient with Waardenburg syndrome. Notice that the vertical lines drawn through the puncta intersect the cornea.

Ectopia lentis

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  Ectopia lentis (EL) is a major criteria for the diagnosis of Marfan syndrome, it may vary from an asymptomatic mild displacement to a significant subluxation that places the equator of the lens in the pupillary axis. Retroillumination image of ectopia lentis.

Entrapment

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  Orbital lymphomat. a. Right inferior rectus entrapment with inability to move the right eye upward past midline. b. Coronal CT scan demonstrating entrapment of the right inferior rectus muscle.

Epiblepharon

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  Epiblepharon. This condition commonly occurs in Asian patients on the lower eyelid.

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  Bilateral lower eyelid epiblepharon with persistent corneal irritation.

Episcleral vessels

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  Indian patient, “arterialized” Episcleral vessels

Exotropia

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  Exotropia, left eye (child)

Eyelid laceration involving the canaliculus

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  Repair of right lower eyelid laceration involving the canaliculus. A, Avulsion injury of the right lower eyelid. B, Lacrimal probe placed demonstrating the canalicular involvement. C, Lacrimal stent placement through the lacerated eyelid. D, Immediate postoperative result after reconstruction.

Fibrous dysplasia

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  Fibrous dysplasia. A, Facial asymmetry. B, CT scan shows characteristic hyperostosis of involved facial bones.

Fish-eggs phenomenon

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  Patient in Singapore - Right eye fish-eggs phenomenon with multiple gas bubbles following intravitreal injection of perfluoropropane gas.

Foveal hypoplasia

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  Right eye hypopigmented fundus with visible choroidal vessels and blunted foveal light reflex suggests foveal hypoplasia.

Fungal ulcer

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  Fungal corneal ulcers are common after vegetative ocular trauma. It can lead to a prolonged, devastating disease.

G-I

Gonococcal (neisseria) conjunctivitis

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  Gonococcal (Neisseria) conjunctivitis in an infant. Marked purulence is distinctive.

Granular corneal dystrophy

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  Characterized by Hyaline deposition in corneal stroma which stained with Mason Trichrome.

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  Granular corneal dystrophy.

Gunderson conjunctival flap

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  Gunderson conjunctival flap

Heerfordt syndrome sarcoid parotitis, lymphadenitis, and uveitis

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  Heerfordt syndrome: sarcoid parotitis, lymphadenitis, and uveitis. This 19-year-old woman had firm, nontender glandular and lymphadenopathic edema to the left side of her face with bilateral panuveitis.

Herpetic dendrite

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  Saudi Arabian patient with herpetic dendrite

Skin vesicles of herpes simplex virus

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  Skin vesicles of herpes simplex virus (HSV) dermatoblepharitis.

Hurler's syndrome

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  Hurler's syndrome, cloudy corneas

Horner-trantas dots

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  Horner-Trantas dots in vernal keratoconjunctivitis.

Human papillomavirus (HPV) infection

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  Conjunctival papillomas are associated with human papillomavirus (HPV) infection. In children, the lesions are typically manifestations of an infection acquired during delivery. In adults, conjunctival apillomas are most likely venereal and are often associated with anogenital lesions. Papillomas due to HPV more frequently rogress to malignancy in patients with the human munodeficiency virus (HIV) infection. Human papillomavirus types 6, 11, 16, and 18 have been identified in benign and malignant conjunctival lesions using various antigen and DNA detection techniques.

Intracorneal hemorrhage

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  Asymptomatic, peripheral visually insignificant Intracorneal hemorrhage seen in a patient with marginal keratitis.

Intralenticular metallic foreign body

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  Patient in IndiaIntralenticular metallic foreign body (IOFB) has been reported in 10% to 41% of open globe injuries. Mechanism of injury is predictive of the presence of IOFBs. High-velocity, relatively small particles are the most common foreign bodies found in the eye. Hammering, grinding, or shaving metal, machine yard work such as lawn mowing, and explosives exposure are particularly high risk.

Iris nodular nevi

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  Slit-lamp photograph of left eye of case 7 demonstrates diffuse iris nodules which are more prominent ipsilateral to her oculodermal changes.

Iris melanoma

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  Iris melanoma is the most common primary neoplasm of the iris and accounts for approximately 5% of all uveal melanomas.

Iris nevus

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  Slit-lamp photograph of a 4-year old Hispanic girl (case 1) shows multiple nodules distributed diffusely on the iris surface

J-L

Keratoglobus

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  Keratoglobus. Generalized protrusion of the cornea.

Kaposi sarcoma lesions

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  (A) Multiple Kaposi sarcoma lesions on bulbar conjunctiva. (B) High-power view of one such lesion reveals its vascular nature.

Keratopathy

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  Keratopathy: various degrees of severity. A, Mild keratopathy. B, Moderate keratopathy. C, Severe keratopathy.

Keratoprosthesis surgery

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  Patient 13, a 34-year-old male who was attacked with acid. A, Preoperative state: right eye, phthisical; left eye, light perception vision. B, Post–stage 2 osteo-odonto-keratoprosthesis surgery/retinal detachment surgery, 20/150 vision.

Laser peripheral iridotomy and anterior chamber angle

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  UBM photographs of the inferior angle of another subject before and after laser peripheral iridotomy that show flattening of the iris and the opening of the angle.

Lateral canthotomy/cantholysis

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  Surgical approach to the orbit combining lateral canthotomy/cantholysis, inferior transconjunctival incision, and medial Lynch (frontoethmoidal) incision. Lateral orbital rim bone removed.

Lattice lines

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  Lattice lines.

Lattice corneal dystrophy

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  Lattice corneal dystrophy (LCD) is an inherited disorder of the eye characterized by the deposition of amyloid resulting in steadily progressive loss of vision. These deposits create linear, “lattice-like” opacities arising primarily in the central cornea, while the peripheral cornea is often spared. They are radially oriented and are accompanied by gradual, superficial opacification of the cornea. Recurrent epithelial erosions are often present, causing ocular irritation and additional vision loss.

Lens-induced glaucoma

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  Lens-induced glaucoma. Old man presented with spontaneous anterior dislocated cataract which was extracted on emergency after instilling pilocarpine eye drops to prevent posterior dislocation and after one month a secondary IOL was placed with good visual recovery.

Lens-induced phacolytic glaucoma

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  Cloudy cornea in adult – a masquerade of phacolytic glaucoma. A 75 year-old female who in 1 weeks’ time had a total loss of vision, pain, redness, and total whitening of the right eye. Her vision in the right eye was PL + PR inaccurate and the left eye 6/12, N9 with glasses. Intraocular pressure was 60 in the right eye and 14 mm in the left eye. She was diagnosed as having cloudy cornea due to phacolytic glaucoma in the right eye. The patient was managed with I.v. mannitol, topical and systemic steroids, antiglaucoma medications to control IOP and reduce inflammation. After one week she underwent SICS+PCIOL implantation and she regained 6/9, N9 vision after s6 weeks postoperative

Lentigo maligna

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  Photograph demonstrating that the involved eyelid skin displays alternating regions of hyperpigmentation and depigmentation. Eyelid margin thickening and madarosis are present.

• 

  Lentigo Maligna of the Eyelid.

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  Photomicrograph demonstrating polygonal dendritic melano-cytes arranged in solitary units along the basal layer of the epidermis (stain,hematoxylin– eosin; original magnification, x100).

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  Photograph demonstrating a variably pigmented placoid lesion with irregular borders diffusely involving the left lower eyelid. Generalized eyelid thickening is present.

Lid and ocular surface manifestations in patients with xeroderma pigment

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  Lid and ocular surface manifestations in patients with xeroderma pigmentosum (XP). A, Conjunctival melanosis (arrows) in case 5, an 8-year-old Asian Indian XP-C patient (XP417BE). Note the feeder vessels to lesions (arrows). B, Early pterygium (arrowhead) and lid pigmentation (arrow) in case 2. C, Severe ectropion, entropion, and ocular inflammation in case 3. D, Lid margin keratinization (arrow) and loss of lashes in case 6, a 14-year-old patient (XP243BE). The patient has a history of skin cancer but no history of ocular surface cancer. Lentigines are present on the eyelids, and the patient has bilateral pterygium (arrowhead) and ectropion. The patient has decreased best-corrected visual acuity, possibly due to amblyopia. Localized corneal clouding at the leading edge of pterygium was suspicious for early malignancy, and biopsy was recommended.

Limbal vernal keratoconjunctivitis

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  Limbal vernal keratoconjunctivitis leading to pseudogerontoxin.

Lymphoproliferative lesion

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  A, Right upper eyelid ptosis and fullness with a palpable mass beneath the orbital rim. B, Coronal MRI demonstrating right lacrimal gland enlargement with infiltration of anterior orbital tissues. C, Axial MRI showing characteristic molding of the lesion to adjacent structures. D, Incisional biopsy of the abnormal infiltration of the lacrimal gland reveals orbital lymphoma (arrow).

M-O

Macular dystrophy of the retina, locus 1

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  Numerous yellow, drusen-like extramacular deposits were present in the retinal mid-periphery of all affected family members.

Macular hole

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  Color photo of macular hole in a patient from Singapore

Measurement of ptosis in primary gaze with ruler

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  Measurement of ptosis in primary gaze with ruler adjacent to frontal plane of face (MRD1); OD is 4 mm, OS is 1 mm.

Melanoma (conjunctiva)

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  Photographs showing conjunctival melanoma in various races. A, White man with (B) conjunctival melanoma resulting from nevus. C, African American woman with (D) conjunctival melanoma from primary acquired melanosis. E, Hispanic woman with (F) conjunctival melanoma de novo.

Metastatic carcinoma

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  A 37-year-old presented with ocular metastasis with primary ductal carcinoma of the left breast. The case presented with complaints of redness and pain OS for 1 month, and there was a past history of a left modified radical mastectomy 3 years previously at the same institution where the patient didn’t complete the chemotherapy. On examination, OD-within normal limits, OS lids appeared edematous, circumcorneal congestion with prominent episcleral vessels seen, anterior chamber had exudative deposits and 1+ grade of cellular activity present, iris was atrophied from 3’o-5’o clock hours.

Microsporidial keratoconjunctivitis

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  a, Slit-lamp biomicroscopy of the conjunctiva of patient no. 6 showing diffuse conjunctival congestion with papillary changes. b, Conjunctiva of patient no. 8 shows conjunctival congestion with follicles.

• 

  Pathology slide, microsporidial Keratoconjunctivitis scrapings

Morning glory disc with exudative RD

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  Morning glory syndrome with serous retinal detachment. Enlarged and funnel-shaped excavation of right optic disc with hyperplastic glial tissues in the central disc, peripapillary pigment abnormality, multiple anomalous straight vessels radiating circumferentially from the optic disc, inferior serous retinal detachment from 3 to 9 o'clock.

Molluscum contagiosum

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  Giant eyelid molluscum contagiosum in a child with AIDS. A 6-year-old boy presented with a 3-month history of multiple, pedunculated, nodules with a central umbilication (Fig 1A). A clinical diagnosis of molluscum contagiosum was made and investigations revealed HIV infection with a CD4 count of 124/ml3. Highly active antiretroviral therapy (HAART) was initiated. The larger lesions were excised (Fig 1B). Characteristic eosinophilic intracytoplasmic inclusion bodies were seen on histopathologic examination (Fig 1C; hematoxylin-eosin 40). The child is currently on maintenance therapy with HAART with no recurrence of the lesions.

• 

  Molluscum contagiosum lesions on eyelid in Black patient

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  Molluscum contagiosum in an African American patient

Mucopolysaccharidosis

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  Mucopolysaccharidosis. Corneal deposit disease.

Munson sign

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  Munson sign. Note the angulation of the lower eyelid with the eye in downgaze.

• 

  Munson's sign in keratoconus.

Neovascular glaucoma

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  Rubeosis iridis in a Pakistani patient

Nevus of ota (eyelids)

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  The slate-gray pigmentation involving the sclera and periorbital area is characteristic of oculodermal melanocytosis (nevus of Ota). Oculodermal melanocytosis is associated with an increased risk of pigmented tumors, such as choroidal melanoma.

Grades of ocular surface squamous neoplasia

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  Photographs of a pterygium and various grades of ocular surface squamous neoplasia: pterygium (A), conjunctiva intra-epithelial neoplasia (CIN) 1 (B), CIN 3 (C), carcinoma in situ (D), squamous cell carcinoma (SCC) grade 1 (E), SCC grade 2 (F), SCC grade 3 (G), and SCC with orbital invasion (H).

Overaction of left inferior oblique

• 

  Overaction of left inferior oblique.

P-R

Papillary conjunctivitis

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  Papillary reaction of bulbar conjunctiva. Conjunctival papillae are most commonly found on bulbar conjunctiva, have a vascular core and are a sign of inflammation.

Primary acquired melanosis (PAM)

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  PAM in a Black patient

Pterygium

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  A Case of inflamed nasal pterygium with cystic degeneration. ccentuates tear film abnormality causing adjacent Dellen or excavation of cornea.

Congenital ptosis

• 

  Congenital ptosis

S-Z

Scleromalacia perforans

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  Scleromalacia Perforans from Long-Standing Bulbar Conjunctival Rhinosporidiosis. A 12-year-old child presented with a 6-month old painless, reddish-blue swelling superior to the upper limbus (Fig 1A). Scleral thinning with uveal show and a conjunctival mass with dot-like, yellowish-white surface excrescences were noted. Excision with a donor scleral patch graft was performed (Fig 1B). Histopathology showed partially separated squamous metaplastic epithelium(Fig 1CeD,), edematous stroma, and numerous thick walled sporangia indicating rhinosporidiosis. Several of these appeared degenerated and empty. Others showed granular debris material (Fig 1C, Hematoxylin-Eosin; Fig 1D, Gomori’s MethenamineSilver 400). Ocular rhinosporidiosis most commonly involves the tarsal conjunctiva. Scleral melt from bulbar conjunctival rhinosporidiosis is known but extremely rare.

Squamous cell carcinoma

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  Ethmoid sinus squamous cell carcinoma in a Black patient. A, Photograph shows fullness of the medial canthal area overlying the mass. Axial (B) and coronal (C)

• 

  Squamous cell carcinoma (SCC) grade 1 in a Black patient

• 

  Squamous cell tumor of conjunctiva in African patient.

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  Conjunctival SCC with prominent leukoplakia developed in a 64-year-old African American man with 5 years of known HIV

• 

  Slightly pigmented conjunctival SCC developed in a 44-year-old Hispanic man with 3 years of known HIV