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“Glowing in the dark” and “cloud with a golden lining” – novel slit-lamp biomicroscopic findings in intracorneal epithelial cyst
*Corresponding author: Daisy Rani Das, Department of Cornea, Sri Sankaradeva Nethralaya, Guwahati, Assam, India. daisydas23@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Das DR, Raj M, Agarwal BM. “Glowing in the dark” and “cloud with a golden lining” – novel slit-lamp biomicroscopic findings in intracorneal epithelial cyst. Lat Am J Ophthalmol. 2025;8:10. doi: 10.25259/LAJO_5_2025
Abstract
Intrastromal corneal epithelial cysts are rare lesions. We report a case of intracorneal cyst in a 14-year-old female, where we demonstrated a unique finding on slit-lamp biomicroscopy. The lesion was seen to scatter light from the retroillumination beam to appear as “glowing” against the dark background. Another unique finding is the demonstration of “glittering” of the light beam at the edges of the intracorneal cyst by a slight change in the angle of retroillumination. We have coined these two unique slit-lamp retroillumination findings as “glowing in the dark” and “cloud with a golden lining”. These two novel findings may serve as valuable clinical diagnostic tools to identify intracorneal epithelial cysts on slit-lamp examination.
Keywords
Cloud with golden lining
Epithelial cyst
Glowing in the dark
Intracorneal cyst
INTRODUCTION
Intrastromal corneal cysts of epithelial origin are rare, non-inflammatory lesions.[1] It can be primary (congenital) or secondary (acquired) in origin. Benign lesions can cause visual disturbances, eye discomfort, and cosmetic problems. Primary corneal cysts occur during embryonic development due to invagination of epithelial cells.[2] Secondary cysts occur when the surface epithelium is migrated to substantia propria of intraocular tissue following trauma, inflammation, and ocular surgery such as cataract, pterygium excision, squint surgery, scleral buckling, and glaucoma drainage device insertion.[3,4] Due to the greater turnover of surface epithelium in children than in adults, the majority of reported cases occur in children.[1,5] The presentation usually involves an obvious lesion noted by the patient and a parent. The cysts are usually oval or circular and may be loculated.[5] Intrastromal corneal cysts characteristically lack redness, enlarge over time, and induce high amounts of astigmatism.[1,6]
CASE REPORT
A 14-year-old female presented with the chief complaint of a whitish opacity in her right eye for 1 year. It was gradual in onset, painless, and had increased in size. No associated decrease in vision, pain, or redness was observed. The patient had no history of ocular surgery or trauma. The best-corrected visual acuity in both the eyes was 20/20. Slit-lamp biomicroscopy (Haag-Streit UK Ltd., Hertfordshire, U.K.) revealed normal conjunctiva and a well-defined whitish, fluffy patch in the mid-stromal layer of the right cornea extending from 9 to 12 o’ clock, measuring approximately 4 mm vertically and 4.5 mm horizontally [Figure 1]. A unique finding was seen on direct retroillumination where the lesion was seen to “glow in the dark” [Figure 2]. In addition, the lesion was demonstrated to mimic a “cloud with a golden lining” with a <10° offset in the direct retroillumination angle [Figure 3]. There was no associated infiltration or vascularization. The corneal reflex was normal. The rest of the anterior segment findings were normal. The anterior segment findings in the left eye were within normal limits. Intraocular pressure was normal in both eyes. Fundus examination results were within normal limits in both eyes. Anterior segment optical coherence tomography (Spectralis, Heidelberg Engineering, Heidelberg, Germany) of the right cornea suggested hyperreflective thickening of the anterior stroma with an intact overlying epithelium. A localized pre-descematic cyst adjoining the limbus at the 9–12 o’ clock meridian was observed [Figure 4]. The endothelial cell counts in both eyes were within normal limits, and a diagnosis of a congenital intrastromal corneal cyst in the right eye was made. As the patient had good vision and parents were reluctant to undergo any surgical measures, a decision for conservative management and follow-up was made.
- Slit-lamp biomicroscopy image of an intracorneal cyst.
- “Glowing in the dark” sign of intracorneal cyst on retroillumination.
- “Cloud with a golden lining” sign of intracorneal cyst on retroillumination.
- Anterior segment optical coherence tomography image showing hypereflective thickening of anterior stroma with a homogenous cystic lesion. Green arrow indicates the optimal positioning and orientation of the scan.
DISCUSSION
Intrastromal corneal epithelial cysts are rare lesions.[1] Corneal cysts were first described by Appia in 1853.[7,8] Few articles suggest the migration of surface epithelial cells into the corneal stroma and the proliferation of these cells following trauma or any intraocular procedure or surgery. We report a unique finding on slit-lamp biomicroscopy, in which the lesion was seen to scatter light from the retroillumination beam to appear as “glowing” against the dark background. Another unique finding is the demonstration of “glittering” of the light beam at the edges of the intracorneal cyst by a slight change in the angle of retroillumination. We have coined these two unique slit-lamp retroillumination findings as “glowing in the dark” and “cloud with a golden lining,” which, to our knowledge, is the first to be reported. These findings may be used as valuable clinical diagnostic tools to identify intracorneal epithelial cysts on slit-lamp examination.
CONCLUSION
“Glowing in the dark” and “cloud with a golden lining” are two novel findings in the slit-lamp biomicroscopic examination of intracorneal epithelial cysts that may serve as useful clinical diagnostic signs of this rare condition.
Ethical approval:
The Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Management of an intrastromal corneal epithelial cyst, from simple drainage to keratoplasty. Oman J Ophthalmol. 2012;5:196-7.
- [CrossRef] [PubMed] [Google Scholar]
- Atypical manifestation of conjunctival epithelial inclusion cyst: A case report. Case Rep Ophthalmol. 2014;5:239-42.
- [CrossRef] [PubMed] [Google Scholar]
- Tenon's cyst presenting as a long-term complication following incision cataract surgery. Case Rep Med. 2013;2013:759267.
- [CrossRef] [PubMed] [Google Scholar]
- Conjunctival inclusion cysts following small incision cataract surgery. Indian J Ophthalmol. 2010;58:423-5.
- [CrossRef] [PubMed] [Google Scholar]
- Corneal cysts. A report of eight cases. Arch Ophthalmol. 1971;86:648-52.
- [CrossRef] [PubMed] [Google Scholar]
- Surgical excision and distilled water lysis of a congenital corneal intrastromal cyst. Am J Ophthalmol Case Rep. 2020;19:100864.
- [CrossRef] [PubMed] [Google Scholar]
- Un cas de kyste congenital sclerocorneen. Ophthalmologica. 1947;114:371-6.
- [CrossRef] [Google Scholar]
