21 year-old HIV negative African male (recently tested negative, per his report) who has been diagnosed in the past with "vernal keratoconjunctivits" (VKC). He has been on steroid eye drops (fluoromethalone, or FML) off and on for the past several years, to control his "VKC".
The patient states ALL of his eye symptoms (itching, ocular discomfort) started about 3 years ago, and he had no eye problems prior to this time. The depigmentation of the eyelids/periorbital skin began within the last 6 months to 1 year. He did not notice that some of his eyelashes are white. He is otherwise healthy. Extensive review of systems (hearing loss, tinnitus, other systemic problems) was completely negative.
Exam:
Visual acuity without correction: 6/5 OD, 6/5 OS (equivalent to 20/15 OD, OS)
Pupils: brisk, no RAPD in either eye
Eyelids: Periorbital vitiligo bilaterally, poliosis of eyelashes--greatest on the eyelashes on the nasal aspect of the upper lids. Deep pigmentation and fullness of caruncle on right and left (more prominent on left). (? caruncular oncocytoma?)
Anterior segment OD, OS: Conjunctiva clear, no perilimbal vitiligo. Corneas clear. Anterior chamber deep and quiet. Iris normal, no lenticular changes.
Posterior segment: No vitreous cell. Mild mid-peripheral pigmentary changes OD, very mild RPE changes in the fovea OS. No "sunset glow" fundus. Retina flat OD, OS.
This patient's diagnosis eludes me. Any thoughts? I have a few, but I will wait for others to throw out their ideas first, so as not to influence peoples' thoughts.
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| Periorbital vitiligo. He also had very dark areas. He almost appeared to have bilateral oncocytomas of the caruncle (?) as well (left worse than right). |
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| Left caruncle |
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| Periorbital vitiligo, bilaterally |
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| Dramatic poliosis |
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