 Don't worry, mine's quick. My name's Lauren Invernoni and I'm a fourth year medical student at the University of Arizona in Tucson, Arizona. I'm here doing a four week research rotation with Dr. Mosha Farr and today I'm going to present one of his patients titled a case report of recurrent epithelial irregularity. So the patient is a 69 year old male who presented first to his general ophthalmologist with complaint of blurry vision in the left eye associated with a foreign body sensation that had been going on for the last two years. His past medical history was basically non-contributory except for a corneal abrasion in the left eye five months prior to this initial presentation. On exam he was found to have male blepharitis in both eyes, mild interior subcapsular cataract in both eyes and in the left cornea he was found to have superficial punctate keratopathy that became confluent at the superior limbis as well as a dendritic pattern of irregular epithelium that's stained with fluorescein. So this patient was initially treated for chronic herpes dendritic keratitis. He was treated with Zergan, Belcyklavir and artificial tears and then two weeks later was started on omnipred drops. After this course of treatment his vision fluctuated between 2060 and 2100 and the epithelial lesions never fully resolved. After 19 weeks a superficial keratectomy and culture were performed. The stain was negative for amoeba and the PCR was negative for herpes symplex and varicella. At this point the patient was started on doxocycling and referred here to the Moran for further workup and treatment. So on presentation here the best corrected visual cutie in the left eye was 2100 and the slit lamp examination showed raised areas of thickened punctate epithelium which originated here at the superior limbis and then extended inferiorly in an hourglass distribution. And then here you can see a closer image of these epithelial infiltrates. This shows the fluorescein stain. You can see a little uptake of dye up here but no clear epithelial defects. Also if you look up here at the superior limbis you can see tortuous blood vessels. And then this photo shows the ocular panace along the superior limbis. Here we have a pentakam image. This shows hyperreflectivity in the central corneal epithelium so you can see that on the left eye whereas in the right it's normal. And then we have the topography of the cornea. You can see in the left eye there's some irregularities in the area of the epithelial infiltrates. So to summarize we have a 69 year old male who presents with a several month history of unilateral punctate epithelial infiltrates, a dendritic pattern of a regular epithelium and ocular panace along the superior limbis who has been unresponsive to antiviral, antibiotic and anti-inflammatory treatment. So does anyone have any ideas for the differential they'd like to share? So we have a broad differential for this patient. He was initially treated for herpesimplex dendritic keratitis based on the dendritic pattern seen when he initially presented. However, he did not respond to this treatment and also the PCR was negative. Floppy eyelid syndrome can also cause a superficial punctate keratopathy basically if the eyelid is accidentally averted during sleep. This leads to corneal exposure. SLK or superior limbal keratoconjunctivitis could also explain some of these findings specifically the thickening inflammation and injection at the superior limbis. However, this is often bilateral and in our patient it was unilateral. Recurrent corneal erosion is also considered as this can also cause a punctate keratopathy. However, this is usually very painful. A localized limbal stem cell deficiency was considered as well as rosacea, blepharoceratitis and last we have ocular surface squamous neoplasia. So this includes both congenitival and corneal intraepithelial neoplasia or CIN and most commonly originates at the limbis. So for this patient based on his clinical course and the exam findings CIN was thought to be most likely. So preliminary diagnosis of CIN was made and the patient was started on interferon drops. After three and a half months the visual acuity in the left eye had improved to 2015 and the cornea showed no more evidence of CIN. You can see here this image was taken one month after interferon was started and there's no evidence of the epithelial infiltrates. And you can also see that the ocular panacea is resolving. So then I've included a brief discussion on CIN. It's relatively rare seen most often in older males with lightly pigmented skin and hair. Other risk factors include UVB radiation, HPV, heavy smoking and petroleum exposure. It can present as blurry vision and foreign body sensation as it did in this patient. But it can also be completely asymptomatic. On exam it's characteristically located at the limbis like we saw here. It can appear gelatinous but can also be leucoplacic or papilla form and it's often associated with tufts of blood vessels. Traditional treatment for CIN is surgical excision with chirotherapy. However more recent treatments include topical chemotherapy such as interferon, mydomycin C, 5-fluoriracil and retinoic acid. The topical chemotherapies are good for lesions that are flat or small and would be difficult to surgically resect. And there's actually a lower recurrence rate when treated with the topical chemotherapy compared to excision. The prognosis with treatment of CIN is good. The lesions are slow growing and have a low malignant potential. So in conclusion this case is an unusual presentation of a relatively rare disorder. CIN can be difficult to diagnose because it's easily mistaken for a variety of other disorders. So it's important in patients like this who are refractory to treatment and have had this going on for years, it's important to have a high clinical suspicion. And I'd like to thank Dr. Moshe Farr and Dr. Muthapam. Are there any questions? Well, sometimes a general pathologist in others can miss a cell in a good case. Thank you.