Pictionary of Eye

Dr. Parthopratim Dutta Majumder
Published Online: August 29th, 2009 | Read Time: 10 minutes, 27 seconds

It is a human tendency to compare everything with day-to-day life happening, objects around them. Proverbs are one such example; theygive some form oflifeadvice with examples of very commonly occurring incidents/things in our daily life. In medical science, we often come across such analogical expressions that had been picked up from some common objects. Because of the resemblance with the morphological appearance of a clinical entity, such analogical terminology often help us to understand the clinical entity in a more straightforward way. In the “Pictionary” section, I have tried to highlight few such terminologies. Please mail me (drparthopratim@gmail.com) the terminologies I have missed here

Animal Fat :

Animal Fats are used in describing mainly two terminologies in ophthalmology. The first one is mutton-fat keratic precipitates. Large greasy-appearing aggregates of inflammatory cells on the corneal endothelium, typically seen in granulomatous anterior uveitis, are termed as “Mutton Fat” Keratic precipitates. The second one is sparsely used in current ophthalmology literature. The term "Chicken Fat" appearance is often used to denote old vitreous hemorrhage due to its characteristics color and appearance in fundus examination.

Bag of Worm appearance:

The term “Bag of Worms” is used in medical science to describe various clinical conditions, and is mainly used to denote the palpation findings of a clinical lesion. ( cf. Isolated retinal racemose hemangioma has been described as a lesion with a “Bag of Worms” appearance). Usually, the term reflects the density of the lesion that has a multi-vermiform pattern.

In ophthalmology, “Bag of Worms” Plexiform neurofibroma consists of proliferation within a nerve sheath, which produces a markedly thickened, tortuous nerve. On palpation, it has been described as resembling a bag of worms.

Bread crumb appearance:

Bread crumbs are small particles of dry bread, which are used for breading or crumbing foods. Granular corneal dystrophy shows discrete stromal opacities with the appearance of bread crumbs. This dystrophy results in hyaline material deposition which appears early in life as discrete. Also snowflakes or "rock candy" is used describe the similar appearance of granular corneal dystrophy. Bread crumbappearance is also used to describe the polychromatic luster in complicated or diabetic cataract

Cracked Mud appearance:

Cracked mud represents drying and contraction of muddy sediment that results due to a reduction in water content. The classical picture of Cracked Mudappearance can be seen in the end-stage Progressive Outer Retinal Necrosis (PORN), where dense white, plaque-like scarring with retinal atrophy occurs. Perivascular sparing of the lesions are responsible for such an appearance.23

Candle wax drippings:

Candle wax dripping, an appearance resembling melted candle wax guttering is synonymous with sarcoidosis. Yellow-white, waxy retinal exudates that appear to stream along retinal veins are seen in sarcoidosis. These are usually referred to as candle wax drippings and are often found in the inferior equatorial retina and occasionally in the posterior pole.

Cartwheel appearance:

The Cartwheel pattern has been described to corelate various structural and pathological morphology. The foveal schisis characteristically creates a cartwheel pattern formed by folds in the internal limiting membrane overlying microcyst within the nerve fiber layer.

Champagne Cork appearance:

It is said that a French monk named Dom Pérignon invented the cork to seal the champagne bottle after he saw Spanish travelers using tree bark to plug their water gourds. Whatever it is, champagne cork appearance is encountered in the late stages of papilloedema, the optic disc takes the appearance of the dome of a champagne cork

Ground Glass appearance

This is the appearance of glass whose surface has been ground to produce a flat but rough (we often term it as matte) finish. Compared to the other terminologies discussed here, this description is very nonspecific and can be seen in various ophthalmic conditions describing opacification. Examples include loss of corneal transparency as in Toxic anterior segment syndrome, keratitis, and various conditions, retinitis in ocular syphilis, etc.

Headlight-in-a-fog appearance:

The headlight of a car shining through the fog at night is often used to describe the typical lesion of toxoplasma retinochoroiditis. In toxoplasmosis, the acute lesions are elevated with indistinct hyperpigmented borders and most often are located in the posterior pole. Ophthalmoscopy is frequently obscured by a dense vitreous exudate or haze, giving the classic "headlight-in-a-fog" appearance.

Pizza pie appearance

Pizza is a world-popular dish of Italian origin. The term pizza pie is dialectal, and pie is used for simplicity in some contexts, such as among pizzeria staff. In ophthalmology,this word is used to describe the typical lesions of cytomegalovirus retinitis which resembles a pizza pie with an admixture of white (retinal inflammation) and red (hemorrhage) colors. The juxtaposition of large zones of whitish, granular necrosis, next to red retinal hemorrhage has led this presentation of CMV retinitis to be called either "pizza-pie" or "cheese and ketchup."

Port-wine stain

Port-wine is a sweet, red, Portuguese fortified wine produced in the Douro Valley of northern Portugal. The hallmark of Sturge-Weber syndrome is frequently described as a port-wine stain and this comparison refers to nevus flammeus. Nevus flammeus is a discoloration of the human skin caused by a vascular anomaly (cavernous hemangioma) and is found in the distribution of first, first and second, or first, second and third divisions of the trigeminal nerve. It is most often unilateral and respects the midline. It is present at birth and sometimes darkens with age.

Salt andpepper appearance

The combination of salt and pepper can be found on every dining table. The tradition of using this combination was originated from 17th-century French cuisine. In ophthalmology,the word “salt and pepper" is used to denote the fundus picture. For example, fundus picture of congenital rubella, in which focal patches of retinal pigment epithelial hypopigmentation (salt) alternate with hyperpigmentation (pepper)is seen.

Scrambled egg appearance:

Scrambled egg is a dish made from eggs stirred or whipped while being gently heated, typically with salt and oil.

The solid yellow egg yolk macular lesion is neither common in vitelliform macular dystrophy/ Best's disease nor is it pathognomonic for this disorder. When it does occur the patient is usually asymptomatic with 6/6 vision. When this egg yolk "ruptures" the vision will then diminish. The appearance of the "scrambled egg" or "pseudohypopyon" maculopathy is well recognized.

Sunset Glow appearance:

The typical sunset glow like appearance occurs in the convalescent or recovery or chronic stage of Vogt-Koyanagi-Harada disease which is characterized by depigmented pale fundus.

Swiss cheese appearance

Swiss cheese is a cheese from Switzerland, often termed as emmental or Emmentaler. it is a yellow, medium-hard cheese, with characteristic large holes. Few bacteria are used for the production of these cheeses. In the late stage of cheese production, there is release of carbon dioxide gas, which slowly forms the bubbles that make holes.

In ophthalmology,the word, swiss cheese is used to describe a variety of lesions. In Band Keratopathy, small lucid areas are noted in the opacity, representing regions where corneal nerves penetrate Bowman's layer. This characteristic picture of band keratopathy is described as a “swiss-cheese” appearance. Also in resolving stages of acute retinal necrosis, retinal pigment epithelium perturbation develops with areas of clearing in the fundus which form a characteristic “Swiss-cheese appearance”.

Tobacco Dust appearance:

Pigmented cells in the vitreous seen in retinal detachments are often compared with tobacco dust.

Tomato Ketchup appearance:

Ketchup is used as a general term for sauce. In Sturge-Weber syndrome, diffuse choroidal hemangioma appears as a broad red-range thickening of the posterior choroid. The tumor appears more red than the background fundus, a finding sometimes called the "tomato ketchup" fundus.

Dr. Parthopratim Dutta Majumder
Sankara Nethralaya, Chennai
Dr. Parthopratim Dutta Majumder completed his graduation and post-graduation from Silchar Medical College & Hospital, Assam University. He completed his fellowship in Medical retina and Uvea from Sankara Nethralaya and joined department of uvea and intraocular inflammation. He was awarded with Dr. TLK Row Endowment Award for the best associate consultant 2010-11. He had received Dr. Nataraj Pillai award and Dr K. R. Dutta award for best paper. He has attended and presented paper in various national and international conferences. His areas of interest include medical management of uveitis and scleritis, phacoemulsification in uveitic cataracts. He is now working as senior consultant in department of uvea & intraocular inflammation, Sankara Nethralaya, Chennai. He has published many articles in various peer and non-peer reviewed journals. He is reviewer of various ophthalmology journals and has served Indian Journal of Ophthalmology as section editor from 2015-17. He has written 56 chapters in various ophthalmology books and edited four books.
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