Letters to the Editor

Up-irrigation of dropped nuclear fragments

during phacoemulsification with the bimanual

irrigation-aspiration system

Periklis D. Brazitikos, Sofia Androudi, Alexandros Alexandridis,

Panagiotis Ekonomidis and Nick T. Papadopoulos

Department of Ophthalmology, Aristotle University, Thessaloniki, Greece

Sir,

N ucleus sinking in the vitreouscavity following extensive pos-

terior capsule rupture is one of themost serious complications of lens phaco-emulsification. Retained lens fragmentsin the vitreous, which can manifestpostoperatively as elevated intraocularpressure, marked inflammation,cystoid macular oedema or retinaldetachment, need to be removed (Kimet al. 1994; Irvine et al. 1992).Nuclear fragments located in the

anterior chamber or mid-vitreous cav-ity are often retrieved immediately withinjection of viscoelastic or aspirationwith phacoemulsification or a vitrect-omy probe. However, aspiration withinthe vitreous gel can be dangerous andsubstantial traction on the retina mayresult in the formation of retinal tears(Aaberg et al. 1997). We describe a sur-gical method of elevating the droppednuclear pieces from the vitreous cavitytowards the anterior chamber withthe use of the bimanual irrigation-aspiration system (Buratto 1998) with-out activating aspiration within thevitreous gel.The bimanual irrigation-aspiration

system (Graf, (Mediconsult, Switzerland)consists of two independent 20-gaugeprobes. One probe has a superior0.3mm opening for aspiration and theother probe has two 0.3mm sideopenings for irrigation. The probes areconnected to the aspiration and irriga-tion tubing lines of a phacoemulsificationsystem for aspiration of the remainingcortex after phacoemulsification of thenucleus.We successfully used the bimanual

irrigation-aspiration system to up-irrigatenuclear fragments dropped in thevitreous because of posterior capsulerupture during lens phacoemulsifica-

tion in three patients in whom thenuclear fragments were stabilized inthe anterior and mid-vitreous cavities.The irrigation probe was insertedthrough a side port incision and placedbeneath the lens fragment. Externalscleral depression with the aspirationprobe was helpful in visualizing thenuclear fragment when it was peripher-ally dislocated and hidden by the iris.Thereafter, irrigation was activatedwith the pedal of the phaco unit, displac-ing the lost fragment towards the ante-rior chamber. The nuclear fragmentwas safely positioned on the iris, orsupported with the injection of visco-elastic, and was finally removed fromthe eye either with the phacoemulsifica-tion probe or with a vectis loop.The surgery was completed with ante-rior vitrectomy, when indicated, and aposterior chamber lens was inserted inthe sulcus. Postoperative visual acuitywas 20/30 in two patients and 20/25in one patient. No complications werenoted during a mean 7monthsfollow-up.When phacoemulsification is compli-

cated by posterior capsule rupture, thelens fragments are often stabilizedwithin the vitreous gel in the anteriorchamber or mid-vitreous cavity if thevitreous is not extensively liquified.Injection of viscoelastic just posteriorto the fragments and aspiration withthe phaco or vitrectomy probe are com-mon surgical maneuvres for retrievingthe lost nuclear pieces. When anattempt is made to aspirate the lostnuclear fragment with the phacoprobe, vitreous is engaged in the aspir-ation aperture of the probe. This maycause excessive vitreous traction to beexerted. This can be hazardous to theretina and may induce retinal tears

(Aaberg et al. 1997). The vitreous cuttermay be used to release any vitreous thatadheres to the lost nuclear fragmentand consequently aspirate soft nuclearmaterial. However, the vitreous cutteris often ineffective in aspirating hardnuclear fragments. By using the irriga-tion probe of the bimanual irrigation-aspiration system to up-irrigate thenuclear fragment from the vitreouscavity towards the anterior chamber,aspiration of the vitreous gel can beavoided. The irrigation probe can beeasily inserted beneath the dislocatedfragment via the side port incision. Irri-gation activated thereafter propels thelost fragment upstream towards theanterior chamber while the aspirationprobe can be used as a scleral depressorto allow the dislocated nuclear frag-ment to be adequately visualized. Themain advantages of this technique lie inits simplicity and the fact that no aspir-ation that may exert substantial vitreoustraction on the retina is activated.

ReferencesAabergTM,RubsamenPE,FlynnHW,ChangS,

MielerWF&SmiddyWE (1997): Giant retinal

tear as a complication of attempted removal of

intravitreal lens fragments during cataract sur-

gery. Am J Ophthalmol 124: 222–226.

Buratto L (1998): Bimanual irrigation/aspir-

ation: Buratto’s technique for removal of sub-

incisional cortex in phacoemulsification. In:

Buratto L (ed). Phacoemulsification: Prin-

ciples and Techniques. Thorofare, New Jersey:

SLACK Inc. 469–479.

Irvine WD, Flynn HW, Murray TG &

Rubsamen PE (1992): Retained lens

fragments after phacoemulsification manifest-

ing as marked intraocular inflammation with

hypopyon. Am J Ophthalmol 114: 610–614.

Kim JE, Flynn HW, Smiddy WE, Murray TG,

Rubsamen PE, Davis JL & Nicholson DH

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

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(1994): Retained lens fragments after

phacoemulsification. Ophthalmology 101:

1827–1832.

Received on August 5th, 2002.

Accepted on November 21st, 2002.

Correspondence:

Periklis D. Brazitikos MD

10 Agias Sophias St

546 22 Thessaloniki

Greece

Tel:þ 302 310 23 72 00Fax:þ 302 310 23 70 33Email: pbrazitikos@hotmail.com

Bilateral optic neuritis in a 9-year-old girl

Niels Rath Tornerup,1 Henrik Carstensen2 and Hans Callø Fledelius1

1University Eye Clinic, Rigshospitalet, University of Copenhagen, Denmark2Paediatric Clinic II, Rigshospitalet, University of Copenhagen, Denmark

Sir,

W hile the incidence of opticneuritis (ON) is fairly

frequentin adults, this inflammatorydisease is rare in children, and it issubsequently unusual for a patient toacquire demyelinating disease. Child-hood presentation of ON mostfrequently occurs around 7 years ofage. Severe bilateral visual loss is acommon feature and papillitis isobserved in more than 70% of subjects.To the best of our knowledge, this

issue has not been addressed previouslyin this journal. We therefore report a9-year-old girl who was admitted withmarkedly reduced sight and blurredoptic disc margins.The subject, the elder of two chil-

dren, had been previously healthy. Shehad followed the recommendednational childhood vaccination pro-gramme. No hereditary dispositiontowards ophthalmic or neurologicaldisorders was noted.Over a period of 10 days in June

2001, the child experienced painfuleyes. She suffered no malaise or fever,but watching television became difficult(dark screen), and during play shewas unable to catch a ball. She thenexperienced nausea and vomiting for3 days and was referred to an ophthal-mologist, who found poor sight andpapilloedema.On admission the child appeared

somatically well. Visual acuity (VA)was 2/60 in both eyes and 20-degreedense central scotomas were noted(Fig. 1). A moderate nonischaemicpapilloedema was apparent. Magneticresonance imaging after Gadoliniumcontrast showed diffusely thickened

Fig. 1. Consecutive kinetic Goldmann perimetries, on day 3 after admittance, after 11weeks and

after 33weeks, from top to bottom. On day 3, bilateral peripheral and central scotomas for white

object IV,4 are seen. The outer borders on the subsequent examinations are for IV,4, the inner

isopters for small object I,4. Final status is almost normal, although with a slight general

restriction in the left eye.

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

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optic nerves, but no plaques or otherfocal changes in the brain (Fig. 2).The patient’s erythrocyte sedimentation

rate (ESR) was 22mm/hour. Her haemo-globin level was normal. Her leucocytecount (14 mia/l) was slightly elevated,although the distribution of white bloodcell subgroups was normal.Serum samples tested negative for

ACE, ANA, ANCA, herpes simplex,cytomegalovirus, borrelia and toxo-plasmosis.A lumbar puncture disclosed a slight

pleocytosis of the cerebrospinal fluid,with mature white blood cells, predom-inantly lymphocytes. Spinal proteinwas normal and without oligoclonalbands. Oral prednisone therapy wasinstituted from day 4, in a daily dosageof 50mg, and tapered off over 4weeks.At day 7, the child’s unaided emme-

tropic VA had improved to 3/36 in botheyes. However, she was still unable todecipher any Ishihara plates. Photopicelektro-retinogram (ERG) and flashvisual evoked potentials (VEP) were nor-mal, but checkerboard VEP had abnor-mal configuration and prolonged latency.At day 9, VA was 6/24 and 6/36. Two

weeks later, it had improved to 6/15and 6/24 in the right and left eyes,respectively.Two and a half months after onset, the

subject’s decimal acuitieswere 0.9 and0.8.The right eye made a few errors on Ishi-hara plates testing, but the left eye stillmade many. No disturbance wasrecorded on Amsler’s chart testing. Afurther 2months later, the patient

achieved decimal acuity >1.0 in botheyes and Ishihara scores close to normal.Goldmann visual field findings are

shown in Fig. 1. On days 3 and 78, alarge test isopter (IV,4) showed periph-eral restriction, whereas the central scot-omas were observed only during thefirst weeks of disease.Five months after the initial symp-

toms appeared, automated static perime-try (octopus 07) appeared normal. At thefinal examination at 8months, however,Goldmann evaluation still showed aslight deficit in the left eye although find-ings for the right eye were normal.One month after presentation,

ophthalmoscopy showed the disc blur-ring had disappeared. At 5months, aslight temporal pallor of the discs wasnoted, particularly of the left.

Discussion

Childhood cases of optic neuritis havenot previously been reported in thiscountry, except for one involving a15-year-old boy in whom the diseasetook a quite atypical course (Fledelius1999); this patient made no visualrecovery and eventually acquired severebilateral optic nerve atrophy, withexcentric 2/60 acuity and no lightsense, respectively.The present case had isolated bilat-

eral ON with disc swelling, without anypreceding exanthema or febrile episode.In contrast, most published cases of

childhood ON are preceded by aninfectious disease, mainly viral, occur-ring within the 2weeks prior to theonset of eye symptoms (Morales et al.2000); the optic nerve affection has gen-erally been considered to be reactive.Vaccination is another possible trigger(Kazarian & Gager 1979). As in ourcase, cerebrospinal fluid analysis hasusually demonstrated only minor find-ings (Lucchinetti et al. 1997; Moraleset al. 2000).Obviously, in childhood ON other

optic nerve pathology must be ruledout. Our patient presented diffuselythickened optic nerves with posteriortram tracking after Gadolinium con-trast (Fig. 2). This is a unique finding,as MRI-verified bilateral enlargementof the optic nerves with tram trackinghas not previously been described inacute ON in the paediatric literature(Cornblath & Quint 1997).Regarding therapy, prompt adminis-

tration of intravenous methylpredniso-lone (10–30mg/kg/day) for about3–5days, followed by an oral taper over1–2months has been recommended(Lucchinetti et al. 1997; Morales et al.2000). We found no reports on Inter-feron-b-1a treatment in childhood ON(Sonderstrom 2001).Without a randomized set-up, how-

ever, the effect of a therapy on a raredisease with an apparently mainlybenign course can only be anticipated.Profound visual loss with central scot-oma is thus typical in childhood ON(Lucchinetti et al. 1997; Morales et al.2000), as is, however, an apparentlygood visual recovery over weeks ormonths (Taylor & Stout 1997). Someauthors have suggested a more guardedprognosis (Morales et al. 2000).According to Brady et al. (1999), theVA of 22% of affected eyes remainsbelow 20/40. From a possibly selectedseries, Lucchinetti et al. (1997) reportednormal VA in only 35% of subjectsafter 40 years’ follow-up, where 26%of subjects had also acquired demye-linating central nervous system disease.Except for this, multiple sclerosis hasbeen reported only occasionally infollow-up of childhood cases of opticneuritis.Our patient regained VA of 6/6.

However, Ishihara colour testing andGoldmann visual field testing both sug-gested a marginal permanent loss ofvisual potential, and eventually a slightpallor of the optic discs was observed.

Fig. 2. T1-weighted fat-saturated MRI scan after Gadolinium contrast shows diffusely thickened

optic nerves with a ‘railway track pattern’ in their posterior halves due to contrast enhancement of

the sheaths.

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

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In conclusion, it is important toemphasize to anxious parents that theprognosis is usually good and that ONrecurrence and eventual developmentof neurological disease seem to repre-sent exceptions to the rule.

References

Brady KM, Brar AS, Lee AG, Coats DKJ,

Paysse EA, Steinkuller PG (1999): Optic

neuritis in children: clinical features and

visual outcome. J AAPOS 3: 98–103.

Cornblath WT & Quint DJ (1997): MRI of

optic nerve enlargement in optic neuritis.

Neurology 48: 821–825.

Fledelius H (1999): Irreversible blindness after

amyl nitrite inhalation. Acta Ophthalmol

Scand 77: 719–721.

Kazarian EL & Gager WE (1979): Optic neur-

itis complicating measles, mumps and rubella

vaccination. Am J Ophthalmol 86: 544–547.

Lucchinetti CF, Kiers L, O’Duffy A, GomezMR,

Cross S, Leawitt JA, O’Brien P, Rodriguez

MJ (1997): Risk factors for developing multiple

sclerosis after childhood optic neuritis. Neuro-

logy 49: 1413–1418.

Morales DS, Siatkowski RM, Howard CW,

Warman R (2000): Optic neuritis in children.

J Pediatr Ophthalmol Strabismus 37: 254–259.

SonderstromM (2001): Optic neuritis and mul-

tiple sclerosis. Acta Ophthalmol Scand 79:

223–227.

Taylor D & Stout A (1997): Optic nerve: conge-

nital abnormalities and optic neuropathies. In:

Taylor D (ed). Paediatric Ophthalmology. 2nd

edn. Oxford: Blackwell Science Ltd. 660–718.

Received on June 25th, 2002.

Accepted on September 16th, 2002.

Correspondence:

Niels Rath Tornerup, MD

Eye Clinic E2061

Rigshospitalet

University of Copenhagen

Blegdamsvej 9

DK-2100 Copenhagen

Denmark

Fax:þ 45 35 45 22 90Email: nrt@dadlnet.dk.

Late opacification of a hydrophilic acrylic intraocular lens

Orhan Baykal

Department ofOphthalmology, Faculty ofMedicine, AtaturkUniversity, Erzurum, Turkey

Sir,

T he small incision cataract extrac-tion with foldable intraocular

lens (IOL) implantation has some advan-tages in that it facilitates faster visualrehabilitation and better patient out-come. However, there may be potentialproblems associated with newer IOLmaterials such as hydrophilic acrylic.One of these may be opacification(Mamalis 2001). Although some casesof opacification have been reported inthe literature, cases of significantdeposition of crystalline material onthe IOL surface are very rare (Werneret al. 2000). One such case, involving a64-year-old woman with a 17-year his-tory of diabetes mellitus and vascularhypertension, is presented in this letter.The patient’s haemoglobin Aic level

at presentation was 14.6%. She hadundergone laser photocoagulationtherapy due to retinopathy diagnosed1 year previously, and was admitteddue to a decrease in visual acuity (VA)in the right eye. A cortical cataract wasdiagnosed and the patient underwentuneventful phacoemulsification andin-the-bag insertion of a hydrophilicacrylic IOL (Ophthalmed, OphthalmedInc., Carlsbad, New Mexico, USA) inthe right eye under topical anaesthesia.The viscoelastic material used wasHealon; the irrigation fluid was BSS plus.

Postoperative retinal examinationrevealed panretinal and macular gridlaser scars. Corrected VA was 6/20 at4weeks post-surgery. Examination at3months revealed that the lens was clearand centralized, and no pathology wasobserved. At 14months post-surgery, thepatient returned with decreased andblurred vision. Corrected VA was then 6/60. Slit lamp biomicroscopy showed thatthe IOLwasmarkedly anddiffusely opaci-fied. The opacified IOL was replacedwith a PMMA IOL. Visual acuityimproved to 6/30 4weeks after surgery.

Electron microscopy scanning (JeolUSA Inc., Peabody, Massachusetts,USA) of the explanted lens showed adiffuse opacification in the central partof the lens, although the edge of theoptic and haptics appeared clear(Fig. 1). At 80� magnification, crystal-line deposits were clearly seen on theanterior surface of the IOL (Fig. 2).When compared with an unusedOphthalmed IOL, infrared spectralanalysis (FT-IR spectroscopy, InfraredAnalysis Inc., Anaheim, California,USA) showed two separate spikes

Fig. 1. Diffuse opacification is seen in the central part of the explanted lens.

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

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(Fig. 3), suggesting the presence ofketon bodies (at 1561 cm1) and smalleramounts of phosphate (at 2085 cm1).Jensen et al. (1994) were first to

describe the formation of crystallinedeposits on the surface of IOLs duringcataract surgery. The same group laterdescribed 22 other cases of intraopera-tive crystallization on the IOL surface.They pointed out that all the severecases were associated with siliconelenses, and that the viscoelastics usedincluded Healon GV, among others.In our case, crystallization occurred

late in the postoperative period. For thisreason, we think the crystallizationdetected in the present case could not bedue to the viscoelastic or irrigation solu-

tion used intraoperatively. The patienthad poorly controlled diabetes and hadundergone laser therapy 1year earlier.In diabetes, the blood–retinal barriermay break down before retinopathy isobserved clinically (Frank 1994). Wespeculate that the accumulation ofketon bodies on the IOL may beexplained by the diabetes, the break-down of the aqueous–blood barrierand the consequent easy passage ofketon bodies (Sacks 1999) acrossthis barrier. We detected a phosphatepeak on infrared spectral analysis.Bucher et al. (1995) considered thatthe accumulation of phosphate may ori-ginate from residual cataractous lensmaterial.

Yu et al. (2001) claimed that diabetesand its complications, posterior capsularopacification and IOL calcification areimportant contributors to visual loss.We conclude that one of the causes ofvisual loss may be the accumulation ofketon bodies on the IOL surface, as firstdetected in the present case.

References

Bucher PJ, Buchi ER & Daicker BC (1995):

Dystrophic calcification of an implanted

hydroxyethylmethacrylate intraocular lens.

Arch Ophthalmol 113: 1431–1435.

Frank RN (1994): Etiologic mechanisms in

diabetic retinopathy. In: Ryan SJ, Schachat

AP, Murphy RB (eds). Retina Vol 2. St

Louis, Missouri: Mosby-Year Book Inc.

1243–1276.

Jensen MK, Crandall AS, Mamalis N &

OlsonRJ (1994): Crystallization on intraocular

lens surfaces associated with the use of Healon

GV. Arch Ophthalmol 112: 1037–1042.

Mamalis N (2001): Hydrophilic acrylic intra-

ocular lenses. [Editorial.] J Cataract Refract

Surg 27: 1339–1340.

Sacks DB (1999): Carbohydrates. In: Burtis

CA, Ashwood ER (eds). Tietz Textbook of

Clinical Chemistry. Philadelphia: W.B.

Saunders 785–787.

Werner L, Apple DJ, Escobar-Gomez M,

Ohrstrom A, Crayford BB, Bianchi R &

Pandey SK (2000): Postoperative deposi-

tion of calcium on the surfaces of a hydrogel

intraocular lens. Ophthalmology 107:

2179–2185.

Yu AKF, Kwan KYW, Chan DUY &

Fong DYT (2001): Clinical features of 46

eyes with calcified hydrogel intraocular lenses.

J Cataract Refract Surg 27: 1596–1606.

Received on June 27th, 2002.

Accepted on September 16th, 2002.

Correspondence:

Dr Orhan Baykal

Department of Ophthalmology

Faculty of Medicine

Ataturk University

25 240 Erzurum

Turkey

Tel:þ 90 442 236 1212/1828Fax:þ 90 442 233 80 98

Fig. 2. Crystalline deposits are seen on the anterior surface of the explanted lens.

Fig. 3. Infrared spectral analysis showing spikes belonging to phosphate (arrow) and ketone

bodies (arrowhead).

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

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A long-standing, deep, intracorneal foreign body

Konstantinos Doulas, Konstantinos Apostolakis and Dionissios Feretis

Ophthalmology Department, General Hospital of Patras, Patra, Greece

Sir,

E ye injuries are a common causeof admittance to emergency

wards and ophthalmic clinics. Foreignbodies in the cornea represent thesecond most common form of eyetrauma, accounting for 40% of eyeinjuries in one study (Monestam &Bjornstig 1991). Most injuries are mildand do not cause significant ocularmorbidity or loss of work. The majorityof corneal foreign bodies can be pre-vented by appropriate eyewear. Wereport a rather unusual case of a long-standing intracorneal foreign body of5 years duration.A 31-year-old man was referred to our

clinic because of an intracorneal foreignbody. He was a long-term wearer of softcontact lenses, changed daily, and he wasotherwise in good health. The patienthad had an accident 5 years earlier, dur-ing which a piece of a plastic spoon thathe had been using to eat an ice-creambroke and became embedded in the cor-neal stroma of his right eye.On examination, visual acuity (VA)

was found to be 20/20 in the left eyeand 20/25 in the right eye. There was

a deep, transparent, foreign body meas-uring 3mm� 3mm in the midcornealstroma of his right eye, surrounded bya very thin fibrous membrane (Fig. 1).There was no epithelial staining or hazein the corneal stroma. No cells or flarecould be detected in the anterior chamberof the right eye. Despite the fact thatVA was remarkably good when testedon Snellen charts, the patient experi-enced glare symptoms during everydayactivities that made removal of the for-eign body necessary. Because we felt theforeign body would be very difficult toremove without entering the anteriorchamber and traumatizing the lens, thepatient underwent an uneventful cornealtransplant operation. The foreign bodywas carefully excised from the patient’scornea and sent to the General StateChemical Laboratory (Athens, Greece)for chemical identification. Fasmato-scopic analysis revealed that the plasticpiece was composed of polystyrene.Many different types of foreign body

can enter the cornea. The managementof deeply embedded corneal foreignbodies will vary according to the nature

of the material involved and theresponse of the cornea (Schein et al.1998). Olorenshaw et al. (1991) reporteda retained cilia in the cornea followingtrauma. Others have reported caterpil-lar hair in the corneal stroma (Teskeet al. 1991). Lu & Taylor (1997)reported three deep, linear, intracornealforeign bodies that were half the thick-ness of the patient’s own hair and dis-appeared after 1 year, leaving only asmall, deep corneal scar. There are nobibliographic references addressing thebiocompatibility of polystyrene withthe ophthalmic tissues. It is interestingthat the fibrous membrane we observedsurrounding the foreign body duringbiomicroscopy of the patient’s righteye had essentially the same morpho-logical features as are found duringwound-healing response after implant-ation of intrastromal rings (ISR) forcorrection of low myopia (Hermieset al. 1991).The importance of using safety

glasses in activities where there is a sig-nificant risk that ocular injury mightoccur can not be stressed sufficiently.This is as important during work activ-ities as it is during leisure pastimes; alltoo many people neglect to wear propersafety equipment because they do notrealize the danger to which they aresubjecting their eyes.

References

Monestam E & Bjornstig U (1991): Eye injuries

in Northern Sweden. Acta Ophthalmol

Scand 69: 1–5.

Hermies FD, Hartmann C, von Ey F,

HolzkamperC&PouliquenY (1991): Biocom-

patibility of a refractive intracorneal PMMA

ring. Fortschr Ophthalmol 88: 790–793.

Lu Y & Taylor HR (1997): A deep, linear,

intracorneal foreign body. Aust N Z J

Ophthalmol 25: 81–82.

Olorenshaw GM, Brooks AM, Grant G &

Gillies WE (1991): Tolerance of the eye for

implanted cilia. Br J Ophthalmol 75:

622–623.

Schein OD, Hibberd PL, Shingleton BI,

Kunzweiler T, Frambach DA, Seddon JM,

Fontan NL & Vinger PF (1998): TheFig. 1. The patient’s right eye, showing an intracorneal foreign body.

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

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spectrum and burden of ocular injury.

Ophthalmology 95: 300–305.

Teske SA, Hirst LW, Gibson BAH et al.

(1991): Caterpillar-induced keratitis. Cornea

10: 317–321.

Received on August 29th, 2002.

Accepted on September 9th, 2002.

Correspondence:

Konstantinos Doulas, MD

55�57 Paulou Paulopoulou str253 31 Patra

Greece

Tel:þ 30 61 62 56 38Fax:þ 30 12 59 12 03Email: kostasdl@otenet.gr

Hand dominance, eye laterality and refraction

Ahmad M. Mansour,1 Zaher M. Sbeity2 and Kassem M. Kassak3

1Department of Ophthalmology, American University of Beirut, Beirut, Lebanon2Department of Ophthalmology, Bonn University Eye Hospital, Bonn, Germany3Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

Sir,

H and dominance has been knownof since antiquity. There are 151

verses in the Old Testament and 49in the New Testament containing refer-ences to right and left hands (Fabbro1994). About 90% of human beings areright-handed and hand dominanceappears to be genetically determined(Fabbro 1994). Little is known aboutthe role hand dominance may play inrefractive differences between the rightand left eyes. To this end, we analysedthe refractive status of eyes withoutocular pathology.We carried out a retrospective study

of the objective cycloplegic (twoapplications of tropicamide 1% inadults in addition to cyclopentolate1% in children) refraction of conse-cutive subjects attending a private clinic.The subjects’ ages ranged from 3 to49years. Subjects with ocular or sys-temic diseases were excluded. Handdominance was ascertained by tele-phone calls. Statistical analyses werecarried out using the paired t-test andANOVA.

Data for a total of 1336 conse-cutive subjects were analysed. Thesecomprised 623 (46.6%) male and

713 (53.4%) female subjects, witha mean age of 22.6 years (standarddeviation¼ 12.0). Hand dominance wasright-sided in 1242 (93.0%) and left-sided in 94 (7.0%) subjects. Mean astig-matism (expressed in positive cylinders)was 0.51 dioptre (SD¼ 0.93) in theright eye and 0.49D (SD¼ 0.92) in theleft eye. The mean astigmatic axis was100.4 degrees (SD¼ 30.2) in the righteye and 93.1 degrees (SD¼ 31.1) in theleft eye (t¼ 4.666; p¼ 0.000). The meanabsolute spherical power (excludingpositive astigmatism) was �1.49D(SD¼ 2.68) in the right eye and�1.36D in the left eye (SD¼ 2.58)(t¼ 4.94; p¼ 0.000). The mean spher-ical equivalence was significantly less inthe right eye, at �1.23D (SD¼ 2.64),than in the left eye, �1.11D(SD¼ 2.54) (t¼ 4.86; p¼ 0.000). Analy-Analysis by ANOVA did not confirm anyrole of hand dominance in the differ-ence between the mean sphericalequivalents of right and left eyes(F¼ 1.233; p¼ 0.267) (Table 1).Results in the present study demon-

strated that the right eyes were, onaverage, slightly more myopic than theleft. No correlation of this difference

with hand dominance was established,probably because of the small samplesize. The present study is disadvantagedby being small and retrospective. Alarger sample size with multivariateanalysis may further clarify the role ofhand dominance. What is needed isa large, prospective study, which takesinto account multiple variables such asocular dominance, ocular rubbing,facial asymmetry, sleeping positionand hand dominance.Ocular dominance studies have

demonstrated around 80% right eyedominance, 10% left eye dominanceand 10% no dominance (Fink 1938;Walls 1951). Fink (1938) found 25%of subjects to have crossed dominance(right hand preference was associatedwith right eye preference in 75% ofcases). Accommodation has beenimplicated in the pathogenesis of mildmyopia (Philips 1990). As the dominanteye is used for near fixation, it isconceivable that fixating with thedominant eye exerts an accommodativeoverload on that eye compared tothe non-fixating contralateral eye,resulting in excess myopia in thedominant eye. Ocular rubbing by the

Table 1. Refraction indices, laterality and hand dominance profile of 1336 subjects.

Male Female Age

(years)

Positive cylinder power/axis Spherical

absolute

Spherical

equivalent

Right-handed 578 664 22.2 (12.2) OD 0.51 (0.93)/101.8 (32.3)

OS 0.49 (0.92)/95.6 (33.0)

OD �1.49 (2.67)OS �1.35 (2.54)

OD �1.23 (2.63)*OS �1.10 (2.51)*

Left-handed 45 49 23.0 (11.9) OD 0.53 (1.02)/105.1 (31.6)

OS 0.47 (0.94)/83.6 (20.9)

OD �1.55 (2.84)OS �1.49 (3.07)

OD �1.28 (2.76)OS �1.26 (2.98)

Values listed are means followed by the standard deviation in parentheses.

OD¼ right eye; OS¼ left eye.* (t¼ 5.06; p ¼ 0.000).

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

82

dominant hand alters the cornealcurvature as in keratoconus (Koenig &Smith 1993) and possibly over-stretchesthe sclera by causing a transient intra-ocular pressure rise during rubbing.Sleeping on one side, thereby squeezingthe eyeball against a pillow, is a poten-tial source of eyeball compression.Using a three-dimensional evaluation,Ferrario et al. (1995) found that theright side of the face can be signifi-cantly larger than the left side. It ispossible that asymmetric eyeballsaccounting for mild myopic differencesbetween right and left eyes accompanyasymmetric faces.

References

Fabbro F (1994): Left and right in the Bible

from a neuropsychological perspective.

Brain Cognition 24: 161–183.

Ferrario VF, Sforza C, Miani A Jr & Serrao G

(1995): A three-dimensional evaluation of

human facial asymmetry. J Anat 186: 103–110.

Fink WH (1938): The dominant eye: its clinical

significance. Arch Ophthalmol 19: 555–582.

Koenig SB & Smith RW (1993): Keratoconus

andcorneal hydrops associatedwith compulsive

eye rubbing. Refract Cornea Surg 9: 383–384.

Phillips CI (1990): Aetiology of myopia. Br

J Ophthalmol 74: 47–48.

Walls GL (1951): A theory of ocular domin-

ance. Arch Ophthalmol 45: 387–412.

Received on June 28th, 2002.

Accepted on October 6th, 2002.

Correspondence:

Ahmad Mansour, MD

Department of Ophthalmology

American University of Beirut

PO Box 113-6044

Beirut

Lebanon

Tel:þ 961 13 74 625Fax:þ 961 17 44 464Email: dr.ahmad@cyberia.net.lb

Recovery of vision after chiasmal optic neuritis

Shin Nonoyama, Yuzo Shibuya, Tatsuo Kodama, Hisashi Masuda and Akihiro Ohira

Department of Ophthalmology, Shimane Medical University, Izumo, Shimane, Japan

Sir,

C hiasmal optic neuritis is a rela-tively rare condition involving

the optic chiasma (Newman et al.1991). The clinical appearance of thisdisease resembles that of retrobulbarneuritis. We describe a patient withchiasmal optic neuritis whose visualacuity (VA) returned to 20/20 from nolight perception (NLP) bilaterally.A 44-year-old woman presented with

a 2-month history of progressive loss ofvision in both eyes. Bilateral VA wasNLP. She had no retrobulbar pain andeye movement was full. Both pupilswere slightly dilated. Direct and indir-ect pupillary light reactions wereabsent. The anterior segment, ocularmedia and fundus, including the opticdisc, appeared normal in each eye.Fluorescein angiography disclosed noleakage from the optic discs bilaterally.The visually evoked potentials showedprolonged latency of the first positivepeak in both eyes. Neurological exam-ination revealed alert consciousness,with no neck stiffness, dysarthria oraccelerated patellar tendon reflex.Results of laboratory examinations ofblood cell counts, urinalysis, serum chem-istries, erythrocyte sedimentation rateand C-reactive protein all fell withinnormal range. Serological test resultsfor syphilis, toxoplasma, rubella,mumps, herpes simplex, varicella zosterand cytomegalovirus were negative.

There was no association between sys-temic connective disorders and thiscase. No symptoms of fever, erythem-atous skin lesions or arthritis wereobserved. Examination of the cerebro-spinal fluid showed clear fluid withnormal pressure (120mmH2O). IgG,IgA, IgM and myelin basic proteinwere within normal range. No oligo-clonal bands were found in the cerebro-spinal fluid. Chest X-ray examination

was normal. Computed tomographyshowed no intracranial lesion. T1-weighted magnetic resonance imaging(MRI) demonstrated high signalintensity of the optic chiasma(Fig. 1). Thus, there were no signs ofcompression of the chiasm. We diag-nosed the patient with chiasmal opticneuritis with bilateral blindness. Mul-tiple sclerosis was highly suspected inthis case.

Fig. 1. MRI T1-weighted image with gadolinium administration. Axial view demonstrating

enhancement of the chiasma.

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The patient was hospitalized andtreated with steroid pulse therapywith methylprednisolone sodiumsuccinate, 1000mg/day, for 3 days.The steroid was gradually tapered.Four days later, VA was light per-ception. Twenty-five days after admis-sion, VA was 3/100 bilaterally.Thereafter, VA improved dramatically.Visual fields in the recovery phase areshown in Fig. 2. By day 36, VA hadimproved to 20/20 and visual fieldsreturned to normal in both eyes.T1-weighted MRI showed normaloptic chiasm (Fig. 3).

Results of neurological and labora-tory examinations led us to suspectmultiple sclerosis with chiasmal opticneuritis in this patient but MRI has sofar failed to reveal any demyelinatingplaques. We have, therefore, diagnosedthis patient with idiopathic chiasmaloptic neuritis. Edwards et al. (1983)reported one case of chiasmal opticneuritis in which normal VA recoveredfrom light perception in a unilateraleye. Newman et al. (1991) described apatient whose VA recovered from NLPto 20/30 in one eye. Although the rea-sons why VA improved from NLP are

unclear, our case demonstrates thatvisual recovery from NLP is possiblein chiasmal optic neuritis. To ourknowledge, our patient represents thefirst case of chiasmal optic neuritis inwhich VA improved to 20/20 fromNLP bilaterally. The subject’s VA hasremained at 20/20 with no recurrencefor more than 3 years. However, carefulfollow-up is necessary because of thepossible development of multiple sclero-sis (Optic Neuritis Study Group 1997).

References

Edwards MK, Gilmor RL & Franco JM

(1983): Computed tomography of chiasmal

optic neuritis. Am J Neuroradiol 4: 816–818.

Newman NJ, Lessell S & Winterkorn JMS

(1991): Optic chiasmal neuritis. Neurology

41: 1203–1210.

Optic Neuritis Study Group (1997): The 5-year

risk of MS after optic neuritis. Experience of

the optic neuritis treatment trial. Neurology

49: 1404–1413.

Received on August 6th, 2002.

Accepted on September 2nd, 2002.

Correspondence:

Akihiro Ohira, MD, PhD

Department of Ophthalmology

Shimane Medical University

89-1 Enya, Izumo

Shimane 693-8501

Japan

Fax:þ 81 853 20 2278Email: aohira@shimane-med.ac.jp

Fig. 2. Goldmann visual fields. On day 31, there are subtle superonasal defects in the left eye. The right visual field is almost normal.

Fig. 3. MRI T1-weighted image with gadolinium administration. Lower signal intensity is seen

in the chiasma.

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Cyst formation after parotid duct transplantation for

severe dry eye

Aki Maruyama,1 Fumie Kagaya,1 Shigenobu Suzuki,1 Shiro Amano,1 Makoto Araie,1

Koji Sakamoto2 and Takayoshi Kojima3

1Department of Ophthalmology, University of Tokyo School of Medicine, Tokyo, Japan2Department of Otolaryngology, University of Tokyo School of Medicine, Tokyo, Japan3Department of Ophthalmology, Omiya Red Cross Hospital, Saitama, Japan

Sir,

T ransplantation of the parotidduct from the mouth to the

inferior conjunctival cul-de-sac for thetreatment of severe dry eye was per-formed in several countries during the1950s�60s (Bennett 1969; Zhang et al.1995). We report an unusual case of apatient who underwent transplantationof the parotid duct for severe dry eyeand developed a large cyst 35 yearsafter the operation.In January 2001, a 58-year-old woman

presented at the Department of

Ophthalmology, University of Tokyo,complaining of a large mass in the rightcheek. She had noticed the mass hadbecome larger during the previous2months. At 7 years of age, the subjecthad suffered from Stevens–Johnsonsyndrome and both her corneas hadbecome opaque. At 23 years of age,she had visited our department andundergone transplantation of the paro-tid duct for severe dry eye in the righteye. During the same year, she under-went penetrating keratoplasty in the

right eye twice but the graft eventuallyfailed and follow-up was lost. When shere-visited our department, complaininga mass measuring 4 cm� 5 cm in theright cheek (Fig. 1A), the right eye wasphthisic, and best corrected visualacuity in the left eye was hand motion.The corneas in both eyes had massivevascularization. The mass was elastic,hard and had no adhesion to the skin.A surgical wound of 13mm in lengthwas observed beneath the mass. Com-puter tomography and magnetic

A

B

Fig. 1. (A) A 4 cm� 5 cm mass was observed in the patient’s right cheek (large arrow), and a surgical wound of 13mm length (small arrow) was seenbeneath the mass. (B) CT showed a cyst of approximately 3 cm in the right cheek (white arrow). Air-fluid level was observed in the cyst. The tumour

had not invaded the neighbouring bone.

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resonance imaging showed a cyst ofapproximately 3 cm in the right cheekand air-fluid level was observed in thecyst (Fig. 1B). A duct appeared to runbeneath the cyst. The tumour had notinvaded the neighbouring bone. Themedical history and the results of exam-inations suggested that the transplantedparotid duct ha formed a cyst.In June 2001, the cyst was removed

from the incision at the outside gingivalarea. The cyst measured 2.5 cm� 1.5 cmand contained dense yellow fluid(Fig. 2). Examined microscopically, the

wall of the excised cyst was seen to con-sist of fibrous connective tissue and tocontain many cells including lympho-cytes and histiocytes. No malignantfindings were observed. Biochemicalanalysis showed that the fluid withinthe cyst contained amylase of 90 IU/l,suggesting the cyst was of parotid ductorigin. No recurrence of the cyst wasfound at the last visit 8months post-operatively.Transplantations of the parotid duct

from the mouth to the inferior conjunc-tival cul-de-sac were performed for

the treatment of severe dry eye duringthe 1950s�60s, but the procedure wasfinally abandoned because of the intri-cate surgical technique and frequentpostoperative complications such asprofound epiphora during eating andcorrespondingly little tearing (Bennett1969; Zhang et al. 1995).The current case shows that this pro-

cedure can induce large cyst formationlong after surgery.

References

Bennett JE (1969): The management of total

Xero-ophthalmia. Arch Ophthalmol 81:

667–682.

Zhang H, Zhou Z, Chen Z & Zhao C (1995):

Management of dry eye with parotid duct

transplantation: a summary of 40 cases. [In

Chinese] Eye Sci 11: 67–69.

Received on July 8th, 2002.

Accepted on September 2nd, 2002.

Correspondence:

Shiro Amano

7-3-1 Hongo

Bunkyo-ku

Tokyo 113-8655

Japan

Tel:þ 81 35 800 5108Fax:þ 81 33 817 0798Email: amanos-tky@umin.ac.jp

Internet-based counselling of remote ophthalmological

patients

Georgios Labiris,1,2 Andreas Petounis,1 Georgios Kitsos,3

Miltiades Aspiotis3 and Konstantinos Psillas3

1Department of Ophthalmology, Patissia General Hospital, Athens, Greece2Intermedico Network, Medical Counselling Division, Athens, Greece3Department of Ophthalmology, University of Ioannina, Greece

Sir,

T he explosive development ofthe Internet, supported by faster

and more stable communications,has granted ophthalmology the tech-nical means of providing reliable,Internet-based counselling services toremote patients. Remote counselling isa form of telemedicine which has devel-oped out of the growing need to pro-vide basic medical services to a widerrange of patients, especially those who

find it difficult, for a variety of reasons,to access conventional services. Weconducted a prospective study over8 years to assess the efficiency of Inter-net-based counselling to remoteophthalmological patients. The Inter-medico Network, a non profit-makingmedical organization, was founded in1993. It has an Internet portal throughwhich users can request informationand advice on ophthalmological mat-

ters via electronic mail (email). Duringthe study period, these requests wereprocessed by 23 physicians, includingconsultant ophthalmologists and gen-eral practitioners, who forwarded theirresponses to the corresponding patients.To be eligible for counselling, requestsmust quote information about age, sex,place of residence and family status andgive a brief account of medical as wellas ophthalmological history. As the

Fig. 2. The excised cyst measured 2.5 cm� 1.5 cm and contained dense yellow fluid.

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

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responses were addressed tomembers ofthe general public, they were presentedusing simple language, void of complexmedical terminology. A seven-membercommittee supervised the scientific andethical standards of the service. It wasmade clear to users in all cases that therole of the service was advisory, andthe importance of physical examinationand appropriate personal patient�doctor contact was emphasized. Internet-based remote counselling is a form ofstore-and-forward tele-ophthalmology.Thus, by definition, it does notsupport acute events and emergencies.During the study period, 1040

ophthalmological patients visited theInternet portal and requested advice.The patient group consisted of 803 men(mean age 44years, range 38–72 years)and 237 women (mean age 48years,range 40–63years). The majority of sub-jects (787) were citizens of western soci-eties (i.e. the USA, the EU, Canada andAustralia) and residents of urban areas(705 subjects) (Table 1). The subjectsrequested remote counselling for a var-iety of reasons. A total of 562 subjectswanted to evaluate Internet-based healthservices; 298 subjects had already con-tacted local ophthalmologists but wereunsatisfied by their overall diagnosticand therapeutic approach, and 219 sub-jects stated that conventional medicalservices were inaccessible or unafford-able. Remote subjects inquired onalmost every field in ophthalmologicaldiscipline. Counselling was granted to993 patients (87.1%). The necessity ofphysical examination and insufficientprovision of medical data were themain reasons for not responding toall requests. In descending order, thesubjects requested information mainlyon ocular manifestations of systemicdiseases (266 requests), glaucoma(183 requests), refractive surgery(180 requests), conjunctival/cornealinfections (92 requests), lacrimalapparatus disorders (67 requests) andpaediatric ophthalmology (35 requests)(Table 2). As well as having their med-ical queries answered, a significant num-ber of remote subjects participated ininteractive educational sessions on com-mon chronic ophthalmological diseases.During these sessions, groups of patients(e.g. patients with glaucoma, patientswith diabetes, etc.) responded to ques-tionnaires and actively participated inweb forums where the principal detailsof the corresponding diseases were dis-

cussed. The importance of compliancewith glaucoma treatment was empha-sized among other issues, as well as thenecessity of tight glucose monitoringand regular ophthalmological follow-up of diabetic patients in order to pre-vent retinal complications.The remote patients’ perceptions of the

service were ascertained by asking themspecific questions concerning the respon-siveness of the service and the quality ofcommunication between themselves andthe medical staff. In order of frequency,remote subjects complained of the pre-dictable delays of the service, languagebarriers (the servicewas offered inEnglishand German only), and availability ofaccess to the Internet. However, the vast

majority of the remote subjects (94%)favoured Internet-based counselling andsaid they planned to use the service again.The doctors who participated in the

study were interviewed and asked to des-cribe their experiences with the service.All of them proposed that Internet-based counselling should be upgradedto the status of a regular medical serviceand sponsored by local health author-ities. They stressed the following pre-requisites as necessary to preventethical and legal irregularities in theservice and to ensure maintenance ofscientific and medical standards:(1) The application of specific legis-lation, preferably initiated by the

Table 1. Demographics users of Internet counselling in this study (n¼ 1040).

Location Requests Urban patients Rural patients

USA 363 236 127

European Union 278 214 64

Canada 101 77 24

Australia 45 29 16

Rest of Europe 67 40 27

Subtotal 787

Africa and Middle East 78 24 54

South America 34 33 1

Rest of world 74 52 22

Subtotal 253

Total 1040 705 335

Table 2. Nature of ophthalmological requests.

Condition Number Issue Number

Glaucoma 183 Miscellaneous 25

Therapy/drug sides 67

Surgical techniques 66

Follow-up questions 9

Co-existing diseases 16

Allergic diseases 57

Refractive surgery/refraction 180

Systemic diseases and the eye 266 Arterial hypertension 55

Autoimmune 34

Systemic infections 23

Vasculopathies 43

Diabetes 78

Miscellaneous 33

Paediatrics 35 Amblyopia 4

Miscellaneous 7

Strabismus 19

Glaucoma 5

Miscellaneous requests Reconstructive ophthalmology 34

Neurophthalmology 12

Dry eyes/lacrimal disorders 67

Conjunctival/corneal infections 92

Tumours 5

Other 2

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EU, regarding Internet-based medicalservices;(2) The adjuvant role of the serviceshould not be changed (it cannotreplace conventional, local counsel-ling), and(3) The importance of personal con-duct between local doctors and patientsshould always be emphasized.Ophthalmology has always pioneeredthe adoption of modern technologies indiagnostic and therapeutic procedures.In this study, the Internet was themedium used to provide all necessaryinformation to remote patients regard-ing their ophthalmological concerns.Most remote patients, even residents ofwestern countries with advanced nationalhealth care systems, presented withmisperceptions and lacked basic informa-tion on major ophthalmological diseasesincluding glaucoma, age-related maculardegeneration and diabetic retinopathy.All these diseases have significant impacton the patient’s quality of life and dra-matically increase the overall cost of carefor national health systems. The highpercentage of misinformed patients maypartly be explained by the fact that manyophthalmological outpatient depart-ments are overcrowded; thus the overalltime many patients spend with their

doctor is limited. On the other hand, itshould be stressed that the term ‘remotepatient’ does not necessarily refer tophysical remoteness or imply that localmedical resources are inadequate. Pov-erty, social isolation, ethnic discrimin-ation, prejudice, cultural ethics andreligion create remote patients even incity centres. The Internet overcomesboth physical and non-physical remote-ness and provides ophthalmologicalpatients with an alternative way ofmaking closer contact with physiciansand having their problems heard andexplained. The benefits of Internet-based counselling are apparent.Educated patients are likely to complybetter with doctors’ instructions, toadhere to preventive medicine pro-grammes and to adopt lifestyles thatoppose potential complications ofophthalmological diseases.The almost universal acceptance

of the service by remote popula-tions and the warm support fromthe doctors involved suggest thatInternet-based counselling should bestudied further and possibly upgradedto provide a regular service in conjunc-tion with conventional medicalpractices.

References

Berland GK, Elliott MN, Morales LS et al.

(2001): Health information on the Internet:

accessibility, quality, and readability in

English and Spanish. J Am Med Assoc 285:

2612–2621.

Blackwell N, Kelly G & Lenton L (1997): Tele-

medicine ophthalmology consultation in

remote Queensland. Med J Aust 167: 583.

Combs JL (2000): Technology. Exploring the

realm of E-health. Trustee 53: 26–28.

Masys DR (1997): Telehealth: the need for evalu-

ation. J Am Med Inform Assoc 4: 69–70.

Peredina DA & Allen A (1995): Telemedicine

technology and clinical applications. J Am

Med Assoc 273: 483–488.

Received on July 8th, 2002.

Accepted on October 10th, 2002.

Correspondence:

Georgios Labiris, MD, MSc

Patissia General Hospital

Chalkidos 15�1711143 Athens

Greece

Tel:þ 30 10 252 2612Tel:þ 30 10 417 4421Email: labiris@usa.net

Bilateral superior ophthalmic vein thrombosis in a young

woman

Michel Michaelides1 and Wagih Aclimandos2

1Moorfields Eye Hospital, Institute of Ophthalmology, London, UK2King’s College Hospital, London, UK

Sir,

A 36-year-old woman presentedto the King’s College Hospital

Ophthalmology Department theOphthalmology Department with bilat-eral red, swollen and prominent eyes.Both the onset and progression of herocular symptoms had been gradualover the preceding 9months. Computertomography and thyroid function testshad been performed by the subject’sgeneral practitioner 8months earlierand were unremarkable.The patient’s visual acuity was 6/5,

N5 in the right eye and 6/6, N5 in theleft. There was no relative afferentpupillary defect. Extraocular move-ments were full and painless. Examin-

ation of the anterior segments revealedbilateral dilated conjunctival andepiscleral vessels with venous ‘arterial-ization’ (Fig. 1). Both eyes were prop-tosed with bilateral inferior scleralshow. Intraocular pressure was17mmHg bilaterally. No ocular bruitwas detectable. Dilated examinationof the left fundus revealed multiplescattered peripheral retinal haemor-rhages (Fig. 2). The patient was takingthe combined oral contraceptive pill(COCP) and was otherwise in goodhealth. There was no history of trauma.In view of the clinical findings, an

indirect caroticocavernous fistula (CCF)was suspected. Doppler ultrasound

was requested to detect possible rever-sal of flow in the orbital veins con-sistent with a CCF. Interestingly, theultrasound detected bilateral dilatedsuperior ophthalmic veins, with partialthrombosis and low antegrade flow inthe right eye, and apparent completethrombosis with no blood flow detectedwithin the vessel in the left eye.The only abnormal investigations were

elevated plasma factor VIII (172m/dL;normal range 45–150m/dL) and raisedfasting cholesterol levels (6.6mmol/L).Our haematology colleagues commencedtreatment of 300mg of aspirin daily anda low cholesterol diet was encouraged.The COCP was also discontinued.

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Three months later, the subject’seyes were less red and swollen. Visualacuity remained unchanged. The retinalhaemorrhages had resolved. Repeatultrasound detected no significantimprovement. The patient remainsunder review by both the ophthalmol-ogy and haematology teams.Superior ophthalmic vein thrombosis

(SOVT) has been documented veryinfrequently. Previous reports havedescribed unilateral superior ophthal-mic vein thrombosis associated withorbital cellulitis (Luxenberg 1991), eth-moidal rhinosinusitis (Berenholz et al.1998) and the combined oral contracep-

tive pill (Jaais & Habib 1994). To thebest of our knowledge this is the firstreported case of bilateral superiorophthalmic vein thrombosis. Raisedfactor VIII has not previously been sug-gested to be associated with ophthalmicvenous thromboses.The differential diagnosis in this case

includes cavernous sinus thrombosis(CST) or CCF. In our opinion, CCFrepresents an unlikely possibility inthis case because of the patient’s rela-tive youth, the lack of history of traumaor hypertension and the gradual onsetof symptoms. The existence of a pre-ceding CST also seems unlikely because

a radiological review of the subject’s CTscans, performed with contrast, did notshow evidence of a CST. In addition,bilateral SOVT has only been reportedin one patient in association with septicCST only (Schuknecht et al. 1998). Ourpatient clearly was not septic and wasotherwise well, which would be mostunusual for a patient with septic or asep-tic CST. Moreover, patients with septicor aseptic CST very commonly haveabnormal eye movements, complain ofpain and often suffer from diplopia(Brismar & Brismar 1977). Our patientwas pain-free, had full extraocularmovements and no diplopia.

Fig. 1. Right and left eyes, showing bilateral dilated, arterialized conjunctival and episcleral vessels with inferior scleral show.

Fig. 2. Fundus photograph of the left eye showing scattered peripheral retinal haemorrhages.

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Venous occlusions in youngerpatients are commonly associated withvarious hypercoagulable states leadingto thrombosis. The high prevalence ofunderlying systemic disease in theseyoung patients necessitates a thoroughevaluation to rule out potentially life-threatening embolic and hypercoagul-able conditions, thereby minimizingadditional systemic and ocular morbid-ity. The only such abnormality detectedin this case was a raised factor VIIIlevel, which has recently been identifiedas representing a significant risk factorfor atherothrombotic events. It has alsobeen suggested that there may be a causalrelationship between raised factor VIIIand acute thrombotic events, even insubjects without significant underlyingatheromatous disease (Gorog et al.1998). In addition, the COCP is an estab-lished risk factor for venous thrombo-embolsim (Suissa et al. 2000).In conclusion, we propose that risk

factors for this previously unreportedpresentation of bilateral SOVT in ayoung woman include COCP use andelevated levels of plasma factor VIII.The initiation of medical treatment

may prevent further ocular and sys-temic morbidity and mortality in thisparticular young woman. However, itshould be noted that cerebral angiog-raphy, which could have definitivelyexcluded a pre-existing CCF or CST,was not performed because the patientwas not willing to accept the small riskof cerebral infarction associated withthis intervention.

References

Berenholz B, Kessler A & Shlomkovitz N (1998):

Superior ophthalmic vein thrombosis – com-

plication of ethmoidal rhinosinusitis. Arch

Otolaryngol Head Neck Surg 1: 95–97.

Brismar G & Brismar J (1977): Aseptic throm-

bosis of orbital veins and cavernous sinus.

Clinical symptomatology. Acta Ophthalmol

(Copenh) 55: 9–22.

Gorog DA, Rakhit R, Parums D, Laffan M &

Davies GJ (1998): Raised factor VIII is asso-

ciated with coronary thrombotic events.

Heart 80: 415–417.

Jaais F & Habib ZA (1994): Unilateral super-

ior ophthalmic vein thrombosis in a user of

oral contraceptives. Med J Malaysia 49:

416–418.

Luxenberg MN (1991): Colour doppler imaging

of superior ophthalmic vein thrombosis.

Arch Ophthalmol 109: 582–583.

Schuknecht B, Simmen D, Yuksel C &

Valavanis A (1998): Tributary venosinus occlu-

sion and septic cavernous sinus thrombosis:

CT and MR findings. Am J Neuroradiol 19:

617–626.

Suissa S, Spitzer WO, Rainville B, Cusson J,

Lewis M & Heinemann L (2000): Recurrent

use of newer oral contraceptives and the risk

of venous thromboembolism. Hum Reprod

15: 817–821.

Received on July 18th, 2002.

Accepted on November 9th, 2002.

Correspondence:

Michel Michaelides BSc, MB BS, MRCOphth

Moorfields Eye Hospital

Institute of Ophthalmology

11–43 Bath Street

London EC1V 9EV

UK

Tel:þ 44 207 608 6866Fax:þ 44 207 608 6806Email: MrMichelMichaelides@hotmail.com

Paediatric periocular granuloma annulare

Scott M. Goldstein, Raymond S. Douglas, Gil Binenbaum and James A. Katowitz

Department of Ophthalmology, Children’s Hospital of Philadelphia, Scheie Eye Insti-

tute, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

Sir,

G ranuloma annulare (GA) is abenign, idiopathic dermatosis

primarily affecting children and youngadults (Wells & Smith 1963). It mani-fests as erythematous or violaceousannular plaques, papules or nodules,typically appearing on the hands orfeet, less commonly on the arms, legs,or trunk, and only rarely on the face orscalp. We present a young boy withperiocular GA and briefly review thisuncommon condition.A 3-year-old black male presented

with several nodules on his right eyelidand eyebrow. His mother reportedthat the lesions first appeared on hislateral brow at the age of 6months,lasted for many months, disappearedand then recurred near the original loca-tion. The child denied any discomfort,

itching or related symptoms. He had ahistory of similar nodules on his fingersat 2 years of age, which were excised andreported as GA. He had also sufferedpneumonia at 6months of age.Physical examination revealed three

2–3mm subcutaneous nodules located inthe right upper eyelid and brow (Fig. 1,top). The lesions were non-tender, firm,and mobile. Two of the nodules weresubcutaneous while the other was deeperat the level of the bony orbital rim. Therewere no overlying skin changes. Theremainder of the eye examination wasnormal, and further dermatological sur-vey revealed several non-tender, skin-coloured nodules near the joints of hisfingers. The subject’s chest radiographand glycosylated haemoglobin levelswere within normal limits.

The child underwent biopsy of the eye-lid and brow lesions. Pathological ana-lysis demonstrated foci of fibrinoiddegeneration surrounded by lymphohis-tiocytic infiltrates in a palisading pattern,consistent with GA (Fig. 1, bottom). Nofurther treatment was offered.

Comment

The name ‘granuloma annulare’ com-bines both pathological and clinicalfeatures of the disease. Microscopically,the disease is characterized by focalgranulomatous inflammation of sub-papillary blood vessels, with centralnecrobiosis of the connective tissueand a surrounding palisading borderof histiocytes (Dahl 1993). Clinically,

ACTA OPHTHALMOLOGICA SCANDINAVICA 2003

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GA may present with annular plaques,nodules or papules in a localized ordisseminated form. The plaque form ismost common and consists of anannular confluence of papules with anerythematous to violaceous centralzone, an elevated border and no over-lying epidermal changes. Lesions aretypically found on the hands, feet andextensor surfaces of the limbs; the trunkis sometimes involved and the face orscalp only rarely. The nodular form ofthe disease exhibits a similar distributionand presents as painless dermal or sub-cutaneous nodules without epidermalchanges. The nodules appear clinicallysimilar to rheumatoid nodules and somecase reports refer to these lesions as‘pseudorheumatoid nodules’, althoughthey are not related to rheumatoiddisease (Burnstine et al. 1994).Although rare, periorbital and orbital

granuloma annulare have been

reported in the dermatology andophthalmology literature. The firstreport of ‘pseudorheumatoid nodules’in the periocular area was publishedby Rao & Font (1975), who described21 patients with such lesions. Since then,only a handful of cases have beendescribed. Almost all patients wereunder 25 years of age and most were intheir first decade of life, althoughreports of patients in their 60s do exist(Burnstine et al. 1994). Interestingly,the nodular form predominates inthese reports when GA occurs in peri-ocular tissues. Other processes that maycause cutaneous or subcutaneouslesions in the eyelid include chalazion,tuberculosis, syphilis, insect bites andlocalized cutaneous lupus. Definitivediagnosis is made through biopsy.Granuloma annulare is a condition

of unknown aetiology. Reported butnot clearly established associations

include trauma, sun exposure, viral infec-tion, diabetes, tuberculosis, sarcoidosis,insect bites and hereditary predisposition(Muhlemann & Williams 1984; Dahl1993) In the case presented, furtherwork-up, including radiographic andserum screens for evaluation of sarcoidand diabetes, was unremarkable.Typically, GA is a relatively harmless

and self-limiting entity that involvesmorepsychological stress than true medicalconcern. While it does not appear toherald an underlying systemic process,many patients are concerned with thecosmetic disability. Fortunately, thelesions tend to regress spontaneouslywithout treatment (Wells & Smith 1963).Focal steroid injection, Psoralen andUltra Violet A light (PUVA) therapy,cryotherapy and other dermatologicalpreparations have been used with somesuccess in refractory cases.The recurrenceof granuloma annulare varies from15–40%, and follow-up observation isindicated (Rao & Font 1975).

References

Burnstine MA, Headington JT, Reifler DM

et al. (1994): Periocular granuloma annulare,

nodular type: occurrence in late middle age.

Arch Ophthalmol 112: 1590–1593.

Dahl MV (1993): Granuloma Annulare In:

Fitzpatrick TB, Eisen AZ, Wolff K et al.

(eds.) Dermatology in General Medicine. 4th

edn. New York: McGraw-Hill 1187–1191.

Muhlemann MF & Williams DRR (1984):

Localized granuloma annulare is associated

with insulin-dependent diabetes mellitus.

Br J Dermatol 111: 325–329.

Rao NA & Font RL (1975): Pseudorheuma-

toid nodules of the ocular adnexa. Am J

Ophthalmol 79: 471–478.

Wells RS & Smith MA (1963): The natural

history of granuloma annulare. Br J Derma-

tol 75: 199–205.

Received on September 2nd, 2002.

Accepted on October 15th, 2002.

Correspondence:

Scott M. Goldstein, MD

Department of Ophthalmology

Scheie Eye Institute

University of Pennsylvania

51 North 39th Street, 5th Floor

Philadelphia

Pennsylvania 19104

USA

Tel:þ 1 215 662 8140Fax:þ 1 215 243 4695Email: scott.goldstein@uphs.upenn.edu

Fig. 1. Top: 3-year-old boy presenting with recurrent periocular nodules. Bottom: biopsy specimen

revealing foci of fibrinoid degeneration with a palisading border of histiocytes. (Haematoxylin-

eosin, original magnification �200.) (Courtesy Pierre Russo, MD, Department of Pathology,Children’s Hospital of Philadelphia.)

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