Clinical and Experimental Ophthalmology 2006; 34: 279–283doi:10.1111/j.1442-9071.2006.1204.x

© 2006 Royal Australian and New Zealand College of Ophthalmologists

Letters to the Editor

Photographic Essays

On examination of the left eye 1 day postoperatively a one-third hyphaema was noted, the anterior chamber was formed andthe IOP was 4 mmHg. One week following the operation he pre-sented with a painless loss of vision in the left eye. On examinationleft visual acuity was light perception only, a complete hyphaemawas noted and IOP was 22 mmHg. The trabeculectomy bleb wasformed. As the IOP was not elevated significantly, further surgerywas delayed.

By 1 month after trabeculectomy the clot had resorbed and theIOP was 25 mmHg; however, corneal staining was noted to extendacross a diameter of 10 mm (Fig. 1). There were no history orexamination findings to suggest any other ocular pathology such asa corneal abnormality or endothelial dysfunction that could havecontributed to the corneal blood staining. The right eye was com-pletely normal. Ten months postoperatively the disc of cornealstaining was reduced to 5 mm, and the patient achieved a visualacuity of 6/19 when looking peripherally (Fig. 2). The IOP was15 mmHg. Over the following 2 years the cornea cleared, resultingin a final visual acuity of 6/9 (Figs 3,4).

DISCUSSION

The UK National Survey of Trabeculectomy reports that hyphaemaoccurs in approximately 25% of patients.2 When a completehyphaema is combined with failure to lower IOP, the patient is atrisk of developing corneal staining. Only one article was found thatdescribes corneal staining in the absence of an elevated IOP.3 Webelieve that an undetected elevation of IOP had occurred betweenclinic reviews in this case.

Several studies4,5 have revealed that corneal discoloration is dueto extra- and intracellular haemoglobin particles, as well as centralintracellular haemosiderin. Haemoglobin particles are posteriorly

Spontaneous resolution of corneal blood staining

ABSTRACT

Herein, a case of a 66-year-old man who developed corneal bloodstaining secondary to hyphaema after trabeculectomy is reported.No significant increase in intraocular pressure was recorded. Thecorneal staining spontaneously cleared from the periphery andresolved fully over the following 2 years.

Key words: cornea, trabeculectomy, intraocular pressure, cor-

neal blood staining.

INTRODUCTION

Corneal blood staining is well described as a complication ofhyphaema in associated with elevated intraocular pressure (IOP).Trauma is the usual antecedent event, with recommended manage-ment being the removal of the clot and aggressive control of IOP.1

Classically the discoloration clears from the corneal peripherybefore clearing centrally and over months the staining may resolvespontaneously. However, in severe cases a corneal graft is requiredto restore vision.

CASE REPORT

A 66-year-old patient had known primary open angle glaucomasince 1996. He was on no systemic medication.

Despite a trabeculectomy in 1997 to his left eye and full medicaltherapy, his IOP remained over 22 mmHg. A repeat trabeculec-tomy was performed in January 2003.

Figure 1. The patient’s left eye 1 month after trabeculectomy. Figure 2. The patient’s left eye 10 months after trabeculectomy.

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© 2006 Royal Australian and New Zealand College of Ophthalmologists

concentrated, and thought to diffuse into the corneal stroma acrossan intact Descemet’s membrane. A gradient of haemoglobindegradation from the posterior to the anterior corneal stroma hasbeen reported with haemosiderin-laden keratocytes predominatinganteriorly.4,5

There is often marked necrosis of keratocytes due to haemoglo-bin overload. The production of cytotoxic oxygen species withinthe blood-stained cornea exposed to light may contribute to thisdegeneration. It has been hypothesized that by limiting light expo-sure it is possible to reduce light-induced and porphyrin-mediatedtoxicity.4

The clearing of the blood staining is thought to be a result ofthe phagocytic action of the keratocytes and diffusion of haemo-globin breakdown products into the conjunctival circulation. After1 year, clearing involves peripheral and posterior stroma, and to alesser degree, the anterior stroma. This was the pattern of clearingseen in this case. Keratocytes in areas of cleared cornea containsmaller amounts of haemosiderin and do not show signs of degen-erative changes.5

It is important to manage raised IOP aggressively in patientswith hyphaema in an effort to prevent corneal blood staining. Thecorneal staining will not resolve in all cases and further surgicalintervention may be required to restore sight.

Clare Fraser MB BS, Simon Liew FRANZCO,Ross Fitzsimmons FRANZCO and

Jennifer Arnold FRANZCOMarsden Eye Specialists, Sydney, New South Wales, Australia

Received 27 June 2005; accepted 10 October 2005.

REFERENCES

1. Graul TA, Ruttum MS, Lloyd MA, Radius RL, Hyndiuk RA.Trabeculectomy for traumatic hyphema with increased intraoc-ular pressure. Am J Ophthalmol 1994; 117: 155–9.

2. Edmunds B, Thompson JR, Salmon JF, Wormald RP. TheNational Survey of Trabeculectomy. III. Early and Late Com-plications. Eye 2002; 16: 297–303.

3. Beyer T, Hirst L. Corneal blood staining at low pressures. ArchOphthalmol 1985; 103: 654–5.

4. McDonnell PJ, Gritz DC, McDonnell JM et al. Florescence ofblood-stained cornea. Cornea 1991; 10: 445–9.

5. Messmer E, Gottsch J, Font R. Blood staining of the cornea: ahistopathological analysis of 16 cases. Cornea 1984; 3: 205–12.

Figure 3. The patient’s left eye 18 months after trabeculectomy.

Figure 4. The patient’s left eye 24 months after trabeculectomy.

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Letter to the Editor

Photographic Essay

Systemic non-Hodgkin’s lymphoma masquerading as Vogt–Koyanagi–Harada disease in an HIV-positive patient

ABSTRACT

A 29-year-old man presented with decreased visual acuity in botheyes secondary to exudative retinal detachment resembling Vogt–Koyanagi–Harada disease. Although fluorescein angiographic picturessupported the clinical findings, there was no choroidal thickeningevident with ultrasonography. In 3 days he developed increased discoedema with peripapillary haemorrhages in both eyes. Further eval-uation revealed HIV-positive status and a systemic non-Hodgkin’slymphoma. The patient responded favourably to the treatment forsystemic non-Hodgkin’s lymphoma confirming our diagnosis ofintraocular metastasis. In bilateral exudative detachment, an absenceof choroidal thickening on ultrasonography and the presence ofperipapillary haemorrhages should prompt a systemic evaluation forcauses other than Vogt–Koyanagi–Harada disease, especially in HIV-positive patients.

Key words: HIV-positive patient, systemic non-Hodgkin’s lym-

phoma, Vogt–Koyanagi–Harada disease.

INTRODUCTION

Intraocular lymphoma is a rare tumour, the two main types beingprimary central nervous system non-Hodgkin’s lymphoma (NHL),and less commonly, systemic NHL that has spread to the eye. NHLis the AIDS-defining condition in approximately 3% of HIV-infected persons.1

We describe a case of systemic NHL in an HIV-positive patientpresenting with bilateral exudative retinal detachment (RD) thatresembled Vogt–Koyanagi–Harada (VKH) disease.