Bilateral Massive Retinal Hemorrhages in a 6-Month-Old Infant

CASE REPORTS AND SMALL CASE SERIES

and clinical course of a patient with the stromal bed was thin; in the left Medical Treatment a LASIK-induced corneal perfora- eye, the corneal flap was very edema- of Operative Corneal tion that affected the final visual acu- tous and a space was visible between Perforation Caused ity. We believe that this report on the the corneal flap and the stromal bed treatment and recovery of the cor- (Figure 1, left). The anterior cham- by Laser In Situ neal perforation will be valuable in- ber was very shallow, and aqueous Keratomileusis formation for refractive surgeons. humor was observed to leak onto the ocular surface with blinking (Figure Laser in situ keratomileusis (LASIK) Report of a Case. A 33-year-old man 1, right). A round, 0.25-mm diam- is an effective procedure to treat a was referred to us with a complaint eter perforation site was observed in wide range of myopia.1 The advan- of decreased visual acuity in the left the center of the stromal bed by slit- tages of LASIK over photorefrac- eye after bilateral simultaneous lamp examination. tive keratectomy (PRK) are rapid vi- LASIK performed 3 days previ- We treated the corneal perfo- sual recovery, lower risk of corneal ously at a different facility. A cor- ration by applying a therapeutic soft haze, greater regression of myopia, neal perforation was noticed in the contact lens with topical antibiot- and less postoperative pain.1-3 How- left eye during LASIK laser abla- ics, oral carbonic anhydrase inhibi- ever, LASIK requires more skillful tion in this eye. The surgeon stated tors, and eye patching. After 1 week surgical technique and more instru- that, before surgery, the patient had of treatment (10th day postopera- mentation than PRK. Thus, inaccu- myopia in both eyes (−9.5 diopters tively), the aqueous humor leakage rate and inadequate procedures dur- [D] −5.0 D ϫ 65° OD and −9.0 D had ceased, the anterior chamber ing LASIK have a higher potential of −5.5 D ϫ 110° OS) and his best- depth was normal, and the corneal complications. corrected visual acuity was 10/20 flap was closer to the stromal bed. The complications of LASIK OU. The corneal flap was intended However, the flap remained edema- include severing of the corneal flap, to be 160 µm thick, otherwise, pre- tous. Topical medications were dis- epithelial ingrowth, flap wrinkling, cise information on the intended ab- continued but the therapeutic con- corneal astigmatism, and corneal in- lation depth could not be obtained tact lens and eye patching were fection.2-4 To our knowledge, only from the surgeon. However, the sur- continued for 3 more weeks. On the one case report by Pallikaris and geon found that the remaining stro- 32nd postoperative day, the edema Siganos5 has been published of cor- mal bed was thin due to excessive and diffuse opacification of the neal perforation following LASIK; it thickness of the corneal flap. corneal flap suddenly resolved with was a survey of their early 43 pa- Our initial examination showed no space observed between the flap tients. Unfortunately, the treat- best-corrected visual acuity of 20/60 and the stromal bed although one ment and the clinical course of the OD and 20/500 OS. Slitlamp exami- had been present on the previous corneal perforation was not re- nation of the right eye revealed that day. The patient’s best spectacle- ported. We describe the treatment the corneal flap was missing and that corrected visual acuity was still de-

Figure 1. Left eye. Three days after bilateral laser in situ keratomileusis. Left, The corneal flap is edematous and a space is evident between the flap and the stromal bed (arrow). The anterior chamber is very shallow. Right, Following a blink, aqueous humor is visible on the ocular surface (arrows).

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1422

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 tic contact lens than to suture the corneal flap, because the suturing method has a high possibility of inducing new irregular astigmatism. This case suggests that eye surgeons should treat corneal perforations by conservative medical therapy, wait- ing at least 1 month before determin- ing the best course of possible subsequent surgical therapy.

Yuichi Hori, MD Hitoshi Wantanabe, MD Naoyuki Maeda, MD Yoshitsugu Inoue, MD Yoshikazu Shimomura, MD Yasuo Tano, MD Suita, Japan

This investigation was supported in Figure 2. Left eye. Thirty-two days after laser in situ keratomileusis and following treatment as described in the “Report of a Case” section. The cornea is generally clear and anterior chamber depth is normal, part by grant-in-aid 09671800 for Sci- but areas of corneal opacification and irregular corneal astigmatism remained. Neovascularization is entific Research from the Japanese evident between the corneal flap and the stromal bed (arrows) and epithelial ingrowth was localized Ministry of Education, Science, and at the temporal edge of the flap (arrowheads). Culture, Tokyo (Dr Watanabe) and by the Osaka Eye Bank Association Fund, Osaka, Japan (Drs Watanabe, creased at 30/50 OS due to residual perforation with photoablation in Maeda, Inoue, and Shimomura). areas of corneal opacification and ir- this case. Corresponding author: Hitoshi regular astigmatism. In addition, The most interesting observa- Watanabe, MD, Department of Oph- neovascularization was noted be- tion was that abrupt clearing of the thalmology, Osaka University Medi- tween the corneal flap and the stro- corneal edema and the recovery of cal School, Room E7, 2-2 Yamad- mal bed and epithelial ingrowth was transparency occurred approxi- aoka, 565-0871 Suita, Japan. present focally at the temporal edge mately 1 month after the injury by of the flap (Figure 2). LASIK. This phenomenon suggests 1. Pallikaris IG, Papatzanaki ME, Siganos DS, Tsi- that wound closure and functional limbaris MK. A corneal flap technique for laser in situ keratomileusis: human studies. Arch Oph- Comment. No standard treatment recovery of the endothelium leads thalmol. 1991;109:1699-1702. has been established for corneal per- to a prompt normalization of the 2. Marinho A, Pinto MC, Pinto R, Vaz F, Neves MC. foration with leakage of aqueous hu- corneal thickness. The site of per- LASIK for high myopia: one year experience. Ophthalmic Surg Lasers. 1996;27(suppl 5):S517- mor onto the ocular surface after foration in the LASIK surgery was S520. LASIK. Because this is the first case 0.25 mm in diameter and, there- 3. Fiander DC, Tayfour F. Excimer laser in situ ker- of corneal perforation due to LASIK fore, may require approximately 1 atomileusis in 124 myopic eyes. J Refract Surg. 1995;11(suppl 3):S234-S238. presenting to our institution, medi- month for recovery of the endothe- 4. Watanabe H, Sato S, Maeda N, Inoue Y, Shimo- cal treatment was intuitive. Never- lial function. mura Y, Tano Y. Bilateral corneal infection as a complication of laser in situ keratomileusis. Arch theless, it was effective; the perfo- Despite recovery of the cornea, Ophthalmol. 1997;115:1593-1594. ration closed, the edema cleared, and high corneal irregular astigmatism 5. Pallikaris IG, Siganos DS. Laser in situ keratomi- visual acuity improved to 30/50 OS. and residual opacification re- leusis to treat myopia: early experience. J Cata- The surgeon did not mention mained, and this patient will even- ract Refract Surg. 1997;23:39-49. whether the patient had keratoco- tually require lamellar or penetrat- nus; however, preoperatively the pa- ing keratoplasty for better vision. One tient had high myopia and astigma- may question whether surgery should tism, with a best-corrected visual have been immediately performed. Infectious Ulcerative acuity of 10/20 OS. In addition, the However, suturing of the flap to pro- Keratitis After Laser stromal bed in the unperforated right mote wound closure carries a high In Situ Keratomileusis eye appeared very thin. These data risk of inducing additional high suggest that the patient may have irregular astigmatism. In our pa- With any laser refractive surgical had keratoconus. In cases of kera- tient who had no suturing, the cor- procedure in which the epithelial toconus, the cornea is thin and ex- neal edema disappeared completely barrier is broken, there is an inher- cessive thickness of the flap may be in 1 month. We can then choose the ent risk of infectious complication. created by the microkeratome be- most appropriate treatment after re- As laser in situ keratomileusis cause of distortion of the cornea, sidual astigmatism and opacifica- (LASIK) becomes more widely avail- resulting in a thin stromal bed. We tion have resolved. In our patient, it able, cases of LASIK-associated in- presume that this may have led to was more effective to use a therapeu- fectious keratitis have begun to be

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1423

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 reported.1-6 We report 6 eyes of 5 patients that developed ulcerative keratitis after LASIK.

Report of Cases. Case 1. A 33-year- old woman noted a foreign body sensation in the right eye 4 days after bilateral LASIK. She was found to have a corneal infiltrate. She was given subconjunctival injections of vancomycin hydrochloride, cefazo- Figure 1. Slitlamp photograph showing Figure 2. Slitlamp photograph showing lin sodium, and betamethasone a paraxial 2-mm-round, anterior stromal scar an epithelial defect at the flap margin sodium phosphate and started on within the flap edge, with striae extending with organizing stromal infiltrate. Visual therapy with ciprofloxacin hydro- radially. Visual acuity 20/40. acuity 20/30. chloride eye drops every 20 minutes. After 3 weeks of minimal to us the next day. On his initial visit, eye, as well as marked punctate kera- improvement with various combi- visual acuity was 20/20 OD and topathy in the left eye. The time at nations of topical ciprofloxacin and 20/40 OS. A curvilinear epithelial de- onset of the epithelial defect is un- prednisolone acetate, the patient was fect with surrounding stromal infil- clear. Cultures were obtained, and referred to the Doheny Eye Insti- trate was noted, extending from the the patient was prescribed topical tute, Los Angeles, Calif. On her 5- to 7-o’clock position at the LASIK ciprofloxacin every hour in the right initial visit to us, visual acuity flap edge. Cultures were obtained, eye and lubrication with artificial was 20/200 OD and 20/20 OS. A and the patient was started on a regi- tears in both eyes. Drops were ta- 1.5 ϫ 2-mm epithelial defect with men of topical fortified vancomy- pered over the next 2 weeks. At 2 surrounding infiltrate was present at cin hydrochloride (25 mg/mL), al- weeks the epithelial defect had re- the 7-o’clock position within the flap ternating hourly with ofloxacin. A solved in the right eye, and punc- edge, extending to approximately cephalosporin was not used be- tate keratopathy had improved in 30% of the stromal thickness in the cause of a history of penicillin al- both eyes. A pinpoint scar re- right eye. Both corneas showed mod- lergy. Two days later the epithelial mained at the 7-o’clock position at erate punctate staining. Corneal defect had widened to just beyond the LASIK flap edge. Final uncor- scrapings for culture and sensitiv- the flap margin and the stromal rected visual acuity was 20/40 OD. ity were obtained. All eye drops were infiltrate had begun to organize No organism was recovered. stopped, and the patient was pre- (Figure 2). Cultures revealed the in- Case 4. A 50-year-old man described topical fortified cefazolin so- fectious organism to be Staphylococ- veloped bilateral eye pain and pho- dium (50 mg/mL) and tobramycin cus aureus. One week later the epi- tophobia 1 day after bilateral LASIK. sulfate (14 mg/mL), alternating ev- thelial defect had healed and the The patient had also undergone ra- ery hour while awake. Within 2 days infiltrate was organizing. The drops dial keratotomy in the left eye 16 reepithelialization had begun, and were tapered to every 3 hours. Over years previously. He had been sero- medications were tapered to every the next week the patient showed positive for the human immunode- 2 hours. One week later the patient continued improvement of the infil- ficiency virus (HIV) for 10 years but had no epithelial defect, but there trate, with consolidation into a small had no major sequelae of the viral was still an organizing infiltrate. The stromal scar at the inferior flap mar- infection. He was taking various anti- next week the infiltrate was nearly gin. Antibiotics were slowly tapered retroviral medications, including resolved, and the eye drops were ta- over the next week. Uncorrected vi- protease inhibitors; his CD4 cell pered off over the ensuing 3 weeks. sual acuity returned to 20/30 OS. count was 0.3 ϫ 109/L, and his viral After 3 weeks the infiltrate had re- Case 3. A 46-year-old woman load was undetectable. Because bi- solved. The patient was left with a complained of a foreign body sen- lateral bacterial keratitis was sus- paraxial, 2-mm-round, anterior stro- sation in her right eye 6 days after pected, both flaps were lifted, cul- mal scar within the flap edge bilateral LASIK. She was found to tures were obtained, and the stromal (Figure 1). No organism was re- have a small infiltrate at the flap beds were irrigated. The patient was covered. Final uncorrected visual edge. The patient had been wear- hospitalized and given topical forti- acuity was 20/40 OD. ing a soft contact lens in her right fied cefazolin sodium (25 mg/mL), Case 2. One year after bilateral eye and was using topical predniso- alternating with gentamycin sulfate LASIK, a 31-year-old male physi- lone acetate in both eyes twice daily. (14 mg/mL), every 30 minutes. Two cian complained of acute tearing and She was prescribed ciprofloxacin eye days after hospitalization, cultures photophobia of the left eye, in which drops every 30 minutes and re- returned positive for ciprofloxacin- he had been using a soft contact lens. ferred to us the next day. On her ini- resistant S aureus. Gentamycin was He was found to have an infiltrate tial visit, best-corrected visual acu- discontinued at this time. Four days at the flap edge. He was started on a ity was 20/80 OD and 20/50 OS, with later the patient’s condition was im- regimen of topical ofloxacin every an 80% epithelial defect of the flap proved and he was discharged with hour, diclofenac 4 times daily, and and a small infiltrate at the 7-o’clock a regimen of hourly topical forti- 1% atropine daily, and was referred position on the flap edge in the right fied cefazolin in both eyes. His con-

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1424

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 dition slowly improved over the next tion at the 5- to 9-o’clock position. 6 weeks as the drops were tapered. Three sutures at the 5-, 10-, and 11- At 6 weeks, the right corneal flap o’clock positions held the flap in was lifted to remove epithelial in- place (Figure 3). Cultures were ob- growth. The patient’s visual acuity tained from the area under the pe- stabilized to 20/40 OD and 20/200 ripheral flap thinning, and the pa- OS. One month after discontinua- tient was started on a regimen of tion of all medications, he noted a topical fortified cefazolin sodium (50 sudden decrease in visual acuity and mg/mL) and tobramycin sulfate (14 the onset of photophobia and was mg/mL), alternating every hour, referred to us. along with ciprofloxacin ointment at Figure 3. Slitlamp photograph showing On his initial visit, visual acu- bedtime. Cultures were positive the an edematous flap overlying a stromal bed, ity was 20/60 OD and 20/400 OS. next day for Streptococcus viridans. with scattered focal infiltrates dispersed between Examination was remarkable for se- Over the next several days, the 8 radial keratotomy incisions. Visual acuity vere blepharitis. The right cornea thinned region of the flap became counting fingers. had a hazy central anterior stromal necrotic, but visual acuity im- scar, with corneal neovasculariza- proved to 20/400 OD. A topical an- tion extending across the flap from tibiotic taper was then started. The Comment. We are beginning to see the 7- to 9-o’clock position. The left inferotemporal peripheral region of more cases of LASIK-associated cornea had 8 radial keratotomy in- the flap was noted to have been lost ulcerative keratitis in our referral cisions with a dense, central, ante- 10 days later. The decision was made practice as LASIK becomes more rior stromal scar, extending to 30% to remove the remaining sutures, lift widely available. Ulcerative kerati- depth, with neovascularization ex- the flap, irrigate the stromal bed, and tis may present at any time after tending across the flap edge from the repair a radial keratotomy incision LASIK; in fact, in 1 of our 5 pa- 8- to 9-o’clock position. The pa- that had opened in the temporal bed. tients it was noted to occur as late tient was treated for blepharitis with However, 2 days later, just prior to as 1 year after surgery. A review of lid hygiene, topical erythromycin the planned surgery, the patient re- our patients suggests a few possible ointment, and oral tetracycline hy- turned with markedly decreased risk factors for the development of drochloride. Penetrating kerato- symptoms and visual acuity im- ulcerative keratitis. Two patients plasty was eventually performed in proved to 20/150 OD. The amount were using soft contact lenses post- the left eye. Final visual acuity was of corneal edema had decreased, and operatively, 1 in association with 20/40 OD and 20/100 OS. the area of flap melt had reepitheli- corticosteroid use. Contact lens wear Case 5. Two days after hyper- alized. The patient refused further and steroid use have long been as- opic LASIK in the right eye, a 54- surgery. Final uncorrected visual sociated with an increased risk of year-old man developed pain and acuity stabilized at 20/60 OD. corneal ulceration.1 In both of our acutely decreased vision in his right cases, the patients were not satis- eye. The patient had undergone ra- Results. All patients were treated fied with the visual outcomes of their dial keratotomy, followed by 2 en- with topical antibiotics for their pre- LASIK procedures and were given hancement procedures in the right sumed infectious ulcerative kerati- corrective contact lenses to aug- eye, 9 years previously. Eight years tis. Four of 5 eyes (3 patients) were ment their surgical correction. Nei- later he elected to undergo myopic culture positive for bacteria. In all ther patient was willing to undergo photorefractive keratectomy, which cases, patients began to show im- enhancement procedures. left him overcorrected. One year provement once a stable antibiotic Two patients had previously later, the patient underwent hyper- regimen had been started and cor- undiagnosed dry eye. Corneal ul- opic LASIK. On a visit to the refer- ticosteroids had been discontin- ceration can be one of the sequelae ring ophthalmologist 2 days later, the ued. Secondary interventions were of keratoconjunctivitis sicca.2 In the flap appeared nonadherent and in- only necessary in 3 eyes (2 pa- setting of LASIK, dry eyes may sig- fected. With the presumptive diag- tients): flap revision in 2 eyes and nificantly prolong epithelial heal- nosis of “flap infection,” the pa- penetrating keratoplasty in 1 eye. All ing time and therefore place the patient underwent flap revision and 5 patients reported foreign body sen- tient at a greater risk for ulcerative suturing. He also received various sation as their chief complaint, with keratitis. topical and subconjunctival anti- 4 of 5 patients reporting severe pho- Our last patient had severe biotics. After 2 weeks without tophobia as well. blepharitis and was HIV positive. In improvement, the patient was re- All patients had residual stro- this particular case, the patient ex- ferred to us. mal scarring after developing ulcer- perienced no adverse sequelae of On his initial visit to us, visual ation, but 4 of 6 eyes (4 patients) had HIV, had a low viral load, and a nor- acuity was counting fingers OD and uncorrected final visual acuities of mal CD4 cell count. It is unclear 20/40 OS. Diffuse corneal edema was 20/40 or better. The remaining 2 eyes whether HIV is a risk factor for ul- noted in the right eye, with scat- had visual acuities of 20/100 or bet- ceration after LASIK. However, HIV- tered focal infiltrates under the flap. ter but had undergone secondary in- positive patients often experience se- The flap was thinned and poorly ad- terventions and had had radial kera- vere ocular surface disease. The herent in a wedge-shaped distribu- totomy performed previously. increased bacterial load associated

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1425

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Review of Cases of LASIK-Associated Ulcerative Keratitis in Present Series and the Literature*

Onset Final Infection- Patient After Treatment Type/ Uncorrected Subjective Related Secondary (Source) LASIK Risk Factors Organism Cultured Duration, wk† Visual Acuity Complaints Complications Interventions Present series Case 1 4 d SPK None Cefazolin, 20/40 FBS, Paraxial scar in None tobramycin/8 photophobia flap (2 mm) Case 2 1 y SCL (worn for Staphylococcus Vancomycin, 20/30 FBS, tearing, Small stromal None correction) aureus ofloxacin/3 photophobia scar at inferior flap margin Case 3 6 d SPK, SCL wear None Ciprofloxacin/2 20/40 FBS Small scar at None and topical 7-o’clock flap corticosteroid edge use (SCL worn for correction) Case 4 1 d s/p RK, HIV+ Ciprofloxacin- Cefazolin, 20/40 FBS, pain, Central corneal (1) Flap lift and (right eye) (10 y), severe resistant gentamycin/7 photophobia scar and irrigation, blepharitis S aureus peripheral NV (2) second flap lift and removal of epithelial ingrowth Case 4 1 d s/p RK, HIV+ Ciprofloxacin- Cefazolin, 20/100 FBS, pain, Severe central (1) Flap lift and (left eye) (10 y), severe resistant gentamycin/7 (postoperative photophobia scarring and irrigation, blepharitis S aureus astigmatism) corneal NV (2) second flap lift and removal of epithelial ingrowth, (3) penetrating keratoplasty Case 5 2 d s/p RK, s/p PRK Streptococcus Cefazolin, 20/60 FBS, Flap thinning Flap revision viridans ciprofloxacin, photophobia and poor tobramycin/3 adhesion, followed by focal necrosis Perez-Santonja 6 d s/p LASIK Nocardia asteroides Tobramycin, 20/45 Photophobia, Central scar Retreatment et al7 vancomycin/6 blurring, ghost images Nascimento 120 d s/p RK N asteroides Sulfacetamide, 20/60 Photophobia, Paracentral scar Cap exchange et al8 prednisolone/6 ghost images Watanabe et al6 3 d None specified S aureus Topical 20/40 Photophobia, Multiple None ofloxacin, IV pain, scattered imipenem and discharge stromal scars cilastatin/6 Aras et al4 6 d None specified None Vancomycin, 20/20 Photophobia, No scarring Likelihood of ciprofloxacin/3 redness diffuse lamellar keratitis Reviglio 5 d None specified Mycobacterium Tobramycin, 20/20 FBS, pain, Central abscess Penetrating et al5 chelonae erythromycin/2 photophobia keratoplasty

*LASIK indicates laser in situ keratomileusis; SPK, superficial punctate keratitis; SCL, soft contact lens; s/p, status post; RK, radial keratotomy; HIV+, human immunodeficiency virus; PRK, photorefractive keratectomy; IV, intravenous; FBS, foreign body sensation; and NV, neovascularization. †Cefazolin was given as cefazolin sodium; tobramycin, tobramycin sulfate; vancomycin, vancomycin hydrochloride; ciprofloxacin, ciprofloxacin hydrochloride; gentamycin, gentamycin sulfate; prednisolone, prednisolone acetate; and cilastatin, cilastatin sodium.

with severe blepharitis, as well as the antibiotics. Final best-corrected vi- a case of bilateral infectious kerati- impaired ability to clear this load, sual acuity was 20/20 with an in- tis, occurring 1 day after bilateral may greatly increase the patient’s risk ferotemporal, 1-mm-round, granu- LASIK, from which S aureus was iso- for infection.3 lar stromal opacity. Reviglio et al5 lated as the causative agent. The pa- A summary review of the lit- reported a case of Mycobacterium tient’s condition improved after a erature reveals several reports of in- chelonae infection centrally on and protracted course of topical and infectious complications associated under the flap 1 month after LASIK. travenous antibiotics, with a final with LASIK (Table). Aras et al4 re- This patient’s condition did not im- best-corrected visual acuity of 20/40 ported a case of corneal interface ab- prove with antibiotics, but had a OU. Scattered stromal opacities re- scess that occurred 6 days after good result with penetrating kera- mained in both eyes. Mulhern et al9 LASIK and improved with topical toplasty. Watanabe et al6 described described a case of corneal abscess

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1426

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 with hypopyon and intense vitre- This work was supported in part by a technically demanding in a soft eye. ous cellular reaction (ie, endoph- grant from Research to Prevent Blind- Tissue adhesives are especially suit- thalmitis) 3 days after LASIK. The ness, Inc, New York, NY (Dr McDon- able for perforations smaller than 1.5 infecting organism was Strepto- nell) and by a grant from the Heed mm, but the application is not al- coccus pneumoniae. The patient’s Ophthalmic Foundation, Chicago, Ill ways easy.1 For larger perforations, condition improved with intrave- (Dr Chuck). a patching material may be used. In nous and topical antibiotics. Final Corresponding author: Peter J. this study we demonstrate that best-corrected visual acuity was McDonnell, MD, Department of Neuro-Patch (B Braun Melsungen 20/25 with a hazy stromal scar. Ophthalmology, University of Cali- AG, Melsungen, Germany), a mi- Perez-Santonja et al7 reported a case fornia Irvine, Gottschaulk Medical croporous, purified polyurethane of infectious keratitis involving the Plaza, 2000 Medical Plaza Dr, material with excellent biocompat- central cornea, secondary to Nocar- 2004, Irvine, CA 92697 (e-mail: ibility properties, can be effective in dia asteroides infection, 6 days after [email protected]). achieving temporary closure of cor- LASIK retreatment. The patient was neal perforations. Neuro-Patch is pri- 1. Mondino BJ, Weissman BA, Farb MD, Pettit TH. treated with antibiotics, and final vi- Corneal ulcers associated with daily-wear and marily used as a dural substitute in sual acuity returned to 20/40 with extended-wear contact lenses. Am J Ophthal- neurosurgery. According to the a small, round central scar. Nasci- mol. 1986;102:58-65. product information, the material al- 8 2. Pfister RR, Murphy GE. Corneal ulceration and mento et al also reported N aster- perforation associated with Sjo¨gren’s syn- lows rapid immigration of connec- oides infection centrally after a cap drome. Arch Ophthalmol. 1980;98:89-94. tive tissue cells and is biostable and 3. Holland GN, Pepose JS, Pettit TH, Gottlieb MS, exchange was performed because of Yee RD, Eoos RY. Acquired immune defi- biocompatible. The material has a severe flap edema. The patient’s con- ciency syndrome: ocular manifestations. Oph- thickness of 0.45 mm, bends eas- dition improved with repeated cap thalmology. 1983;90:859-873. ily, and has a variable pore size rang- 4. Aras C, Ozdamar A, Bahcecioglu H, Sener B. exchange and topical antibiotics. Fi- Corneal interface abscess after excimer laser in ing from 1 to 50 µm. The poly- nal visual acuity was 20/200 with a situ keratomileusis. J Refract Surg. 1998;14: urethane fibers have a thickness of paracentral leukoma. 156-157. approximately 5 to 10 µm. 5. Reviglio V, Rodriguez ML, Picoti GS, Paradello It should be emphasized that all M, Luna JD, Juarez CP. Mycobacterium chelo- of these described cases of infectious nae keratitis following laser in situ keratomi- Report of Cases. Case 1. An 84- leusis. J Refract Surg. 1998;14:357-360. ulcerative keratitis differ from the en- 6. Watanabe H, Sato S, Maeda N, Inoue Y, Shi- year-old woman with rheumatoid ar- tity of “diffuse lamellar keratitis” de- momura Y, Tano Y. Bilateral corneal infection thritis developed a 2 ϫ 3-mm cen- scribed by Smith and Maloney.10 They as a complication of laser in situ keratomileu- tral corneal perforation 2 weeks after sis. Arch Ophthalmol. 1997;115:1593-1594. described a syndrome with infil- 7. Perez-Santonja JJ, Sakla HF, Abad JL, Zorra- phacoemulsification of the left eye. trates that were diffuse, multifocal, quino A, Esteban J, Alio JL. Nocardial kerati- Since donor tissue was not avail- and confined to the flap interface, with tis after laser in situ keratomileusis. J Refract Surg. 1997;13:314-317. able at that time for emergency graft- no posterior or anterior extension, 8. Nascimento EG, Carvalho MJ, de Freitas D, ing and the perforation was too large and with an intact overlying epithe- Campos M. Nocardial keratitis following my- to apply tissue adhesive, it was de- opic keratomileusis. J Refract Surg. 1995;11: lium in each case. None of the infil- 210-211. cided to use Neuro-Patch for clo- trates we observed were confined to 9. Mulhern MG, Condon PI, O’Keefe M. Endoph- sure of the perforation. the interface, and an epithelial de- thalmitis after astigmatic myopic laser in situ After all necrotic corneal tis- keratomileusis. J Cataract Refract Surg. 1997; fect was always present. 23:948-950. sue had been removed, the edges of While not all of our cases had 10. Smith RJ, Maloney RK. Diffuse lamellar kera- the piece of Neuro-Patch were positive cultures for organisms, the titis: a new syndrome in lamellar refractive surgery. Ophthalmology. 1998;105:1721-1726. matched to the shape of the wound clinical appearance and response to bed. A 2 ϫ 3-mm patch was cut and treatment were typical of infec- sutured into the defect with six 10-0 tious keratitis. Most also had anti- nylon sutures, and the cornea was biotic therapy prior to culture. covered with a bandage contact lens. The increasing number of re- Six months later, the patch was still ported cases of infectious keratitis af- Use of a Polyurethane perfectly positioned with neither ter LASIK, while still very small, pro- Patch for Temporary aqueous leakage nor any signs of vides additional support for a Closure of a Sterile anterior chamber inflammation conservative approach when con- Corneal Perforation (Figure 1). Meanwhile the patient sidering bilateral surgery and when had been treated with prednisone, discussing informed consent. Treatments for corneal perforation 30 mg daily, and methotrexate, 10 after thinning processes include mg weekly, and a penetrating kera- Peter A. Quiros, MD acute penetrating keratoplasty, la- toplasty was performed. Findings Roy S. Chuck, MD, PhD mellar keratoplasty, grafting of con- from histologic examination of the Ronald E. Smith, MD junctival flaps, suturing of a scleral corneal button revealed epithelial- John A. Irvine, MD lamella into the perforation, tarsor- ization of the patch and infiltration Peter J. McDonnell, MD rhaphy, and sealing of the perfora- of fibroblastlike cells into the deeper Los Angeles, Calif tion site with tissue adhesives.1 How- layers of the patch (Figure 2). No Lawrence C. Chao, MD ever, the use of homologous tissue inflammatory cells were seen in Peter J. McDonnell, MD is often followed by immunologi- the stroma or patch. Findings from Irvine, Calif cal allograft rejection and may be transmission electron microscopy

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1427

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Figure 1. Case 1. Six months after suturing, the patch was still perfectly Figure 3. Case 2. A 2 ϫ 1.5-mm piece of Neuro-Patch (a microporous, purified positioned with neither aqueous leakage nor any signs of anterior chamber polyurethane material) was fastened tightly to the corneal wound margins in inflammation. neurotrophic corneal thinning. No anterior chamber inflammation was seen.

Figure 2. Case 1. Findings from histologic examination of the corneal button Figure 4. Case 2. Nine months after placement of a piece of Neuro-Patch with the incorporated piece of Neuro-Patch (a microporous, purified (a microporous, purified polyurethane material), the stroma had regenerated polyurethane material) revealed epithelialization of the patch, infiltration of to approximately 50% of the original thickness. fibroblastlike cells, and the absence of inflammatory cells (hematoxylin-eosin stain, original magnification, ϫ55).

revealed invagination of epithelial topathy caused by infrequent blink- Comment. The closure of corneal cells into the patch and the forma- ing. A 2 ϫ 1.5-mm piece of Neuro- perforations with human tissue in tion of a new basal membrane by the Patch was sutured into the perfora- noninfectious corneal thinning is epithelial cells. In addition, there was tion with six 10-0 nylon sutures hampered by rejection of the cor- collagen formation of the kerato- (Figure 3). Prior to treatment, in- neal graft and by the recurrence of cytes around the fibrillar architec- formed consent was obtained from corneal thinning in the donor. Fac- ture of the patch. the patient’s parents. One month tors include the timing of the perfo- Despite the systemic immuno- later, the sutures were removed, and ration, which often necessitates im- suppression and topical treatment the patch was tightly fastened to the mediate closure in a patient at risk of with serum drops, the patient devel- corneal wound margins. Postopera- immune reactions with high levels of oped marginal thinning of the graft. tively, neither anterior chamber corneal polymorphonuclear cells, col- A conjunctival flap ended in necro- leakage nor signs of anterior cham- lagenases, and proteases that de- sis, and ultimately tarsorrhaphy was ber inflammation were noted. Nev- stroy corneal collagen and proteogly- performed. Nineteen months post- ertheless, after tapering the topical cans.1 Nobe et al2 recently reported keratoplasty, the graft was relatively preservative-free 0.5% predniso- that all grafts failed in 4 patients with clear with mild punctate epitheliopa- lone, the patch was lost. Findings rheumatoid arthritis and corneal per- thy, and the patient’s visual acuity was from an examination with the pa- foration. Palay et al3 demonstrated a counting fingers OS. tient under general anesthesia re- survival probability of only 32% 2 Case 2. A 5-year-old boy with vealed that the stromal thickness had years after the first keratoplasty in pa- Smith-Lemli-Opitz syndrome, an au- increased to 50% of the original tients with rheumatoid arthritis. In a tosomal recessive disorder with se- thickness (Figure 4). Twelve study by Bernauer et al,4 penetrating vere psychomotor retardation and months after the placement of the keratoplasty in corneal thinning re- microcephaly, was seen for a 2 ϫ 1.5- patch, the eye was quiet, and the epi- sulted in an 80% failure of the grafts mm corneal perforation in the right thelial surface was well controlled 6 months postoperatively. Notable cornea owing to neurotrophic kera- with artificial tears and ointments. improvement in graft survival could

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1428

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 be achieved with immunosuppres- Patch allows the surgeon to schedule use are bitter taste and local ocular sion, suggesting that a delay of pen- graftsurgeryuntilthetimecornealdis- complaints such as burning, blurred etrating keratoplasty until the inflam- ease is adequately controlled. Finally, vision, itching, tearing, foreign body mation has subsided would be in one case, graft surgery was avoided sensation, stinging, eyelid discom- beneficial. since stromal regeneration occurred fort, and nonspecific conjunctival The use of tissue adhesives has underneath the patch. hyperemia.1,2 As dorzolamide rep- been advocated for perforations that resents a completely new class of are less than 1.5 to 2 mm and have Rudy M. M. A. Nuyts, MD, PhD topical ocular drugs, its spectrum of a small amount of surrounding stro- Marjolein J.C.Kooijman-DeGroot,MD side effects is not yet as well de- mal ulceration.1 The application of Maarten Prins, BSc fined as for older drugs. With the in- the smallest amount of glue to cre- Elisabeth Pels, PhD creased use of dorzolamide, it is im- ate a smooth surface may be tech- Amsterdam, the Netherlands portant to be aware of possible nically demanding, and multiple ap- unreported side effects that will in- plications may be needed.5 In a large The authors have neither commer- variably occur. We report the un- study6 of 80 patients with corneal cial, proprietary, or financial inter- usual finding of a severe sterile pu- perforation or impending perfora- est in Neuro-Patch nor did they re- rulent conjunctivitis in 7 patients tion, N-butyl-cyanoacrylate re- ceive payment as consultants. using dorzolamide drops that remained in place for an average of 50 Corresponding author: Rudy M. solved immediately after discontinu- days, and 44% of patients healed M. A. Nuyts, MD, PhD, Department ation of treatment. We believe that without further treatment. With re- of Ophthalmology, Academic Hospi- this condition is most probably at- spect to impending or actual perfo- tal Maastricht, Postbus 5800, 6202 AZ tributed to the use of this drug. ration associated with rheumatoid Maastricht, the Netherlands. arthritis, use of tissue adhesive was Report of Cases. Case 1. A 73-year- successful in 6 of 12 cases. 1. Portnoy SL, Insler MS, Kaufman HE. Surgical old male patient had been treated bi- management of corneal ulceration and perfora- We sutured Neuro-Patch into 2 tion. Surv Ophthalmol. 1989;34:47-58. laterally with 0.5% betaxolol hydro- corneal perforations and observed 2. Nobe JR, Moura BT, Robin JB, Smith RE. Re- chloride twice a day and 2% sults of penetrating keratoplasty for the treat- good adhesion of the patch to the host ment of corneal perforations. Arch Ophthalmol. pilocarpine 3 times a day during sev- tissue. Epithelialization of the patch 1990;108:939-941. eral years for chronic angle-closure occurred gradually without any signs 3. Palay DA, Stulting RD, Waring GO III, Wilson glaucoma after an acute attack of LA. Penetrating keratoplasty in patients with of inflammation of the anterior eye rheumatoid arthritis. Ophthalmology. 1992;99: angle closure in the right eye. Be- chamber. Findings from histopatho- 622-627. cause of bradycardia of unknown ori- logic examination demonstrated the 4. Bernauer W, Ficker LA, Watson PG, Dart JK. The gin, treatment with betaxolol was dis- management of corneal perforations associated development of an epithelial cell layer with rheumatoid arthritis: an analysis of 32 eyes. continued and replaced by 2% above the patch, and findings from Ophthalmology. 1995;102:1325-1337. dorzolamide hydrochloride (Tru- 5. Leahey AB, Gottsch JD, Stark WJ. Clinical ex- electron microscopy showed the be- perience with N-butyl cyanoacrylate (Nex- sopt) drops. Other topical medica- ginning of the deposition of the basal acryl) tissue adhesive. Ophthalmology. 1993;100: tions included occasional fucidic acid membrane. Legeais et al7 reported a 173-180. gel for chronic blepharitis and, once 6. Weiss JL, Williams P, Lindstrom RL, Doughman study of 6 patients treated with a tem- DJ. The use of tissue adhesive in corneal perfo- to twice a year, additional 0.1% fluo- porary polytetrafluoroethylene graft rations. Ophthalmology. 1983;90:610-615. rometholone drops for episodes of 0.7 to 1.0 mm in thickness (Gore- 7. Legeais JM, Renard G, D’Hermies F, Rossi C, marginal keratitis. One month after Pouliquen Y. Surgical management of corneal per- Tex). Although this material was well foration with expanded polytetrafluoroethylene the change of therapy, the patient re- tolerated, no epithelialization of the (Gore-Tex). Ophthalmic Surg. 1991;22:213-217. turned, complaining of red eyes with 8. Dori D, Beiran I, Carmi R, Miller B. Synthetic implant or cellular ingrowth into the patch for scleral tissue loss. Eur J Ophthalmol. a bilateral purulent discharge that was porous polymer was seen on histo- 1997;7:105-107. first ascribed to recrudescence of logic examination. Portnoy et al1 de- blepharitis. There was a diffuse pap- scribed the successful use of lyophi- illary reaction in the inferior palpe- lized donor tissue (Kerato-Patch; bral conjunctiva and cul-de-sac that Allergan Medical Optics, Irvine, Calif) Sterile Mucopurulent was less prounouced in the superior as a planolamellar button to manage Conjunctivitis Associated palpebral conjunctiva as well as hy- central stromal ulceration. Recently, With the Use of peremia of the bulbar conjunctiva Neuro-Patch also has been used for Dorzolamide Eyedrops that was preponderant inferiorly. the closure of a scleral defect after the Treatment with fucidic acid gel was spread of infection that was the re- Dorzolamide hydrochloride, a non- temporarily discontinued to per- sult of an explosion with multiple bacteriostatic sulfonamide deriva- form conjunctival bacterial cul- shrapnel.8 tive, is the first topical carbonic tures, according to standard ophthal- We believe that Neuro-Patch of- anhydrase inhibitor clinically avail- mologic microbiologic practice, fers an additional method for the tem- able. It reduces intraocular pres- which did not show any growth of or- porary closure of corneal perforations. sure by inhibiting aqueous humor ganisms. A 10-day course of a fixed Itsadvantagesinlcudetheeaseintech- production in the ocular ciliary combination of 0.1% dexametha- nical handling and the excellent bio- processes.1 sone phosphate and 0.5% chloram- compatibility as proven by these 2 The most common adverse ef- phenicol drops was given in addi- cases. In addition, the use of Neuro- fects associated with dorzolamide tion to the long-term fucidic acid gel

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1429

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 redness and tearing in the left eye that was attributed to a moderate ectro- pion of the inner third of the inferior lid; a plasty of the lacrimal punc- tum was performed with resolution of symptoms. Several months later, she complained of stinging and purulent discharge in her left eye. On examination, there was an inferior bulbar and palpebral hyperemia and a thickened conjunctiva without a frank papillary reaction but the presence of purulent secretions. The cornea was clear and no dermatitis was noted. Conjunctival bacterial cultures were negative. Dorzolamide treatment was interrupted and all symptoms resolved within 24 hours and signs resolved within 3 days. Case 1. Hyperemia of bulbar and palpebral conjunctiva. Note thickened palpebral conjunctiva Other Cases. Four additional bi- with a papillary reaction, rugae in the cul-de-sac, and the presence of purulent secretions. lateral cases that received bilateral dorzolamide therapy, for which no treatment. One month later, the pa- ferral was a bilateral refractory pu- bacterial examinations were per- tient consulted us again and com- rulent conjunctivitis present for the formed, were diagnosed soon after we plained of the same, persisting symp- last 4 months that had been treated had been aware of the described side toms. The purulent discharge was with 4 different antibiotics, includ- effect. The durations of dorzolamide massive and the cul-de-sac was ing fucidic acid, lomefloxacin, chlor- treatment until occurrence of the ad- thickened with rugae (Figure). A amphenicol, and a combination of verse clinical signs were 12, 21, 21, second bacterial culture was again neomycin and bacitracin. Bacterial and 22 months. The duration until negative. Pilocarpine drops were cultures had been performed twice af- dorzolamide discontinuation was 2 discontinued and replaced by sys- ter a 48-hour antibiotic washout pe- months in two patients, 3 months in temic acetazolamide sodium, 500 mg riod. The initial swab revealed no bac- one patient, and 4 months in another twice a day, because a cataract opera- terial growth and the second swab patient. All patients had been treated tion was planned. Several courses of showed only saprophytic organisms unsuccessfully by several courses of antibiotic drops, including a neomy- (Staphylococcus epidermidis and topicalantibioticsandatleast1course cin sulfate– polymyxin B sulfate– Corynebacterium). On examination, of corticosteroid eye preparation. gramicidin combination, the fluoro- a thickened inferior palpebral con- Resolution of symptoms and disap- quinolone 0.3% lomefloxacin junctiva with a prominent papillary pearance of the mucopurulent dis- hydrochloride, and again 0.5% chlor- reaction was noted. Some papillae charge occurred in all 4 patients 24 amphenicol, had absolutely no ef- were very large, having the size of fol- to 72 hours after discontinuation of fect on the purulent conjunctivitis. licles, and there were rugae in the in- topical dorzolamide treatment, with The planned cataract operation had ferior cul-de-sac with prominent pu- progressive regression of signs. to be postponed 3 times. It was only rulent secretions. Dorzolamide drops after the discontinuation of the dor- were discontinued and replaced by Comment. Dorzolamide is a topi- zolamide drops that rapid resolu- systemic acetazolamide. Chloram- cally active carbonic anhydrase in- tion of all symptoms within 2 days oc- phenicol drops that had been pre- hibitor used in a 2% ophthalmic so- curred, with progressive regression of scribed by his ophthalmologist were lution for the treatment of elevated signs. The cataract of the right eye was continued. The purulent discharge intraocular pressure in patients with operated on uneventfully 1 week later. and symptoms resolved almost com- ocular hypertension or glaucoma.1 It The patient remained without recur- pletely within 36 hours with progres- may be used as first-line therapy for rence during a follow-up of 2 years. sive regression of the other signs and patients who are unable to tolerate Case 2. A 77-year-old pseudo- no recurrence during an 11-month ␤-blockers. It can also be used as an phakic patient was sucessfully treated follow-up. add-on therapy when more than one for glaucoma with 0.5% timolol ma- Case 3. An 81-year-old female drug is needed. Dorzolamide is gen- leate (Timoptic) for more than 2 patient was treated for 2 years with erally well tolerated and has few ad- years. Six months before his refer- 2% carteolol hydrochloride twice a verse effects. Mild stinging and burn- ral, 0.5% timolol maleate drops had day in both eyes for ocular hyperten- ing on instillation, resolving within been replaced by dorzolamide drops sion; dorzolamide was added in her minutes, and a bitter taste following because of “cardiovascular prob- left eye because of uncontrolled in- instillation have been reported in up lems.” The patient had also been traocular pressure. Three months af- to 27% of patients.1,2 Allergic reac- treated for blepharitis and meibomi- ter initiation of dorzolamide treat- tions, mainly nonspecific conjuncti- tis in the past. The reason for his re- ment, she complained of occasional val irritation and lid reactions, have

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1430

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 been described in 10% to 15% of plained purulent conjunctivitis in patients. White granular deposits on patients taking dorzolamide drops. the bottle tip have also been reported.3 Corinne C. Schnyder, MD We describe herein an unre- Van Tao Tran, MD ported adverse effect due to dorzol- Andre´ Mermoud, MD, PD amide treatment occurring in 7 pa- Carl P. Herbort, MD, PD tients. The well-defined clinical Lausanne, Switzerland picture of a sterile purulent conjunctivitis developed gradually in all pa- Corresponding author: Carl P. Her- tients after several weeks or months bort, MD, PD, Department of Oph- thalmology, University of Lausanne, Figure 1. Fundus photograph of the left eye of dorzolamide treatment and all pa- showing the large nematode in the nasal retina. tients were mistakenly treated for a 15 Ave de France, CH-1004 Lau- Narrowing of the retinal vessels and diffuse bacterial conjunctivitis for 2 to 4 sanne, Switzerland. degeneration of the retinal pigment epithelium are apparent. months. The following elements rep- 1. Serle JB. Pharmacological advances in the treat- resent strong arguments for a rela- ment of glaucoma. Drugs Aging. 1994;5:156-170. tion between the clinical picture re- 2. Balfour JA, Wilde MI. Dorzolamide: a review of in the right eye had acute visual loss its pharmacology and therapeutic potential in the ported and dorzolamide use: (1) the management of glaucoma and ocular hyperten- in his left eye in June 1995. Visual prompt and spectacular improve- sion. Drugs Aging. 1997;10:384-403. acuity was 20/40 OS and 20/200 OD. 3. ZambarakjiHJ,SpencerAF,VernonSA.Anunusual ment in all 7 patients after the dis- side effect of dorzolamide. Eye. 1997;11:418-420. Biomicroscopy revealed a normal an- continuation of dorzolamide, (2) the 4. Wilson FM II. Adverse external ocular effects of terior segment and fundus in the unilateral involvement in the pa- topical ophthalmic medications. Surv Ophthal- right eye and trace cells in the an- tient who was treated unilaterally mol. 1979;24:57-88. terior chamber and anterior vitre- with dorzolamide, and (3) the re- ous of the left eye. Signs of mild vi- peatedly negative bacterial cultures tritis and papillitis associated with in the 3 first patients. The presence The First South American diffuse RPE alterations were pre- of the preservative benzalkonium Case of Diffuse Unilateral sent in the left eye. Early-stage DUSN chloride in other drops that were well Subacute Neuroretinitis was diagnosed, and argon laser treat- tolerated by all patients eliminates Caused by a Large ment was applied to the superior this substance as a possible factor for Nematode temporal retina where a small worm the reported side effect. The ab- was presumed to be present. After sence of itching and dermatitis as well Diffuse unilateral subacute neuroreti- 4 weeks of laser treatment, visual as the gradual developement of symp- nitis (DUSN) is characterized by early acuity was 20/20 OS and the ocular toms over months speaks more for a visual complaints, vitritis, papillitis, inflammation had lessened. The pa- toxic type of conjunctival involve- and recurrence of evanescent gray- tient returned 2 years later with se- ment rather than a predominantly al- white outer retinal lesions and later vere visual loss in the left eye. Vi- lergic reaction. Although allergic and by progressive visual loss, optic atro- sual acuity was counting fingers and toxic conjunctivitis are theoreti- phy, retinal vessel narrowing, and dif- an afferent pupillary defect was ob- 4 cally different clinical entities, it is fuse retinal pigment epithelium (RPE) served. Examination through a not always easy to sort out the con- degeneration occurring unilaterally in slightly cloudy vitreous showed a tribution of toxic or immunologic healthy patients.1 Classically, a mo- 1500- to 2000-µm, white, motile mechanisms in clinical practice. In- tile, white, glistening nematode may nematode in the nasal retina stead of discussing the mechanism in- be found during any disease stage, and (Figure 1). The optic nerve was volved, we stress the well-character- pale and narrowing of the retinal ves- ized findings that all patients had in See also page 1349 sels associated with evidence of more common. Dorzolamide is used pre- RPE involvement was observed. De- dominantly in an elderly glaucoma- should be suspected even in patients spite no history of exposure to rac- tous population in which blephari- with advanced optic atrophy and de- coons, a similar second-stage lar- tis is a common finding. The clinical generative RPE changes. At least 2 vae of Baylisascaris procyonis was picture described herein might well unidentified nematodes are associ- suggested as a probable cause of be ascribed to an infectious conjunc- ated with the syndrome. In endemic DUSN. The patient had no other tivitis related to blepharitis, and thus areas of the southeastern United States systemic complaints, and the uni- may lead to prolonged, unnecessary and South America, the nematode is dentified large worm was de- antibiotic use as was the case for all 400 to 700 µm; in the northern mid- stroyed by strong photocoagula- our patients. Because of the delayed western United States and Germany tion (Figure 2). Visual acuity onset of adverse signs, after pro- the nematode is 1500 to 2000 µm.1-6 improved to 20/200 OS and had not longed dorzolamide use, the link to We report the first South American changed at the final examination dorzolamide is not always obvious. case of DUSN caused by the larger (August 1998) (Figure 3). It is therefore important that the cli- nematode. nician be aware of this adverse ef- Comment. In Brazil, DUSN is infect, which should be suspected in Report of a Case. A healthy 15-year- creasingly considered an impor- cases of recalcitrant and unex- old boy with a history of amblyopia tant cause of posterior uveitis in chil-

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1431

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 JDM. Diffuse unilateral subacute neuroretinitis in South America. Arch Ophthalmol. 1992;110: 1261-1263. 3. Cunha de Souza E, Nakashima Y. Diffuse unilateral subacute neuroretinitis: report of trans- vitreal surgical removal of a subretinal nematode. Ophthalmology. 1995;102:1183-1186. 4. Kazacos KR, Vestre WA, Kazacos EA, Ray- mond LA. Diffuse unilateral subacute neuroretinitis syndrome: probable cause. Arch Ophthal- mol. 1984;102:967-968. 5. Ku¨ chle M, Knorr HLJ, Medenblik-Frysch S, et al. Diffuse unilateral subacute neuroretinitis syndrome in a German, most likely caused by the raccoon roundworm, Baylisascaris procyonis. Graefes Figure 2. Fundus photograph of the left eye Figure 3. Recent fundus photograph of the left Arch Clin Exp Ophthalmol. 1993;231:48-51. immediately after treatment of the worm with eye showing the fundus 1 year after laser 6. Kazakos KR, Vestre WA, Kazakos EA. Raccoon strong application of argon laser. treatment. More pronounced fundus ascarid larvae (Baylisascaris procyonis) as a cause degeneration and a pale optic nerve are of ocular larva migrans. Invest Ophthalmol Vis Sci. dren and young healthy adults. Most apparent. 1984;25:1177-1183. patients are unaware of the disease and several other animals are poten- until ocular examination per- tial intermediate hosts and become formed in school or an ocular ex- infected by ingesting B procyonis eggs Bilateral Massive amination later in life.2,3 The typi- from raccoon feces. The larvae hatch Retinal Hemorrhages cal late signs of DUSN predominate in the small intestine, enter the sys- in a 6-Month-Old Infant: in these cases, and a solitary 400- to temic circulation, and are distrib- A Diagnostic Dilemma 700-µm nematode is frequently pre- uted to various organs, including the sent at this stage, even years after dis- Retinal hemorrhages in infants eye.4,5 In humans, B procyonis may ease onset. According to Gass,1 la- sometimes pose a diagnostic di- cause visceral larva migrans, cere- ser treatment of the nematode at any lemma for ophthalmologists. brospinal nematodiasis, and ocular disease stage may improve visual larva migrans. Fatal cases of B pro- acuity and inflammatory ocular Report of a Case. A 6-month-old in- cyonis larva migrans have been re- signs. However, in our experience fant was treated in the hospital for a ported.1,4,5 Although Brazil is not an this improvement may be tempo- rotavirus gastroenteritis. Two days af- area endemic for raccoons, and cases rary, even if laser is applied to reti- ter discharge from the hospital, he was of B procyonis ocular infection have nal areas simulating the presence of readmitted, profoundly dehydrated not been reported in South America, a worm. It is possible that some la- and in hypovolemic shock. He had we believe that our case could be the ser response in the RPE may inter- collapsed and was unresponsive. His first. The presence of skunks in the fere temporarily with the activity of Glasgow Coma Scale score was 4, and peridomiciliary area of our patient the subretinal worm. his pupils were fixed and dilated. He makes this possibility likely.4,5 Dogs In 1984, Kazacos et al4 showed was intubated and ventilated. Serum and rats should also be considered that at least some DUSN cases are and plasma levels were measured and potential sources of infection. It is im- caused by B procyonis (Nematoda, revealed hypernatremic dehydra- portant to emphasize that other spe- family Ascarididae larvae), which are tion consistent with severe water cies of nematodes should be consid- common intestinal roundworms of loss via the gastrointestinal tract: so- ered as potential candidates for the lower carnivores, including rac- dium, 169 mmol/L; potassium, 7.3 cause of our patient’s symptoms. As coons and skunks. Those authors ex- mmol/L; chloride, 136 mmol/L; urea more local clinicians and veterinar- perimentally produced DUSN in pri- nitrogen, 25 mmol/L (70 mg/dL); and ians become aware of these larger mates that were fed B procyonis eggs.6 creatinine, 222 µmol/L (2.51 mg/dL) ocular nematode infections, other im- Additionally, the size of the intrareti- .The infant was acidotic with a pH of portant epidemiologic findings will nal larvae and previous patients’ con- 6.8; PO , 10.6; PCO , 5.2; standard bi- be reported. 2 2 tact with raccoons made the hypoth- carbonate, 6.8 mmol/L; and base ex- esis that B procyonis was the probable cess, 23 mmol/L. Arnaldo P. Cialdini, MD cause of the disease even stronger. Observations from fundus- Eduardo C. de Souza, MD In their opinion, DUSN is caused by copy revealed massive bilateral reti- Marcos P. A´ vila, MD 2 species of nematodes or 2 sizes of nal hemorrhages radiating from Goia´s, Brazil a single species, reflecting different the posterior pole of the eyeball ages of larvae.4,5 The latter seems to (Figure 1). Findings from coagu- Reprints: Arnaldo Cialdini, MD, Av- apply to our patient. Unlike Toxo- lation studies, complete blood cell enue T2, Number 401, Alto Setor Bueno, cara species, which do not exceed and differential cell counts, and CEP 74210-010, Goiaˆnia, Goia´s, Bra- 700 µm, Baylisascaris larvae grow thrombophilic screens were nor- zil (e-mail: [email protected]). considerably, from about 300 µm at mal. His profiles for amino acid, fatty

hatching to 2000 µm or larger, the 1. Gass JDM. Diffuse unilateral subacute neuro- acid, and organic acid were normal. size most frequently recovered from retinitis. In: Gass JDM, ed. Stereoscopic Atlas of A computed axial tomographic scan clinically affected animals.4 Adult Macular Diseases: Diagnosis and Treatment. 4th of the brain showed diffuse cerebral ed. St Louis, Mo: Mosby–Year Book Inc; 1997: B procyonis worms may also infect 622-628. edema, subdural blood in the tem- rats, squirrels, and dogs. Humans 2. Cunha de Souza E, Lustosa da Cunha S, Gass poral fossa, and diffuse subarach-

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1432

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 noid hemorrhage (Figure 2). The with disseminated intravascular co- Comment. Retinal hemorrhages in infant’s clinical condition deterio- agulation.Nonaccidentalinjury(NAI) infancy are believed to be a cardi- rated and he died. was suspected because of the findings nal sign of NAI. They may occur in Findings from histopathologic from clinical examination; in particu- up to 89% of infants with NAI.1 They examination of the eyes revealed mas- lar, massive retinal hemorrhages in as- may result from direct head trauma sive retinal hemorrhages with subhya- sociation with intracerebral hemor- or the acceleration and decelera- loid and subretinal hemorrhages in rhage.However,therewasnoevidence tion forces generated by the shak- both eyes (Figure 3). The brain scan of trauma. A skeletal survey revealed ing of the head. Shaken baby syn- revealed venous and capillary conges- no abnormalities. The findings from drome is a unique form of child tion with subarachnoid hemorrhage, clinicalexamination were consistent abuse in which the only consistent a subdural collection, and focal intra- with severe hypernatremic dehydra- external physical signs are ocular cerebral hemorrhages. There was also tioncausingdiffuseintracerebralhem- manifestations. Differential diag- diffuse microvessel thrombosis in orrhage, subarachnoid hemorrhage, noses of retinal hemorrhages in- manyorgans,includingthelungs,kid- retinal hemorrhages, and ultimately clude thrombocytopenias, leuke- neys, and myocardium, consistent brain death. mias, and infections such as infective endocarditis. In this case profound electro- lyte disturbance, namely, hypernatremic dehydration, caused intracerebral, subdural, and subarachnoid hemorrhages. Hypernatremia causes cerebral cellular dehydration and results in brain shrinkage. This leads to the rupture of bridging veins, causing subdural and intracerebral hemorrhages. Elevated intracranial pressure leads to increased retinal venous pressure and results in retinal hemorrhages. Finberg2,3 reported 12 cases of subarachnoid or subdural hemorrhage from hypernatremic dehydration in infants, 2 of whom died and 10 who had severe residual neuro- logical damage. Pathologic effects of hypernatremia were also reported following a nursery disaster in which an improper infant food mixture- Figure 1. Retinal hemorrhages radiating from the posterior pole of the eyeball in a 6-month-old infant. containing an excess of sodium chlo-

Figure 2. Noncontrast computed axial tomographic scans of the brain. Left, The arrow indicates subdural hemorrhage in the temporal fossa. Right, Diffuse cerebral edema and subarachnoid hemorrhage are indicated by the arrows.

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1433

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 visual acuity of 6/12 OU. Conver- gence-retraction nystagmus, pupillary light-near dissociation, and slight limitation of upward gaze were present bilaterally. Diplopia was noted on right gaze with evidence of slight underaction of the left superior oblique. Findings from slitlamp examination were normal. Di- lated fundus examination revealed bilateral 2+ vitreous cells and marked optic nerve head edema (Figure 1). Tortuosity of the retinal vessels with areas of focal sheathing and exu- dates in a “candle wax dripping” configuration were also present. Large clumps of vitreous cells were noted in the inferior vitreous base bi- Figure 3. Findings from histopathologic examination of the retina show subretinal (single arrow), laterally. intraretinal (double arrows), and subhyaloid hemorrhage (triple arrows). Fluorescein angiography revealed numerous areas of segmen- ride was administered to infants. 1. Tyagi AK, Scotcher S, Kozeis N, Willshaw HE. tal hyperfluorescence of the retinal Can convulsions alone cause retinal hemor- Findings from autopsy showed sub- rhages in infants? Br J Ophthalmol. 1998;82:659- venules along the temporal arcades arachnoid hemorrhage, intracere- 660. and leakage from both discs bilat- bral hemorrhage, cortical venous 2. Finberg L. Pathogenesis of lesions in the ner- erally. Neither capillary nonperfu- vous system in hypernatremic states. Pediat- thrombosis, and venous infarc- rics. 1959;19:40-45. sion nor retinal neovascularization tions. Similar cases in adults have 3. Finberg L, Harrison HE. Hypernatremia in in- was noted. Laboratory investiga- fants [editorial]. Pediatrics. 1955;16:1. shown widespread cerebral hemor- 4. Davis RL, Robertson DN. Textbook of Neuropa- tions indicated a minimally el- 4 rhage. Infants are more suscep- thology. 2nd ed. Baltimore, Md: Williams & evated erythrocyte sedimentation tible to hypernatremia because of Wilkins; 1990. rate and a normal serum angioten- 5. Han BK, Lee M, Yoon HK. Cranial ultrasound their large surface area and poor re- and CT findings in infants with hypernatremic sin-converting enzyme level. Find- nal concentrating ability. The typi- dehydration. Pediatr Radiol. 1997:9;739-742. ings from tuberculin skin test, rapid cal radiological findings from com- plasma reagin test, and chest x-ray puted tomographic scans of infants film were normal. A preliminary di- with hypernatremia include brain agnosis of sarcoidosis was sus- parenchymal abnormalities, multi- Retinal Periphlebitis pected. The patient was referred to focal areas of hemorrhage, and in- in a Patient With Pineal the neurology service for evalua- farction.5 Retinal hemorrhages were Germinoma tion of possible central nervous sys- not documented in these cases. tem involvement. In conclusion, we report a case Patients with pineal germinomas Computed tomographic scans of massive bilateral retinal hemor- commonly show signs and symp- and magnetic resonance images rhages and intracranial hemor- toms related to increased intracra- revealed a partially calcified homog- rhages attributable to profound hy- nial pressure and direct compres- enous 3-cm pineal mass and ob- pernatremic dehydration in an sion of the upper brainstem or structive hydrocephalus. The neu- infant. The findings from clinical ex- cerebellum.1 Ocular manifesta- rology service felt the clinical and amination are similar to those seen tions typically include papilledema radiographic findings were consis- in NAI. It is important to highlight and extraocular movement distur- tent with a germinoma and recom- this to avoid potential mistaken di- bances. We describe a patient with mended radiotherapy. Based on the agnoses. Unexplained retinal hem- a pineal germinoma who had pos- clinical examination and the pres- orrhages in infancy mandate a full terior segment inflammatory ence of the sarcoidlike appearance clinical workup. The NAI remains changes. in the fundus, the ophthalmology high on our list of differential diag- service recommended biopsy to ob- noses, but other pathologic condi- Report of a Case. A 14-year-old boy tain a tissue diagnosis. tions can mimic NAI and have an of East Indian descent sought care A ventriculostomy of the third identical clinical presentation. because of a 2-month history of float- ventricle with endoscopic biopsy was ers and difficulty with visual tasks. performed. Findings from histo- Sinead Fenton, FRCS The patient complained of head- logic examination confirmed the di- Deirdre Murray, MRCP aches, nausea, vomiting, and an in- agnosis of a germinoma. A cerebro- Paul Thornton, MD termittent auditory bruit in the right spinal fluid specimen was analyzed, Susan Kennedy, FRCPath ear. Systemic examination dis- and the results were negative for tu- Michael O’Keefe, FRCOphth closed an unsteady gait and tremor. mor markers and inflammatory cells. Dublin, Ireland Ophthalmic examination revealed a Fractionated focal radiotherapy (45

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1434

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Figure 1. Black and white (left) and color (right) fundus photographs demonstrating diffuse optic disc swelling and hyperemia in the left eye. Multiple foci of perivenous “candle wax drippings” are present.

Figure 2. Black and white (left) and color (right) fundus photographs show marked resolution of optic disc edema and perivenous exudation in the left eye 3 weeks following completion of radiotherapy.

Gy) was administered over a 5-week ance was strikingly similar to that the pineal tumor on the retinal vas- period. Follow-up serial fundus ex- seen in patients with retinal involve- culature in a manner comparable to aminations revealed a marked de- ment of sarcoidosis. It has been es- a paraneoplastic syndrome. crease in optic disc edema and peri- timated that up to 35% of individu- To our knowledge there are no phlebitis bilaterally. Complete als with posterior segment reported cases of paraneoplastic syn- resolution of retinal findings was involvement of sarcoidosis will have dromes associated with pineal ger- noted by 3 weeks after termination concomitant central nervous sys- minoma. There are, however, nu- of radiation therapy (Figure 2). tem disease.2 Despite the normal find- merous examples of paraneoplastic Throughout the patient’s medical ings from chest x-ray film and nor- syndromes associated with semino- course, no local or systemic corti- mal levels for angiotensin-converting mas of the testis and dysgermino- costeroid treatment was used. enzyme, our clinical suspicion for sar- mas of the ovary, both of which are coidosis remained strong enough to histologically similar to intracra- Comment. Germinoma is the most warrant our insistence that tissue bi- nial germinomas.1 These latter tu- common intracranial germ cell tu- opsy be performed prior to radia- mors have been associated with hy- mor and typically arises in the pi- tion treatment. percalcemia and demyelination neal gland or suprasellar region. It Both the histologic confirma- disorders.3 occurs frequently in boys aged 10 tion and the prompt resolution of the Paraneoplastic syndromes typi- to 12 years and often is seen with retinal lesions following radio- cally manifest with widespread outer ophthalmic manifestations.1 In our therapy to a distal site supported our retinal findings resulting in visual patient the most striking ophthal- new hypothesis that the fundus find- loss and have been associated with mic clinical finding was the pres- ings were related to the tumor. a number of different carcinomas.4 ence of intraocular inflammation and Though unproven, this suggests the The pineal gland contains differen- retinal phlebitis. The fundus appear- possibility of a remote influence of tiated photoreceptor tissue and pos-

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1435

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 sibly may be a source of antigenic presentation in the context of germinoma. The pineal gland may also be involved in patients with sympa- thetic ophthalmia and trilateral retinoblastoma.5 We report this case to bring at- tention to the possible association of retinal vasculitis with germ cell tumors. Knowledge of this association may prevent unnecessary biop- sies in future cases.

Charmaine W. Chang, BSc Dawn Hay, RN Tom S. Chang, MD, FRCSC Randy Nguyen, MD Christopher J. Lyons, MB, FRCSC Vancouver, British Columbia Figure 1. Initial presentation of the right orbit. Note the destruction of the right canthus involving the upper eyelid and several larvae appearing through the whole extent of the lesion. Corresponding author: Tom S. Chang, Section B, 2550 Willow St, Vancouver, British Columbia, Canada V5Z 3N9.

1. Bruce JN, Connolly ES Jr, Stein BM. Pineal cell and germ cell tumors. In: Kaye AH, Laws ER Jr, eds. Brain Tumors: An Encyclopedic Approach. Ed- inburgh, Scotland: Churchill Livingstone; 1995: 725-751. 2. Stanbury RM, Graham EM, Murray PL. Sarcoid- osis. Int Ophthalmol Clin. 1995;35:123-137. 3. Wong K, Poon P, Berry K, Coppin C, Kostashuk E. Paraneoplastic demyelinating disorder in the brain of a patient with seminoma. J Comput As- sisted Tomogr. 1998;22:136-138. 4. Wagner RF, Nathanson L. Paraneoplastic syndromes, tumor markers, and other unusual features of malignant melanoma. J Am Acad Dermatol. 1989;14:249-256. 5. Murphee AL, Rother C. Retinoblastoma. In: Ryan SJ, Schachat AP, eds. Retina. Vol 1. St Louis, Mo: Mosby–Year Book Inc; 1989:517-556.

Figure 2. Slitlamp examination with forced eyelid opening. Note the aspect of the larvae Massive Orbital in the orbital connective tissue. Myiasis Infestation of a sugarcane alcoholic beverage. The patient underwent orbital Infestation by dipterous fly larvae in The patient reported undergoing ex- exenteration under general anesthe- ocular and orbital tissues (ophthal- eresis of a suspected skin cancer in sia (Figure 3) and more than 100 momyiasis) occurs throughout the his right inferior eyelid a few years larvae of Cochliomyia hominivorax world, mostly in children and older previously that then recurred with (Coquerell) (Diptera: Calliphori- people and, depending on the ge- an exudative inferior eyelid lesion. dae) were removed. Findings from nus of the fly, the infestation can be In addition, alcoholism of 30 years’ histological analysis of the speci- by single or multiple larvae.1 We re- duration was mentioned. men showed the presence of basal port a case of orbital myiasis in a man Findings from examination cell carcinoma in the eyelid with in- who had more than 100 larvae re- revealed periorbital edema, erosion filtration into the muscle layer; the moved, followed by orbital exen- of the skin and conjunctiva of the margins were free of neoplasm. This teration. inner canthus of his right orbit, and patient’s oculoplastic aspect has been a wound full of larvae that dis- followed up periodically to provide Report of a Case. A 54-year-old man placed the eye globe to the outer a satisfactory cosmetic result. In ad- had severe pain and swelling in his canthus. Findings from gross ex- dition, a psychiatrist was enrolled to right orbital region. The sensation amination revealed a hypotonic provide needed assistance. was noted 4 hours prior to exami- eye, an inflamed conjunctiva, and nation, just after waking up from an a severely swollen cornea. Visual Comment. Ophthalmomyiasis is estimated 24-hour sleep in a coun- acuity OD was no light perception considered a rare, life-threatening tryside house after ingesting a bottle (Figure 1 and Figure 2). condition. Mechanical removal with

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1436

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 gained popularity among young- sters since they are relatively cheap, can be purchased without age restrictions, and look real. To our knowledge, no reports have previously been published on eye injuries caused by these guns. The purpose of this study is to illustrate their potential ocular hazards and to propose preventive measures.

Airsoft Guns. Airsoft guns consist of a plastic pistol that shoots hard plastic bullets with a diameter of 6.0 mm (Figure 1). These bullets are available in different weights (0.12, 0.2, and 0.25 g), all of which are much lighter than the lead bullets Figure 3. The aspect of the eye after elimination of larvae and orbital exenteration. used in BB guns (0.52-1.6 g). The guns use the direct force of a spring coil or compressed air to fire bul- or without chemical immobiliza- tion was necessary to contain the lets. In an independent ballistic in- tion of the larvae are the options of progression of the infestation. vestigation,1 the calculated energy for treatment, depending on the time bullets weighing 0.2 and 0.12 g and degree of infestation. The pres- Eduardo M. Rocha, MD was 0.363 and 0.347 J, respec- ervation of larvae in ethanol for ge- Jorge L. Yvanoff, MD tively. This energy results in veloci- nus identification may be useful for Leopoldo M. S. Silva, MD ties of 61.5 and 74.9 m/s, respec- epidemiological purposes and the Angelo P. Prado, PhD tively, and in-flight ranges of 30 to subsequent application of large- Roberto Caldato, MD 50 m, respectively. The bullets are scale measures to reduce the fly Campinas, Brazil made of a very hard and noncom- population. Outbreaks of C homi- pressible plastic material and thus, nivorax have been reported, and al- Corresponding author: Eduardo M. Ro- do not absorb energy. They can though considered to be confined cha, MD, Faculty of Medical Sciences, cause injuries, even when they rico- to the New World, reports have State University of Campinas (UNI- chet from rigid surfaces. In com- identified the parasite in Africa and CAMP), Rua Alexandre Fleming, parison, BB gun bullets reach speeds 2 Asia. s/n, Campinas, SP, CEP 13081-970, of 100 to 200 m/s and a flight range The massive infestation seen Brazil (e-mail: [email protected]). of 100 to 150 m. here may have been precipitated by an open wound caused by basal cell 1. Kersten RC, Shoukrey NM, Tabbara KF. Orbital Patients. Between October 1996 and carcinoma in the nasal canthus. This myiasis. Ophthalmology. 1986;86:1228-1232. July 1998, 9 male patients were 2. Chodosh J, Clarridge J. Ophthalmomyiasis: a re- treated, 8 at the eye clinic of the Uni- hypothesis is based on previous ob- view with special reference to Cochliomyia homi- servations that adult flies of C hominivorax. Clin Infect Dis. 1992;14:444-449. versity of Bern and 1 at the eye clinic 3. Holt GG, Adams TS, Sundet WD. Attraction and of the University of Basel, Switzer- nivorax locate their hosts via visual ovipositional response of screw worms, Cochlio- and olfactory stimuli and are myia hominivorax (Diptera: Calliphoridae), to land, for ocular injuries caused by simulated bovine wounds. J Med Entomol. 1979; airsoft bullets. After reviewing the strongly stimulated by fresh blood, 16:248-253. usually present in this type of skin neoplasia.3 Alcoholism and the prolonged state of unconscious- ness in a rural location contributed Ocular Injuries Caused to the fast destruction of the orbit of by Airsoft Guns our patient. Exenteration was con- ducted to prevent intracranial pro- In the past 2 years, we observed in gression. our outpatient clinic an escalating Although there is no method number of ocular injuries caused by for completely protecting against “airsoft” or “softgun” toy weapons. myiasis, prevention may be con- In contrast to the conspicuous haz- ducted on a local scale by practic- ard of classical air guns (BB guns), ing adequate personal hygiene and this new kind of toy weapon improper care of wounds. To our plies a dangerously misleading knowledge, this is the first reported harmlessness, both because of the case of ophthalmomyiais caused by airsoft name and because the gun is Figure 1. Realistic looking plastic airsoft pistol C hominivorax in which exentera- made of plastic. These toy guns have and bullet of 6-mm diameter.

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1437

Anterior Segment Injuries Visual Acuity Patient Corneal Epithelial Stromal Traumatic Angle ↑ IOP No. Age, y Eye Initial Final Abrasion Edema Edema Hematocornea Hyphema Mydriasis Iridodialysis Recession Temporary Cataract 1 17 OS 20/60 20/20 x x x 2 12 OS CF 20/20 x x x x x x x x 3 17 OS 20/20 20/20 4 16 OS 20/100 20/20 x x x x x 5 13 OD 20/20 20/20 x 6 11 OD LP 20/25 x x x x x x x 7 13 OD 20/25 20/20 x x 8 12 OD 20/25 20/20 x x x x 9 14 OS CF 20/20 x x x x x x

*↑ indicates increase in; IOP, intraocular pressure; CF, counting fingers; LP, light perception; x, finding present on initial clinical examination; conserv, conservative treatment; IOL, implantation of a posterior chamber intraocular lens; and ppV, pars plana vitrectomy.

vitreous hemorrhage. Initial and final visual acuity was 20/20. The area of choroidal rupture remained un- changed during the 14-month follow-up.

Comment. Previous to our series, ocular injuries due to air guns have been reported only in the context of BB guns,2 including penetrating globe injuries or retrobulbar optic nerve trauma leading to severe visual impairment or loss of the eye.3,4 Other severe nonocular injuries have been observed, some of which have led to death.5 This severity is due to the much higher energy of BB bullets (0.072 J/mm2)—which ex- ceedes that necessary for scleral pen- etration (0.06 J/mm2)6—than the Figure 2. Case 2. Corneal erosion in size and shape of an airsoft bullet. Note beginning stromal edema considerably lower energy density and descemet folds. (0.01 J/mm2) of airsoft bullets.1 In our series, airsoft bullet in- medical charts, patients were sched- Cataract development was observed juries ranged from light contusions uled for an additional eye examina- in 3 patients; 2 showed a transient to severe sight-threatening closed- tion. Mean follow-up was 8.8 months increase of intraocular pressure due globe injuries. These are less severe (range, 0.5-24 months). Mean ± SD to hemorrhagic glaucoma. Cham- than with BB guns, possibly because age was 13.9 ± 2.3 years (range, 11-17 ber angle recession was present in 2 airsoft bullets are larger and have years). All patients were male and patients, iridodialysis in another. lower energy. The worst injury in our only 1 eye was affected. In 2 cases, Injuries of the posterior seg- series was a total hyphema com- bullets ricocheted from a wall into the ment were observed in 5 eyes. In 1 bined with traumatic cataract, and a eye; in the other 7 cases, the eye was of these eyes, there was total hy- dense vitreous hemorrhage. hit directly. phema with subsequent hematocor- However, in contrast to BB nea and dense vitreous hemor- guns, airsoft guns are easily avail- Results. A summary of the results rhage. A pars plana vitrectomy, able and their sale is not restricted is given in the Table. Initial visual combined with phacoemulsifica- by age. Airsoft guns were designed acuity was counting fingers or light tion and a posterior chamber lens as a toy and are still marketed as a perception in 3 patients, between 20/ implantation, was performed. Ini- toy. The innocent name and mis- 100 and 20/25 in 4, and 20/20 in 2. tial visual acuity was light percep- leading marketing contribute to the Final visual acuity was 20/20 in 8 pa- tion; final visual acuity of 20/25 was danger of airsoft guns. Safety goggles tients and 20/25 in 1. attained 3 months after injury. are not supplied with the guns, but In 6 patients, corneal erosion Another case of posterior seg- are at least recommended in prod- and stromal edema matching the ment injury showed a peripheral uct manuals. In all cases, goggles bullet size (Figure 2) were seen. choroidal rupture but only a small could have prevented injuries.

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1438

©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Airsoft guns should not be con- Corresponding author: Beatrice E. sidered to be toys but rather, as Frueh, MD, Department of Ophthal- weapons with the potential of caus- mology, University Hospital, Inselspi- Posterior Segment Injuries ing severe eye injuries. Globe rup- tal, Freiburgstrasse, CH-3010 Bern, Vitreous Choroidal Retinal tures or penetrating traumas were Switzerland (e-mail: beatrice.frueh Hemorrhage Rupture Edema Procedure not observed in our series, but 1 in- [email protected]). x x conserv jury was severe enough to require in- conserv traocular surgery. In the United x x x conserv States, some states recently passed 1. Kneubu¨ hl B. Ballistische Kolumne: Bogen, Arm- conserv legislations limiting the import and brust und andere Federwaffen. Internationales conserv Waffenmagazin. 1998;3:160-162. sale of these weapons. 2. Bond S, Schnier G, Miller F. Air-powered guns: x x IOL/ppV All patients with eye injuries due too much firepower to be a toy. J Trauma. 1996; x x conserv 41:674-678. x conserv to airsoft guns should be referred to 3. Schein O, Enger C, Tielsch J. The context and conserv an ophthalmologist for further evalu- consequences of ocular injuries from air guns. ation. Safety goggles should be in- Am J Ophthalmol. 1994;117:501-506. 4. Sharif K, McGhee C, Tomlinson R. Ocular trauma cluded with the guns and wearing caused by air-gun pellets: a ten-year survey. Eye. them should be mandatory while 1990;4(pt 6):855-860. 5. Amirjamshidi A, Abassioun K, Roosbeh H. Air- playing. Age or sale restrictions gun pellet injuries to the head and neck. Surg Airsoft guns have the addi- should also be considered. Neurol. 1997;47:331-338. tional liability that it is very easy to 6. Sellier A, Kneubu¨ hl B. Wound ballistics of handgun ammunition. In: Wound Ballistic and replace the plastic bullets with much Johannes C. Fleischhauer, MD the Scientific Background. Amsterdam, the heavier steel or lead bullets, which David Goldblum, MD Netherlands: Elsevier Science Publishers; 1994: develop the same energy at a dis- Beatrice E. Frueh, MD chap 6. 7. Kneubu¨ hl B. Ballistische Kolumne: Bogen, Arm- tance of 40 to 50 m that plastic bul- Fritz Koerner, MD brust und andere Federwaffen. Internationales lets develop at 10 m.7 Bern, Switzerland Waffenmagazin. 1998;5:328-330.

ARCH OPHTHALMOL / VOL 117, OCT 1999 WWW.ARCHOPHTHALMOL.COM 1439