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Sir, Metastatic Calcification in the Eye Is Often Seen in the Cornea and the Interpalpebral Conjunctiva. in Hypercalcaemic Subje

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Sir, Metastatic Calcification in the Eye Is Often Seen in the Cornea and the Interpalpebral Conjunctiva. in Hypercalcaemic Subje 804 LETTERS TO THE JOURNAL References described in the sclera.1 Rarely has calcium been 1 1. Schepens CL, Acosta F. Scleral implants: an historical detected in the uvea. There have been few previous perspective. Surv OphthalmoI1991;35:447-53. case reports of patient with clinically evident 2. Wizina RA. Removal of solid silicone rubber explants choroidal calcification following hypercalcaemia due after retinal detachment surgery. Am J Ophthalmol to primary hyperparathyroidism 2. We present the 1983;95:495-7. clinical and investigative findings of a patient who 3. Deutsch J, Aggarwal RK, Eagling EM. Removal of had been treated for primary hyperparathyroidism · scleral explant elements: a 10-year retrospective study. and who was found some years later to have Eye 1992;6:570-3. choroidal calcification. 4. Delaney WV, Tomisi PF, Hampton GR, et al. Complications of scleral buckling procedures. Arch OphthalmoI1987;105:702-3. Case Report A 60-year-old woman with a complex medical history was referred to the eye clinic in September 1991. She Sir, was diagnosed with infiltrating carcinoma of the Choroidal Calcification in Primary Hyperpara­ breast in January 1991. She had a right mastectomy thyroidism and axillary clearance in February 1991 and was Metastatic calcificationin the eye is often seen in the subsequently placed on tamoxifen 20 mg daily. cornea and the interpalpebral conjunctiva. In Visual deterioration on the right prompted referral hypercalcaemic subjects calcium has also been for examination for uveal metastases. Fig. 1. Fundus photographs showing the creamy-white to yellow-orange lesions representing areas of choroidal calcification: Top left, right superior vessel arcades; bottom left, right temporal vessel arcades; top right, left superior vessel arcades; bottom right, left inferotemporal vessel arcade. LETTERS TO THE JOURNAL 805 Discussion The differential diagnosis of the retinal lesions in this patient may include multiple choroidal osteomata. They occur much more frequently in the juxtapapil­ lary choroid and are usually solitary.4 Choroidal metastases should also be considered in this patient, especially with a history of breast carcinoma. Rapid growth is usually a feature, though this may have been halted by the tamoxifen and followed by regression and calcification. The lesions may repre­ sent previously undiagnosed multifocal choroiditis with secondary calcification. Bilateral regressed retinoblastoma would seem unlikely, especially with the preservation of excellent vision.s Multiple idiopathic sclerochoroidal calcifications have been Fig. 2. Low-gain B-scan ultrasound demonstrating areas described in older patients but these are usually of high reflectivity at the level of the choroid. located near the superotemporal vessel arcades only, whereas there were also inferiorly located lesions in In January 1980 she underwent partial parathy­ 6 7 roidectomy (2Yz glands) for primary hyperparathy­ our patient. , This patient's history and clinical findings suggest roidism. Post-operatively she was hypocalcaemic. that hypercalcaemia due to hyperparathyroidism was This was treated briefly with calcium supplements the cause of the ocular lesions. The dense nature of and she has subsequently been normocalcaemic. Pre­ these, as demonstrated by ultrasonography, shows operative investigations revealed serum calcium them to be calcium in composition. The pattern of levels of 3.04 mmolll, serum phosphate of 0.96 distribution may suggest that calcium had been mmolll and parathyroid levels of 0.14 f,Lg/1 (normal deposited in or around the lobules of the choroidal being 0.1-0.73 f,Lg/I). Radiographs showed chondro­ circulation. This probably occurred during a long calcinosis and soft tissue calcification. There was no period of undiagnosed hypercalcaemia and has subperiosteal reabsorption. Urinary calcium and remained so following satisfactory treatment of the phosphate were 4.38 and 18.6 mmol per 24 hours hyperparathyroidism. respectively. A prednisolone suppression test was negative. Despite a normal parathyroid level the A. M. O'Driscoll patient's consultant physician felt that the hypercal­ M. M. Quraishy caemia was due to primary hyperparathyroidism. In N. C. Andrew 1960 she had a phosphate renal calculus removed. Department of Ophthalmology She also claimed to have had rheumatic fever at the Kent and Canterbury Hospital age of 21 years and scarlet fever at the age of 18 Ethelbert Road months. Canterbury The patient's corrected visual acuity was 6/18 on Kent CTl 3NG the right and 6/6 on the left when she presented to UK the eye clinic. Both eyes were free of active Correspondence to: inflammation and there was no conjunctival or Anthony M. O'Driscoll, FRCOphth corneal calcification. Fundus examination (Fig. 1) Birmingham and Midland Eye Hospital revealed bilateral and fairly symmetrical, raised Church Street creamy-white to yellow-orange lesions arranged Birmingham B3 2NS deep to the vessel arcades that were more promi­ UK nent superiorly. They were round to oval in shape and some appeared to coalesce. The pigment References epithelium was clumped at the margins of a few of 1. Berkow JW, Fine BS, Zimmerman LE. Unusual ocular the lesions. Very low gain B-scan ultrasonography calcification in hyperparathyroidism, Am J Ophthalmol demonstrated high reflectivity from the lesions and 1968;66:812-24. 2. Goldstein BG, Miller J. Metastatic calcification of the shadowing behind them (Fig. 2). Fluorescein angio­ choroid in a patient with primary hyperparathyroidism. graphy was omitted because of a history of Retina 1982;2:76-9. hypersensitivity. Posterior subcapsular opacification 3. Suzuki J, Takeda M, Sekine N, Kanno M, Kii T, Kofune M, et ai. Bilateral metastatic sclerochoroidal calcification was identified on the right and following cataract in a patient with hyperparathyroidism. Ophthalmologica surgery the corrected acuity was 6/6. 1992;205:10-4. 806 LETTERS TO THE JOURNAL 4. Shields CL, Shields JA, Augsburger JJ. Choroidal atrophy was noted in the right eye. Diamox 500 mg osteoma. Surv OphthalmoI1988;33:17-27. intravenously, ocular massage, expired air rebreath­ 5. Sanborn GE, Augsburger JJ, Shields JA. Spontaneous ing and anterior chamber paracentesis were adminis­ regression of bilateral retinoblastoma. Br J Ophthalmol 1982;66:685. tered. These measures, however, failed to alleviate 6. Munier F, Zografos L, Schnyder P. Idiopathic sc1er­ his symptoms. He was anticoagulated with 50 000 IU ochoroidal calcification: new observations. Eur J heparin subcutaneously and started on 300 mg OphthalmoI1991;1:167-72. aspirin o.d.. 7. Sivalingam A, Shields CL, Shields JA, McNamara JA, Jampol LM, Wood WJ, Daubert G. Idiopathic sc1er­ Investigations ochoroidal calcification. Ophthalmology 1991; 98:720-4. Full blood count, erythrocyte sedimentation rate, activated partial thromboplastin time and thrombin time were normal; as were euglobulin clot lysis time Sir, before and after limb occlusion. Platelet aggregation Bilateral Buried Optic Nerve Drusen Presenting (on aspirin; with 1 and 5 /-Lmol ADP) was normal. with Central Retinal Artery Occlusion at High Screens for antinuclear antibody, antineutrophil Altitude cytoplasmic antibody, antiphospholipid antibodies, Retinal ischaemia at high altitude is well recog­ rheumatoid factor and Treponema pallidumhaemag­ 1 2 nised • and may have disastrous consequences. glutination test were negative. Serum biochemistry and lipid profile showed no abnormality. Doppler Case Report carotid ultrasonography was unremarkable and A 48-year-old man presented with a sudden loss of trans-oesophageal echocardiography showed a par­ vision in his left eye during descent to landing at tial atrial-septal defect but no SOurce for cardiac Heathrow airport. Five years previously a similar emboli. An orbital CT scan showed bilateral buried incident occurred in his right eye during a skiing optic nerve drusen (Figs. 2, 3) which were confirmed holiday, after descent from high altitude, resulting in by ultrasonography. hand movements vision. He was otherwise fit and Doppler ultrasonography demonstrated a central intermittently took 300 mg aspirin o.d. as prophy­ retinal artery blood velocity of 0.03 mls in the right ) laxis. eye and 0.06 mls in the left eye (NR 0.1 m/s . The The vision was hand movements in both eyes; both patient was discharged home and local ophthalmol­ anterior segments were normal and both pupils ogy and medical outpatient appointments were made reacted slowly to light. A left central artery for immediate support and follow-up. occlusion (CRAO) was diagnosed (Fig. 1) and optic Fig. 1. Retinal photograph of the lefteye. Note the central retinal artery occlusion and absence of optic nerve head Fig. 2. Orbital CT scan of the right orbit. Note the large abnormalities. buried drusen within the optic nerve. .
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