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protrusion occurs above the area of thinning, Br J Ophthalmol: first published as 10.1136/bjo.80.10.928 on 1 October 1996. Downloaded from whereas in keratoconus the maximal protru- sion occurs in the thinned area. Also, the iron lines typical ofkeratoconus are absent here. In keratoglobus thinming and protrusion occur over the entire cornea rather than in one area as in this case. The unilateral presentation in this case is unusual, for PMD is considered a bilateral condition."2 Although bilateral conditions often present asymmetrically in degree or time, the left eye in this case shows no signs of corneal involvement 30 years after the first eye Figure 1 (A) Photograph of right eye showing became symptomatic and past the age that cornealprotrusion. (B) Slit-lamp photograph of PMD typically is diagnosed. Cases of unilat- same eye showing band ofclear corneal thinning Figure 1 Slit-lamp photograph, showing the 1-2 mm above limbus. eral PMD associated with other corneal thin- central corneal infiltrate (arrow). Two satellites ning disorders such as keratoconus in the can be discerned. The corresponding visual acuity opposite eye have been reported,34 but this is was 201200. the first case of isolated unilateral PMD in an elderly patient. BRET B WAGENHORST Columbia, SC 29209, USA

Accepted for publication 24 May 1996

1 Krachmer JH. Pellucid marginal corneal degen- eration. Arch Ophthalmol 1978;%: 1217-21. 2 Krachmer JH, Feder RS, Belin MW. Kerato- conus and related noninflammatory corneal IW W;W' 'M- thinning disorders. Surv Ophthalmol 1984;28: 293-322. Figure 2 Light microscopy ofcorneal scraping 3 Lisch K. Torische Vorwolbung der Hormhaut. material in potassium hydroxide solution: Kin MonatsblAugenheilkd 1970;157:523-8. Nocardia organisms appear as rectangular 4 Nagy M, Vigvary L. Beitrage zur Atiologie der degeneratio marginalis pellucida corneae. Kin branching rods (arrow) surrounded by corneal MonatsblAugenheilkd 1972;161:604-1 1. debris. sium hydroxide solution by light microscopy Amikacin may be drug of choice in (Fig 2). Long rectangular elements were Nocardia keratitis discerned between stromal debris. Mean- while, culture of material from the first scrap- EDrroR,-While Nocardia infections usually ing revealed Nocardia species. Further sub- follow a selflimiting course, rapid extension of classification was impossible owing to scarcity the primary focus and dissemination have of material and slow growth of the organism. 2 Corneoscope photograph ofright Figure (A) been reported in immunosuppressed pa- Subsequently, the patient was put on topical http://bjo.bmj.com/ eye demonstrating marked, against the rule astigmatism. (B) Corneoscope photograph ofleft tients.' Owing to the more frequent use of amikacin 5% every 2 hours and amphotericin eye demonstrating sphericity. immunosuppressive drugs, Nocardia infec- 0.5% five times a day. tions are diagnosed with increasing fre- Two months later, scar tissue was observed thinning, or abnormal protrusion. The dilated quency.2 Case reports have recently encour- in the subepithelial corneal stroma and best fundus examination was unremarkable in both aged the use of topical amikacin in Nocardia corrected visual acuity had recovered to eyes. Intraocular pressures were 10 and 15 keratitis.3 We present another patient with this 20/25. mm Hg right and left eye, respectively, by condition treated successfully with topical pneumotonometry. Keratometry was 40.75 by amikacin. COMMENT on September 29, 2021 by guest. Protected copyright. 53.5 x 180 right eye and 42.5 by 42.50 left Exogenous ocular inoculation by Nocardia eye. Corneoscope photographs revealed CASE REPORT species usually affects the cornea. An intact marked against the rule astigmatism in the A 31-year-old man noticed a foreign body immune response is critical for the eradication right eye and no apparent corneal astigmatism sensation in the right eye after drilling into the of Nocardia infections. Topical steroids were in the left (Fig 2). ceiling of a decayed building. He presented to reported to aggravate the disintegration of a local ophthalmologist, who removed two comeal tissue.4 COMMENT metal fragments from the right cornea. Nocardia keratitis can result in permanent This patient was noted to have corneal Although a treatment with norfloxacin eye- reduction of visual acuity due to corneal scar- findings in the right eye consistent with PMD drops, subconjunctival corticosteroid, and ring. Unfortunately, an exact differentiation including a clear, narrow band of corneal antibiotic injections was initiated, symptoms between yeast-like fungi, diphtheroids, Nocar- thinning above the inferior limbus with maxi- were progressively aggravated. Three weeks dia, and non-tuberculous mycobacteria is not mal anterior displacement and apparently later, a central corneal infiltrate had devel- possible by light microscopy. Culture often normal thickness cornea above this thinned oped. Oral fluconazole, 200 mg a day, and fails to isolate the organism and antibiotic band. Corneal topography shows fairly regular topical kanamycin ointment were added to the sensitivity test results do not correlate with the against the rule astigmatism. These findings treatment. clinical response in keratitis.' However, early are all present only in the right eye. The left Five weeks later, the patient presented to detection and treatment of Nocardia are criti- eye shows no evidence of degeneration and is the university eye clinic. The uncorrected cal for a satisfactory outcome. without astigmatism by keratometry and visual acuity (UCVA) was 20/200 in the right Sulphonamides have been used as first corneoscopy. Other possible causes of the and 20/20 in the left eye. Slit-lamp examin- choice therapy in Nocardia keratitis in the peripheral corneal thinning observed in the ation of the right cornea disclosed a central, past, but results have been controversial.4 Bet- right eye include Tierren's degeneration, subepithelial infiltrate with two satellite ter clinical responses ofNocardia keratitis have Mooren's ulcer, rheumatoid corneal thinning, lesions (Fig 1). A corneal scraping was been reported with topical trimethoprim- keratoconus, and keratoglobus. performed immediately. The Gram stain sulphamethoxazole,6 but susceptibility tests This case can be distinguished from revealed Gram positive coccoid elements. Pre- suggested a 92.5% resistance of Nocardia Tierren's degeneration by the absence of vas- suming keratomycosis, the patient was put on asteroides to trimethoprim-sulphamethoxazole.' cular invasion or lipid infiltration. The lack of topical amphotericin 0.5% hourly. Two weeks Amikacin is the treatment of choice in corneal ulceration or systemic connective later, the UCVA of the right eye had human disseminated nocardiosis.' In vitro tissue disease makes Mooren's ulcer or diminished to hand movement as a result of susceptibility tests failed to detect resistance rheumatoid aetiologies unlikely. This case dif- expansion of the lesion. Material from a of Nocardia to amikacin.' Although paratoxic- fers from keratoconus in that the maximal second scraping was examined in 10% potas- ity oftopical amikacin 10% has been observed Letters 929 in a rabbit model,7 we did not encounter side 5 whereas primary CNS lymphoma fiequently effects in our patient. The favourable outcome involves the retina and optic nerve. However, Br J Ophthalmol: first published as 10.1136/bjo.80.10.928 on 1 October 1996. Downloaded from of the case presented suggests that topical it was unusual that all four ofthe six cases that amikacin should be considered an effective reported cell type were T cell lymphoma3 s and safe drug for the treatment of Nocardia since only 5% of systemic lymphoma is of T keratitis. cell or mycosis fungoides origin. As more PETER OLIVER DENK cases of iris lymphoma are categorised accu- SOLON THANOS rately by immunofluorescent cell surface HANS-JURGEN THIEL marker antigens, and as our case suggests, B Universt Eye Clinic, Tbingen, Germany cell iris lymphoma may be diagnosed more frequently. The mechanism of involvement of Correspondence to: Oliver Denk, Schleichstrasse the right iris from the ipsilateral nasopharynx 12,72076 Tubingen, Germany. could have included direct extension along the sympathetic chain, CNS spread secondary to Accepted for publication 28 June 1996 perineural involvement, or metastasis. FWgum Slit-lamp photograph of right eye showing dzffuse nodular iris thikAening. Inset:~ Three reported patients were treated with 1 Boiron P, Provost F, Chevier G, Dupont B. systemic chemotherapy,3 4 two because of Review of nocardial infections in France 1987- high power photmicrograph of cytolgical 1990. Eur J Clin Microbiol Infect Dis 1992; specimen showing Iwmphoma cell and positive simultaneous recurrence of systemic 11:709-14. in munocytochemical sutaiingfor the pan B cell lymphoma,3 two were enucleated,3 and one 2 Chen CJ. Nocardia asteroides endophthalmitis. marker CD20 (L26). was treated with extemal beam radiotherapy.3 Ophdialmic Surg 1983;14:502-5. 3 Dewsnup DH, Wright DN. In vitro susceptibility One patient treated by systemic chemotherapy of Nocardia asteroides to 25 antimicrobial had progression of the ocular lesion but the agents. Anmimrob Agent Chemother 1984;25: I other three cases treated conservatively re- 165-7 gressed after therapy. 4 Douglas RM, Grove DI, Elliott J, Looke DFM, -i'.N Jordan AS. Corneal ulceration due to Nocardia 4'?!! While combination chemotherapy is indi- asteroides. Aust NZJ Ophtiabmol 1991;19:317- cated for iris lymphoma with systemic involve- 20. ment, we suggest external beam radiotherapy 5 Helm CJ, Holland GN, Lin R, Berlin OGW, in Bruckner DA. Comparison oftopical antibiotics may be justified isolated ocular cases. for treating mycobacterium fortuitum keratitis Radiation induced cataract is expected al- in an animal model. AmJ Ophthbaol 1993;116: though this may not be a major consideration 700-7. if life expectancy is short. 6 Hirst LW, Harrison GK, Merz WG, Stark WJ. Nocardia asteroides keratitis. Br Y Ophthalm 1979;63:449-54. Support provided by the Eye TImor Research Foun- 7 Husain N, Matoba AY, Wilhelmus KR, Jones dation, Philadelphia, PA, USA. DB. Isolation and therapy ofNocardia keratitis. Invest Ophthalmol Vts Sci 1995;36 (Suppl):S155. PHILIP G HYKIN Figure 2 Slit-lamp photograph ofthe right iris Ocular Oncology Service and die Retina Service, showing iris crypts and mildpersistent ectropion Wis Eye Hospial, uvea 3 months after radiotherapy. There is no Recurrent systemic B cell lymphoma of residual iris thickening. Thomas_efferson Unmersity, Phiadephia, PA, USA the iris JERRY A SHIELDS brown and the left iris blue. Ectropion uvea CAROL L SHIELDS EDrroR,-Recognised clinical findings of was present superiorly, but there was no iris Ocular Oncology Service, Wills Eye Hospital, intraocular lymphoma include vitritis, solid neovascularisation or lens abnormality. The ThomasJefferson Unversiy, Phdadelphia, PA, USA retinal diffuse segment examination was unre- pigment epithelial detachments, posterior HORMOZ EHYA http://bjo.bmj.com/ retinal and choroidal infiltrates, retinal haem- markable. Systemic examination was normal. Deparnment ofPathology, Fox Chase Cancer Center, orrhage, perivasculitis, retinal necrosis, and Uncomplicated fine needle aspiration PhEiadelphia, PA, USA optic neuritis.' Anterior uveitis secondary to biopsy of the solid mass was performed via ELIZABETH SIDERIDES posterior segment intraocular lymphoma is a superior temporal approach. Cytological St Joseph Medical Centre, Stamford, CT, USA recognised, but isolated primary or recurrent evaluation of the specimen showed the pres- Correspondence to: Jerry A Shields, MD, Ocular iris lymphoma is rare. We report a case of ence of large atypical lymphocytes, morpho- Oncology Service, Wills Eye Hospital, 900 Walnut non-Hodgkin's lymphoma involving only the logically compatible with non-Hodgkin's Street, Philadelphia, PA 19107, USA. iris. lymphoma. Immunocytochemical studies re- Accepted for publication 28 June 1996 vealed positive staining of the cells for CD20 on September 29, 2021 by guest. Protected copyright. CASE REPORT (L26) (Fig 1: inset), a pan B cell marker, and 1 Shields JA, Shields CL. Intraocular tumors: a text A 25-year-old white woman reported blurred negative staining for CD45RO (UCHL1), a and adas. Philadelphia: WB Saunders, pan T cell marker. The patient underwent 1992:498-510. vision in the right eye for 3 weeks. Eighteen 2 Locasio JA. Neoplastic causes of anterior seg- months earlier, she had presented with a right anterior external beam radiotherapy to the ment inflammation. Int Ophthalmol Clin 1983; seventh nerve palsy and was found to have a right iris, receiving 1980 cGy in 11 equal frac- 23:111-21. right nasopharyngeal and parapharyngeal tions. Three months later, the visual acuity 3 Goldey SH, Stern GA, Oblon DJ, Mendenhall was 20/20 and there was no thickening of the NP, Smith LJ, Duque RE. Immunophenotypic mass extending posteriorly to the right carotid characterisation of an unusual T-cell lymphoma sheath with perineural spread. Biopsy revealed iris in the right eye, although the iris was less presenting as anterior uveitis. Arch Ophthabnol diffuse large B cell lymphoma and lumbar mobile than the left and there was some 1989;107:1349-53. persistent ectropion uvea of the pupillary 4 Hanamura A, Maeda H, Kuwayama W, Takano puncture was positive for malignant lym- Y Infiltration into the aqueous humor in a phocytes. She was managed with systemic margin (Fig 2). patient with malignant lymphoma. Jap J Clin cyclophosphamide, vincristine, and doxoru- Haematol 1992;33:1845-50. 5 Jensen OA, Johansen S, Kiss K. Intraocular T-cell bicin, and intrathecal methotrexate and cyt- COMMENT lymphoma mimicking intraocular disease. arabine, followed by external beam radio- Anterior segment intraocular lymphoma in Graefes Arch Clin Exp Ophthalmol 1994;232: therapy to the nasopharyngeal area with eye the presence of a normal fundus is rare. The 148-52. shielding. At completion of therapy, all repeat first case reported was one in which an iris studies including cerebrospinal fluid examin- nodule was confirmed to be a lymphomatous ation were normal and she remained in remis- lesion histopathologically after enucleation.' Treatment of subfoveal pigment sion until presentation 18 months later. To our knowledge, six other cases have been epithelial detachments with distant On examination, the visual acuity was 20/30 fully reported," two presenting with non- extrafoveal choroidal neovascular in the right eye and 20/20 in the left. Intraocu- granulomatous uveitis,34 one with neovascular membranes lar pressures were 16 mm Hg in both eyes. glaucoma,' and three with diffuse iris thicken- The left eye was normal, the right showed ing."3 In all six cases, as well as in this case, the EDrroR,-Subfoveal retinal pigment epithelial central corneal oedema with fine diffuse iris lymphoma was associated with systemic detachments larger than 1 disc diameter in keratic precipitates and moderate cells and non-Hodgkin's lymphoma, which had been patients over the age of 55 have a poor visual flare in the anterior chamber. The entire right previously diagnosed in five, rather than prognosis.' Laser photocoagulation of a con- iris was thickened and a diffuse solid mass was primary CNS lymphoma. This is not surpris- tiguous extrafoveal choroidal neovascular present superiorly (Fig 1). There was notice- ing as systemic lymphoma is typically associ- membrane sometimes causes flattening of a able iris heterochromia, with the right iris ated with uveal tract ocular involvement, retinal pigment epithelial detachment and