802 British Journal of Ophthalmology 1997;81:802–805 Br J Ophthalmol: first published as 10.1136/bjo.81.9.802 on 1 September 1997. Downloaded from LETTERS TO THE EDITOR

Cellular infiltration of Cloquet’s canal 20/40 with a −3.0 D correction. Intraocular radial structures of the vitreous, surrounding pressures were 12 and 13 mm Hg, respec- the course of the Cloquet’s canal. EDITOR,—Biomicroscopic evaluation of the tively. Biomicroscopic examination of the TIBOR MILIBÁK Cloquet’s canal is diYcult in a normal eye. right eye was unremarkable. The left eye was 1st Department of Ophthalmology, Semmelweis Although Goldmann, based on his extensive quiet, slit lamp examination revealed partial University Medical School, 1 biomicroscopic studies, described as early as cataract, a vitreous flare, and cell infiltration in Budapest, VIII, Tömö u 25-29, H-1083, Hungary 1954 the detailed biomicroscopic anatomy of the anterior vitreous. Biomicroscopy of the Accepted for publication 20 June 1997 it, normally only parts of the Cloquet’s canal vitreous with a contact lens revealed diVuse are available for direct biomicroscopic obser- flare and cell infiltration. Cloquet’s canal was 1 Goldmann H. Zur Biomikroskopie des vation. made distinct by a marked cellular infiltration In this report I present a case in which not Glasskörpers. Ophthalmologica (Basel) (Fig 1). The course of the central canal curved 1949;127:334-339. only the entire course of the Cloquet’s canal down in the vicinity of the retina and ascended 2 Goldmann H. The diagnostic value of biomicro- became visible by a marked cellular infiltra- towards the lens. Cell infiltration around the scopy of the posterior parts of the eye. BrJOph- tion of the vitreous, but the cell infiltration thalmol 1961;45:449–60. canal emphasised the radial structure of the 3 Busacca H. Un nouveau phénomène observé itself dramatically improved the visibility of child’s vitreous, surrounding the course of the dans la corps vitré antérior au cours des uvéites. fine structures of the surrounding vitreous. Ophthalmologica 1953;126:355–60. Cloquet’s canal (Fig 2). There were no abnor- 4 Akiba J, Kakehashi A, Hikichi T, Trempe CL. malities in the fundus or on the pars plana. Vitreous findings in cases of optic nerve pits and CASE REPORT Fluorescein angiography could not be per- serous macular detachment. Am J Ophthalmol A 9-year-old white boy discovered visual dete- formed because of the cataract, the vitreous 1993;116/1:38–41. rioration of the left eye by the incidental cov- haze, and the patient’s inability to cooperate. ering of his right eye. The patient’s previous Results of general physical examination and medical history was uneventful: chickenpox chest x ray were unremarkable. Laboratory and epidemic parotiditis occurred in early evaluation showed an erythrocyte sedimenta- Demonstration of herpes simplex childhood. tion rate of 5 mm in the first hour, a negative from lens aspirate in healed acute retinal Uncorrected visual acuity was 20/20 right rheumatoid factor, a normal complete blood, necrosis syndrome eye and 20/200 left eye, which improved to normal titres against Toxoplasma, Toxocara, Brucella, Listeria, Lyme, and HIV. A clinical EDITOR,—The herpes group of , mainly diagnosis of chronic posterior uveitis was the (HZV), and more made, but specific therapy was not consid- rarely, the herpes simplex (HSV) types 1 and 1 ered. 2, and cytomegalovirus (CMV), have been 2 3 After follow up of 1 year, visual acuity and demonstrated in aqueous humour, vitreous, 4 the partial cataract in the left eye remained or retinal biopsy specimens in the active unchanged, the structure of the vitreous had phase of acute retinal necrosis (ARN), by iso- become disorganised, the vitreous haze and lation, immunological methods, electron the infiltration of Cloquet’s canal disappeared, microscopy, and polymerase chain reaction. However, several reports indicate the inability and only a limited number of cells in the to demonstrate the virus from intraocular retrolental space could be observed. Fundus specimens in the healed stage of the disease.45 examination showed no abnormality. We report a case of ARN in which HSV 1 was isolated from intraocular fluid containing COMMENT 1 lens aspirate, 3 ⁄2 months after complete http://bjo.bmj.com/ During development and early childhood regression of the disease. We believe that this Cloquet’s canal extends almost in a direct is the first such original finding to be reported. anteroposterior course from the optic disc towards the posterior capsule of the lens. With CASE REPORT Figure 1 Slit lamp biomicroscopic appearance aging, Cloquet’s canal changes: in the adult it A 23-year-old man presented with a history of of heavily infiltrated Cloquet’s canal seen emerges from the optic nerve head, and in the headache, sudden blurring of vision, and mild through the QuadrAspheric contact lens. Central posterior part of the vitreous cavity it curves pain in the left eye for 3 weeks. Six years ear- part of the vitreous space. The normal course of down, while in the anterior vitreous it emerges lier the patient had lost his vision in the right the central canal is altered by the cellular 2 on September 28, 2021 by guest. Protected copyright. again towards the lens. The canal becomes eye following an acute attack of inflammation, infiltration. Saccular dilatations are present at obliterated in its middle part in the adult eye. the anterior end of the tractus. The whole course the details of which were not known. In some cases saccular dilatation of the canal His vision was no light perception in the of the Cloquet’s canal is surrounded by a layer 1 of infiltrated cloudy vitreous where signs of the may occur. Under pathological conditions right eye and 6/36 in the left eye. The right eye radial orientation can be seen. the course or the visibility of the Cloquet’s had band-shaped keratopathy, organised exu- canal can change considerably. Uveitis may dates in the anterior chamber, and compli- cause greater delineation of the canal in the cated cataract. The left eye showed multiple area of the retrolental space (ascending large keratic precipitates, aqueous flare 2+, 23 phenomena), whereas of the aqueous cells 2+. There was no view of the posterior pole may cause the canal to turn fundus in the right eye. The left fundus downwards in front of the optic disc. Cells showed typical confluent areas of retinal may even infiltrate the Cloquet’s canal in front of the retina. It has also been suggested that intravitreal traction on the optic pit by the anomalous Cloquet’s canal may have a role in the development of macular detachment in pits of the optic nerve.4 The present case clearly highlights these changes to the biomi- croscopic anatomy of the vitreous caused by dense cellular infiltration of the vitreous. This case clearly demonstrates: the entire intravit- real course of the Cloquet’s canal an oblitera- tion of its anterior parts the presence of saccu- Figure 2 Computer graphic of Figure 1 taken lar dilatation of the canal in the anterior third with embossed filter. Computer imaging Figure 1 Microphotograph showing HSV enhances visibility of the subtle radial structures of the vitreous cavity the eVect of the cellular antigen in vero cells inoculated with lens aspirate of the vitreous, surrounding the course of the infiltration on the intravitreal course of the detected by immunofluorescence (magnification Cloquet’s canal. infiltrated Cloquet’s canal and the subtle × 112). Letters 803 Br J Ophthalmol: first published as 10.1136/bjo.81.9.802 on 1 September 1997. Downloaded from necrosis in the mid periphery with vitreous 7 Robinovitch T, Nozik RA, Vavenhorst MP: Bilat- haze, suggestive of ARN. eral acute retinal necrosis syndrome. Am J Oph- 1989; :735–6. The patient was treated with intravenous thalmol 108 1500 mg/m2 of body surface area/day in three divided doses, oral prednisolone, 40 Vitrectomy and autologous thrombocyte mg per day, topical betamethasone hourly, adhesion of an accidental macular hole and atropine twice daily, for 1 week. His visual caused by Nd:YAG laser acuity improved to 6/18 in the left eye with regression of inflammation. He was then EDITOR,—A 30-year-old physics scientist treated with oral aciclovir 400 mg, five times looked accidently with his left eye directly into daily for 4 weeks. But subsequently the patient the path of a 1.064 nm Nd:YAG laser beam. developed dense vitreous membranes obscur- The laser variables were not known. He expe- ing the fundus details and a pars plana vitrec- rienced a dramatic decrease in vision in this tomy was carried out 10 days later. Vitreous eye. Upon examination at the local hospital, aspirate on immunofluorescence (IF), using a the patient’s corrected vision was 0.16 for the panel of antisera of HSV (Dako A/S, Den- left eye, the intraocular pressure (IOP) was mark), VZV (polyclonal human serum), and within normal range, and the cornea and lens Figure 2 Posterior pole 9 month after CMV (Dako A/S, Denmark) showed the HSV were unremarkable. On funduscopy, an obvi- vitrectomy and thrombocyte adhesion. The edges viral antigen. Vitreous aspirate also revealed ous retinal defect, partially covered with of the hole are reattached, centrally an retinal both anti-HSV IgM and IgG at >1:40 pigment epithelium hypertrophy developed. The blood, was observed in the region of the fovea. visual acuity was 0.6. dilutions by enzyme linked immunosorbent Vitreal bleeding could be seen above the tem- test assay (ELISA). An ELISA test for HZV poral inferior vessel arcade. The ophthalmic month onward, increasing pigmentation in the and CMV showed no antibody. A week later, examination of the right eye was unremark- region of the hole could be observed (Fig 2); the retina detached and was reattached by able. this corresponded with a further increase in revitrectomy with scleral buckling. On follow Initially, the patient was treated with high the patient’s vision. up after 1 month there was complete dose corticosteroids and acetazolamide. Ten regression of with scarring and no evi- days after the accident, he was transferred to dence of inflammation in the anterior segment COMMENT our department for evaluation. At this time Laser beam accidents occur mainly in those or vitreous cavity. However, vision deterio- the corrected vision in the patient’s left eye 1–4 rated due to progressive nuclear sclerosis. An professionally involved with lasers. The with eccentric fixation was 0.2. A well defined majority of the ocular accidents involve the extracapsular cataract extraction with in- circular macular hole (approximate diameter traocular lens implantation was performed Nd:YAG laser, which is used in medicine for 300 nm) with upright edges was observed; its diagnostic and therapeutic purposes as well as 1 2 3 ⁄ months later. The lens aspirate was inocu- centre corresponded exactly with the foveola 2 lated into vero cell line. It showed the growth in many areas of research. The mechanism of (Fig 1). The vitreal haemorrhage had de- injury diVers from the thermal retinal injuries with the characteristic cytopathic eVect of creased considerably. HSV.The isolated virus was identified as HSV caused by argon, krypton, diode, or colour Over the following 4 weeks, no further lasers23and involves the photomechanical and by IF (Fig 1) which was further confirmed by treatment was given. As there was no change 3 a neutralisation test as HSV type 1 using HSV thermal tearing of the retinal tissue. in the size of the foramen or an improvement Nd:YAG lasers use very short laser pulses of 1 and HSV 2 antisera. CMV and VZV were in the patient’s vision 6 weeks after the not isolated. The patient had no evidence of 1 µs or shorter. They produce mechanical side accident, a vitrectomy of the left eye was eVects like expansive microexplosions by active retinitis at 2 months’ follow up after undertaken. It included removal of the poste- cataract extraction. plasma formation. With the Q-switched op- rior vitreous membrane, particularly in the eration mode pulse durations of a few area of the edges of the hole. To aid its closure, nanoseconds to a few microseconds can be COMMENT an autologous thrombocyte concentrate created. As the energy is delivered in short Thompson et al have reported three cases of (ATC) was placed over the retinal hole. The time spans, very high peak powers up to hun-

ARN due to possible reactivation of HSV type vitreous chamber was subsequently filled with dreds of megawatts can be emitted, which lead http://bjo.bmj.com/ 6 30% SF gas and the patient lay on his back 3 2. Recurrence in ARN, though rare, has been 6 to tissue disruption. 7 reported in the same eye even after 6 years. for 6 hours, followed by a strict programme of In milder injuries retinal or vitreal haemor- Our case indicates that the virus causing ARN prone position for 7 days. The postoperative rhages only are observed. The visual prognosis can remain viable in the eye long after clinical course was uncomplicated. in the more severe injuries with tissue disrup- regression, and can probably play a potential During the follow up investigations in the tion is dependent on the distance of the retinal role in recurrence due to reactivation. first, second, third, sixth, and ninth postopera- hole from the fovea. The usual conservatively tive months, a gradual increase in the patient’s JYOTIRMAY BISWAS treated patient experiences a severe and HAJIB N MADHAVAN vision to 0.6 was observed. The patient had permanent decrease in vision.4 lost his metamorphopsia and the size of the on September 28, 2021 by guest. Protected copyright. SENGAMEDU S BADRINATH Thach et al reported five cases of Nd:YAG Medical and Vision Research Foundation, central scotoma remarkably decreased. There laser beam injuries whereby the patients were 18 College Road, Madras - 600 006, India was no development of a nuclear cataract fol- treated conservatively.4 In two of these five Correspondence to: Dr Jyotirmay Biswas. lowing gas vitreal replacement. In the first patients, the resulting retinal holes included Accepted for publication 14 May 1997 postoperative months, the edges of the former the fovea and 1 year later, the visual acuity retinal hole were smoothly reattached and the remained at 0.3 and 0.05, respectively. In one foramen itself could only be seen with of the patients with a centrally situated hole, a 1 Duker JS, Blumenkranz MS. Diagnosis and diYculty. From the fourth postoperative management of acute retinal necrosis (ARN) spontaneous closure occurred within 3 weeks syndrome. Surv Ophthalmol 1991;35:327–43. following the accident. This corresponded 2 Suttorp-Schulten MSA, Zaal MJV, Luyendijk L, with an increase in the patient’s visual acuity. Bos PJM, Kijlstra A, Rothova A. Aqueous chamber tap and serology in acute retinal The two remaining patients had parafoveolar necrosis. Am J Ophthalmol 1989;108:327. holes and the visual acuity was not severely 3 Soushi S, Ozawa H, Matsuhashi M, Shimazaki J, aVected by the accident. Saga U, Kurata T. Demonstration of varicella In our patient, the retinal hole was large zoster virus antigens in the vitreous aspirate of patients with acute retinal necrosis syndrome. with involvement of the fovea and a severe Ophthalmology 1988;95:1394–8. decrease in visual acuity to 0.16. As there was 4 Freeman WR, Wiley CA, Gross JG, Thomas EL, no sign of a possible spontaneous closure 6 Rao NA, Liggett PE. Endoretinal biopsy in immunosuppressed and healthy patients with weeks after the accident, a similar operative retinitis: indications, utility and techniques. procedure to that performed in older patients Ophthalmology 1989;96:1559–65. with idiopathic macular holes was performed.5 5 Freeman WR, Thomas EL, Rao NA, Pepose JS, Idiopathic holes are thought to be caused by a Trousdale MD, Howes EL, et al. Demonstration of herpes group virus in acute retinal necrosis tangential traction of the posterior vitreous or syndrome. Am J Ophthalmol 1986;102:701–9. an epiretinal membrane resulting in a foveolar 6 Thompson WS, Culbertson WW, Smiddy WE, dehiscence and enlargement of the retinal Robertson JE, Rosenbaum JT. Acute retinal hole. The rationale in performing a vitrectomy necrosis caused by reactivation of herpes Figure 1 Large macular hole with upright edges simplex virus type 2. Am J Ophthalmol 1994; 6 weeks after Nd-YAG laser accident. The visual is to relieve the traction on the rims of the hole 118:205–11. acuity was 0.2. by vitreous cortical peeling and to achieve 804 Letters Br J Ophthalmol: first published as 10.1136/bjo.81.9.802 on 1 September 1997. Downloaded from reattachment of the retina and recovery of the sia. Other ocular signs described in aniridia sensory function of the reattached photore- (foveal hypoplasia, nystagmus) were not found ceptors. Chorioretinal adhesion around the in our case. This has already been described as region of the foramen edges has been aided by manifestation of the large clinical variability of several adjuvants. Our experience with ATC the disease.6 To our knowledge, inherited ani- in patients with idiopathic macular holes sug- ridia, as in our patient, has never been gests that the closure rate is higher when this described in tuberous sclerosis. adhesive is combined with the gas tamponade Aniridia is an autosomic dominant inher- instead of the latter procedure alone; this is ited disease, but sporadic non-familial forms supported by the results of Gaudric et al in exist. Our patient had no contact with his their pilot study.6 The preparation of the family and had no descendants so we were autologous thrombocyte concentrate followed unable to document the transmission of his the technique described by Gaudric et al 6 and iris hypoplasia. was performed just before vitrectomy. Figure 2 Hypoplasia of the left iris associated It is diYcult to establish whether the occur- with focal atrophy. There is also a nasal rence of aniridia and autosomal dominant S POTTHÖFER subluxation of the lens. M H FOERSTER tuberous sclerosis in this same patient is coin- Freie Universität Berlin, cidental or if there is a genetic link between Universitätsklinikum Benjamin Franklin, described case of aniridia in a patient with them. Aniridia arises from mutations in the Augenklinik und Poliklinik, Berlin, Germany tuberous sclerosis. PAX6 gene located on the chromosome Correspondence to: S Potthöfer. 11p13, resulting in a defect in the control of Accepted for publication 1 May 1997 CASE REPORT neural crest cell migration into the developing 7 A 62-year-old white man with inherited eye. In tuberous sclerosis, linkage studies revealed mutations on chromosomes 9q34 1 Gabel VP, Birngruber R, Lorenz B, Lang GK. tuberous sclerosis, diagnosed in his early Clinical observations of six cases of laser injury childhood, was referred for ophthalmic assess- and 16p13. Genetic studies initially suggested to the eye. Health Physics 1989;56:705–10. ment. The classic diagnostic triad of the that mutations on chromosome 11 (also 2 Marshall J. Structural aspects of laser-induced disease1 was present—mental retardation, epi- involved in aniridia) might be responsible in damage and their functional implications. lepsy, and adenoma sebaceum (Fig 1). Sys- tuberous sclerosis, but new data do not Health Physics 1989;56:617–24. 8 3 Birngruber R. Laser output characteristics. temic involvement also included documented provide evidence for such a mutation. There Health Physics 1989;56:605–11. renal hamartomas resulting in renal failure are no available data that could suggest a 4 Thach AB, Lopez PF, Snady-McCoy LC, Golub and kidney transplantation. common mutation for both aniridia and BM Frambach DA. Accidental Nd-YAG laser tuberous sclerosis. As our patient refused injuries to the macula. Am J Ophthalmol His past ocular history was unremarkable, 1995;119:767–73. including denial of ocular trauma or episodes genetic testing, further observations and chro- 5 Kelly NE, Wendel RT. Vitreous surgery for of ocular redness. The patient denied instilla- mosome studies are necessary to establish if idiopathic macular holes. Arch Ophthalmol occurrence of aniridia in tuberous sclerosis is 1991;109:654–9. tion of any local treatment. The best corrected 6 Gaudric A, Massin P, Paques M, Santiago PY. visual acuity was 20/80 in his right eye and stochastic or due to a genetic linkage. Autologous platelet concentrate for the treat- 20/200 in his left eye. On biomicroscopic D MILEA ment of full-thickness macular holes. Graefes Arch Clin Exp Ophthalmol 1995;233:549–54. examination, corneas were clear except super- C BURILLON ficial opacification in the periphery. Both Clinique Ophtalmologique Universitaire, anterior chambers were deep. The left eye had Hôpital Edouard Herriot, Lyon, France an almost complete aniridia on 360°, with Correspondence to: Dan Milea, MD, Clinique only a slim, unreactive portion of the iris Ophtalmologique Universitaire, Pavillon C, Hôpital Aniridia in a patient with tuberous attached to the angle (Fig 2). The patient Edouard Herriot, 3, Place Arsonval, 69003 Lyon, sclerosis stated that he had always noted the absence of France. the left iris. Pilocarpine instillation in the left Accepted for publication 28 April 1997 EDITOR,—Tuberous sclerosis is a multisystem eye had no eVect on the iris morphology. disorder of autosomal dominant inheritance. 1 Miller NR. Walsh and Hoyt’s clinical neuro-

Gonioscopy did not show presence of anterior http://bjo.bmj.com/ Associated pathological ocular findings in- Vol 3. 4th ed. Baltimore: Williams synechiae and the angle was normal, totally opthalmology. clude depigmented retinal areas and retinal and Wilkins, 1988:1765–88. open. The pupil in the other eye was round, of hamartomas.1 Less common are the iris 2 Kranias G, Romano PE. Depigmented iris sector normal size, but the iris presented diVuse in tuberous sclerosis. Am J Ophthalmol 1977;83: abnormalities such as depigmentation or stromal defects. Intraocular pressure, as deter- 758–93. atypical colobomas.2–5 We report the first 3 Lucchese NJ, Goldberg MF. Iris and fundus pig- mined with aplanation tonometry was 14 mm mentary changes in tuberous sclerosis. J Pediatr Hg in both eyes and no signs of glaucoma Ophthalmol Strabismus 1981;18:45–6. were detectable. A left focal cataract was 4 Gutman I, Dunn D, Behrens M, Gold A, Odel J, Olarte MR. Hypopigmented iris spot, an early present and the lens had a minimal nasal sub- sign of tuberous sclerosis. Ophthalmology 1982; luxation (Fig 2). Fundus examination of the 89:1155–9. on September 28, 2021 by guest. Protected copyright. left eye revealed a yellowish-white mass above 5 Tridon P, Marchand P, CoVe P. Sclérose the macula, consistent with a retinal hamar- tubéreuse de Bourneville et malformations ocu- laires. Oto-Neuro-Opht 1977;49:43–6. toma, but the patient refused a fluorescein 6 Pearce WG. Variability of iris defects in auto- angiography. somal dominant aniridia. Can J Ophthalmol 1994;29:25–9. 7 Churchill A, Booth A. Genetics of aniridia and COMMENT anterior segment dysgenesis. Br J Ophthalmol Iris abnormalities such as hypopigmented 1996;80:669–73. 8 Sampson JR, Janssen LAJ, Sandkuijl LA. Linkage spots or atypical iris colobomas are rare in investigation of three putative tuberous sclerosis patients with tuberous sclerosis. Previous determining loci on chromosomes 9q, 11q and reports suggest an embryological explanation 12q. J Med Genet 1992;29:861–6. of these anomalies by faulty migration of cells derived from the neural crest.3 In our patient, the origin of the almost complete absence of the iris was diYcult to determine. Secondary Squamous cell carcinoma of the iris atrophy was ruled out by the clinical palpebral conjunctiva features and as there was neither history nor clinical evidence of previous surgery, trauma, EDITOR,—Squamous cell carcinoma is a ma- acute glaucoma episodes, heterochromia, or lignancy that occurs frequently on the skin of ocular inflammation. No posterior embryo- the eyelid; however, it is uncommon on the toxon or systemic stigmata of Rieger’s syn- conjunctiva. The conjunctival form of the drome were evident. squamous cell carcinoma constitutes 7–15% The almost complete absence of the iris of conjunctival and corneal epithelial associated with a focal cataract, subluxation of tumours.12This malignancy normally behaves the lens and peripheral opacification of the in a non-aggressive fashion, and the most rare Figure 1 Characteristic facial distribution of cornea were consistent with the diagnosis of form of this tumour is the palpebral conjunc- adenoma sebaceum. aniridia, which is a misnomer for iris hypopla- tival squamous cell carcinoma.3 We report a Letters 805 Br J Ophthalmol: first published as 10.1136/bjo.81.9.802 on 1 September 1997. Downloaded from carcinoma. No regional adenopathy was et al reported on a patient with invasive present. squamous cell carcinoma of the palpebral Treatment consisted of surgical excision of conjunctiva, masquerading as chronic con- the tumour witha2mmsafety margin, and junctivitis, who was treated with radiotherapy cryotherapy was applied to the underlying for a total dose of 54 Gy.6 The tumour tissue using the cryoprobe technique. recurred after 7 weeks of follow up. This Histopathological examination disclosed a patient died from complications of metastatic moderately diVerentiated squamous cell carci- breast carcinoma. noma arising from the palpebral conjunctiva Our patient had a tumour histopathologi- (Fig 2). Malignant cells formed nests or sheets cally classified as moderately diVerentiated of epithelial cells. They had scant eosinophilic squamous cell carcinoma. Surgical and cryo- cytoplasm and intercellular bridge. Mitosis therapy were successfully used without recur- was sparsely observed in the specimens. The rence of the tumour or metastasis after a 1 basement membrane of the conjunctiva was year follow up. infiltrated in several areas by the tumoral cells. Several reports of squamous cell carcinoma Three months after surgical excision of the of the conjunctiva masquerading as chronic tumour, a multiple conjunctival and tarsal conjunctivitis have been reported.4–6 Our Figure 1 A 10 × 12 mm papillary lesion is biopsy was performed on the upper eyelid. patient had a history of lacrimation and ocular present at the upper palpebral conjunctiva. The findings were negative for tumour. In the discomfort which are symptoms of conjuncti- tarsus abnormal epithelial cell growth was vitis. This factor probably delayed the correct observed but no malignant changes were diagnosis. Squamous cell carcinoma of the found. In a 12 month follow up there was no conjunctiva must be considered as a diVeren- recurrence of the tumour. tial diagnosis in patients with unilateral In situ hybridisation for human papilloma chronic conjunctivitis. virus types 6, 11, 16, 18, 31, 33, and 51 was CELSO S MATSUMOTO negative. KAZUO NAKATSUKA MASAMOTO IMAIZUMI COMMENT Department of Ophthalmology, Conjunctival squamous cell carcinoma of the Oita Medical University, Oita, Japan palpebra is very rare. In our review of the literature, it appears that only seven cases have Correspondence to: Celso S Matsumoto, MD, been reported previously.3–6 Department of Ophthalmology, Oita Medical Uni- Recently, human papilloma virus (HPV) versity, Hasama-machi, Oita, 879–55, Japan. Accepted for publication 1 May 1997 Figure 2 Histopathological study revealed a antigens and DNA have been detected in con- moderately diVerentiated squamous cell junctival neoplasia, and their implication in carcinoma (haematoxylin and eosin, × 130). the pathogenesis of squamous cell carcinoma and other epithelial tumours has been 1 Grossniklaus HE, Green WR, Luckenbach M, case of primary conjunctival squamous cell suggested.7 We applied in situ hybridisation to Chann CC. Conjunctival lesions in adults: a clinical and histopathologic review. Cornea carcinoma of the palpebra treated successfully detect HPV types 6, 11, 16, 18, 31, 33, and 51 1987; 6:78–116. with surgical excision and cryotherapy. in paraYn embedded tissue. HPV was not 2 Erie JC, Campbell RJ, Liesegang TJ. Conjuncti- present in the specimens. This finding sug- val and corneal intraepithelial and invasive neo- plasia. Ophthalmology1986;93:176–83. gests that, in this patient, HPV was not associ- 3 Blodi FC. Squamous cell carcinoma of the CASE REPORT ated with squamous cell carcinoma of the conjunctiva. Doc Ophthalmol 1973;34:93–108. A 69-year-old woman witha2yearhistory of conjunctiva. 4 Theodore FH. Conjunctival carcinoma mas- ocular discomfort and lacrimation was re- Conjunctival squamous cell carcinoma can querading as chronic conjunctivitis. EENT Monthly1967;46:1419–20. ferred to us with a clinical diagnosis of be treated successfully with excision, radio- 5 Thygeson P. Observations on conjunctival neo- http://bjo.bmj.com/ papilloma. The tumour was surgically excised therapy, or cryotherapy. In the series of three plasms masquerading as chronic conjunctivitis in another institution with recurrence of the patients described by Theodore, conjunctival or keratitis. Trans Am Acad Ophthalmol Otolaryn- gol 1969;73:969–77. tumour in the same eyelid location. squamous cell carcinoma was treated with 6 Goldberg SH, Riedy DK, Lanjillo JH. Invasive Eversion of the left upper eyelid disclosed a intense radiotherapy.4 squamous cell carcinoma of the palpebral papillary tumoral mass over the tarsus in the Thygeson reported on two patients with conjunctiva. Graefes Arch Ophthalmol 1993;231: palpebral conjunctival surface, extending 2.5 papillary squamous cell carcinoma of the 246–48 7 McDonnel JM, McDonnel PJ, Stout WC, mm from the posterior eyelid margin to the palpebral conjunctiva. One of these patients Martin WJ. Human papilloma virus DNA in a superior fornix, measuring 10 × 12 mm (Fig received radiation therapy and the other was recurrent squamous carcinoma of the eyelid. 1). Incisional biopsy revealed squamous cell treated with excision of the tumour.5 Goldberg Arch Ophthalmol 1989;107:1631–4. on September 28, 2021 by guest. Protected copyright. 806 British Journal of Ophthalmology 1997;81:806–807 Br J Ophthalmol: first published as 10.1136/bjo.81.9.802 on 1 September 1997. Downloaded from 1 Foley-Nolan A, McCann A, O’Keefe M. Atro- during ultrasonic agitation of the anterior cham- pine penalisation versus occlusion as the pri- ber. J Cataract Refract Surg 1991;17:613–6. mary treatment for amblyopia. Br J Ophthalmol 4 Fechner PU, Fechner MU. Methylcellulose and CORRESPONDENCE 1997;81:54–60. lens implantation. Br J Ophthalmol 1983;67: 2 Movshon JA, Van Sluyters RC. Visual neural 259–63. development. Annu Rev Psychol 1981;92:416– 21.

On the treatment of amblyopia

EDITOR,—I have read with interest the paper by Foley-Nolan et al 1 on the use of atropine as an alternative to occlusion for treating am- Retinopathy of prematurity blyopia. Presumably all the patients entering OBITUARY EDITOR,—Treating retinopathy of prematurity their trial had strabismus, otherwise there (ROP) is a procedure requiring significant would not have been suppression but some degrees of skill and patience. The surgeon degree of normal binocularity. It should be usually has to treat the peripheral retina, a task pointed out that the daily instillation of that is frequently made diYcult because of the atropine into the fixing eye, as advocated by Peter Llewellyn Blaxter 2 small eye in the premature baby and also Worth, may be of use only in those cases in because in many cases visualisation is further Peter Blaxter died suddenly on the 3rd May whom the visual acuity of the squinting eye is complicated by poor pupillary dilatation ‘not much less than 6/36’; in fact, the mean secondary to the disease process. Optical clar- 1997 from a heart attack. He had suVered visual acuity in 36 of their atropine treated ity, for laser treatment in particular, is from circulatory problems for some years group was 6/60. But if amblyopia ex anopsia is therefore of paramount importance in at- and shortly after his retirement developed a of such magnitude that central fixation is lost, tempting to maintain adequate visualisation in homonymous hemianopia as a result of an in the most distressing cases cycloplegia of the these diYcult cases. However, it is unavoid- occipital lobe infarct, a cruel blow which he fixing eye will prove useless, the patient will ably compromised as a result of corneal bore with stoicism. keep on using the fixing eye, treated with atro- drying necessitated by the need not only for a He was born in 1918 and educated at Ton- pine or not. Only occlusion, permanent occlu- speculum but also because the background bridge School. His medical training was at St sion, 6 days a week, will do the trick. On the ambient temperature is frequently elevated John’s College, Cambridge and Guy’s Hospi- other hand, if there is no strabismus, but above normal ‘room temperature’. Corneal tal. Following qualification in 1942 he held orthotropia, and some degree of normal clarity is maintained by the application of bal- house appointments at Guy’s and following a binocularity, the results of any treatment, and anced salt solution (BSS) or hypromellose the pertinent indications, would depend on 0.3% drops which are administered by an three year period of National Service began the ultimate cause of the disturbance. assistant at ‘convenient’ moments during the his ophthalmic career at Guy’s and Moor- I felt that a chance to clarify the point was in procedure. fields. In 1950 he was appointed consultant order. Ocucoat (Storz Ophthalmics Products) is a ophthalmologist at Fulham Hospital. During sterile, non-pyrogenic, optically clear visco- the period 1948–54 he also held the post of A URRETS-ZAVALIA elastic material containing 2% hydroxypropyl Casilla De Correo 301, 5000 Cordoba, Argentina research assistant at the Institute of Ophthal- methylcellulose. It is usually indicated as a mology. In 1954 he left London and moved surgical aid in procedures of the anterior seg- north to Manchester where until 1982 he 1 Foley-Nolan A, McCann A, O’Keefe M. Atro- ment of the eye, most commonly cataract was consultant ophthalmic surgeon at the 1–4 pine penalisation versus occlusion as the pri- surgery. It is supplied ina1mlsingle use Manchester Royal Eye Hospital. From 1956 mary treatment for amblyopia. Br J Ophthalmol glass syringe. to 1982 he was also ophthalmic surgeon to 1997;81:54–60. Recently, we have used Ocucoat, instead of 2 Worth C. the Manchester Jewish Hospital. During his http://bjo.bmj.com/ Squint: its causes, pathology and treat- hypromellose drops as an aid to improving ment. 4th ed. Philadelphia: P Blackiston and Son professional career he was a vice president of & Co, 1915:107. and maintaining optical clarity during the treatment of ROP. We find that it permits the ophthalmic section of the Royal Society excellent visualisation and because of the of Medicine, president of the North of viscous nature of the material it remains in England Ophthalmological Society in 1971, and also held the vice presidency and was a Reply situ throughout the procedure. Its ocular safety is beyond any reasonable doubt and council member of OSUK. From 1967 to 1 EDITOR,—In our published trial, the patients indeed we have seen no adverse eVects on the 1982 he was on the Council of the Faculty of were assigned to two treatment groups, group eye since we began using Ocucoat; but Ophthalmologists and was master of the on September 28, 2021 by guest. Protected copyright. A where they were treated with atropine nevertheless we irrigate the eye thoroughly on Oxford Ophthalmological Congress in 1975 penalisation, and group P where they were completing the treatment. We also find that and 1976. He was an examiner for the Oph- treated with occlusion on therapy. In both the wetting eVect of Ocucoat can be pro- thalmic Nursing Board, the British Orthoptic groups approximately 90% had strabismus. longed by the occasional administration of Board, and on the Court of Examiners of the hypromellose drops. The mean visual acuities in groups A and P Royal College of Surgeons for several years. before treatment were 6/50 and 6/60 respec- In conclusion, we have found the viscoelas- tic Ocucoat, most commonly used in intra- I had the privilege of training under Peter tively. Blaxter. He was a delight to work with and Previous experimental work has shown that ocular surgery, to be a valuable adjunctive tool in the management of threshold ROP. Finally, had a deceptively simple approach to clinical a reduction in spatial pattern stimuli alone ophthalmology. However, behind his almost and not light is all that is necessary to shift we have no commercial interest in the casual approach lay a very keen mind which dominance to the non-dominant eye.2 There- product. had the ability to lay bare the important facts fore, it is reasonable to expect that penalisa- DAVID KENT very rapidly. Surgically he was deft and gen- tion by degrading visual stimuli should be DAVID CLARK eVective even if there was no strabismic devia- Walton Hospital, Rice Lane, tle and never carried out any unnecessary tion. Liverpool L9 1AE manoeuvres, perhaps a result of his training We agree that, previously, atropine penalisa- with H B Stallard. His main interest was tion treatment of amblyopia was considered to ocular motility, again perhaps influenced by 1 Glasser DB, Osborn DC, Nordeen JF, Yuan-I M. another of his contemporaries, T Keith Lyle. be useful only for lesser degrees of amblyopia. Endothelial protection and viscoelastic reten- However, as can be seen from our results sub- tion during phacoemulsification and intraocular Peter was a very generous host, and many stantial improvements were achieved in group implantation. Arch Ophthalmol 1991;109:1438– people including his staV enjoyed his hospi- A, where the pretreatment mean visual acuity 40. 2 Gregory Smith S, Lindstrom RL. 2% Hydroxy- tality at Wilmslow. was 6/50. propyl methylcellulose as a viscous surgical He is survived by his wife Patricia, two adjunct. A multicentre prospective randomised AISLING FOLEY-NOLAN sons, and a daughter who is a general trial. J Cataract Refract Surg 1991;17:839–42. MICHAEL O’KEEFE 3 Monson MC, Manabu T, Mamalis N, Olson RJ, practitioner in South Africa. The Children’s Hospital, Temple Street, Olson RJ. Protective eVects of Healon and Dublin 1, Ireland Ocucoat against air bubble endothelial damage W G CODDINGTON 807 Correspondence, Obituary, Notices Br J Ophthalmol: first published as 10.1136/bjo.81.9.802 on 1 September 1997. Downloaded from 6th International Paediatric 20th Annual Wilmer Institute’s Current NOTICES Ophthalmology Meeting Concepts in Ophthalmology The 6th International Paediatric Ophthalmol- The 20th Annual Wilmer Institute’s Current ogy Meeting will be held on 24–25 September Concepts in Ophthalmology will be held on 1997 in Dublin, Ireland. Topics include grand 5–10 February 1998 at the Hyatt Regency round, neuro-ophthalmology, strabismus, Cerromar Beach Hotel, Dorado, Puerto Rico. Retinopathy of Prematurity childhood tumours. Further details: Ms Kath- Further details: Program Coordinator, Johns leen Kelly, Suite 5, Mater Private Hospital, Hopkins Medical Institutions, OYce of Con- The latest issue of the Journal of Community Eccles Street, Dublin 7, Ireland. (Tel: +3531 tinuing Medical education, Turner 20/720 Rutland Avenue, Baltimore, MD 21205, Eye Health (no 22) deals with retinopathy of 838 4444, ext 1759; fax: +3531 838 6314.) prematurity. Editorial by Alistair R Fielder. USA. (Tel: 410 955-2959: fax: 410 955-0807; For further information please contact Ann email: [email protected];homepage: http://ww2.med.jhu.edu.cme) Naughton, ICEH, Institute of Ophthalmol- British and Eire Association of ogy, 11–43 Bath Street, London EC1V 9EL. Vitreoretinal Surgeons (BEAVRS) Tel: 0171 608 6910. Annual subscription: £25. Free to eye health workers in developing A meeting of the British and Eire Association 15th Annual Wilmer Institute’s Current countries. of Vitreoretinal Surgeons (BEAVRS) will be Concepts in Ophthalmology held in Birmingham on 16–17 October 1997. The 15th Annual Wilmer Institute’s Current Further details: Mr Graham R Kirkby, Concepts in Ophthalmology will be held on consultant ophthalmic surgeon, The Birming- Tübingen Practical Angiography Course 15–20 March 1998 at Manor Vail Lodge, Vail, ham and Midland Eye Centre, City Hospital, Colorado. Further details: Program Coordi- The Tübingen Practical Angiography Course NHS Trust, Birmingham B18 7QU. (Tel: nator, Johns Hopkins Medical Institutions, (International Faculty) will take place on 6 0121-554 3801; fax: 0121-507 6791.) OYce of Continuing Medical education, September 1997 at the Auditorium, Univer- Turner 20/720 Rutland Avenue, Baltimore, sity Dental Clinic, Osianderstrasse 2–8, Tü- MD 21205, USA. (Tel: 410 955-2959: fax: bingen, Germany. Further details; F Gelisken, Diabetic Retinopathy and Vitreoretinal 410 955-0807; email: [email protected]. MD, Congress Secretariat Dept III, Univer- Surgery Advanced Topics jhu.edu; homepage:http://ww2.med.jhu.edu. sity Eye Clinic, Schleichstrasse 12, 72076 cme) Tübingen, Germany. (Tel: +49 (0) 7071 A meeting under the auspices of the OYce of 2987448; fax: +49 (0) 7071 293746; email: Continuing Medical Education will be held [email protected]) on 17–18 October 1997 at the Thomas B Turner Building, Johns Hopkins Medical XXVIIIth International Congress of Institutions, Baltimore, Maryland, USA. Fur- Ophthalmology 5th International Symposium on Ocular ther details: OYce of Continuing Medical Circulation and Neovascularisation education, Johns Hopkins Medical Institu- The XXVIIIth International Congress of Oph- tions, Turner 20, 720 Rutland Avenue, thalmology will be held in Amsterdam on The 5th International Symposium on Ocular Baltimore, MD 21205-2195, USA. (Tel: 21–26 June 1998. Further details: Eurocongres Circulation and Neovascularisation will be (410) 955-2959; fax: (410) 955-0807; email: Conference Management, Jan van Goyenkade held on 15–19 September 1997 in Kyoto, [email protected]) 11, 1075 HP Amsterdam, the Netherlands. Japan. Further details: Professor Dr Masa- (Tel: +31-20-6793411; fax: +31-20-6737306; nobu Uyama, Secretary General of the internet http://www.solution.nl/ico-98/) Organising Committee, Department of Oph- International Centennial Meeting on thalmology, Kansai Medical University, Pseudoxanthoma Elasticum http://bjo.bmj.com/ Moriguchi, Osaka 570, Japan. (fax: 81-6-997- First Combined International 3475.) PXE International, Inc, along with the Na- tional Institute of Arthritis, Musculoskeletal Symposium on Ocular Immunology and and Skin Diseases (NIH), is sponsoring an Inflammation 2nd International Symposium on ARMD International Centennial Meeting on Pseu- doxanthoma Elasticum (PXE) on 6–7 No- The First Combined International Sympo- The 2nd International Symposium on ARMD vember 1997 in Bethesda, MD, USA. The sium on Ocular Immunology and Inflamma- tion eill be held in Amsterdam on 27 June–1 will be held at Glasgow University, Scotland meeting will focus on genetic, extracellular July 1998. The meeting is sponsored by the on September 28, 2021 by guest. Protected copyright. under the auspices of the Royal College of matrix, and clinical issues. Further details: International Ocular Immunology and In- Ophthalmologists on 16–18 September 1997. Sharon Terry, MA, President PXE Inter- flammation Society, the International Uveitis Further details: Dr G E Marshall, Eye national, Inc, 23 Mountain Street, Sharon, Study Group, and the Immunology and Department, Western Infirmary, 38 Church MA 02067, USA. (Tel and fax: 617 784 3817; Immunopathology of the Eye organisation. Street, Glasgow G11 6NT, UK. (Tel: 0141 email: [email protected]) Further details: Professor Aize Kijlstra, The 211 2094; fax: 0141 339 7485; email: Netherlands Ophthalmic Research Institute, [email protected]) PO Box 12141, 1100 AC Amsterdam, Neth- 10th Annual Wilmer Institute’s Current erlands (email: [email protected]) Concepts in Ophthalmology XXXIst National Ophthalmology Congress The 10th Annual Wilmer Institute’s Current 2nd International Conference on Ocular Concepts in Ophthalmology will be held on Infections The XXXIst National Ophthalmology Con- 11–13 December 1997 at the Johns Hopkins gress will be held on 16–20 September 1997 Medical Institutions, Baltimore, Maryland. The 2nd International Conference on Ocular in the Istanbul Convention and Exhibition Further details: Program Coordinator, Johns Infections will be held on 22–26 August 1998 Centre, Istanbul, Turkey. Further details; Hopkins Medical Institutions, OYce of Con- in Munich, Germany. Further details: Profes- Murat Karacorlu, MD, Congress Scientific tinuing Medical education, Turner 20/720 sor J Frucht-Pery, 2nd International Confer- Secretariat, Valikonagi Cad, Sezai Selek Sok Rutland Avenue, Baltimore, MD 21205, ence on Ocular Infections, PO Box 50006, Tel No 8/5, Nisantasi, Istanbul 80200, Turkey. USA. (Tel: 410 955-2959: fax: 410 955-0807; Aviv, 61500, Israel. (Tel: 972 3 5140000; (Fax: +90 (212) 233 2425; email: email: [email protected]; homepage: fax: 972 3 5175674 or 5140077; email: [email protected]) http://ww2.med.jhu.edu.cme) [email protected]) 808 British Journal of Ophthalmology 1997;81:808 Br J Ophthalmol: first published as 10.1136/bjo.81.9.802 on 1 September 1997. Downloaded from INSTRUCTIONS FOR AUTHORS

Adherence to the following guidelines is ophthalmology. Review articles will be References in the text must be cited in essential if eYcient and expeditious process- approximately 3000-5000 words in length numerical order of first appearance. ing of your manuscript is to be achieved. including references and may contain display References in the list must be given in the Manuscripts will be returned to authors for items (Figures and Tables). Most review arti- numerical order in which they first appear in revision before peer review if they are submit- cles are commissioned but uninvited reviews the text, not in alphabetical order of authors’ ted in incorrect format. Please indicate in a are welcomed. Prior discussion with the names. References with one to six authors covering letter which category of paper your Editor is recommended. All reviews are must include all authors’ names; for references article represents. subject to independent refereeing. with more than six authors the first six should The British Journal of Ophthalmology is an be given and then et al. Titles of journals international journal covering all aspects of should be abbreviated in accordance with the LETTERS TO THE EDITOR 1 clinical ophthalmology and the visual/ Case reports will be published as ‘Letters to Index Medicus or given in full. References to ophthalmic sciences. Contributors should the editor’. These are normally 500–600 books must include names of editor(s) if there consider the widely varying readership and is one, town where published, name of words written in the form of a letter with a 2 write clear, simple articles with the minimum maximum of two display items (Figures and publisher, year, volume, page numbers. of technical detail. Space in the journal is lim- Tables). The letter should include an ited and articles should therefore be as concise introductory section (without heading), the 1 Kaye SB, Shimeld C, Grinfield E, Maitland NJ, as possible. One page of text is approximately case report (heading: Case report) and a com- 1000 words. Hill TJ, Easty DL. Non-traumatic acquisition of ment (heading: Comment), plus a maximum infection through the eye. Manuscripts should be sent to the editor of 10 references. Br J Ophthalmol 1992; 76: 412-8. who selects them on the basis of their suitabil- 2 Jakobiec FA, Font RL. Orbit. In: Spencer WB, ed. ity for the journal and of reports from Ophthalmic pathology: an atlas and textbook. 3rd independent referees. Manuscripts are ac- CORRESPONDENCE ed. Philadelphia: Saunders, 1986: 2461-76. Letters are normally constructed in the form knowledged on receipt and the majority References will not be checked in the edito- of scientific correspondence and are usually (>80%) are sent for review. 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REVIEW ARTICLES REFERENCES Substantive review articles will be included In accordance with the Vancouver agreement Reprints under the section ‘Perspective’ and will references are cited by the numerical system. These may be ordered from the OVprint address any aspect of clinical or laboratory They must be typed double spaced. OYce when proofs are returned.