CASE REPORTS AND SMALL CASE SERIES

followed by preserved artificial tears Case 2. An 87-year-old woman Corneal Toxicity Associated and lubricating ointment for 1 was referred for a and sec- With Latanoprost month, which failed to heal the epi- ondary 6 weeks after cata- thelium. Her medical history was sig- ract surgery in the right eye. Her ocu- Latanoprost is a new topical pros- nificant for type 1 diabetes mellitus lar history was unremarkable. Her taglandin analog used to lower in- of 40 years’ duration, aortic valve medical history included diet- traocular pressure. Adverse effects replacement, and a stroke. Sys- controlled diabetes of 10 years’ du- reported with use of latanoprost in- temic medications included insu- ration and hypertension. Systemic clude cystoid , ante- lin, warfarin sodium, lisinopril, bu- medications included enalapril ma- rior , choroidal effusions, fa- metanide, and aspirin. leate, verapamil hydrochloride, and cial rash, hyperpigmentation of On examination, visual acuity acetazolamide sodium. Ocular medi- , and hyperpigmenta- was counting fingers at 2 ft OD and cations included 1% prednisolone tion.1,2 We describe 4 patients who 20/400 OS. The right showed acetate, dorzolamide, and timolol developed pseudodendrites during an inferonasal linear dendritiform le- maleate to the right eye. treatment with latanoprost. sion. The lesion was composed of On initial examination, visual swollen, hazy epithelial cells with- acuity was 20/200 OD and 20/50 OS. Report of Cases. Case 1. A 77-year- out typical epithelial ulceration and Anterior segment examination of the old woman was referred to us with terminal bulbs of dendritic herpes right eye was significant for a 15% a suspected diagnosis of herpes sim- simplex . There was mild hyphema and a diffuse vitreous hem- plex keratitis. Her ocular history was edema of the adjacent cornea, with orrhage with an intraocular pres- significant for bilateral diabetic reti- a few filaments. The left cornea sure of 24 mm Hg. The patient was nopathy necessitating vitrectomies showed focal central epithelial map referred for glaucoma and and retinal laser treatments, fol- changes. A diagnosis of toxic kera- consults. lowed by glaucoma for which the pa- titis was made. Latanoprost was dis- Three months later, the pa- tient was treated with levobunolol continued, and the levobunolol regi- tient was reexamined for com- hydrochloride twice daily to both men was decreased to once daily in plaints of irritation and tearing in the eyes. Treatment with latanoprost was the right eye. Therapy with preser- right eye. Ocular medications had then added to the right eye for in- vative-free artificial tears and eryth- been modified to include latano- traocular pressure control. Three romycin ointment were started. Fol- prost once daily in the right eye. Vi- weeks after treatment with latano- low-up 2 weeks later showed a sual acuity was now 20/40 OD, with prost, the patient experienced symp- dendritiform epithelial haze in the no evidence of residual hyphema. toms of pain and irritation second- affected area with no residual dis- Corneal examination showed a lin- ary to a corneal abrasion in the right comfort. Follow-up at 3 months ear pseudodendritic pattern across eye. The abrasion was treated with showed a completely healed epithe- the inferior cornea. The left eye was a bandage contact for 1 week, lium with no surface abnormality. normal.

Figure 1. Case 3. Dendritiform lesion on the left cornea following 5 months Figure 2. Case 3. Fluorescein uptake of the dendritiform lesion. of treatment with latanoprost. The lesion shows heaped epithelial ridges and was associated with a papillary .

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Figure 3. Case 4. Lesion on the left cornea following 15 months of Figure 4. Case 4. Dendritiform lesion highlighted with fluorescein. latanoprost therapy. Dendritiform edges surround a central confluent punctate epitheliopathy.

A diagnosis of toxic keratopa- tions to the left eye were stopped Prostanoids have been shown thy was made. Latanoprost was dis- and treatment with erythromycin to produce an increase in con- continued, and treatment with pre- ointment started. Four days later, junctival hyperemia and ocular servative-free tears and erythromycin the visual acuity had improved to irritation. Their effect on the cor- ointment started. Four weeks later, 20/50 OS; the central abrasion had neal epithelium is unknown, al- the dendritiform lesion had healed healed with a faint residual pseudo- though numerous prostaglandin completely, leaving a few residual su- dendritic pattern. receptors exist in the corneal epi- perficial punctate erosions. Case 4. A 79-year-old man was thelium. Case 3. A 63-year-old man was referred for evaluation of persistent Another observation was the as- referred for evaluation of a dendriti- irritation and blurred vision in his sociation with diabetes (2 of 4 cases), form lesion and chronic conjuncti- only eye. His right eye was phthisi- which is itself associated with defects vitis in the left eye. He had a pri- cal following trauma, and his left eye in corneal epithelium and epithelial mary open-angle glaucoma, for had undergone trabeculectomy for healing. It is possible that diabetic cor- which he had undergone trabecu- advanced glaucoma. Topical medi- neas may be more susceptible to the lectomy in the right eye and argon cations included latanoprost, timo- additive effects of an epitheliotoxic laser trabeculoplasty in the left. lol, and erythromycin ointment in drug. Medical history included depres- the left eye. Latanoprost may induce den- sion, which was treated with lithium Visual acuity was 20/100 OS. dritiform corneal lesions that are re- carbonate and nortriptyline hydro- The showed a fine pap- versible with discontinuation of the chloride. Nine months prior to pre- illary response. The cornea had cen- drug. sentation, his topical glaucoma tral confluent superficial punctate regimen was switched from a com- erosions with an inferior dendriti- Sudha Sudesh, FRCOphth bination of timolol, pilocarpine, and form lesion overlying a mild stro- Elisabeth J. Cohen, MD dorzolamide hydrochloride to a mal haze (Figure 3 and Figure 4). Christopher J. Rapuano, MD combination of timolol, bri- Toxic epitheliopathy was diag- Richard P. Wilson, MD monidine tartrate, and latanoprost nosed and treatment with latano- Philadelphia, Pa in the left eye. A follicular conjunc- prost was discontinued. Three weeks tivitis developed and treatment with later there was complete resolution Corresponding author: Sudha Sudesh, brimonidine was discontinued. De- of the dendritiform lesion. FRCOphth, Cornea Service, Wills Eye spite this change, the patient con- Hospital, 900 Walnut St, Philadel- tinued to have symptoms of irrita- Comment. The development of den- phia PA 19107. tion, and 2 weeks later developed an dritiform epitheliopathy as a sign of epithelial defect with a dendriti- corneal toxicity has been previously 1. Warwar RE, Bullock JD, Ballal D. Cystoid macu- form border. Our examination described with the use of topical an- lar edema and anterior uveitis associated with latanoprost use. Ophthalmology. 1998;105:263- showed visual acuities of 20/400 OD tiviral, antibiotic, ␤-blocker admin- 268. and 20/80 OS. The left conjunctiva istration and preservatives in contact 2. Rowe JA, Hattenhauer MG, Herman DC. Ad- showed a diffuse papillary reac- lens solutions.3-5 In each of our cases, verse side effects associated with latanoprost. Am J Ophthalmol. 1997;124:683-685. tion. A dendritiform lesion ex- latanoprost can be singled out as the 3. Margulies LJ, Mannis MJ. Dendritic corneal le- tended across the inferior cornea inciting medication since symptoms sions associated with soft contact lens wear. Arch Figure 1 Figure 2 Ophthalmol. 1983;101:1551-1553. ( and ). The an- and signs followed addition of latano- 4. Wilson FM. Adverse external ocular effects of terior segment of the right eye was prost to the medication regimen. Fur- topical ophthalmic medications. Surv Ophthal- normal. thermore, specific discontinuation of mol. 1979;24:57-88. 5. Wilhelmus KR, McCulloch RR, Gross RL. Den- Toxic reaction to eyedrops was the drug was associated with prompt dritic keratopathy associated with beta blocker suspected; all glaucoma medica- resolution of signs. eyedrops. Cornea. 1990;9:335-337.

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 able to open the eye. The right eye was flected superiorly (Figure 3). The su- Removal of a Fishhook normal. Computed tomographic (CT) tures were clamped to the drape to in the and Cornea scanning was performed and sug- allow visualization of the . Using a Vertical gested that the hook extended The hook had entered verti- through the eyelid and cornea into the cally in the center of the cornea. The Eyelid-Splitting Technique anterior chamber (Figure 2). The pa- corneal wound was confined mainly Ocular fishhook injuries are rare, yet tient was started on a regimen of in- to the stroma with a small region su- potentially vision threatening. Cor- travenous cefazolin sodium and gen- periorly extending full thickness into neal scarring,1,2 ,3,4 tamicin sulfate. He was taken to the the anterior chamber. A corneal and endophthalmitis1 may result. operating room and general anesthe- incision was made anterior to the Prompt surgical intervention is rec- sia was administered. barb so that the hook could be re- ommended1; however, the construc- The globe could not be visual- moved gently. The anterior cham- tion of a barbed fishhook makes re- ized and the hook could not be cut ber was re-formed using balanced moval of these objects difficult. We since it was completely embedded and salt solution after the removal of the report what we believe is a new tech- flush with the skin. There was also se- hook, and two 10-0 nylon sutures nique to remove a fishhook in a pa- rious concern that trying to cut the were used to close the corneal tient with penetration of both the eye- thick metal could result in further in- wound. No leakage was noted after lidandcornea.Toourknowledge,this juries to the globe. The eyelid was in- this procedure. combined injury has not been re- filtrated with 1% lidocaine hydro- The eyelid retraction sutures ported previously. chloride with epinephrine 1: were removed. Multiple inter- 200 000. Using a No. 15 Beaver blade, rupted 5-0 polyglactin 910 (Vicryl; Report of a Case. A 24-year-old man a full-thickness eyelid incision was Ethicon, Inc, Somerville, NJ) su- was first seen in the emergency de- created from the margin of the up- tures were placed at partial thick- partment after a fishing injury in per eyelid vertically to the fishhook, ness through tarsus. At the apex, a which a fishhook struck his left eye. followed by bipolar cautery for he- buried interrupted suture re-formed One barbed hook of a treble fish- mostasis. A 4-0 silk suture was placed the margin. No. 6-0 plain gut su- hook was embedded in the left up- through the apex of each of the 2 eye- tures were used to close the subcu- per lid (Figure 1) and he was un- lid flaps that were created and re- taneous tissues and the skin.

Figure 1. Barbed hook of treble fishhook embedded fully in the left upper Figure 3. Surgical eyelid-splitting procedure performed and the upper eyelid eyelid. retracted with 2 sutures to allow visibility of the cornea.

A

Figure 2. Computed tomographic scan axial image showing possible fishhook penetration into the anterior chamber of the left eye. Figure 4. Well-healed corneal laceration and eyelid incision after 4 months.

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 On the first postoperative day, tion of the eyelid and cornea has not visual acuity was counting fingers at been previously reported. Splitting 3 ft. The anterior chamber was deep of the upper eyelid using a full- with marked inflammation, and thickness vertical eyelid incision may there was significant corneal edema. be a useful technique when visibil- The patient was maintained on a ity of a foreign body is limited and regimen of topical ofloxacin and in- the risk to the globe from addi- travenous antibiotics for 3 days. He tional manipulation is high. was discharged on a regimen of oral ciprofloxacin hydrochloride and Vincent A. Deramo, MD topical ofloxacin. Four months af- Marlon Maus, MD A slitlamp photograph of the patient’s right eye ter surgery, visual acuity with a soft Elizabeth Cohen, MD shows the intraocular lens suspended in the John Jeffers, MD capsular bag. There is no iris. The ciliary contact lens was 20/20. The cor- process tips are visible (arrow). neal laceration and eyelid incision Philadelphia, Pa were well healed (Figure 4). Reprints: Marlon Maus, MD, Oculo- limbus and was 5.25 mm in length. Comment. Removal of a fishhook plastic Department, Wills Eye Hospi- She did well until 12 weeks later, penetrating the globe can be very tal, 900 Walnut St, Philadelphia, PA when she fell and struck her right challenging. Several techniques have 19107. orbital region on a cabinet edge been described in the literature. One while on vacation. She noted an im- such technique is the “advance and 1. Aiello LP, Iwamoto M, Guyer DR. Penetrating mediate loss of vision to the level of ocular fish-hook injuries. Surgical manage- cut method,” in which the hook is ment and long-term visual outcome. Ophthal- hand motions. Four days later, upon grasped and rotated to create a new mology. 1992;99:862-866. returning to Los Angeles, Calif, she exit site for the tip. The barb is then 2. Kuljaca Z, Markovic P. Penetrating ocular fish- came to us for an ophthalmologic hook injury. Eye. 1995;9:385-386. cut off using wire cutters, and the 3. Grand MG, Lobes LA, Jr Technique for remov- examination. barbless hook is backed out through ing a fishhook from the posterior segment of the Examination of the right eye the entry site.1 If the hook is lo- eye. Arch Ophthalmol. 1980;98:152-153. showed light perception visual acu- 4. Mandelcorn MS, Crichton A. Fish hook re- cated primarily within the corneal moval from vitreous and retina: case report. Arch ity with marked ecchymosis of the stroma, a perpendicular incision can Ophthalmol. 1989;107:493. and orbital region. Slitlamp be made in the corneal tissue ante- examination revealed the superior rior to the hook.2 In cases in which 5 clock hours positions of the bul- the fishhook penetrates the retina, bar conjunctiva to have a grayish the needle cover technique can be Traumatic Total Iridectomy discoloration. A layered hyphema useful.3 A large-bore needle is in- Due to Iris Extrusion occupied 75% of the anterior serted into the entry wound and the Through a Self-sealing chamber. The remaining portion barb is engaged in the needle lu- Incision of the anterior chamber was filled men. The needle and hook are then with a dispersed hyphema. There removed simultaneously to mini- Blunt ocular trauma occurring in the was no view of the iris or poste- mize tissue damage. postoperative period after cataract rior segment structures. Applana- Aiello et al1 reported a series of extraction can result in severe vi- tion pressures were 38 mm Hg in ocular fishhook injuries. Similar to sual loss with extrusion of iris, vit- the right eye and 16 mm Hg in the patients in that series, our patient reous, and retinal tissue through the left. Because of the possibility of was a young man with left eye in- ruptured cataract wound. We re- an occult-ruptured globe, the volvement, which was seen in most port a case of isolated iris loss in a patient underwent surgical explo- cases. Like most cases, final visual pseudophakic patient who had un- ration of the globe that same acuity in our patient was good. dergone sutureless cataract extrac- morning. In our case, advancing the fish- tion and intraocular lens implanta- Surgical exploration disclosed hook was not possible owing to the tion. There are reports of phakic a blue-gray iris lying in the subcon- deep position of the hook in the eye patients who developed isolated junctival space adjacent to a self- and the unknown position in the an- traumatic aniridia after corneal and sealing superior scleral cataract terior chamber. A vertical eyelid- scleral ruptures.1-4 To our knowl- wound. The iris, admixed with splitting technique allowed full vis- edge, this is the first case of iso- Tenon capsule and blood, was ibility of the cornea with minimal lated traumatic total iridectomy in adherent to the underlying . manipulation of the hook. Since most a pseudophakic patient. Three interrupted 10-0 nylon su- of the hook was intracorneal, a cor- tures were placed to close the V- neal incision over the barb allowed for Report of a Case. An 82-year-old shaped scleral cataract wound. The easy removal. Careful repair of the woman with age-related macular de- anterior chamber hyphema was then surgically created marginal eyelid lac- generation and geographic atrophy evacuated. No iris was found in- eration resulted in a well-healed eye- had undergone cataract extraction of side the eyeball. The posterior cham- lid with minimal scarring. the right eye and intraocular lens im- ber intraocular lens was in good po- To our knowledge, a fishhook plantation. The scleral self-sealing sition in the lens capsular bag injury with simultaneous penetra- cataract wound was posterior to the (Figure).

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 One month later, a pars plana postulated that a glass splinter (at- and the iris extruded through the in- vitrectomy was performed to evacu- tached to the wood) lacerated the cision. With the sudden expansion of ate a persistent vitreous hemor- cornea, engaged the prolapsing the eyeball after the impact, the iris, rhage. Visual acuity improved from iris, and tore the iris from the iris stuck in the wound, was avulsed from hand motions preoperatively to root. the iris root. The posterior struc- 20/300 postoperatively. Intraocu- In their series of traumatic tures were held back by the intra- lar pressure stabilized at 21 mm Hg. aniridia, Trobe and Keeney2 de- ocular lens implant. This occur- The visual acuity was limited to scribed a patient who suffered trau- rence of traumatic total iridectomy 20/300 by geographic atrophy due to matic total iridectomy without trau- due to blunt trauma in the setting of age-related . matic . Their patient had a self-sealing cataract wound has not been struck in his eye by a rock frag- been previously reported. Fortu- Comment. Isolated traumatic ex- ment while riding a motorcycle. An nately, due to the intraocular lens im- pulsion of the iris has been de- iris fragment was found in the cor- plant’s presence, there was a good scribed in association with contu- neoscleral wound; the natural lens outcome. sion injuries to the globe in phakic was intact. Follow-up during the patients. To our knowledge, this is next 6 months showed maintained Jennifer I. Lim, MD the first report of traumatic total iri- 20/25 visual acuity and normal in- Angela Nahl, MD dectomy in a pseudophakic patient traocular pressure. Richard Johnston, MD with retention of a posterior cham- There have been reports of 2 Glen Jarus, MD ber intraocular lens implant. other patients with traumatic total Los Angeles, Calif Previous reports described pa- iridectomy after suffering small per- tients in whom the iris was ex- forating perilimbal wounds.3 In 1 pa- Reprints: Jennifer I. Lim, MD, Doheny pulsed through a corneoscleral tient, the iris extruded through a full- Eye Institute, USC School of Medi- laceration1-3 or through a full-thick- thickness glaucoma fistula when the cine, 1450 San Pablo St, Suite 4703, ness glaucoma fistula.4 Romem and conjunctival bleb ruptured.4 It was Los Angeles, CA 90033 (e-mail: Singer1 described a man who was postulated that an abrupt rise of in- [email protected]). struck by a piece of wood and suf- traocular pressure led to extrusion 1. Romem M, Singer L. Traumatic aniridia. Br J Oph- fered a corneoscleral laceration ex- of the iris through the fistula. thalmol. 1973;57:613-614. tending from the limbus to the equa- In our patient, we postulate that 2. Trobe JD, Keeney AH. Traumatic aniridia. Am tor temporally. That patient was the blunt trauma led to an abrupt el- Ophthalmol. 1974;78:1006-1008. 3. Conrads H, Dakkak H. Total aniridia: a prob- found to have isolated traumatic to- evation of the intraocular pressure. lem of bulbus rupture [German]. Klin Monatsbl tal iridectomy; the natural lens was As a result of the force exerted on the Augenheilkd. 1981;178:377-378. 4. Burger M, Mackensen G. Aniridia caused by con- intact. During a 2-year follow-up, the globe and the elevated intraocular tusion-related rupture of a bleb following Elli- visual acuity recovered and was pressure, the previously closed self- ot’s trepanation [German]. Klin Monatsbl Au- maintained at 20/20. The authors sealing corneoscleral incision opened genheilkd. 1982;181:123-124.

From the Archives of the ARCHIVES

A look at the past. . .

OLLINS describes the views of Van Graefe, De Wecker, Nordenson, Raehlmann, as to the causes of retinal detach- ment and ruptures and reports two cases in which microscopic examination supported Elschnig’s theory as to the C cause of ruptures n retinal detachments. In each case a small portion of retina remained attached in the yellow- spot region to which it was adherent, having been torn off the detached portion, owing to choroiditic adhesions. Whenever an eye is cut open, the edges of the retina turn in, hence the fact that the edges turn in in ruptures is of no importance as evidence for or against any particular theory.

Reference: Arch Ophthalmol. 1897;26:480.

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