LETTERS TO THE JOURNAL

Sir, possibility of loiasis, which causes significantmorbidity if Serious Eye Injuries Caused by Coin Throwing treatment is delayed. We report on three cases of serious eye injury which occurred during a league football match in Leicester in Case Report 1992. A young Nigerian woman repeatedly attended casualty Case 1. A female aged 17 years was hit by a coin, causing complaining of something moving around her eyes. The vertical, bilinear corneal abrasions and macroscopic vision remained 6/6 in each eye and there were no ocular hyphaema. signs on three visits over an I8-month period. A psycho­ Case 2. A male aged 17 years was hit by a coin, causing somatic disorder was being considered until she presented vertical, bilinear corneal abrasions, microscopic to us with an unbearable recurrence of symptoms. A worm hyphaema and commotio retinae. was seen wriggling under the bulbar of the Case 3. A male aged 20 years was hit by a projectile, prob­ right eye (Fig. 1). Microscopic examination, following ably a coin, sustaining a vertical rupture of the excision under local anaesthesia, identified the filarial which required immediate surgical repair. He also sus­ . A routine full blood count before a tained a traumatic and and was gynaecological procedure had shown an of left with a blind, shrunken eye with no prospect of 16% (normal range 1-6%), but its significance was not recovery. realised. The patient was treated with a 3-week course of oral citrate (DEC) without complica­ A total of 34 injuries occurred at this single game includ­ tions. No further symptoms have been reported for 18 ing three other serious eye injuries, namely two chemical months following treatment. bums and a direct assault with a plastic chair resulting in facial lacerations, hyphaema, dialysis and traumatic Discussion cataract. Tropical ocular is rarely considered in the dif­ Injury due to football violence is well recognised. Coin ferential diagnosis in eye clinics in the United Kingdom throwing must represent a significantthreat because of the because of its rarity. is publicised because obvious availability of the projectiles, the ease of con­ it is an important cause of blindness. With increasing glo­ cealing intent and the devastating effect. bal travel ophthalmologists should be aware of less impor­ It is of interest that in the two described cases where the tant which nevertheless have the potential to coin did not penetrate the globe, bilinear (,tram-line') cor­ cause significant symptoms. neal abrasions were present, the two lines corresponding Loa loa is nematode parasite which is in Cen- to the edges of the coin. This feature may well tum out to be characteristic of this particular type of injury.

N. Andrew Frost, FRCS, MRCP Taj B. Hassan, MRCP Department of Ophthalmology and Department of Acci­ dent and Emergency, Leicester Royal Infirmary, Leicester LE 1 5WW, UK

Sir, Unexplained Foreign Body Sensation: Thinking of Loiasis in At Risk Patients Prevents Significant Morbidity

Increasing travel between the United Kingdom and West/ Fig. 1. An adult filarial nematode Loa loa seen under the Central has made it important to be alert to the bulbar conjunctiva of the right eye (arrows).

Eye (1993) 7, 714-71S LETTERS TO THE JOURNAL 715 tral and West Africa. Ocular features may include pain, 4. Klion AD, Massoughbodji A, Sadeler BC, Ottesen EA, Nutman mobile foreign body sensation and irritation caused by TB. Loiasis in endemic and nonendemic populations: immun­ ologically mediated differences in clinical presentation. I Infect worms moving under the periorbital skin and conjunctiva. Dis 1991;163:1318-25. Acute periorbital angioedema and conjunctival nodules 5. Andy JJ, Bishara FF, Soyinka 00, Odesanmi WOo Loiasis as a are early and late complications of worm death. I.2 , possible trigger of African endomyocardial fibrosis: a case report from Nigeria. Acta Trop (Basel) 1981;38:179-86. cataract and exudative retinal detachment occur in patients 6. Klion AD, Eisenstein EM, Smimiotopoulos TT, Neumann MP, with adult worms in the anterior chamber of the eye, but Nutman TB. Pulmonary involvement in loiasis. Am Rev Respir this presentation is fortunately rare.3 Important medical Dis 1992;145:961-3. complications have recently been documented. A neph­ 7. Richard-Lenob1e D, Kombila M, Rupp E, Gaxotte P, Nguiri C, Aziz M. in loiasis associated with or without concom­ up to 22% of cases.4 Chest complica­ ropathy can occur in itant O. volvulus and M. perstans . Am I Trop Hyg tions, cured by treatment, include endomyocardial fibrosis 1988;39:480-3. and pleural effusion.5,6 8. Chippaux IP, Emould IC, Gardon J, Gardon-Wendel N, Chandre In a suspicious case without signs, eosinophilia and a F, Barberi N. Ivermectin treatment of loiasis. Trans R Soc Trop Med Hyg 1992;86:289. rising titre of antifilarial antibody may be helpful. A definitive diagnosis is made by demonstrating a microfil­ araemia, which is most common at mid-day. Twenty Sir, millilitres of citrated blood is taken, filtered and the Cotton-wool Spots in Giant Cell Arteritis stained filterexamined for microfilariae.There is a greater A 69-year-old woman was referred to the Eye Casualty tendency for amicrofilaraemicdisease in expatriates com­ Department complaining of recurrent fading of vision in pared with endemic patients4 so that medical treatment either eye during the preceding 6 weeks. This typically sometimes needs to be initiated solely on clinical grounds. occurred twice daily and lasted 30 minutes. Initially she A 3-week course of oral DEC 6 mg/kg t.d.s. is used on had also noticed horizontal but this resolved. On an out-patient basis unless there is a heavy micro­ further questioning she described weight loss and leth­ filaraemia, in which case in-patient monitoring is impor­ argy, together with headache and shoulder pain, starting 4 tant because of serious adverse reactions such as months previously. She was being treated for angina and encephalitis. Ivermectin is a safer microfilariacidal drug hypertension. that is used as a single oral dose, It is particularly valuable Unaided visual acuities were 6/9 in each eye. Visual in multiple filarial infections where the incidence of side fieldswere full to confrontation and she had normal ­ effects with DEC is greater.7 Multiple doses of ivermectin lary responses. The temporal arteries were strikingly have recently been used but are unable to eradicate micro­ prominent on each side, and were hard and non-pulsatile filaria.s The drug, while useful in mass treatment pro­ although not tender. grammes, is an adjunct to DEC in the cure of loiasis. Fundoscopy showed normal discs with spontaneous Surgical intervention may lead to serious allergic reac­ venous pulsation. However each disc was surrounded by a tions associated with worm destruction and is only indi­ cluster of large cotton-wool spots (Fig. 1). It was this cated for immediate relief of distressing local symptoms. abnormality which had prompted her referral to our department. The cotton-wool spots were not associated C. K. Patel, BSc, MBBS with any detectable vascular abnormality or East Surrey Hospital, haemorrhages. Three Arch Road, Blood tests showed a greatly raised erythrocyte sedi­ Redhill, mentation rate (ESR; 120 mmihour), a slightly reduced Surrey RH 1 5RH, UK haemoglobin (10.0 g/dl) and a normal random glucose D. Churchill, BA, MRCP, DTM&H level. Her blood pressure was 215/ 105 mmHg. Hospital for Tropical Diseases, Treatment was commenced at once with hydrocortisone London, UK 100 mg intravenously, then oral prednisolone, initially M. Teimory, FRCOphth 80 mg daily. On the day following admission we per­ H. Tabendeh, MRCP, FRCS, FRCOphth formed biopsy of her right temporal artery. This showed St. George's Hospital, classical giant cell arteritis with destruction of the elastic London, UK layer, associated giant cells and chronic . She had one further episode of visual loss on the day The patient in this report was under the care of Mr. G. M. following admission. Subsequently her symptoms rapidly Thompson, Department of Ophthalmology, St. George's Hospi­ improved, her ESR declined, and she was discharged on a tal, Blackshaw Road, London SWl7 OQT, UK. reducing course of prednisolone. Six weeks later the cot­ References ton-wool spots had virtually disappeared. 1. Sandford-Smith I. Eye diseases in hot climates, 2nd ed. Bristol: At her most recent review, 3 months after presentation, Wright, 1990:173-86. she remained well on prednisolone 11 mg daily. Unaided 2. Carme B, Botaka E, Lehenaff YM. Filaire loa-loa morte en acuities were 6/5 in each eye and pupillary responses were position sous-conjonctiva1e. I Fr OphtalmoI1988;11:865-7. 3. Osuntokun 0, Olurin O. Filarial worm (Loa loa) in the anterior normal. Her optic discs were of normal colour and there chamber: report of two cases. Br J Ophthalmol 1975;59: 166-7. were no cotton-wool spots.