The pigmentation has been attributed primarily to Dilatation of the revealed the presence of a hypertrophy but also mild hyperplasia of the retinal localised traumatic cataract adjacent to the scarred . A pigment epithelium. The streaks, as seen in the present posterior subcapsular cataract was also present, case, radiate out to the periphery passing deep to the accounting for his drop in vision. The posterior segment retinal vessels along the course of sclerosed choroidal was normal. Both anterior and posterior segments were vessels? The precise stimulus for pigmentation adjacent entirely quiet and no foreign body was as yet visualised. to the choroidal vessels has not been identified. A CT scan showed a radiopaque foreign body The presence of Siegrist's streaks is of prognostic temporal and anterior to the right crystalline lens importance.8 These lesions indicate the presence of fibrinoid necrosis, a manifestation of accelerated (malignant) hypertension, which is a medical emergency requiring admission to hospital for prompt treatment. It is therefore essential that following detection of this unusual finding the patient be immediately referred to a physician for appropriate management.

References

1. Duke Elder S, editor. Diseases of the uveal tract. In: System of , vol. 9. St Louis: CV Mosby, 1966:629-34. 2. Morse PH. Elschnig spots and hypertensive choroidopathy. Am J Ophthalmol 1968;66:844-52. 3. Burian HM. Pigment epithelium changes in arteriosclerotic choroidopathy. Am J Ophthalmol 1969;68:412-6. 4. SiegristA. Beitrag zur Kenntnis derArteriosklerose der Augengefasse. In: IXth International Congress on (a) Ophthalmology 1899:131-9. 5. Phol ML. Siegrist's streaks in hypertensive choroidopathy. JAm OptomAssoc 1987;59:372-6. 6. Rayn SJ. Hypertension. In: , vol. 2. St Louis: CV Mosby, 1989:453. 7. Green WR. Systemic diseases with retinal involvement. In: Spencer WH, editor. Ophthalmic pathology: an atlas and textbook. Philadelphia: WB Saunders, 1985:1034-47. 8. Scholtz RO. Epivascular choroidal pigment streaks: their pathology and possible prognostic significance. Bull Johns Hopkins Hosp 1945;77:345-71.

P. Puri A.P. Watson � Department of Ophthalmology Southport General Infirmary Southport PR8 6PH, UK

(b1 Sir,

Surgical exploration minimised by ultrasound biomicroscopy localisation of intraocular foreign body Anterior segment foreign bodies can be difficult to localise. This case illustrates how precise ultrasound biomicroscopy (UBM) localisation of an iris foreign body allowed for pre-operative planning and surgical removal with minimal explorative trauma.

Case report

A 40-year-old man presented with decreased vision in the right eye of about 2 months' duration. He gave a history of a foreign body sensation in the same eye I1f2 years ago whilst supervising the cutting of metal sheets. (e) He thought little of it as there was no pain or blurring of vision. No medical treatment was sought. Examination Fig. 1. (a) Corneal entry wound and iris scar. (b) CT scan showing the showed a small corneal scar close to the temporal limbus foreign body temporal and anterior to the lens. (c) UBM showing the and associated with an underlying iris scar (Fig. la). iris location of the foreign body.

234 (Fig. Ib) but exact localisation of the foreign body in Audrey L.G. Looi Gus Gazzard relation to adjacent ocular structures was not possible. Donald T.H. Tan UBM more clearly identified a foreign body lying on the Singapore National Eye Centre posterior iris surface, close to the iris root and not Singapore involving the ciliary body. This showed up as a dense Audrey L.G. Looi � echo from the iris and the posterior iris surface (Fig. Ic). Singapore National Eye Centre Right phacoemulsification of the cataract with 11 Third Hospital Avenue intraocular lens implant was performed followed by a Singapore 168751 peripheral iridectomy with removal of the foreign body within the resected iris. A 10.0 prolene suture was used Sir, to close the iridectomy medially so that a smaller Haemorrhagic conjunctivitis as an initial manifestation peripheral iridectomy was achieved. The post-operative of systemic meningococcal disease course was uneventful and the patient regained 6/6 Systemic meningococcal disease is commonly seen in the vision 3 days after surgey. paediatric age group and the main portal of entry is the nasopharynx. However, an increasing number of cases Comment have been reported in which the conjunctiva has been an important site of entry for meningococcus. We report a Careful planning is vital in the surgical management of case of meningococcal septicaemia following an intraocular foreign body (IOFB). Of crucial haemorrhagic conjunctivitis. importance is the precise location of the foreign body itself. In this patient, the tell-tale signs of a penetrating Case report injury were subtle but definite: the corneal and corresponding iris scars as well as the localised traumatic A previously healthy 14-year-old boy was referred to eye cataract. This sort of subtle ocular damage is classically casualty with a presumed diagnosis of left orbital seen in hammering injuries and an IOFB must be actively cellulitis. He had presented the previous day to the local sought to avoid further blinding complications such as casualty department with an injected sore left eye, with siderosis.1•2 As the IOFB could not be visualised, associated discharge, and was treated there with topical localisation depended on imaging techniques. Orbital chloramphenicol by the nurse practitioner. That night he radiographs may be useful in detecting IOFBs but some developed general lethargy and a fever, and was referred foreign bodies, including metallic splinters, have been to the eye department the following day with a missed by plain radiographs? Orbital CT scans are good presumed diagnosis of left orbital cellulitis. in detecting foreign bodies but may not provide precise In the eye casualty, ocular examination revealed a localisation, as in this case. That leaves ultrasonography visual acuity of 6/5 in the right eye and 6/18 in the left to provide better images. B-scan ultrasonography is more eye. Anterior segment examination revealed oedematous useful for localisation of posterior segment IOFBs left upper and lower lids and an injected left conjunctiva whereas UBM gives much better resolution and enables with copious green mucopurulent discharge. There was a precise pre-operative localisation of anteriorly situated large superior subconjunctival haemorrhage and IOFBs.4•5 This, in turn, enables the surgeon to plan ahead punctate epithelial erosions on the left . and perform the operation with minimal exploration and Systemically he was clearly unwell and had a body trauma: for example, if the foreign body had been temperature of 39.4 0c. He had a non-blanching localised to the lens or ciliary body, the appropriate maculopapular rash on his chest and back, which his surgical procedure would have been careful lensectomy / mother reported had only corne on in the last few hours. phacoemusification and iridocyclectomy respectively. He had no meningeal sign on presentation. He was UBM can thus play an important role in the management of anterior segment IOFBs.

References

1. Migneco MK, Simpson DE. Penetrating injury from hammering with subtle ocular damage. JAm OptomAssoc 1992;63:634-7. 2. McElvanneyAM, FielderAR. Intraocular foreign body missed by radiography. BMJ 1993;306:1060-1. 3. Talamo JH, Topping TM, MaummeneeAE, Green WR. Ultrastructural studies of cornea, iris and lens in a case of siderosis bulbi. Ophthalmology 1985;92:1675-80. 4. Chakrabarti HS,Atta HR. Use of ultrasound biomicroscopy in the localisation and management of an anteriorly situated intraocular foreign body. Br J Ophthalmol 1998;82:459-60. 5. Pavlin CJ, Harasiewicz K, Shearer MD, et al. Clinical use of Fig. 1. Photograph of the left eye with subconjunctival haemorrhage ultrasound biomicroscopy. Ophthalmology 1991;98:287-95. superiorly and purulent conjunctivitis.

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