496 Br J Ophthalmol 2001;85:496–503 the left eye, a left pars plana lensectomy and patients with VKH and one with sympathetic vitrectomy were performed to assess the visual ophthalmia reacted against the MART 1 LETTERS TO potential of this eye. The retina was found to melanoma antigen (an antigen carried by skin Br J Ophthalmol: first published as 10.1136/bjo.85.4.496f on 1 April 2001. Downloaded from be flat, and the macula healthy; therefore, and eye melanocytes), when presented in THE EDITOR enucleation was not performed. By 3 months association with HLA-A2. Interestingly, two she had regained a visual acuity of 6/6 in the of their three VKH patients carried HLA-A2, sympathising eye, and 6/12 in the exciting eye HLA-B51, HLA-DR4, and a further VKH (with a contact lens incorporating a pupil and patient carried the HLA-A2, and HLA-DR4 Sympathetic ophthalmia associated with an aphakic correction). antigens. Their sympathetic ophthalmia pa- high frequency deafness However, at 4 months post-injury, reduc- tient was also A2 positive, but was not positive tion of the prednisolone dose to 12.5 mg, and for either HLA-B51 or HLA-DR4. Our EDITOR,—Sympathetic ophthalmia with deaf- reduction of cyclosporin A to give a trough patient was HLA typed and found to carry ness has been reported rarely.12 We describe level of 70 µg/l, was followed by a flare of ante- HLA-A2, HLA-B51, HLA-DR4. one such case and explore a hypothesis rior uveitis in both the exciting and sympathis- HLA-A2 and HLA-DR4 are common and whereby genetic susceptibility may be associ- ing eyes. This responded to increased pred- linked antigens, occurring together in approxi- ated with cross reactivity of antigens derived nisolone (15 mg) and an increase in the dose mately 33% of the population, but HLA-B51 from common neural crest tissue. of cyclosporin A to achieve a trough level of is less common. From 537 random transplant 140 µg/l. At this time the exciting eye began to organ donors HLA typed over 3 years, we cal- display white choroidal lesions consistent with CASE REPORT culated the frequency of HLA-A2, HLA-B51, the appearance of Dalen Fuchs nodules (Fig A 72 year old woman who had previously HLA-DR4 in the regional population. These 1). Prednisolone was gradually reduced to undergone a left trabeculectomy had a fall in specificities were present together in only which she sustained a Colles fracture and a 12.5 mg without further complications and seven donors, giving a frequency of 1.3%. We left total hyphaema. By 14 days the blood had she ultimately achieved a visual acuity of 6/9 propose that patients carrying HLA-A2, cleared suYciently to reveal that she had in both eyes. Despite treatment, her hearing HLA-B51, and HLA-DR4 are at increased expelled the entire left iris into the trabeculec- loss gradually progressed to 90 dB; this has risk of damage arising in melanocytes of tomy bleb, with extensive dispersion of uveal not recovered. diverse tissues when one tissue is injured, pigment into the subconjunctival space. She whether in VKH or sympathetic ophthalmia. COMMENT was also found to have dislocated the lens, MARIE COMER and had sustained a choroidal detachment Sympathetic ophthalmia with features of CRAIG TAYLOR (confirmed by ultrasonography). A non- Vogt-Koyanagi-Harada disease (VKH), was SIMON CHEN granulomatous anterior uveitis was noted in initially reported in the 19th century.1 More KEITH MARTIN the left eye at this time. The initial visual acu- recently, Nirankari et al have reported one KERRY JORDAN ity was light perception in the left eye and 6/12 case of sympathetic ophthalmia with profound PAUL MEYER in the right eye. high frequency deafness which did not re- Department of Ophthalmology, Clinic 3, On the 25th day after the original injury, she cover.2 Rao and Marak3 have performed a Addenbrooke’s Hospital, Cambridge, UK experienced pain and blurring of vision in her clinicopathological survey of 100 pathological Correspondence to: M Comer right eye, with the simultaneous onset of bilat- specimens of eyes enucleated because of sym- Accepted for publication 19 September 2000 eral deafness (with an initial high frequency pathetic ophthalmia. Four of these had VKH hearing loss of 60 dB). She was found to have overlap features, of which two had hearing 1 Duke Elder S. In: Diseases of the uveal tract system a brisk anterior uveitis, with a dense vitritis in loss. The association of sympathetic ophthal- of ophthalmology. Vol IX. London: Henry this eye, through which rugose choroidal mia and deafness is clearly rare, which raises Kimpton, p574. thickening could just be discerned. At this the question of what such overlap cases can 2 Nirankari M, Khanna K, Chawla G, et al. stage, the right visual acuity had declined to teach us about the pathogenesis of VKH. Sympathetic ophthalmitis with total deafness. J 4 All Ind Ophthalmol Soc 1970;18:29–32. 6/24, and the left eye achieved hand move- Woods attempted to explain why deafness 3 Rao N, Marak G. Sympathetic ophthalmia simu- ments. could occur in VKH, hypothesising that lating Vogt-Koyanagi-Harada disease: a clinico- http://bjo.bmj.com/ A diagnosis of sympathetic ophthalmia was pigment present in the auditory labyrinth and pathological study of four cases. Jpn J Ophthal- made. She received two infusions of intra- the eye could be common targets of autoim- mol 1983;27:506–11. 4 Woods AC. Uveitis of proven, prbable, or venous methylprednisolone (1 g each) and munity. The auditory labyrinth and the uvea suspected viral aetiology (Chapter 7). Endo- oral prednisolone (20 mg daily) was started. are known to have a common embryological genous inflammations of the uveal tract. Baltimore: Cyclosporin A was commenced, and the dose origin in the neural crest. Could a genetic pre- Williams and Wilkins, 1961:269. adjusted to achieve a trough level of 200 µg/l disposition facilitate the recognition of such 5 Sugita S, Sagawa K, Mochizuki M, et al. Melano- 5 cyte lysis by cytotoxic T lymphocytes recognis- (despite a history of breast cancer in remis- shared antigens? Sugita et al have recently ing the MART-1 melanoma antigen in HLA A2 sion). In view of the severity of the injury to reported that cytotoxic T cells from three patients with Vogt-Koyanagi-Harada disease. Int Immunol 1996;8:799–803. on October 1, 2021 by guest. Protected copyright. Similarities in the packaging of cyanoacrylate nail glue and ophthalmic preparations: an ongoing problem EDITOR,—We would like to raise concern over an ongoing problem—namely, the similarity between the packaging used for fingernail extension glue (cyanoacrylate “superglue”) and topical ophthalmic preparations. These concerns were raised as long as 16 years ago1 and yet no action or progress has since been instituted by the manufacturers of these containers. Both nail glue and ophthalmic preparations are almost identically packaged in 5–10 ml clear, round bodied, soft plastic dropper type bottles with a white non-locking twist cap which are often manufactured in the same factory.1 The caps are even interchangeable. Discrimination between these products is therefore made unnecessarily diYcult, par- ticularly for patients who need to use regular topical medication—for example, glaucoma Figure 1 (A) Sympathising eye: acute uveitis (pigment ring after pupillary dilatation). (B) Exciting and contact lens wearers2 and patients who are eye: aniridia and hyphaema. (C) Exciting eye: iris pigment in trabeculectomy bleb. (D) Exciting eye: multifocal pale subretinal lesions, representing early Dalen Fuchs nodules. partially sighted or blind. www.bjophthalmol.com Letters 497 Furthermore, once superglue has been installed into the eye, it undergoes instantane- ous polymerisation,1 so that no therapeutic Br J Ophthalmol: first published as 10.1136/bjo.85.4.496f on 1 April 2001. Downloaded from window of opportunity exists to irrigate the glue from the eye. Ocular injuries reported following super- glue administration have included corneal abrasions, punctate epithelial keratopathy, eyelash loss, skin excoriation, and conjunctivi- tis.3 There is also the initial fear of blindness generated by an instant tarsorrhaphy.4 CASE REPORT There have been multiple reports of the mistaken ocular use of nail adhesive in adults.1–4 We have recently treated two paediatric patients for accidental ocular administration of nail adhesive glue, in one case a direct result of confusion about the packaging. The young- Figure 1 (A) and (B) show disconjugate vertical and torsional eye movement when the patient is est was a baby aged 3 months, who had been asked to look to one side (direction of arrow). Horizontal gaze and upward movement above the midline are limited. (C) Axial T2 weighted magnetic resonance imaging shows a high signal intensity prescribed chloramphenicol 0.5% eye drops in pons (arrows) due to infarction. for conjunctivitis. The mother confused the antibiotic eye drops with the nail adhesive drops which were mistakenly installed into the the patient to communicate by way of ocular Brain MRI revealed an extensive infarct in the left eye, causing a partial tarsorrhaphy, eyelash movement, either conjugate upward or down- ventral pons (Fig 1C). clumping, and a corneal abrasion. ward. The second case was ofa3yearoldchild Here, we report an unusual case of COMMENT locked-in syndrome presenting disconjugate whose brother was receiving antibiotic eye- We report an unusual non-concomitant verti- vertical and torsional ocular movement, mim- drops for conjunctivitis. The child imitated cal and torsional eye movements with a large icking seesaw nystagmus (SSN). her mother’s actions by installing drops in her brainstem infarction that rendered him own eye but used nail adhesive instead.