Eyelid Neuroma Associated with Swim Goggle

CASE REPORTS AND SMALL CASE SERIES

ophthalmic medications. The pa- netic hemochromatosis, intestinal Corneal Findings tient received multiple phlebotomy iron absorption is significantly in- in Hemochromatosis treatments in 1997. creased, and causes deposition of At the time of our initial oph- iron in the liver, skin, pancreas, Corneal pigmentation deposition thalmic examination in March 1996, joints, and heart. The organs in- has been reported in many sys- the best-corrected visual acuity was volved become impaired with con- temic diseases. These include the 20/40 OD and 20/40 OS. The pa- tinued accumulation. lysosomal diseases, Wilson disease, tient’s eyelids were not abnormal in Acquired hemochromatosis oc- amyloidosis, multiple myeloma, color; the lenses had a mild degree curs from hemolysis (usually from cystinosis, and hemochromatosis. of nuclear sclerosis. The conjunc- thalassemia or sideroblastic ane- These underlying conditions must tiva and cornea of both eyes showed mia) or multiple transfusions. Un- be considered in the differential small fine brown pigmentary depos- like primary hemochromatosis, iron diagnosis of corneal deposits, as its. The diffuse corneal pigment was deposition occurs first in reticulo- they might be treatable. We focus slightly greater inferiorly than su- endothelial cells. As the process con- on an unusual case of corneal iron periorly, with a clear zone of ap- tinues, the reticuloendothelial sys- deposition in a patient with proximately 1.5 mm between the tem becomes saturated, and acquired hemochromatosis. pigment and the limbus, in the in- parenchymal cell deposition also oc- traepithelial and anterior third of the curs, leading to many of the same Report of a Case. A 70-year-old Rus- stroma (Figure 1 and Figure 2). systemic manifestations as genetic sian woman immigrated to the The conjunctival pigment was ex- hemochromatosis. United States in 1995. She was seen tremely fine, diffuse, and interpal- Ocular hemosiderosis is iron by the ophthalmology department pebral. The extremities revealed no toxicity confined to the eye due to because of gradually worsening vi- abnormal pigmentation. a retained intraocular iron foreign sion since 1990. Her medical his- Laboratory test results since body or persistent intraocular hem- tory was notable for type II diabe- 1995 have revealed serum ferritin orrhage. The iron deposition oc- tes, hypertension, arthritis, anemia, levels between 793 and 1173 µg/L curs in most parts of the eye, but es- gastritis, and liver dysfunction. She (reference range, 10-291 µg/L), pecially involves the posterior had been diagnosed with anemia in with a normal iron-binding capac- segment. Severe visual loss can re- 1988, and received weekly intrave- ity, and abnormal liver function. A sult from vitreal degeneration with nous iron injections between 1988 liver biopsy specimen in 1996 formation of contraction bands and and 1989 after daily injections for 3 revealed iron pigment in paren- retinal degeneration.1 weeks. The dosage of each injec- chymal cells and cirrhotic changes The ophthalmic manifesta- tion and the type of anemia that was consistent with hemochromatosis. tions of genetic or acquired hemo- present could not be ascertained. She chromatosis are quite different denied alcohol abuse, previous ocu- Comment. Hemochromatosis can be from the effects of ocular hemo- lar trauma, or the use of any topical genetic (primary) or acquired. In ge- siderosis. In genetic or acquired

Figure 1. Low-power view revealing diffuse pattern of pigment in this quiet un- Figure 2. High-power view demonstrating fine brown corneal pigment seen inflamed eye (cilia and eyelid pigment is artifact ) (original magnification ϫ7.5). on direct and indirect retroillumination (original magnification ϫ30).

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 disease, the deposition is generally limited to the sclera and ciliary Retained Nuclear Fragment body.1,2 Hudson3 analyzed 5 post- in the Anterior Segment mortem cases of biopsy-proven hemochromatosis and observed Several studies have examined the no abnormalities other than con- management of retained nuclear frag- junctival aneurysms and fundus ments in the posterior segment of the changes similar to early diabetic eye.1-2 Bohigian and Wexler3 re- retinopathy (2 of the 5 patients cently treated 2 patients with nuclear had diabetes). In fact, Hudson fragments in the anterior chamber of stated that “no other ocular find- their eyes after phacoemulsifica- Figure 1. Slitlamp view showing a ings characteristic of hemochro- tion. We also treated a patient with wedge-shaped area of corneal edema localized matosis have been observed.”3 a retained nuclear fragment in the an- to the inferior cornea. Our patient is, to our knowl- terior segment of the eye. edge, the first reported case of corneal iron deposition in acquired Report of a Case. An 86-year-old hemochromatosis. Only 1 previous woman underwent a phacoemul- report in the literature has de- sification cataract extraction with pos- scribed a similar clinical picture. terior chamber intraocular lens im- Urrets-Zavalia and Katz4 noted cor- plantation in the right eye. Her visual neal iron deposition and termed it acuity improved to 20/25 OD 1 month “corneal hemochromatosis,” postoperatively. A persistent ante- because there was no systemic iron rior chamber reaction was noted 6 overload. They described a “multi- weeks postoperatively following ta- tude of minute refringent dots in pering of 1% prednisolone acetate. Figure 2. Gonioscopic view of inferior angle the anterior third of the corneal She had a sudden decrease in vision demonstrates a retained lens fragment. stroma,” an appearance similar to 10 weeks later. Visual acuity had di- our patient. Both eyes required minished to 20/200 OD. Slitlamp ex- ferior corneal edema. A similar pat- penetrating keratoplasty due to amination showed a wedge-shaped tern of migration of intraocular corneal opacity. Davies et al2 area of corneal edema (Figure 1). foreign bodies into the anterior cham- reported conjunctival pigmenta- Trace cell and flare were present in the ber angle has been reported previ- tion encroaching onto the limbus anterior chamber. Gonioscopy re- ously.4 Like intraocular foreign bod- in their series of patients with vealed a small lens fragment in the in- ies in the anterior segment, nuclear hemochromatosis. No treatment ferior angle (Figure 2). fragments can incite a prolonged in- was advised for our patient, as her Hourly, 1% prednisolone ac- flammatory reaction or mechani- visual acuity was good. Further- etate was administered. There was no cally damage the endothelium, lead- more, as it may require 2 to 3 years improvement after 1 week, and she ing to localized corneal edema.4 for phlebotomy to reduce substan- underwent removal of the lens frag- There are similarities between tially the total body iron stores, the ment through a temporal incision. our patient and the 2 patients previ- intracorneal iron theoretically may We used 2% pilocarpine hydrochlo- ously described by Bohigian and also clear with the passage of time. ride preoperatively for pupillary con- Wexler.3 Persistent corneal edema striction, and intraoperative gonios- and mild inflammation character- Douglas R. Lazzaro, MD copy was performed to localize the ized all eyes with retained nuclear Ken Lin, MD fragment. Histopathologic examina- fragments in the anterior segment. As Jonathan A. Stevens, OD tion revealed eosinophilic tissue ar- with the prior cases, topical cortico- Brooklyn, NY ranged in lamellae consistent with steroid therapy was ineffective in our lens nucleus. The most recent fol- patient and surgical removal of the low-up examination, 2 months after nuclear fragment was required to im- removal of the fragment, showed im- prove the corneal edema. Because re- Reprints: Douglas R. Lazzaro, MD, provement of the corneal edema, and tained lens fragments can migrate 7901 Fourth Ave, Brooklyn, NY the patient’s visual acuity had im- when changes in posture occur, we 11209. proved to 20/30 OD. recommend preoperative treatment 1. Roth AM, Foos RY. Ocular pathologic changes with pilocarpine to constrict the pu- in primary hemochromatosis. Arch Ophthal- Comment. We hypothesize that the pil and decrease the likelihood of mi- mol. 1972;87:507-514. lens fragment in our patient re- 2. Davies G, Dymock I, Harry J, Williams R. Depo- gration behind the iris. Intraopera- sition of melanin and iron in ocular structures mained sequestered behind the iris tive gonioscopy before removal is also in hemochromatosis. Br J Ophthalmol. 1972;56: for several months after cataract sur- crucial for accurate localization. 338-342. 3. Hudson JR. Ocular findings in haemochroma- gery and produced a chronic, low- tosis. Br J Ophthalmol. 1953;37:242-246. grade inflammation. It later mi- Steven J. Gedde, MD 4. Urrets-Zavalia A Jr, Katz C. Corneal hemochro- grated into the anterior chamber, Carol L. Karp, MD matosis: a unique type of corneal dystrophy involving the anterior stroma and both limiting gravitating to the inferior angle and Donald L. Budenz, MD membranes. Am J Ophthalmol. 1971;72:88-96. resulting in the acute onset of in- Miami, Fla

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Reprints: Steven J. Gedde, MD, Bas- Though the patient experi- phonuclear cells (2+). The aqueous com Palmer Eye Institute, 900 NW enced persistent intense pain and specimen contained polymorpho- 17th St, Miami, FL 33136 (e-mail: redness of the left eye that began the nuclear cells (1+) but no organ- [email protected]). night of the surgery, he did not re- isms. Microbiological cultures sub- turn for follow-up examination un- sequently grew C indologen from 1. Blodi BA, Flynn HW, Blodi CF, Folk JC, Daily MJ. Retained nuclei after cataract surgery. Oph- til 7 days later, when he was re- both specimens. thalmology. 1992;99:41-44. ferred to the University of British One month later, the visual 2. Gilliland GD, Hutton WL, Fuller DG. Retained Columbia Eye Care Center, Van- acuity had improved to 20/200 OS. intravitreal lens fragments after cataract surgery. Ophthalmology. 1992;99:1263-1269. couver. The fibrin in the anterior chamber 3. Bohigian GM, Wexler SA. Complications of re- Examination disclosed a vi- had largely resolved. The periph- tained nuclear fragments in the anterior chamber after phacoemulsification with posterior sual acuity of 20/30 OD and hand eral retina was visible but the pres- chamber lens implant. Am J Ophthalmol. 1997; motions OS. The intraocular pres- ence of vitreous debris obscured a 123:546-547. sures were 20 mm Hg OD and 45 clear view of the macular region. No 4. Runyan TE. Anterior chamber. In: Concussive and Penetrating Injuries of the Globe and Optic mm Hg OS. Slitlamp examination retinal necrosis was present. Ten Nerve. St Louis, Mo: Mosby–Year Book Inc; disclosed a markedly edematous left weeks after the antibiotic injection, 1975:34-52. cornea with cells (4+) and flare in the visual acuity was 20/70 OS. Mild the anterior chamber with exten- persistent corneal edema was noted. sive fibrin and a layered hypopyon Results of a fundus examination (Figure). Fundus examination re- were unremarkable. vealed only a hazy red reflex. Endophthalmitis Induced The patient underwent an im- Comment. Chryseomonas indolo- by Chryseomonas mediate anterior chamber and vit- gen is an aerobic motile gram- indologen reous aspiration followed by an in- negative rod with a distinct yellow- travitreal injection of 1 mg of orange pigment seen most Bacterial endophthalmitis is a rare vancomycin (1 mg/0.1 mL), 2 mg of commonly in petroleum-contami- ocular disease that often has a poor ceftazidime (2 mg/0.1 mL), and 1 mg nated soils.2 Chryseomonas is one of visual outcome. The investigators for of dexamethasone (1 mg/0.1 mL). a few bacteria species that is ca- the Endophthalmitis Vitrectomy Therapy was begun with acetazol- pable of utilizing hydrocarbons as its Study have developed guidelines for amide, 250 mg once daily; 1% pred- sole source of carbon and energy. treatment of patients with endoph- nisolone acetate once daily; 0.5% This group of organisms rarely thalmitis in addition to reporting timolol maleate twice daily; and causes systemic infections, and such prognostic indicators. Although vi- ciprofloxacin drops hourly. Six cases are often related to the intro- sual acuity at the time of evalua- hours later, the pain had largely sub- duction of indwelling lines or pros- tion was the best predictor of final sided. The clinical appearance re- theses.3 It morphologically re- visual outcome, microbiological fac- mained unchanged except for a re- sembles Pseudomonas species and tors seem to play an important pre- duction of the intraocular pressure was originally categorized in that ge- dictive role.1 Patients with endoph- to 25 mm Hg OS. nus. The 2 organisms are phyloge- thalmitis related to gram-negative The vitreous specimen revealed netically similar and share select organisms fared considerably worse gram-negative rods and polymor- common RNA sequences.4 compared with cases associated with gram-positive organisms. We report a case of gram- negative endophthalmitis following cataract surgery induced by Chrys- eomonas indologen. To our knowledge, this description represents the first reported case of endophthalmitis caused by this organism.

Report of a Case. A healthy 92-year- old white man underwent phacoemulsification of a cataract of the left eye, during which a dehiscence of the posterior capsule and posterior displacement of lens material oc- curred. An anterior vitrectomy was performed and a posterior chamber intraocular lens was placed in the ciliary sulcus. During rotation of the implant, it subluxed into the vitreous cavity. An anterior chamber in- Slitlamp photograph 1 week after cataract surgery showing conjunctival injection, corneal edema, and traocular lens was then inserted. anterior chamber fibrin with hypopyon.

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 While Pseudomonas infection is Pars plana vitrectomy was per- posits have been chemically se- virulent and often devastating, formed in the left eye in July 1992. quenced. Prealbumin has a high Chryseomonas infection tends to take Histopathologic stains were consis- proportion of proteins in the ␤- a more indolent course with less ex- tent with amyloidosis. The pa- pleated sheet structure, which may tensive inflammation and necrosis. tient’s postoperative visual acuity im- polymerize into the amyloid fibril. To our knowledge, this is the first proved to 20/20 OS, but amyloidosis Prealbumin synthesis has been seen reported case of endophthalmitis has a high recurrence rate.1 Vitrec- in retinal pigment epithelium,4 al- caused by this rare organism. Of par- tomy in the right eye was per- though the major source is consid- ticular interest is the fact that our pa- formed in August 1992, with con- ered to be the liver. Other research tient went untreated for 7 days but comitant endolaser panretinal suggests that vitreoretinal amyloid still recovered useful vision. photocoagulation to destroy the pos- has a retinal vascular origin.5 sible site of production or secre- The mechanism by which la- Tom S. Chang, MD, FRCSC tion. In May 1993, the patient was ser panretinal photocoagulation led Khaled Tawansy, MD symptom free with visual acuity of to resolution of vitreoretinal amy- Dawn Hay, RN 20/20 OU; however, results of her loidosis is unclear. A secondary ef- Simon Holland, MB, FRCSC ophthalmic examination showed fect on the retinal vasculature could Vancouver, British Columbia asymmetric intraocular pressure of have reduced secretion of amyloid 16 mm Hg OD and 21 mm Hg OS, formed elsewhere, eg, in the liver. Al- Corresponding author: Tom S. Chang, with a clear posterior segment in the ternatively, destruction of retinal pig- MD, FRCSC, Department of Ophthal- right eye and opacities in the vitre- ment epithelium could have de- mology, University of British Colum- ous in the left eye. In June 1994, vi- stroyed the site of amyloid synthesis. bia, 2550 Willow St, Vancouver, BC, sual acuity had deteriorated to 20/25 In our patient, glaucoma was prob- Canada V5Z 3N9. OD and 20/80 OS, with intraocular ably due to amyloid obstructing tra- pressure at 14 mm Hg OD and 57 becular meshwork. The panretinal 1. The Endophthalmitis Vitrectomy Study Group. argon laser photocoagulation prob- Microbiologic factors and visual outcome in the mm Hg OS. The left eye showed an Endophthalmitis Vitrectomy Study. Am J Oph- afferent pupillary defect, large re- ably helped reduce the amount of thalmol. 1996;122:830-846. current vitreous opacities, optic amyloid deposited in the trabecu- 2. Rahav G, Simhon A, Mattan Y, Moses AE, Sacks T. Infections with Chryseomonas luteola (CDC nerve cupping, and marked visual lar meshwork. group Ve-1) and Flavimonas oryzihabitans (CDC field loss. Panretinal argon laser photo- group Ve-2). Medicine. 1995;74:83-88. Maximum medical treatment coagulation prevented recurrence of 3. Smith-Greenier LL, Adkins A. Degradation of di- clofop-methyl pure cultures of bacteria isolated did not sufficiently control intra- amyloid deposits in the vitreous. The from Manitoban soils. Can J Microbiol. 1996;42: ocular pressure, and a mitomycin- small number of individuals with 227-233. ocular amyloidosis prevents inves- 4. Anzai Y, Kudo Y, Oyaizu H. The phylogeny of augmented trabeculectomy failed af- the genera Chryseomonas, Flavimonas, and Pseu- ter several months. In February tigating laser therapy with a clini- domonas supports synonymy of these three gen- 1995, the patient underwent pars cal trial. We are optimistic, how- era. Int J Syst Bacteriol. 1997;47:249-251. plana vitrectomy with endolaser ever, that our observations may panretinal photocoagulation and prove useful in treating other pa- placement of an Ahmed glaucoma tients with this condition. drainage tube. The patient has done Panretinal Photocoagulation well since that time; the most re- Michael D. Baum, MD in the Treatment of cent ophthalmic examination in July Howard S. Weiss, MD Vitreoretinal Amyloidosis 1997 showed a visual acuity of 20/30 Reginald J. Sanders, MD OD and 20/40 OS consistent with Washington, DC We performed vitrectomy on both mild cataract, intraocular pressure eyes of a patient with bilateral vit- of 10 mm Hg OD and 13 mm Hg OS, reoretinal amyloidosis. In one eye, and clear vitreous in both eyes. She concurrent panretinal photocoagu- has been diagnosed with cardiac, Reprints: Michael D. Baum, MD, lation prevented recurrence. neurological, and gastrointestinal 8830 Cameron St, Silver Spring, MD deposition of amyloid. 20910.

Report of a Case. In August 1991, 1. Sandgren O. Ocular amyloidosis, with special ref- a 52-year-old African American Comment. Amyloidosis is consid- erence to the hereditary forms with vitreous in- woman complained of floaters in ered a complex of related diseases volvement. Surv Ophthalmol. 1995;40:173-96. 2. Doft BH, Machemer R, Skinner M, et al. Pars both eyes. Visual acuity was 20/25 characterized by extracellular depo- plana vitrectomy for vitreous amyloidosis. Oph- OD and 20/20 OS. Results of oph- sition of amyloid protein.2 Amy- thalmology. 1987;94:607-611. thalmic examination showed no ab- loid fibrils are composed of various 3. Eanes ED, Glenner GG. X-ray diffraction studies on amyloid filaments. J Histochem Cyto- normalities, except for acellular vit- proteins arranged in a ␤-pleated chem. 1968;16:673-677. reous opacities, and no treatment sheet configuration.3 4. Cavallaro T, Martone RL, Dwork AJ, Schon EA, Herbert J. The retinal pigment epithelium is the was advised. By June 1992, visual Various protein abnormalities unique site of transthyretin synthesis in the rat acuity had decreased to 20/40 OU, can cause amyloidosis. Genetically eye. Invest Ophthalmol Vis Sci. 1990;31:497- consistent with increased vitreous aberrant prealbumin is thought to be 501. 5. Tsukahara S, Matsuo T. Fluorographical find- opacities and the diagnosis of prob- responsible for all cases of vitreo- ings in familial primary amyloidosis. Ophthal- able amyloidosis was made. retinal amyloidosis in which the de- mologica. 1978;176:301-307.

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We report a case of primary pulmonary hypertension (PPH) that led to uveal effusion and macular edema. In our patient, these symptoms rap- Figure 1. Left, Macular edema in the left eye with some retinal pigment epithelial mottling best seen idly resolved with the administra- inferiorly and superotemporally. Right, Late venous phase of the fluorescein angiogram of the same eye tion of acetazolamide. demonstrating diffuse macular edema, retinal pigment epithelial mottling, and no vascular leakage.

Report of a Case. A 33-year-old Figure 2. Optical coherence tomography (OCT) of the left macula taken after reappearance of the macular woman had a 3-month history of bi- edema on withdrawing therapy with acetazolamide (left) and 23 hours later after its reintroduction, showing resorption of the fluid (right). Note the different scales: the left image was demonstrated with lateral blurred vision and eye pain. linear OCT using a 6.69-mm beam and the right image using a 2.83-mm beam. She was treated with 30 mg of prednisolone daily (0.5 mg/kg) for pre- sumed posterior scleritis for 3 weeks with no improvement and was re- ferred to our unit. A diagnosis of PPH had previously been made on the basis of right-sided heart failure with an elevated pulmonary ar- terial pressure of no obvious cause. Maintenance therapy consisted of di- uretics, vasodilators (diltiazem hy- drochloride), and anticoagulation. Her mother also had PPH. On examination, corrected visual acuity was 20/90 OD and 20/40 OS. There was bilateral conjunctival chemosis with dilated nonarte- rialized episcleral vessels, but no anterior uveitis. Intraocular pressures hypoxia. Results of routine biochem- often fatal due to progressive right- were 10 mm Hg OD and 9 mm Hg istry testing were normal. sided heart failure with vasoconstric- OS. Fundus examination revealed bi- Treatment with oral acetazol- tion, vascular wall remodeling, and lateral macular edema with retinal amide (sustained release, 250 mg thrombosisinsituofsmallpulmonary pigment epithelium mottling twice daily) was begun, with resolu- arteries. Its cause is unknown, but the (Figure 1, left) and bilateral infe- tion of the serous retinal detachments gene for familial PPH (a minority of rior serous retinal detachments. On and macular edema within 6 days, re- cases) has been recently localized to general examination, blood pres- sulting in unaided visual acuities of chromosome 2q31-32.1 sure was 110/70 mm Hg and signs 20/20 OD and 20/15 OS. Systemic Bilateral serous detachments of right-sided heart strain includ- symptomsandsignswereunchanged. similar to the uveal effusion syn- ing elevated jugular venous pres- Subsequent discontinuation of drome have been reported before in sure, ankle edema, right ventricu- treatment after 6 months resulted in PPH and variously attributed to reti- lar heave, systolic murmur, and a recurrence of symptoms and signs nal and choroidal stasis,2 oxygen- palpable liver edge were evident. in the left eye within 1 week. Opti- induced vasoconstriction,3 and el- B-scan ultrasonography dem- cal coherence tomographic scans evated venous pressure and Valsalva onstrated choroidal thickening and were performed and demonstrated effect due to vomiting,4 but acet- fluorescein angiography demon- edema and serous elevation of the azolamide has not been previously strated widespread retinal pigment macula (Figure 2, left). Oral acet- tried in these patients. Elevated ve- epithelium mottling and macular azolamide was reintroduced and op- nous pressure in the orbit could lead edema without retinal vascular leak- tical coherence tomographic scan- to this clinical picture as, for ex- age (Figure 1, right). A complete ning after 23 hours demonstrated an ample, uveal effusion has been re- blood cell count showed a hemoglo- almost complete resolution of both ported in caroticocavernous fistu- bin level of 165 g/L (reference range, (Figure 2, right). lae. However, right-sided heart 120-150 g/L) and a hematocrit of 0.49 failure in the more common second- (reference range, 0.36-0.47) in keep- Comment. Primary pulmonary hy- ary pulmonary hypertension has not ing with the polycythemia of chronic pertension is a rare condition and is been reported to cause macular

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 edema and serous detachment. The wound. Corneal edema, disrupted remarkable feature in our patient was Traumatic Foveal Relocation lens material, and a hemorrhage pre- the appearance of diffuse macular With Good Visual Acuity cluded a view to the retina. Ultrason- edema without retinal vascular leak- ography revealed a possible supero- age. Its rapid disappearance with ac- Neovascular age-related macular de- nasal retinal detachment. etazolamide, a drug known to re- generation is a major cause of vi- A vitrectomy was performed 18 solve macular edema in other sual loss in elderly patients.1 Treat- days after his injury, removing the disorders of retinal pigment epithe- ment options are limited for most of traumatically disrupted lens and lium,5 suggests retinal pigment epi- these patients. Surgical relocation of hemorrhagic vitreous. The corneal thelial dysfunction in our patient. the foveal retina to an area of healthy clarity had improved adequately to retinal pigment epithelium (RPE) proceed without a temporary kera- Christopher J. Hammond, MRCP, 2-6 FRCOphth has been described. We report a toprosthesis. Devinder S. Chauhan, FRCOphth case of traumatic foveal relocation The retina was tractionally el- Miles S. Stanford, MSc, MD, FRCS, with good visual acuity. evated in a ridge extending from the FRCOphth optic disc to the 11-o’clock posi- London, England Report of a Case. An 18-year-old tion periphery where depressed ex- man suffered a bottle rocket injury amination revealed retinal incarcera- Corresponding author: Christopher J. with resultant trauma to his left eye. tion in the original rupture site. The Hammond, MRCP, FRCOphth, De- His right eye was not injured and had borders of the ridge had a concave partment of Ophthalmology, United an uncorrected visual acuity of 20/ appearance and no evidence of a Medical and Dental Schools, St Tho- 20. Left eye evaluation revealed light break was found. The macula was at- mas Hospital, Lambeth Palace Road, perception visual acuity without as- tached, but rotated superiorly. The London SE1 7EH, England (e-mail: sociated light projection. A 50% hy- vitreous base was trimmed 360° with [email protected]). phema and corneoscleral laceration scleral indentation and a 3.5-mm cir- were present. The laceration ex- cumferential buckle was placed to 1. Nichols WC, Koller DL, Slovis B, et al. Local- tended 2 mm posterior to the limbus support the vitreous base. No gas or ization of the gene for familial primary pulmonary hypertension to chromosome 2q31-32. Nat at the 9- and 12-o’clock positions, in- silicone oil was used. Genet. 1997;15:277-280. volved the superonasal corneal quad- The subretinal fluid beneath 2. Van Camp G, Renard M, Verougstraete C, et al. rant, and extended to the center of the the tractional retinal elevation Ophthalmologic complications in primary pulmonary hypertension. Chest. 1990;98:1543- visual axis. Repair of the laceration resolved, resulting in a dry fold 1544. with excision of prolapsed iris was postoperatively (Figure 1). His 3. Scheider A, Asiyo M, Habersetzer K. Serose ab- performed the day of the injury by the remaining retina remained latio Retinae unter O2-Therapie bei primarer pul- monaler Hypertonie. Fortschr Ophthalmol. 1991; referring physician. attached. His fovea was found to be 88:346-349. The patient was seen at our in- rotated superiorly 43° with the 4. Akduman L, Del Priore LV, Kaplan HJ, Meredith T. Uveal effusion syndrome associated with pri- stitution 4 days following his in- darker RPE of the central macula mary pulmonary hypertension and vomiting. Am jury. Left eye visual acuity was light visible beneath the retina adjacent J Ophthalmol. 1996;121:578-580. perception, intraocular pressure was to the inferotemporal arcade ves- 5. Cox SN, Weinstein G, Arden GB, Bird AC. Treat- ment of chronic macular edema with acetazol- 10 mm Hg, and an ophthalmic ex- sels. Fine spiral folds were seen at amide. Arch Ophthalmol. 1988;106:1190-1195. amination showed an intact corneal the superotemporal disc margin

Figure 1. Dry retinal fold extending from the optic disc to the 11-o’clock Figure 2. Superior foveal relocation. Darker macular retinal pigment position. epithelium is superior to the inferotemporal arcade vessels (solid arrow). Fovea is rotated 43° counterclockwise (open arrow).

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 (Figure 2). He fixated reliably on 1. Bressler NM. Submacular surgery: are random- ing of the upper eyelid related to their ized trials necessary? Arch Ophthalmol. 1995; the area of foveal relocation and had 113:1557-1560. use of swim goggles. The report did a corrected visual acuity of 20/60 OS 2. Machemer R, Steinhorst UH. Retinal separa- not include microscopic analysis of at 6 weeks. The visual acuity was ob- tion, retinotomy, and macular relocation, II: a the involved tissue, and the authors surgical approach for age-related macular de- tained despite vascularization of the generation? Graefes Arch Clin Exp Ophthalmol. believed that the swelling was due to corneal wound and corneal sutures 1993;231:635-641. microtrauma from the rims of the within the visual axis. He reported 3. Lindsey P, Finkelstein D, D’Anna S. Experimen- plastic goggles. tal retinal relocation [Association for Research excyclorotation of images in his left in Vision and Ophthalmology abstract]. Invest We report our experience with eye. Ophthalmol Vis Sci. 1983;24(suppl 3):242. the swimmer’s eyelid syndrome as 4. Ninomiya Y, Lewis JM, Hasegawa T, Tano Y. Reti- notomy and foveal translocation for surgical man- well as histopathologic analysis from Comment. Therapy for neovascu- agement of subfoveal choroidal neovascular mem- one patient. It appears that trau- lar age-related macular degenera- branes. Am J Ophthalmol 1996;122:613-621. matic neuroma is the cause of the 5. de Juan E, Loewenstein A, Bressler NM, Alex- tion is limited. Photocoagulation of ander J. Tranlocation of the retina for manage- mass effect in swimmer’s eyelid. choroidal neovascularization is use- ment of subfoveal choroidal neovasculariza- ful for a small percentage of pa- tion, II: a preliminary report in humans. Am J Report of a Case. A 22-year-old man Ophthalmol 1998;125:635-646. tients. Surgical removal of choroi- 6. Toth CA. Macular translocation: techniques and had a 5-year history of bilateral up- dal neovascularization has limited results. Paper presented at: Vitreoretinal Up- per eyelid masses, which was worse 1 date 1997; October 1997; San Francisco, Calif. success in improving vision. 7. Ts’o MOM, Friedman E. The retinal pigment epi- on the right side. The patient had been In age-related macular degen- thelium, I: comparative histology. Arch Ophthal- in competitive swimming for 9 years eration many components of the mol. 1967;78:641-649. and used hard plastic swim goggles. 8. Yoneya S, Ts’o MOM. Angioarchitecture of the hu- complex of macular RPE, Bruch’s manchoroid.ArchOphthalmol.1987;105:681-687. He denied any previous episodes of membrane, and choriocapillaris are facial or ocular trauma. An ophthal- dysfunctional. Surgically relocat- mic examination of visual acuity, pu- ing the fovea to an area of healthy pillary response, and extraocular RPE that may preserve foveal func- Eyelid Neuroma Associated movements, as well as slitlamp ex- tion has been proposed. Different With Swim Goggle Use amination showed no abnormalities. surgical methods have been de- An external examination revealed bi- scribed to accomplish foveal relo- The use of plastic swim goggles has lateral, sub-brow nodules, located in cation.2-6 been associated with several compli- the area of the supraorbital notch, The macular area is character- cations including supraorbital neu- with the right nodule being larger ized by the greatest density of RPE ralgia, periorbital leukoderma, con- than the left (Figure 1). No point melanin pigmentation7 and a lobu- tact dermatitis, and even traumatic tenderness was elicited. Excision of lar choroidal angioarchitecture that ruptured globe.1,2 Others have re- the right nodule was performed un- allows for extremely fast circula- ported on the “competition swim- der local anesthesia, and there was no tion.8 The ability of extramacular mer’s eyelid syndrome,” a pseudo- numbness or paresthesia in the dis- RPE and choriocapillaris to sup- baggy eyelid localized to the medial tribution of the fifth cranial nerve, first port good foveal function is rela- part of the superior eyelid.3 The au- division, either before or after surgi- tively unknown. thors described 2 young, competi- cal treatment. Histopathologic analy- Our patient demonstrates good tive swimmers with localized swell- sis revealed a haphazard prolifera- visual acuity following foveal relocation to an area of extramacular RPE. Assuming comparatively good extramacular RPE function in patients with age-related macular degeneration, foveal relocation may of- fer a surgical alternative to the limited treatment options available to those with subfoveal choroidal neovascularization.

Kevin K. Toller, MD Dean P. Hainsworth, MD Columbia, Mo

Supported in part by an unrestricted grant from Research to Prevent Blind- ness, Inc, New York, NY. Corresponding author: Dean P. Hainsworth, MD, Mason Eye Insti- tute, One Hospital Dr, Columbia, MO 65212 (e-mail: dean_hainsworth Figure 1. A firm mass, 7ϫ9 mm, in right upper eyelid of our patient. Skin change occurs (arrow) at site @muccmail.missouri.edu). where edge of goggle contacts skin.

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Figure 2. Left, View of representative nerve fascicles including axons with their investiture of myelin, Schwann cells, and fibroblasts, including perineurium, captured in section (hematoxylin-eosin, original magnification ϫ40). Right, High-power view of the same area (hematoxylin-eosin, original magnification ϫ200).

analysis of all surgical specimens ob- tained from patients with competitive swimmer’s eyelid syndrome. Treatment for this entity may con- sist of switching to a more padded style of goggle, discontinuation of goggle use, or surgical excision of the affected tissue.

David L. Wirta, MD Roger A. Dailey, MD John L. Wobig, MD, MBA Portland, Ore

Figure 3. The fit of the nonpadded, Swedish-style swim goggles used by our patient. This work was supported in part by an tion, including all elements of nerve romas involving the orbit are rare and unrestricted grant from Research to Pre- fascicles: axons, myelin, Schwann usually have been associated with or- vent Blindness Inc, New York, NY (Dr cells, and fibroblasts (Figure 2). Af- bital surgery or enucleation. Trau- Dailey), and by a grant from the Lester ter 12 months the eyelid is without matic neuromata from blunt trauma T. Jones endowed chair in Oculoplas- clinical recurrence. are far less common than from pen- tics, Portland, Ore (Dr Wobig). etrating injury or surgery. Corresponding author: Roger A. Comment. Amputation, or trau- In our practice we have seen at Dailey, MD, Casey Eye Institute, 3375 matic, neuroma of the eyelid has been least 3 cases of young competitive SWTerwilligerRd,Portland,OR97201. 4 described in one previous report. swimmers with upper eyelid swell- 1. Jonasson F. Swimming goggles causing severe Neuroma developed in the patient af- ing and a nodule localized to the me- eye injuries. BMJ. 1977;1:881. ter a blunt periorbital trauma with a dial sub-brow region. We believe this 2. Jacobson RI. More “goggle headache”: supraorbital neuralgia. N Engl J Med.1983;308:1363. rock, which resulted in swelling and syndrome is caused by the use of 3. Rubin JM, Mallem M. La paupie`re du nageur de ptosis of the affected eyelid. Trau- nonpadded, hard plastic swim compe´tition. J Fr Ophtalmol. 1995;18:426-434. Figure 3 4. Glasgow BJ, Vinters HV, Foos RY. Traumatic neu- matic neuroma is most often seen af- goggles ( ). Our case illus- roma of the eyelid associated with ptosis. Oph- ter surgical or traumatic transection trates at least one pathologic lesion thal Plast Reconstr Surg. 1990;6:269-272 of peripheral nerves, and has also been associated with this clinical entity. 5. Messmer EP, Camara J, Boniuk M, Font RL. Am- 5 putation neuroma of the orbit: report of 2 cases reported in the orbit, hand, foot, face, This interesting finding warrants fur- and review of the literature. Ophthalmology. 1984; vagina, pancreas, and bile duct. Neu- ther investigation via microscopic 91:1420-1423.

100 Years Ago in the ARCHIVES

A look at the past...

nellen prescribes a stenopaic glass for his keratoconus patients. Since vision is of wider range when the horizontal slit is broad, and of greater acuteness when the slit is narrow, he has constructed a wedge-shaped slit broad in the Speriphery and ending in a sharp point in the centre. Reference: Arch Ophthalmol. 1898;27:131.

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