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Bilateral Recurrent Erosion of Cornea
AMERICAN
964
JOURNAL
TABLE 2 INCIDENCE OF CONGENITAL CATARACT AND CONGENITAL GLAUCOMA
Rubellar cardiac disease Nonrubellar cardiac disease General population DISCUSSION
AND
Congenital Cataract (%)
Congenital Glaucoma (%)
50.00 0.50 0.24 2
18.5 0.40 0.01-0.04 3
CONCLUSIONS
Since the work of Gregg, who showed a definite association between viral infections and congenital cardiac and ocular malforma tions, there has been continued interest in the role played by these viruses in the for mation of congenital abnormalities. Recent studies tend to indicate that the Coxackie-B virus may be involved in the production of idiopathic cardiac defects. The difference in the incidence of the ocular malformations in nonrubellar cardiac malformations as com pared with those in rubellar cardiac dis ease would tend to implicate a different mechanism or a different virus. 303 East Chicago Avenue (60611) REFERENCES 1. Alfano, J . E . : The ocular aspects of the ma ternal rubella syndrome. Tr. Am. Acad. Ophth. Otolaryng., in press. 2. Svets, N. A., and Banulescu, M . : Congenital cataracts with familial characteristics. Oftalmologica, 4:337, 1959. 3. Duke-Elder, S.: System of Ophthalmology: Volume I I I . Normal and Abnormal Development. St. Louis, Mosby, 1963, p. 551.
BILATERAL RECURRENT EROSION O F CORNEA MARTIN A.
FLYNN,
M.D.
AND
D A N I E L B.
ESTERLY,
Pasadena,
M.D.
California
Recurrent corneal erosion usually follows trauma. In Thygeson's 1 series of 32 cases, 30 followed corneal injury in which there was extensive damage to the epithelium. A few cases appear to arise spontaneously. A
OF OPHTHALMOLOGY
NOVEMBER,
1966
diagnostic feature of the disease is its recur rence when the eye is first opened in the morning. The epithelium is torn loose from Bowman's membrane and hangs as an epi thelial filament. The eye becomes red and painful and tearing is profuse. After some time, varying from hours in the microform type to days in the macroform variety, the epithelium may reform and the eye becomes white and comfortable only to relapse at some later date. In the macroform type, the attacks usually occur at long intervals, while in the microform type, the attacks come at frequent intervals. Between attacks, the cor nea may show minute grayish-white spots in the epithelium in the area of previous ero sion. Duke-Elder,2 while conceding that some cases follow trauma, states that, in other cases, the condition may be dystrophic in nature, the injury acting merely as a trigger mechanism. He cites its occasional bilateral occurrence 36 without a history of trauma as suggestive of an underlying dystrophic na ture. Since a review of the literature demon strated the rarity of the condition as a bilat eral disease, it was felt that the following case of bilateral involvement should be re ported. CASE REPORT A 33-year-old white woman complained of ir ritation and foreign-body sensation in her left eye for one week prior to being examined on June 16, 1965. This commenced in the morning on awakening and improved in the afternoon. She gave a history of having been hit in the left eye with a piece of paper two months previously at which time she sustained a corneal abrasion which was treated elsewhere. On examination, her left eye was moderately injected and there was an area of denuded cornea about two mm in diameter just inferior to the pupillary area. There was some edema of the ad jacent stroma but no infiltration of the edge or base of the defect. The right eye was normal. With atropine, neosporin ointment and firm patching, the erosion was epithelized three days later. She was given boric-acid ointment to instill in the eye at bedtime. Five months later on November 8, 1965, the patient was again seen because of pain, foreignbody sensation and photophobia, this time in the
VOL. 62, NO. 5
NOTES, CASES, INSTRUMENTS
right eye. The right eye was moderately injected. The cornea was denuded of epithelium in an ir regular area, about one and one-half mm in di ameter, below the pupillary area. There was superficial stromal edema and a moderate aqueous flare and cells. The left cornea showed three or four white punctate spots in the epithelium below center, the tell-tale sign of the former erosion. The visual acuity was 20/20 in each eye. On treatment with atropine, neosporin ointment and patching, the defect epithelized in a few days, with subsidence of the secondary iritis. One month later, she was again seen com plaining of pain in her left eye. The vision in each eye was 20/15. The left eye was mildly in jected. The left cornea showed a small erosion in the same area as the previous erosion, below the pupillary area. There was stromal and endothelial edema. Although the right eye was symptom free and pale, there was a patch of epithelial edema below the pupillary area with questionable staining. There were also a few subepithelial grayish-white spots, indicative of the former ero sion. The eyes responded satisfactorily to neospo rin ointment, atropine and patching. On January 25, 1966, the patient was seen in the hospital, one week following surgery for a malignancy of the colon. She had severe pain and foreign-body sensation, this time in her right eye. An area of cornea one and one-half mm in diam eter below the pupil stained with fluorescein. Healing was complete in 24 hours on local anti biotics, a cycloplegic and patching. COMMENT 7
I n Chandler's bilateral case, the left cor nea developed recurrent erosion following a slight injury with a twig. T w o years later the other eye was struck by a corner of a piece of paper and the patient developed re current erosion in this eye also. I n the pres ent case, while there was a history of trau ma to the left eye, the patient cannot recall any such insult to the right eye. The rarity of bilateral involvement may be explained by infrequency of suitable bi lateral trauma in susceptible patients. I t is not unlikely that bilateral recurrent erosion may be seen more frequently in the future due to corneal insult from contact lenses. That recurrent erosion can follow a poorly tolerated contact lens is illustrated by the following case: A 28-year-old white woman was seen on Octo ber 22, 1964, because of pain in her right eye on awakening two days previously. She had obtained contact lenses from an optometrist 10 months pre
965
viously, which she had discontinued wearing after six months because of discomfort. During this attempt to wear the contact lenses, she experi enced severe pain in her right eye which came on following the removal of the lens one evening and lasted 24 hours. She was not seen at that time, so we do not know the extent of injury to the cornea. Her refractive error was: R.E., —10D sph C 0.75D cyl ax 180°, 20/20 + 2; L.E., -8.75D sph C —0.75D cyl ax 170°, 20/20. On slitlamp exami nation her cornea showed no evidence of recent or past abrasion. She was seen again on November 13, 1964, be cause of pain and tearing in the right eye which commenced on awakening and lasted for about 15 minutes. On slitlamp examination, the cornea showed no evidence of erosion. Over the ensuing few months she experienced similar episodes of pain and tearing in the right eye on awakening, every few weeks. On August 18, 1965, she was seen because of severe pain in the right eye which had started that morning and had not abated. She stated that, recently, she had been having morning eye pain much more often. The eye was moderately injected and tearing profusely. The cornea showed an erosion of the epithelium one cm in diameter in the midline below the pupillary area. There was no evidence of any infection in the denuded area. The defect epithelized satisfactorily with binocular patches, a cycloplegic and local antibiotic. Since then she has used boric-acid ointment in the eye each night with success, thus far, in preventing further attacks. SUMMARY
A case of bilateral recurrent erosion of the cornea is presented. T h e r e was a history of trauma in one eye but not in its fellow. A review of the literature demonstrated the rarity of bilateral involvement. Bilateral in volvement may become more prevalent due to trauma from contact lenses: A case of unilateral recurrent erosion following injury by a contact lens is presented. Recurrent erosion as a complication of contact-lens wearing has not been previously reported. 104 North Madison
(91101)
REFERENCES
1. Thygeson, P.: Observations on recurrent erosion of the cornea. Am. J. Ophth. 47:48 (May Pt. II) 1959. 2. Duke-Elder, S.: System of Ophthalmology: Volume VIII: Diseases of the Outer Eye: Part I I : Cornea and Sclera. St. Louis, Mosby, 1965. 3. Hirsch, C.: Ueber die sogen. recidivierende Erosion der Hornhaut (Arlt) und ihre Behan-
AMERICAN JOURNAL OF OPHTHALMOLOGY
966
dlung. Schr. Ther. Hyg. Auges, 1:161, 1898. 4. Salus, R.: Ueber traumatische und nichttraumatische recidivierende Epithelerkrankung der Hornhaut. Klin. Mbl. Augenh. 68:673, 1922. 5. Procksch, M.: Beitrag zur Klinik und Therapie der rezidivierenden Hornhauterosion. Klin. Mbl. Augenh. 77:383, 1926. 6. Spektor, S.: Klinisches zur Frage der Aetiologie von doppelseitigen rezidivierenden Erosionen der Hornhaut. Klin. Mbl. Augenh. 87:661, 1931. 7. Chandler, P . : Recurrent erosion of cornea. Am. J. Ophth. 28:33S, 1945.
IRIDOSCHISIS A
CASE REPORT
T I T U S D.
PAYNE,
M.D.
NOVEMBER, 1966
oschisis of both eyes. The pupils were very small, resembling those seen with stronger miotics. The stroma of the iris below the pupils were split away from the black pigment epithelium and dila tor fibers. Most of the stromal fibers appeared to be ruptured near the sphincter of the iris, with the loose ends floating freely in the aqueous. There were no cells or pigment granules in the anterior chamber. No flare was noted. The iris appeared normal except in the area of iridoschisis (fig. 1). Bilateral posterior subcapsular cataracts were present. A refractive error of —2.0D sph was found in both eyes but no significant visual improvement could be obtained. Tonography re vealed C values of 0.18, R.E., and 0.17, L.E. Visual fields were five to 10 degrees in each eye. The chamber angles were open but narrow. Se vere cupping and atrophy were present bilaterally. The patient was put on 2% epinephrine bitartrate drops and the glaucoma was readily controlled. The pupils would readily constrict and dilate while on epinephrine.
AND ROBERT P. T H O M A S ,
M.D.
Augusta, Georgia T h e term iridoschisis was introduced in 1945 by Loewenstein and Foster 1 to describe splitting of the iris, which was first reported in 1922 by Schmitt. 2 Since then about 40 articles have appeared in the literature. T h e present case is of interest in that the irido schisis followed the use of a miotic. C A S E REPORT
A 79-year-old white man had noted failing vi sion in both eyes over the previous year. Five months prior to our examination, he consulted an ophthalmologist who found vision to be: R.E., 20/100; L.E., hand movements at six inches. In traocular pressure (Schio'tz) was: R.E., 20 mm Hg., L.E., 35 mm Hg. Aside from early posterior subcapsular lens opacities there were no abnor malities in either eye on slitlamp examination. The patient was started on 2% pilocarpine every six hours in each eye. One month later, the pa tient returned and ocular tensions of 20 mm Hg bilaterally were found. Vision and slitlamp exam inations were unchanged. Three months prior to our seeing this patient he was hospitalized for back pain, heart failure and chronic lung disease. He was found to have multiple spontaneous compression fractures of his thoracic and lumbar vertebra with no nerve in volvement. He was transferred to a local hos pital for management. He continued his 2% pilo carpine throughout these two hospitalizations. We first saw this patient during the second hospitalization for his glaucoma and found iridFrom the Department of Surgery (Ophthalmol ogy), Medical College of Georgia.
DISCUSSION
Bo'jer 4 and Tornquist and Swegmark 5 have written excellent reviews of the litera ture concerning iridoschisis. Loewenstein and Foster 1 and Albers and Klien 6 have re ported the pathologic findings in this condi tion. In the former report a cleft was found between the anterior and posterior iris stro ma. T h e posterior stromal tissue remains attached to the pigment epithelium and dila tor fibers while the very atrophic anterior stroma splits into fibers containing blood vessels. These stromal fibers and blood ves sels are attached to the peripheral portion of the iris with the loose end floating freely in the aqueous. Theories as to the etiology of iridoschisis are: 1. Loewenstein and Foster 1 thought the condition results from primary senile atro phy which may be aggravated by proteolytic enzymes in the aqueous resulting from the metabolism of these glaucomatous eyes. 2. Loewenstein, Foster and Sledge 3 re ported a case of iridoschisis resulting from sudden trauma fracturing the nasal bone. T h e y supposed that the contusion had forced aqueous humor to be pressed into the iris stroma with great force. T h e aqueous thus dissected along the dilatator fibers splitting the iris into an anterior and poste rior part.
964
JOURNAL
TABLE 2 INCIDENCE OF CONGENITAL CATARACT AND CONGENITAL GLAUCOMA
Rubellar cardiac disease Nonrubellar cardiac disease General population DISCUSSION
AND
Congenital Cataract (%)
Congenital Glaucoma (%)
50.00 0.50 0.24 2
18.5 0.40 0.01-0.04 3
CONCLUSIONS
Since the work of Gregg, who showed a definite association between viral infections and congenital cardiac and ocular malforma tions, there has been continued interest in the role played by these viruses in the for mation of congenital abnormalities. Recent studies tend to indicate that the Coxackie-B virus may be involved in the production of idiopathic cardiac defects. The difference in the incidence of the ocular malformations in nonrubellar cardiac malformations as com pared with those in rubellar cardiac dis ease would tend to implicate a different mechanism or a different virus. 303 East Chicago Avenue (60611) REFERENCES 1. Alfano, J . E . : The ocular aspects of the ma ternal rubella syndrome. Tr. Am. Acad. Ophth. Otolaryng., in press. 2. Svets, N. A., and Banulescu, M . : Congenital cataracts with familial characteristics. Oftalmologica, 4:337, 1959. 3. Duke-Elder, S.: System of Ophthalmology: Volume I I I . Normal and Abnormal Development. St. Louis, Mosby, 1963, p. 551.
BILATERAL RECURRENT EROSION O F CORNEA MARTIN A.
FLYNN,
M.D.
AND
D A N I E L B.
ESTERLY,
Pasadena,
M.D.
California
Recurrent corneal erosion usually follows trauma. In Thygeson's 1 series of 32 cases, 30 followed corneal injury in which there was extensive damage to the epithelium. A few cases appear to arise spontaneously. A
OF OPHTHALMOLOGY
NOVEMBER,
1966
diagnostic feature of the disease is its recur rence when the eye is first opened in the morning. The epithelium is torn loose from Bowman's membrane and hangs as an epi thelial filament. The eye becomes red and painful and tearing is profuse. After some time, varying from hours in the microform type to days in the macroform variety, the epithelium may reform and the eye becomes white and comfortable only to relapse at some later date. In the macroform type, the attacks usually occur at long intervals, while in the microform type, the attacks come at frequent intervals. Between attacks, the cor nea may show minute grayish-white spots in the epithelium in the area of previous ero sion. Duke-Elder,2 while conceding that some cases follow trauma, states that, in other cases, the condition may be dystrophic in nature, the injury acting merely as a trigger mechanism. He cites its occasional bilateral occurrence 36 without a history of trauma as suggestive of an underlying dystrophic na ture. Since a review of the literature demon strated the rarity of the condition as a bilat eral disease, it was felt that the following case of bilateral involvement should be re ported. CASE REPORT A 33-year-old white woman complained of ir ritation and foreign-body sensation in her left eye for one week prior to being examined on June 16, 1965. This commenced in the morning on awakening and improved in the afternoon. She gave a history of having been hit in the left eye with a piece of paper two months previously at which time she sustained a corneal abrasion which was treated elsewhere. On examination, her left eye was moderately injected and there was an area of denuded cornea about two mm in diameter just inferior to the pupillary area. There was some edema of the ad jacent stroma but no infiltration of the edge or base of the defect. The right eye was normal. With atropine, neosporin ointment and firm patching, the erosion was epithelized three days later. She was given boric-acid ointment to instill in the eye at bedtime. Five months later on November 8, 1965, the patient was again seen because of pain, foreignbody sensation and photophobia, this time in the
VOL. 62, NO. 5
NOTES, CASES, INSTRUMENTS
right eye. The right eye was moderately injected. The cornea was denuded of epithelium in an ir regular area, about one and one-half mm in di ameter, below the pupillary area. There was superficial stromal edema and a moderate aqueous flare and cells. The left cornea showed three or four white punctate spots in the epithelium below center, the tell-tale sign of the former erosion. The visual acuity was 20/20 in each eye. On treatment with atropine, neosporin ointment and patching, the defect epithelized in a few days, with subsidence of the secondary iritis. One month later, she was again seen com plaining of pain in her left eye. The vision in each eye was 20/15. The left eye was mildly in jected. The left cornea showed a small erosion in the same area as the previous erosion, below the pupillary area. There was stromal and endothelial edema. Although the right eye was symptom free and pale, there was a patch of epithelial edema below the pupillary area with questionable staining. There were also a few subepithelial grayish-white spots, indicative of the former ero sion. The eyes responded satisfactorily to neospo rin ointment, atropine and patching. On January 25, 1966, the patient was seen in the hospital, one week following surgery for a malignancy of the colon. She had severe pain and foreign-body sensation, this time in her right eye. An area of cornea one and one-half mm in diam eter below the pupil stained with fluorescein. Healing was complete in 24 hours on local anti biotics, a cycloplegic and patching. COMMENT 7
I n Chandler's bilateral case, the left cor nea developed recurrent erosion following a slight injury with a twig. T w o years later the other eye was struck by a corner of a piece of paper and the patient developed re current erosion in this eye also. I n the pres ent case, while there was a history of trau ma to the left eye, the patient cannot recall any such insult to the right eye. The rarity of bilateral involvement may be explained by infrequency of suitable bi lateral trauma in susceptible patients. I t is not unlikely that bilateral recurrent erosion may be seen more frequently in the future due to corneal insult from contact lenses. That recurrent erosion can follow a poorly tolerated contact lens is illustrated by the following case: A 28-year-old white woman was seen on Octo ber 22, 1964, because of pain in her right eye on awakening two days previously. She had obtained contact lenses from an optometrist 10 months pre
965
viously, which she had discontinued wearing after six months because of discomfort. During this attempt to wear the contact lenses, she experi enced severe pain in her right eye which came on following the removal of the lens one evening and lasted 24 hours. She was not seen at that time, so we do not know the extent of injury to the cornea. Her refractive error was: R.E., —10D sph C 0.75D cyl ax 180°, 20/20 + 2; L.E., -8.75D sph C —0.75D cyl ax 170°, 20/20. On slitlamp exami nation her cornea showed no evidence of recent or past abrasion. She was seen again on November 13, 1964, be cause of pain and tearing in the right eye which commenced on awakening and lasted for about 15 minutes. On slitlamp examination, the cornea showed no evidence of erosion. Over the ensuing few months she experienced similar episodes of pain and tearing in the right eye on awakening, every few weeks. On August 18, 1965, she was seen because of severe pain in the right eye which had started that morning and had not abated. She stated that, recently, she had been having morning eye pain much more often. The eye was moderately injected and tearing profusely. The cornea showed an erosion of the epithelium one cm in diameter in the midline below the pupillary area. There was no evidence of any infection in the denuded area. The defect epithelized satisfactorily with binocular patches, a cycloplegic and local antibiotic. Since then she has used boric-acid ointment in the eye each night with success, thus far, in preventing further attacks. SUMMARY
A case of bilateral recurrent erosion of the cornea is presented. T h e r e was a history of trauma in one eye but not in its fellow. A review of the literature demonstrated the rarity of bilateral involvement. Bilateral in volvement may become more prevalent due to trauma from contact lenses: A case of unilateral recurrent erosion following injury by a contact lens is presented. Recurrent erosion as a complication of contact-lens wearing has not been previously reported. 104 North Madison
(91101)
REFERENCES
1. Thygeson, P.: Observations on recurrent erosion of the cornea. Am. J. Ophth. 47:48 (May Pt. II) 1959. 2. Duke-Elder, S.: System of Ophthalmology: Volume VIII: Diseases of the Outer Eye: Part I I : Cornea and Sclera. St. Louis, Mosby, 1965. 3. Hirsch, C.: Ueber die sogen. recidivierende Erosion der Hornhaut (Arlt) und ihre Behan-
AMERICAN JOURNAL OF OPHTHALMOLOGY
966
dlung. Schr. Ther. Hyg. Auges, 1:161, 1898. 4. Salus, R.: Ueber traumatische und nichttraumatische recidivierende Epithelerkrankung der Hornhaut. Klin. Mbl. Augenh. 68:673, 1922. 5. Procksch, M.: Beitrag zur Klinik und Therapie der rezidivierenden Hornhauterosion. Klin. Mbl. Augenh. 77:383, 1926. 6. Spektor, S.: Klinisches zur Frage der Aetiologie von doppelseitigen rezidivierenden Erosionen der Hornhaut. Klin. Mbl. Augenh. 87:661, 1931. 7. Chandler, P . : Recurrent erosion of cornea. Am. J. Ophth. 28:33S, 1945.
IRIDOSCHISIS A
CASE REPORT
T I T U S D.
PAYNE,
M.D.
NOVEMBER, 1966
oschisis of both eyes. The pupils were very small, resembling those seen with stronger miotics. The stroma of the iris below the pupils were split away from the black pigment epithelium and dila tor fibers. Most of the stromal fibers appeared to be ruptured near the sphincter of the iris, with the loose ends floating freely in the aqueous. There were no cells or pigment granules in the anterior chamber. No flare was noted. The iris appeared normal except in the area of iridoschisis (fig. 1). Bilateral posterior subcapsular cataracts were present. A refractive error of —2.0D sph was found in both eyes but no significant visual improvement could be obtained. Tonography re vealed C values of 0.18, R.E., and 0.17, L.E. Visual fields were five to 10 degrees in each eye. The chamber angles were open but narrow. Se vere cupping and atrophy were present bilaterally. The patient was put on 2% epinephrine bitartrate drops and the glaucoma was readily controlled. The pupils would readily constrict and dilate while on epinephrine.
AND ROBERT P. T H O M A S ,
M.D.
Augusta, Georgia T h e term iridoschisis was introduced in 1945 by Loewenstein and Foster 1 to describe splitting of the iris, which was first reported in 1922 by Schmitt. 2 Since then about 40 articles have appeared in the literature. T h e present case is of interest in that the irido schisis followed the use of a miotic. C A S E REPORT
A 79-year-old white man had noted failing vi sion in both eyes over the previous year. Five months prior to our examination, he consulted an ophthalmologist who found vision to be: R.E., 20/100; L.E., hand movements at six inches. In traocular pressure (Schio'tz) was: R.E., 20 mm Hg., L.E., 35 mm Hg. Aside from early posterior subcapsular lens opacities there were no abnor malities in either eye on slitlamp examination. The patient was started on 2% pilocarpine every six hours in each eye. One month later, the pa tient returned and ocular tensions of 20 mm Hg bilaterally were found. Vision and slitlamp exam inations were unchanged. Three months prior to our seeing this patient he was hospitalized for back pain, heart failure and chronic lung disease. He was found to have multiple spontaneous compression fractures of his thoracic and lumbar vertebra with no nerve in volvement. He was transferred to a local hos pital for management. He continued his 2% pilo carpine throughout these two hospitalizations. We first saw this patient during the second hospitalization for his glaucoma and found iridFrom the Department of Surgery (Ophthalmol ogy), Medical College of Georgia.
DISCUSSION
Bo'jer 4 and Tornquist and Swegmark 5 have written excellent reviews of the litera ture concerning iridoschisis. Loewenstein and Foster 1 and Albers and Klien 6 have re ported the pathologic findings in this condi tion. In the former report a cleft was found between the anterior and posterior iris stro ma. T h e posterior stromal tissue remains attached to the pigment epithelium and dila tor fibers while the very atrophic anterior stroma splits into fibers containing blood vessels. These stromal fibers and blood ves sels are attached to the peripheral portion of the iris with the loose end floating freely in the aqueous. Theories as to the etiology of iridoschisis are: 1. Loewenstein and Foster 1 thought the condition results from primary senile atro phy which may be aggravated by proteolytic enzymes in the aqueous resulting from the metabolism of these glaucomatous eyes. 2. Loewenstein, Foster and Sledge 3 re ported a case of iridoschisis resulting from sudden trauma fracturing the nasal bone. T h e y supposed that the contusion had forced aqueous humor to be pressed into the iris stroma with great force. T h e aqueous thus dissected along the dilatator fibers splitting the iris into an anterior and poste rior part.