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Airbag-associated Bilateral Hyphemas and Angle Recession
250
AMERICAN JOURNAL OF OPHTHALMOLOGY
vial, which contained sterile saline, and was sent to the Centers for Disease Control and Prevention in Atlanta, Georgia. The patient initially received 750 mg of oral ciprofloxacin twice per day for two weeks and topical cipro floxacin four times per day. Eye redness and irritation initially improved but worsened about two months later. On reexamination, the conjunctival nodule was again noted and an incisional biopsy was performed. He was treat ed with topical combined tobramycin and dexamethasone four times per day and 2 g per day of oral erythromycin. The result was an incom plete response. He subsequently received a one-month course of oral ciprofloxacin, 750 mg twice per day, and 600 mg of rifampin once per day, with a marked clinical improvement. Histologie examination of the conjunctival biopsy specimen disclosed granulomas, which contained multinucleated giant cells and a chronic inflammatory infiltrate, consisting of lymphocytes, plasma cells, and histiocytes. Special stains for fungi and acid-fast bacilli were negative. A Steiner stain showed organ isms suggestive of cat scratch bacilli in giant cells. The Rochalimaea culture from the con junctival swabbing was overgrown by bacteria. The DNA from the initial conjunctival swab bing was extracted and amplified to yield the 389-base pair polymerase chain reaction prod uct that is characteristic of both R. henselae and R. quintana.3 This polymerase chain reaction product hybridized to the R. henselae-speci&c oligonucleotide probe RH1. 3 Rochalimaea has been isolated from a variety of sources, including blood and tissue. By swabbing the conjunctival nodule, we used a convenient and noninvasive method of obtain ing a specimen for polymerase chain reaction analysis. Routine culture for R. henselae is rare ly positive because of its fastidious and slowgrowing nature. The polymerase chain reaction assay applied here has been shown to be a highly sensitive technique for detecting R. hen selae in lymph node tissue from patients with cat scratch disease. This report extends the application of that assay to a conjunctival swab and demonstrates the utility of the polymerase chain reaction to detect R. henselae.
References 1. Jawad, A. S., and Amen, A. A.: Cat scratch dis ease presenting as the oculoglandular syndrome of Parinaud. A report of two cases. Postgrad. Med. J. 66:467, 1990.
August, 1994
2. Chrousos, G. A., Drack, A. V., Young, M., Kattah, J., and Sirdofsky, M.: Neuroretinitis in cat scratch disease. J. Clin. Neuro. Ophthalmol. 10:92, 1990. 3. Anderson, B., Sims, K., Regnery, R., Robinson, L., Schmidt, M. ]., Gorel, S., Hagar, C , and Edwards, K.: Detection of Rochalimaea henselae DNA in speci mens from a cat-scratch disease patient by PCR. J. Clin. Microbiol. 32:942, 1994.
Airbag-associated Bilateral Hyphemas and Angle Recession Paul J. Driver, M.D., L. Frank C a s h w e l l , M.D., and R. Patrick Yeatts, M.D. Department of Ophthalmology, Bowman Gray School of Medicine, Wake Forest University Eye Cen ter. Inquiries to Paul J. Driver, M.D., Medical Center Boule vard, Winston-Salem, NC 27157-1033. There have been several recently published reports of ocular trauma secondary to a driver's-side airbag deployment. These injuries in clude periorbital fractures, alkaline keratitis, cornea! abrasions, hyphema, angle recession, lens subluxation, posttraumatic cataract, reti nal detachment, and vitreous and retinal hem orrhages. 1 5 We observed a case of bilateral hyphemas and bilateral angle recessions as the result of an airbag injury. A 38-year-old man wearing a three-point, lap-shoulder belt was driving an automobile at 35 to 45 miles per hour when it hit a stationary vehicle and overturned, with shattering of the windshield and inflation of the airbag. He was wearing daily-wear soft contact lenses, which were lost at the time of the accident. A re strained, front-seat passenger, who did not have an airbag, was uninjured. External injuries were limited to superficial nasal abrasions, bilateral periorbital abrasions, and bilateral eyelid ecchymoses. Pinhole Snellen visual acuity was R.E.: 20/30 and L.E.: 20/80. Hertel exophthalmometry was 21 mm in each eye with a baseline of 96 mm. Ocular movements were unrestricted. Slit- lamp exam ination showed bilateral, subconjunctival hem orrhages; no particles of glass were identified. There were small corneal abrasions and Descemet's membrane folds bilaterally. There was a 5% hyphema and a superotemporal tear of the iris sphincter in the right eye and a 25% hy phema in the left eye. The crystalline lenses were in position and clear. Ophthalmoscopic examination showed extensive commotio reti-
Vol. 118, No. 2
Letters to The Journal
nae and small preretinal hemorrhages in the right eye; fundus details could not be seen in the left eye. Intraocular pressures were 10 mm Hg and 15 mm Hg in the right eye and left eye, respectively. Cranial computed tomographic results were normal. The patient was hospitalized and recovered uneventfully. His intraocular pressures re mained less than 20 mm Hg without antiglaucoma medications. Subsequent ophthalmoscopic examination of the left eye yielded normal findings. Ocular examination one month after the accident demonstrated a bestcorrected Snellen visual acuity of 20/15 in both eyes. Gonioscopy showed angle recession from the 7:30 meridian to the 12:30 meridian in the right eye and 360 degrees of angle recession in the left eye (Figs. 1 and 2). No retinal tears or dialysis were seen on ophthalmoscopic exami nation with scierai depression. In 1991, Rimmer and Shuler 1 reported a case of unilateral microscopic hyphema thought to be secondary to airbag inflation, and Mishler 2 described a case of unilateral layered hyphema as well as angle recession caused by deploy ment of an airbag. Another case of airbagrelated unilateral hyphema and angle recession was reported by Lesher, Durrie, and Stiles 3 in 1993. We observed a case in which the hyphema and angle recession associated with airbag inju ry were bilateral. The symmetric nature of the ocular injuries and facial abrasions implicate the airbag as being the cause of the injuries. The patient's ocular prominence, as measured by Hertel exophthalmometry, may have been a contributing factor. Airbags are now available on most new cars, and it is likely that an increase in ocular injuries attributable to them will be observed. Further
251
Fig. 2 (Driver, Cashwell, and Yeatts). Gonioscopic view of inferonasal left anterior chamber angle. A broad area of widened ciliary body band is seen. improvement in the design of airbags may re duce their potential for causing ocular injury.
References 1. Rimmer, S., and Shuler, J. D.: Severe ocular trauma from a driver's-side air bag. Arch. Ophthalmol. 109:774, 1991. 2. Mishler, K. E.: Hyphema caused by air bag. Arch. Ophthalmol. 109:1635, 1991. 3. Lesher, M. P., Durrie, D. S., and Stiles, M. C: Corneal edema, hyphema, and angle recession after air bag inflation. Arch. Ophthalmol. 111:1320, 1993. 4. Scott, I. U., John, G. R., and Stark, W. J.: Airbag-associated ocular injury and periorbital frac tures. Arch. Ophthalmol. 111:25, 1993. 5. Smally, A. J., Binzer, A., Dolin, S., and Viano, D.: Alkaline chemical keratitis. Eye injury from airbags. Ann. Emerg. Med. 21:1400, 1992.
A Serious Complication of Intrableb Injection of Autologous Blood for the Treatment of Postfiltration Hypotony Mandi M. Zaltas, M.D., and Joel S. S c h u m a n , M.D. New England Eye Center, Tufts University School of Medicine.
Fig. 1 (Driver, Cashwell, and Yeatts). Gonioscopic view of temporal portion of the right anterior cham ber angle. Note incomplete tearing of the iris inser tion from the angle wall (arrow).
Inquiries to Joel S. Schuman, M.D., New England Eye Center, 750 Washington St., Box 450, Boston, MA 02111. We observed a complication after an injection of autologous blood into the bleb of a patient with chronic hypotony. We used the technique described by Wise.1 The patient was a 63-year-
AMERICAN JOURNAL OF OPHTHALMOLOGY
vial, which contained sterile saline, and was sent to the Centers for Disease Control and Prevention in Atlanta, Georgia. The patient initially received 750 mg of oral ciprofloxacin twice per day for two weeks and topical cipro floxacin four times per day. Eye redness and irritation initially improved but worsened about two months later. On reexamination, the conjunctival nodule was again noted and an incisional biopsy was performed. He was treat ed with topical combined tobramycin and dexamethasone four times per day and 2 g per day of oral erythromycin. The result was an incom plete response. He subsequently received a one-month course of oral ciprofloxacin, 750 mg twice per day, and 600 mg of rifampin once per day, with a marked clinical improvement. Histologie examination of the conjunctival biopsy specimen disclosed granulomas, which contained multinucleated giant cells and a chronic inflammatory infiltrate, consisting of lymphocytes, plasma cells, and histiocytes. Special stains for fungi and acid-fast bacilli were negative. A Steiner stain showed organ isms suggestive of cat scratch bacilli in giant cells. The Rochalimaea culture from the con junctival swabbing was overgrown by bacteria. The DNA from the initial conjunctival swab bing was extracted and amplified to yield the 389-base pair polymerase chain reaction prod uct that is characteristic of both R. henselae and R. quintana.3 This polymerase chain reaction product hybridized to the R. henselae-speci&c oligonucleotide probe RH1. 3 Rochalimaea has been isolated from a variety of sources, including blood and tissue. By swabbing the conjunctival nodule, we used a convenient and noninvasive method of obtain ing a specimen for polymerase chain reaction analysis. Routine culture for R. henselae is rare ly positive because of its fastidious and slowgrowing nature. The polymerase chain reaction assay applied here has been shown to be a highly sensitive technique for detecting R. hen selae in lymph node tissue from patients with cat scratch disease. This report extends the application of that assay to a conjunctival swab and demonstrates the utility of the polymerase chain reaction to detect R. henselae.
References 1. Jawad, A. S., and Amen, A. A.: Cat scratch dis ease presenting as the oculoglandular syndrome of Parinaud. A report of two cases. Postgrad. Med. J. 66:467, 1990.
August, 1994
2. Chrousos, G. A., Drack, A. V., Young, M., Kattah, J., and Sirdofsky, M.: Neuroretinitis in cat scratch disease. J. Clin. Neuro. Ophthalmol. 10:92, 1990. 3. Anderson, B., Sims, K., Regnery, R., Robinson, L., Schmidt, M. ]., Gorel, S., Hagar, C , and Edwards, K.: Detection of Rochalimaea henselae DNA in speci mens from a cat-scratch disease patient by PCR. J. Clin. Microbiol. 32:942, 1994.
Airbag-associated Bilateral Hyphemas and Angle Recession Paul J. Driver, M.D., L. Frank C a s h w e l l , M.D., and R. Patrick Yeatts, M.D. Department of Ophthalmology, Bowman Gray School of Medicine, Wake Forest University Eye Cen ter. Inquiries to Paul J. Driver, M.D., Medical Center Boule vard, Winston-Salem, NC 27157-1033. There have been several recently published reports of ocular trauma secondary to a driver's-side airbag deployment. These injuries in clude periorbital fractures, alkaline keratitis, cornea! abrasions, hyphema, angle recession, lens subluxation, posttraumatic cataract, reti nal detachment, and vitreous and retinal hem orrhages. 1 5 We observed a case of bilateral hyphemas and bilateral angle recessions as the result of an airbag injury. A 38-year-old man wearing a three-point, lap-shoulder belt was driving an automobile at 35 to 45 miles per hour when it hit a stationary vehicle and overturned, with shattering of the windshield and inflation of the airbag. He was wearing daily-wear soft contact lenses, which were lost at the time of the accident. A re strained, front-seat passenger, who did not have an airbag, was uninjured. External injuries were limited to superficial nasal abrasions, bilateral periorbital abrasions, and bilateral eyelid ecchymoses. Pinhole Snellen visual acuity was R.E.: 20/30 and L.E.: 20/80. Hertel exophthalmometry was 21 mm in each eye with a baseline of 96 mm. Ocular movements were unrestricted. Slit- lamp exam ination showed bilateral, subconjunctival hem orrhages; no particles of glass were identified. There were small corneal abrasions and Descemet's membrane folds bilaterally. There was a 5% hyphema and a superotemporal tear of the iris sphincter in the right eye and a 25% hy phema in the left eye. The crystalline lenses were in position and clear. Ophthalmoscopic examination showed extensive commotio reti-
Vol. 118, No. 2
Letters to The Journal
nae and small preretinal hemorrhages in the right eye; fundus details could not be seen in the left eye. Intraocular pressures were 10 mm Hg and 15 mm Hg in the right eye and left eye, respectively. Cranial computed tomographic results were normal. The patient was hospitalized and recovered uneventfully. His intraocular pressures re mained less than 20 mm Hg without antiglaucoma medications. Subsequent ophthalmoscopic examination of the left eye yielded normal findings. Ocular examination one month after the accident demonstrated a bestcorrected Snellen visual acuity of 20/15 in both eyes. Gonioscopy showed angle recession from the 7:30 meridian to the 12:30 meridian in the right eye and 360 degrees of angle recession in the left eye (Figs. 1 and 2). No retinal tears or dialysis were seen on ophthalmoscopic exami nation with scierai depression. In 1991, Rimmer and Shuler 1 reported a case of unilateral microscopic hyphema thought to be secondary to airbag inflation, and Mishler 2 described a case of unilateral layered hyphema as well as angle recession caused by deploy ment of an airbag. Another case of airbagrelated unilateral hyphema and angle recession was reported by Lesher, Durrie, and Stiles 3 in 1993. We observed a case in which the hyphema and angle recession associated with airbag inju ry were bilateral. The symmetric nature of the ocular injuries and facial abrasions implicate the airbag as being the cause of the injuries. The patient's ocular prominence, as measured by Hertel exophthalmometry, may have been a contributing factor. Airbags are now available on most new cars, and it is likely that an increase in ocular injuries attributable to them will be observed. Further
251
Fig. 2 (Driver, Cashwell, and Yeatts). Gonioscopic view of inferonasal left anterior chamber angle. A broad area of widened ciliary body band is seen. improvement in the design of airbags may re duce their potential for causing ocular injury.
References 1. Rimmer, S., and Shuler, J. D.: Severe ocular trauma from a driver's-side air bag. Arch. Ophthalmol. 109:774, 1991. 2. Mishler, K. E.: Hyphema caused by air bag. Arch. Ophthalmol. 109:1635, 1991. 3. Lesher, M. P., Durrie, D. S., and Stiles, M. C: Corneal edema, hyphema, and angle recession after air bag inflation. Arch. Ophthalmol. 111:1320, 1993. 4. Scott, I. U., John, G. R., and Stark, W. J.: Airbag-associated ocular injury and periorbital frac tures. Arch. Ophthalmol. 111:25, 1993. 5. Smally, A. J., Binzer, A., Dolin, S., and Viano, D.: Alkaline chemical keratitis. Eye injury from airbags. Ann. Emerg. Med. 21:1400, 1992.
A Serious Complication of Intrableb Injection of Autologous Blood for the Treatment of Postfiltration Hypotony Mandi M. Zaltas, M.D., and Joel S. S c h u m a n , M.D. New England Eye Center, Tufts University School of Medicine.
Fig. 1 (Driver, Cashwell, and Yeatts). Gonioscopic view of temporal portion of the right anterior cham ber angle. Note incomplete tearing of the iris inser tion from the angle wall (arrow).
Inquiries to Joel S. Schuman, M.D., New England Eye Center, 750 Washington St., Box 450, Boston, MA 02111. We observed a complication after an injection of autologous blood into the bleb of a patient with chronic hypotony. We used the technique described by Wise.1 The patient was a 63-year-