- Email: [email protected]
Lymphoma
REFERENCES
1. Van Groeningen CJ, Godefridus JP, Schornagel JH, et al. Phase I clinical and pharmacokinetic study of oral S-1 in patients with advanced solid tumors. J Clin Oncol 2000;18:2772–2779. 2. Hoff PM, Saad ED, Ajani JA, et al. Phase I study with pharmacokinetics of S-1 on an oral daily schedule for 28 days in patients with solid tumors. Clin Cancer Res 2003;9:134 – 142. 3. Fukushima M, Shimamoto Y, Kato T, et al. Anticancer activity and toxicity of S-1, an oral combination of tegafur and two biochemical modulators, compared with continuous i.v. infusion of 5-FU. Anticancer Drugs 1998;9:817– 823. 4. Agarwal MR, Esmaeli B, Burnstine MA. Squamous metaplasia of the canaliculi associated with 5-fluorouracil: a clinicopathologic case report. Ophthalmology 2002;109:2359 –2361. 5. Fezza JP, Wesley RE, Klippenstein KA. The treatment of punctual and canalicular stenosis in patients on systemic 5-FU. Ophthalmic Surg Lasers 1999;30:105–108. 6. Esmaeli B, Ahmadi MA, Rivera E, et al. Docetaxel secretion in tears: Association with lacrimal drainage obstruction. Arch Ophthalmol 2002;120:1180 –1182. 7. Esmaeli B, Hidaji L, Adnin RB, et al. Blockage of the lacrimal drainage apparatus as a side effect of Docetaxel. Cancer 2003;98:504 –507.
Bilateral Orbital Tumor as Initial Presenting Sign in Human T-cell Leukemia Virus-1 Associated Adult T-cell Leukemia/Lymphoma Tadanobu Yoshikawa, MD, Nahoko Ogata, MD, PhD, Kanji Takahashi, MD, PhD, Shinichiro Mori, MD, PhD, Yoshiko Uemura, MD, PhD, and Miyo Matsumura, MD, PhD PURPOSE: To report a case of human T-cell leukemia virus type1 (HTLV-1)–associated adult T-cell leukemia/ lymphoma (ATLL) whose initial sign was exophthalmos. DESIGN: Case report. METHODS: A 64-year-old Japanese man presented with exophthalmos and choroidal folds of the right eye without general symptoms and received ophthalmologic and laboratory examination, magnetic resonance imaging (MRI), and orbital biopsy. RESULTS: Antibodies against HTLV-1 were extremely high but atypical lymphocytes were not present in the peripheral blood. MRI showed multiple tumorous lesions
in both orbits. Orbital biopsy revealed an orbital mass that consisted of atypical lymphocytes originally from T cells and established the diagnosis of lymphoadenopathy type of ATLL. CONCLUSION: Although ocular involvement by ATLL is extremely rare, ATLL can first present in the orbit, and only the results of a biopsy can provide definitive information for its diagnosis. (Am J Ophthalmol 2005;140: 327–329. © 2005 by Elsevier Inc. All rights reserved.)
A
DULT T-CELL LEUKEMIA/LYMPHOMA (ATLL) IS A PE-
BRIEF REPORTS
327
Accepted for publication Jan 31, 2005. From the Department of Ophthalmology (T.Y., N.O., K.T., M.M.), First Department of Internal Medicine (S.M.), and Second Department of Pathology (Y.U.), Kansai Medical University, Osaka, Japan. Inquiries to Nahoko Ogata, MD, PhD, Department of Ophthalmology, Kansai Medical University, Fumizono-cho 10-15, Moriguchi, Osaka 570-8507, Japan; fax: 81-6-6993-2222; e-mail: [email protected]
VOL. 140, NO. 2
FIGURE 1. (Top left) Photograph of patient with T cell lymphoma/leukemia at initial examination in our hospital. (Middle left) Fundus photograph of the right eye. The optic disk is normal but choroidal folds (arrows) are present. (Top right) T1-weighted MRI sequences acquired in the horizontal plane showing multiple low intensity lesions (arrows) in the orbit bilaterally. (Middle right) T2-weighted MRI sequences. Orbital lesions show low intensity (arrows) in the orbit bilaterally. (Bottom left) Photograph of patient 3 months after chemotherapy showing that exophthalmos had regressed. (Bottom right) T1-weighted MRI sequences 3 months after chemotherapy. Multiple low intensity lesions in both orbits are not present.
ripheral T-cell malignancy caused by human T-cell leukemia virus type 1 (HTLV-1).1 Common clinical features of ATLL are generalized lymphadenopathy, hepatosplenomegaly, skin alterations, hypercalcemia, and highly pleomorphic lymphoid cells in the peripheral blood.1 Although ATLL is known to invade various sites, ocular tissues are rarely involved. The patient was a 64-year-old Japanese man. He had been healthy but he noted a swelling of the right eyelid on September 22, 2003. The eye symptoms continued to worsen, and he consulted our hospital on October 10, 2003.
FIGURE 2. Pathologic examination and immunohistochemical studies. (Top left) Specimens show diffuse infiltration of atypical lymphocytes. Hematoxylin and eosin staining. Some lymphocytes with multiple irregular lobulated nuclei can be seen (inset). (Top right) Atypical lymphocytes are stained brown and are positive for CD3, a T-cell antigen. (Bottom left) Atypical lymphocytes are also positive for CD5, a T-cell antigen. (Bottom right) Atypical lymphocytes are not stained brown and are negative for CD79a, a B-cell antigen. Scale bars ⴝ 50 m.
the orbit was recommended. The procedures were explained to the patient and a written informed consent was obtained. The results of the biopsy performed on hematoxylin and eosin sections of tissues showed diffuse infiltration of atypical lymphocytes in the orbital lipoidal tissue. The atypical lymphocytes were positive for CD3 and CD5, T-cell antigen markers, and were negative for CD79a, a B-cell antigen marker (Figure 2). These results indicated that the orbital mass consisted of atypical lymphocytes originally from T cells, a typical phenotype of ATLL cells.1 Thus, the results of the biopsy of the orbital tissues established the tumor as a lymphoadenopathy type of ATLL. Chemotherapy (vincristine, doxorubicin, cyclophosphamide, and prednisolone) led to remission, and the orbital tumor and exophthalmos regressed (Figure 1). He is in good condition over a year after the chemotherapy.
Ophthalmologic examination showed a 4 mm exophthalmos of the right eye with eyelid edema and resistance to retropulsion (Figure 1). His visual acuity was 20/25 in the right eye and 20/20 in the left eye. The conjunctiva of the right eye was markedly swollen, but no intraocular inflammation was found in either eyes. The optic disks were normal, but choroidal folds were present in the right eye (Figure 1). Magnetic resonance imaging (MRI) revealed multiple tumorous lesions in both orbits (Figure 1). Laboratory evaluation revealed a red cell count of 439 ⫻ 104/dl, white blood cell count of 89 ⫻ 102/dl including 8% lymphocytes with no atypical lymphocytes. The level of antibodies against the HTLV-1 in the serum was extremely high at 32,769 times. Additionally, HTLV-1 provirus DNA was detected in blood lymphocytes. However, he did not have skin lesions or generalized adenopathy, thus a biopsy of 328
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
AUGUST 2005
ATLL can be classified into subtypes clinically.1 The most common is the acute form, and the rare lymphomatous form is characterized by isolated lymphadenopathy without leukemia. Malignant lymphoid tumors in the orbit are most often composed of B cells. Although ocular involvement by ATLL is extremely rare, some ocular manifestations in ATLL have been reported, for example, the direct infiltration of tumor cells and opportunistic infections into the choroid and retina.2–5 Lauer and associates2 first reported a patient who developed an extraocular orbital tumor with the acute-type of ATLL. However, all of the previous cases with orbital invasion had been diagnosed with ATLL before the ocular involvement.2,5 Our patient presented with exophthalmos at the onset of ATLL and did not have general symptoms. Therefore, only the results of the biopsy of the orbital tumor established the diagnosis. Thus, clinicians should be aware that ATLL can first present in ocular tissues, and only a biopsy can provide definitive information for its diagnosis.
DESIGN: Prospective case-control study. METHODS: UBM was used to measure scleral
thickness in five subjects with uveal effusion syndrome and five matched controls. We also used MRI to measure scleral thickness in three subjects. RESULTS: The mean thicknesses for eyes with uveal effusion syndrome versus control eyes were 0.65 ⴞ 0.08 mm and 0.55 ⴞ 0.05 mm, respectively (mean difference 0.10, P value ⴝ .13). MRI measurements of three subjects showed abnormally thick sclera but were imprecise. CONCLUSIONS: UBM can be used to measure scleral thickness, and our results support the finding that patients with uveal effusion syndrome have abnormally thick sclera. Compared with MRI, UBM may be a more accurate and precise method of measuring scleral thickness. UBM can be a useful adjunctive test in the management of uveal effusion syndrome. (Am J Ophthalmol 2005; 140:329 –331. © 2005 by Elsevier Inc. All rights reserved.)
REFERENCES
1. Harris NL, Jaffe ES, Stein H, et al. A revised EuropeanAmerican classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361–1392. 2. Lauer SA, Fisher J, Jones J, Gartner S, Dutcher J, Hoxie JA. Orbital T-cell lymphoma in human T-cell leukemia virus-1 infection. Ophthalmology 1988;95:110 –115. 3. Kohno T, Uchida H, Inomata H, Fukushima S, Takeshita M, Kikuchi M. Ocular manifestation of adult T-cell leukemia/ lymphoma. Ophthalmology 1993;100:1794 –1799. 4. Levy-Clarke GA, Buggage RR, Shenn D, Vaughn LO, Chan C, Davis JL. Human T-cell lymphotropic virus type-1 associated T-cell leukemia/lymphoma masquerading as necrotizing retinal vasculitis. Ophthalmology 2002;109: 1717–1722. 5. Mori A, Deguchi HE, Mishima K, Kitaoka T, Amemiya T. A case of uveal, palpebral, and orbital invasions in adult T-cell leukemia. Jpn J Ophthalmol 2003;247:599 – 602.
Measurement of Scleral Thickness in Uveal Effusion Syndrome Andrew Lam, MD, Robert P. Sambursky, MD, and Joseph I. Maguire, MD PURPOSE: To measure scleral thickness in patients with and without uveal effusion syndrome using ultrasound biomicroscopy (UBM) and magnetic resonance imaging (MRI). Accepted for publication Feb 1, 2005. From the Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania. Supported by grant no. 04-590-2-30500 from the Eye Research Institute and Wills Eye Hospital, Philadelphia, Pennsylvania. Inquiries to Andrew Lam, MD, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107; fax: 215-825-4732; e-mail: andrew.lam@ aya.yale.edu
VOL. 140, NO. 2
I
N 1963, SCHEPENS AND BROCKHURST WERE THE FIRST TO
use the term “uveal effusion syndrome” to describe a condition characterized by recurrent, spontaneous serous retinal and ciliochoroidal detachments.1 Gass and Jallow linked the condition to a scleral abnormality that impaired normal transscleral outflow of protein from the suprachoroidal space.2,3 They proposed scleral windows as a surgical remedy.4 In 2000, Uyama and associates published a case series showing that scleral window surgery was successful in patients with abnormally thick sclera (as measured by magnetic resonance imaging [MRI]), but was not helpful in patients with normal sclera.5 We conducted a prospective, case-control study using ultrasound biomicroscopy (UBM) to determine scleral thickness in eyes with uveal effusion syndrome and compared these data with measurements made by MRI. We identified five patients with a history of uveal effusion syndrome and five controls from the clinics at Wills Eye Hospital. Controls were matched for age (⫾7 years), race, gender, and any history of glaucoma. Institutional Review Board approval was obtained for the study and written informed consent was obtained from each patient. UBM was performed bilaterally. Measurements of scleral thickness were recorded in four meridians: 12, 3, 6, and 9 o’clock. The measurements were made 2 mm and 3 mm posterior to the scleral spur, which was used as a landmark in each eye, and two measurements were made at each individual site. Total mean scleral thickness, an average of the measurements at 2 mm and 3 mm, was calculated. Orbital MRI scans were performed on three of the five uveal effusion syndrome patients (Patients 2, 4, and 5). The other two patients declined MRI scans. Scleral thickness measurements were recorded at the equator at 12, 3, 6, and 9 o’clock meridians, and at the posterior pole. A
BRIEF REPORTS
329
1. Van Groeningen CJ, Godefridus JP, Schornagel JH, et al. Phase I clinical and pharmacokinetic study of oral S-1 in patients with advanced solid tumors. J Clin Oncol 2000;18:2772–2779. 2. Hoff PM, Saad ED, Ajani JA, et al. Phase I study with pharmacokinetics of S-1 on an oral daily schedule for 28 days in patients with solid tumors. Clin Cancer Res 2003;9:134 – 142. 3. Fukushima M, Shimamoto Y, Kato T, et al. Anticancer activity and toxicity of S-1, an oral combination of tegafur and two biochemical modulators, compared with continuous i.v. infusion of 5-FU. Anticancer Drugs 1998;9:817– 823. 4. Agarwal MR, Esmaeli B, Burnstine MA. Squamous metaplasia of the canaliculi associated with 5-fluorouracil: a clinicopathologic case report. Ophthalmology 2002;109:2359 –2361. 5. Fezza JP, Wesley RE, Klippenstein KA. The treatment of punctual and canalicular stenosis in patients on systemic 5-FU. Ophthalmic Surg Lasers 1999;30:105–108. 6. Esmaeli B, Ahmadi MA, Rivera E, et al. Docetaxel secretion in tears: Association with lacrimal drainage obstruction. Arch Ophthalmol 2002;120:1180 –1182. 7. Esmaeli B, Hidaji L, Adnin RB, et al. Blockage of the lacrimal drainage apparatus as a side effect of Docetaxel. Cancer 2003;98:504 –507.
Bilateral Orbital Tumor as Initial Presenting Sign in Human T-cell Leukemia Virus-1 Associated Adult T-cell Leukemia/Lymphoma Tadanobu Yoshikawa, MD, Nahoko Ogata, MD, PhD, Kanji Takahashi, MD, PhD, Shinichiro Mori, MD, PhD, Yoshiko Uemura, MD, PhD, and Miyo Matsumura, MD, PhD PURPOSE: To report a case of human T-cell leukemia virus type1 (HTLV-1)–associated adult T-cell leukemia/ lymphoma (ATLL) whose initial sign was exophthalmos. DESIGN: Case report. METHODS: A 64-year-old Japanese man presented with exophthalmos and choroidal folds of the right eye without general symptoms and received ophthalmologic and laboratory examination, magnetic resonance imaging (MRI), and orbital biopsy. RESULTS: Antibodies against HTLV-1 were extremely high but atypical lymphocytes were not present in the peripheral blood. MRI showed multiple tumorous lesions
in both orbits. Orbital biopsy revealed an orbital mass that consisted of atypical lymphocytes originally from T cells and established the diagnosis of lymphoadenopathy type of ATLL. CONCLUSION: Although ocular involvement by ATLL is extremely rare, ATLL can first present in the orbit, and only the results of a biopsy can provide definitive information for its diagnosis. (Am J Ophthalmol 2005;140: 327–329. © 2005 by Elsevier Inc. All rights reserved.)
A
DULT T-CELL LEUKEMIA/LYMPHOMA (ATLL) IS A PE-
BRIEF REPORTS
327
Accepted for publication Jan 31, 2005. From the Department of Ophthalmology (T.Y., N.O., K.T., M.M.), First Department of Internal Medicine (S.M.), and Second Department of Pathology (Y.U.), Kansai Medical University, Osaka, Japan. Inquiries to Nahoko Ogata, MD, PhD, Department of Ophthalmology, Kansai Medical University, Fumizono-cho 10-15, Moriguchi, Osaka 570-8507, Japan; fax: 81-6-6993-2222; e-mail: [email protected]
VOL. 140, NO. 2
FIGURE 1. (Top left) Photograph of patient with T cell lymphoma/leukemia at initial examination in our hospital. (Middle left) Fundus photograph of the right eye. The optic disk is normal but choroidal folds (arrows) are present. (Top right) T1-weighted MRI sequences acquired in the horizontal plane showing multiple low intensity lesions (arrows) in the orbit bilaterally. (Middle right) T2-weighted MRI sequences. Orbital lesions show low intensity (arrows) in the orbit bilaterally. (Bottom left) Photograph of patient 3 months after chemotherapy showing that exophthalmos had regressed. (Bottom right) T1-weighted MRI sequences 3 months after chemotherapy. Multiple low intensity lesions in both orbits are not present.
ripheral T-cell malignancy caused by human T-cell leukemia virus type 1 (HTLV-1).1 Common clinical features of ATLL are generalized lymphadenopathy, hepatosplenomegaly, skin alterations, hypercalcemia, and highly pleomorphic lymphoid cells in the peripheral blood.1 Although ATLL is known to invade various sites, ocular tissues are rarely involved. The patient was a 64-year-old Japanese man. He had been healthy but he noted a swelling of the right eyelid on September 22, 2003. The eye symptoms continued to worsen, and he consulted our hospital on October 10, 2003.
FIGURE 2. Pathologic examination and immunohistochemical studies. (Top left) Specimens show diffuse infiltration of atypical lymphocytes. Hematoxylin and eosin staining. Some lymphocytes with multiple irregular lobulated nuclei can be seen (inset). (Top right) Atypical lymphocytes are stained brown and are positive for CD3, a T-cell antigen. (Bottom left) Atypical lymphocytes are also positive for CD5, a T-cell antigen. (Bottom right) Atypical lymphocytes are not stained brown and are negative for CD79a, a B-cell antigen. Scale bars ⴝ 50 m.
the orbit was recommended. The procedures were explained to the patient and a written informed consent was obtained. The results of the biopsy performed on hematoxylin and eosin sections of tissues showed diffuse infiltration of atypical lymphocytes in the orbital lipoidal tissue. The atypical lymphocytes were positive for CD3 and CD5, T-cell antigen markers, and were negative for CD79a, a B-cell antigen marker (Figure 2). These results indicated that the orbital mass consisted of atypical lymphocytes originally from T cells, a typical phenotype of ATLL cells.1 Thus, the results of the biopsy of the orbital tissues established the tumor as a lymphoadenopathy type of ATLL. Chemotherapy (vincristine, doxorubicin, cyclophosphamide, and prednisolone) led to remission, and the orbital tumor and exophthalmos regressed (Figure 1). He is in good condition over a year after the chemotherapy.
Ophthalmologic examination showed a 4 mm exophthalmos of the right eye with eyelid edema and resistance to retropulsion (Figure 1). His visual acuity was 20/25 in the right eye and 20/20 in the left eye. The conjunctiva of the right eye was markedly swollen, but no intraocular inflammation was found in either eyes. The optic disks were normal, but choroidal folds were present in the right eye (Figure 1). Magnetic resonance imaging (MRI) revealed multiple tumorous lesions in both orbits (Figure 1). Laboratory evaluation revealed a red cell count of 439 ⫻ 104/dl, white blood cell count of 89 ⫻ 102/dl including 8% lymphocytes with no atypical lymphocytes. The level of antibodies against the HTLV-1 in the serum was extremely high at 32,769 times. Additionally, HTLV-1 provirus DNA was detected in blood lymphocytes. However, he did not have skin lesions or generalized adenopathy, thus a biopsy of 328
AMERICAN JOURNAL
OF
OPHTHALMOLOGY
AUGUST 2005
ATLL can be classified into subtypes clinically.1 The most common is the acute form, and the rare lymphomatous form is characterized by isolated lymphadenopathy without leukemia. Malignant lymphoid tumors in the orbit are most often composed of B cells. Although ocular involvement by ATLL is extremely rare, some ocular manifestations in ATLL have been reported, for example, the direct infiltration of tumor cells and opportunistic infections into the choroid and retina.2–5 Lauer and associates2 first reported a patient who developed an extraocular orbital tumor with the acute-type of ATLL. However, all of the previous cases with orbital invasion had been diagnosed with ATLL before the ocular involvement.2,5 Our patient presented with exophthalmos at the onset of ATLL and did not have general symptoms. Therefore, only the results of the biopsy of the orbital tumor established the diagnosis. Thus, clinicians should be aware that ATLL can first present in ocular tissues, and only a biopsy can provide definitive information for its diagnosis.
DESIGN: Prospective case-control study. METHODS: UBM was used to measure scleral
thickness in five subjects with uveal effusion syndrome and five matched controls. We also used MRI to measure scleral thickness in three subjects. RESULTS: The mean thicknesses for eyes with uveal effusion syndrome versus control eyes were 0.65 ⴞ 0.08 mm and 0.55 ⴞ 0.05 mm, respectively (mean difference 0.10, P value ⴝ .13). MRI measurements of three subjects showed abnormally thick sclera but were imprecise. CONCLUSIONS: UBM can be used to measure scleral thickness, and our results support the finding that patients with uveal effusion syndrome have abnormally thick sclera. Compared with MRI, UBM may be a more accurate and precise method of measuring scleral thickness. UBM can be a useful adjunctive test in the management of uveal effusion syndrome. (Am J Ophthalmol 2005; 140:329 –331. © 2005 by Elsevier Inc. All rights reserved.)
REFERENCES
1. Harris NL, Jaffe ES, Stein H, et al. A revised EuropeanAmerican classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361–1392. 2. Lauer SA, Fisher J, Jones J, Gartner S, Dutcher J, Hoxie JA. Orbital T-cell lymphoma in human T-cell leukemia virus-1 infection. Ophthalmology 1988;95:110 –115. 3. Kohno T, Uchida H, Inomata H, Fukushima S, Takeshita M, Kikuchi M. Ocular manifestation of adult T-cell leukemia/ lymphoma. Ophthalmology 1993;100:1794 –1799. 4. Levy-Clarke GA, Buggage RR, Shenn D, Vaughn LO, Chan C, Davis JL. Human T-cell lymphotropic virus type-1 associated T-cell leukemia/lymphoma masquerading as necrotizing retinal vasculitis. Ophthalmology 2002;109: 1717–1722. 5. Mori A, Deguchi HE, Mishima K, Kitaoka T, Amemiya T. A case of uveal, palpebral, and orbital invasions in adult T-cell leukemia. Jpn J Ophthalmol 2003;247:599 – 602.
Measurement of Scleral Thickness in Uveal Effusion Syndrome Andrew Lam, MD, Robert P. Sambursky, MD, and Joseph I. Maguire, MD PURPOSE: To measure scleral thickness in patients with and without uveal effusion syndrome using ultrasound biomicroscopy (UBM) and magnetic resonance imaging (MRI). Accepted for publication Feb 1, 2005. From the Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania. Supported by grant no. 04-590-2-30500 from the Eye Research Institute and Wills Eye Hospital, Philadelphia, Pennsylvania. Inquiries to Andrew Lam, MD, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107; fax: 215-825-4732; e-mail: andrew.lam@ aya.yale.edu
VOL. 140, NO. 2
I
N 1963, SCHEPENS AND BROCKHURST WERE THE FIRST TO
use the term “uveal effusion syndrome” to describe a condition characterized by recurrent, spontaneous serous retinal and ciliochoroidal detachments.1 Gass and Jallow linked the condition to a scleral abnormality that impaired normal transscleral outflow of protein from the suprachoroidal space.2,3 They proposed scleral windows as a surgical remedy.4 In 2000, Uyama and associates published a case series showing that scleral window surgery was successful in patients with abnormally thick sclera (as measured by magnetic resonance imaging [MRI]), but was not helpful in patients with normal sclera.5 We conducted a prospective, case-control study using ultrasound biomicroscopy (UBM) to determine scleral thickness in eyes with uveal effusion syndrome and compared these data with measurements made by MRI. We identified five patients with a history of uveal effusion syndrome and five controls from the clinics at Wills Eye Hospital. Controls were matched for age (⫾7 years), race, gender, and any history of glaucoma. Institutional Review Board approval was obtained for the study and written informed consent was obtained from each patient. UBM was performed bilaterally. Measurements of scleral thickness were recorded in four meridians: 12, 3, 6, and 9 o’clock. The measurements were made 2 mm and 3 mm posterior to the scleral spur, which was used as a landmark in each eye, and two measurements were made at each individual site. Total mean scleral thickness, an average of the measurements at 2 mm and 3 mm, was calculated. Orbital MRI scans were performed on three of the five uveal effusion syndrome patients (Patients 2, 4, and 5). The other two patients declined MRI scans. Scleral thickness measurements were recorded at the equator at 12, 3, 6, and 9 o’clock meridians, and at the posterior pole. A
BRIEF REPORTS
329