N O T E S , CASES, I N S T R U M E N T S IODISM W I T H S E V E R E OCULAR INVOLVEMENT* REPORT OF A CASE H.
KRIEGER GOLDBERG,
M.D.
Baltimore The purpose of this report is to record a case of bilateral edema of the lids and conjunctivae, bullous keratitis, and hypopyon secondary to iodine poisoning. Such severe ocular involvement is rarely observed. M. F., a white woman, aged 68 years, was first seen at the Johns Hopkins Hospital in February, 1905. She complained of stiffness of the hands and feet. For a year she had experienced tingling of the right foot and a pain which radiated to her right hip from the right leg. She had had fleeting pains in her arms. Also, she had noticed that she could not differentiate coins or buttons when placed in her left hand. Complete examination, supervised by Dr. Osier, showed only astereognosis of the left hand and moderate ataxia of both arms. Attention was drawn to the peculiar personality of the patient by Dr. Osier, but no details were stated. During her stay in the hospital she was given a saturated solution of potassium iodide. The initial dose was IS min. and this was increased 2 min. every other day. After four weeks the iodide was discontinued because an iodide rash appeared on the extremities and face. Four days after discontinuing the iodides, the symptoms had entirely disappeared. Following the patient's return to her home she continued to have "rheumatic" attacks and on her own initiative she took * From the Wilmer Ophthalmological Institute of the Johns Hopkins Hospital and University, Baltimore, Maryland.
potassium iodide in the same dosage that had been given to her in the hospital. After using the drug for any length of time she invariably developed a skin eruption over the face and extremities. Sometimes the eruption was macular and at other times it was pustular or vesicular. Cessation of the drug always resulted in disappearance of the rash. The patient noted that with each succeeding skin eruption, a shorter period of iodine consumption was necessary to produce the rash. She had not used the iodides for about one year until in February, 1938, she commenced taking 30 min. t.i.d. with increasing doses every other day. After three weeks a vesicular skin eruption appeared over the face, arms (figs. 1 and 2 ) , and legs. However, on this occasion the patient persisted in the use of the iodide. On March 8th her eyes became painful and her vision failed rapidly. She again entered the hospital on March 11th, when her vision was reduced to light perception in both eyes. OCULAR EXAMINATION
There was such edema and redness of the lids that they could not be opened voluntarily by the patient. The bulbar conjunctiva of the right eye was chemotic. The cornea was grayish and infiltrated. The iris was similarly discolored. The pupil was contracted, irregular, and adherent to the lens. There was a thin layer of exudate over the surface of the iris with loss of all normal luster and markings. There was a small hypopyon in the inferior angle of the anterior chamber. Tension was normal. The left eye presented a more advanced generalized chemosis. The cornea was grayish and hazy in color. Outlines of the pupil could barely be seen. There was a heavy
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exudate over the anterior surface of the iris and a large hypopyon half filled the anterior chamber. There was a definite loss of epithelium in a small area toward the 3-o'clock position which stained with fluorescein. Tension was normal. There
the center there were five or six small blebs which appeared to be on the posterior surface of the cornea and to arise between Descemet's membrane and the endothelium (fig. 3 ) . General physical examination was essentially negative except for the ocular and dermatological findings. The result of the neurological examination revealed the same ataxia of the arms and astereognosis of the left hand which had been found on her first admission. Her personality had not changed. She was inordinately proud of the fact that Sir William Osier had prescribed for her. This probably accounted for her continuing the prescriptions in spite of the repeated atFigs. 1 and 2 (Goldberg). Cutaneous lesions of face and arms on admission.
was a bare suggestion of red reflex in both eyes. Vision was light perception with good projection in each eye. There were a few bullae over the right cornea and several very faintly staining areas where there had probably been other recent bullae. On the left cornea towards
tacks of iodism. She definitely relished reciting the routine of her disability and her method of combating it. The Wassermann reaction, blood gonococcal fixation test, blood chemistry, and blood cytology were entirely negative. Cultures taken from the bullae of the skin were sterile. The survey of various
NOTES, CASES, INSTRUMENTS systems was negative. Examination for iodine in the urine showed its presence in large quantities. On March 11th, the day of admission, the patient was given instillations of atropine one percent t.i.d. and iodides were stopped. Immediately the patient made an unusual and rapid improvement. On March 12th the left cornea no longer stained. On March 15th the patient was able to count fingers at two feet with the right eye and the iris pattern was readily distinguished (fig. 4 ) . On March 22d the vision was 20/200 in each eye. Nuclear sclerosis made it unlikely that further visual improvement could follow. The right eye was otherwise normal. The left eye at this time continued to show some folding of Descemets' membrane in the areas where the bullae had been observed. The skin eruption had entirely disappeared and iodine was no longer demonstrable in the urine. The patient continued to progress in an uncomplicated manner and therefore 14 days after admission she was discharged. COM MENT
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Fig. 3 (Goldberg). Stereoscopic photographs of right and left eyes on admissioti. Edema of conjunctiva, corneae, and bilateral hypopyon are present.
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Fig. 4 (Goldberg). Stereoscopic photographs of right and left eyes nine days later.
Swelling of the lids and conjunctiva is frequently observed after iodides have b een prescribed.1 Such symptoms may apPear without an iodide rash appearing,
More severe ocular involvement has been observed. Lewin, 2 in 1899 and again in 1925, recorded retinal hemorrhages and corneal lesions resembling the bullae seen
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on the skin as resulting from the use of iodides. Hallopeau 3 in 1899 described a case in which bullae of the cornea appeared, the cornea became almost entirely opaque and the pupils were fixed to light and were irregular. Discontinuance of the drug was followed by disappearance of the lesions which reappeared when the drug was again prescribed. The case here reported, although similar to that of
Hallopeau, was even more severe. It would seem obvious that the ocular condition observed in the case here reported arose from lesions in the eye which were similar to those frequently observed in the skin. The hypopyon therefore resulted from the irritation of the corneal bullae which caused an irritative iritis and hence a sterile hypopyon. Wilmer Ophthalmological Institute.
REFERENCES 1
d'Epenay, M., and Hallopeau, M. Ann. de derm, et syph., 1906, v. 7, p. 580. Lewin, L. Lehrbuch der Toxikologie. Verlag von Georg Stilke, Berlin, 1929, p. 106. ' Hallopeau, M. Ann. de derm, et syph., 1888, v. 2, p. 760. 2