- Email: [email protected]
Vertebral Artery Occlusion Complicating Perimetry
516
AMERICAN JOURNAL OF OPHTHALMOLOGY
April, 1991
5. Buechner, S. Α., Winkelmann, R. Κ., and Banks, P. M.: T-cell subsets in cutaneous sarcoidosis. Arch. Dermatol. 119:728, 1 9 8 3 .
Vertebral Artery Occlusion Complicating Perimetry Jacques De Keyser, M.D., Luc Herroelen, M.D., and Luc Van Langenhove, M . D . Fig. 2 (Mansour and Chan). Granuloma around black tattoo pigments (hematoxylin and eosin, x 100).
a n d t i t a n i u m . T h e h i s t o l o g i c p a t t e r n of r e a c t i o n to t a t t o o s i n c l u d e s diffuse l y m p h o h i s t i o c y t i c infiltrate, l i c h e n o i d r e a c t i o n , a n d s a r c o i d a l granuloma.^ H a n a d a , C h i y o y a , a n d K a t a b i r a ' d e s c r i b e d the findings in a 3 1 - y e a r - o l d m a n w h o d e v e l o p e d s y m p t o m s s i m i l a r to t h o s e o f s y s t e m i c s a r c o i d o s i s after e x t e n s i v e t a t t o o i n g . These included uveitis and noncaseating gran u l o m a t o u s r e a c t i o n in skin t a t t o o s , l y m p h nodes, and lung tissue. This case demonstrated granuloma formation with p r e d o m i n a n c e o f m o n o n u c l e a r c e l l s . T h e h i g h r a t i o of Β l y m p h o c y t e s a n d m a c r o p h a g e s and equal number of T-helper and T-suppressor s u p p r e s s o r cells are i n d i c a t i v e o f d e l a y e d h y p e r s e n s i t i v i t y r e a c t i o n , u n l i k e that o f s a r c o i d o sis."'^ T h e c o n c u r r e n t u v e i t i s a n d skin i n d u r a tion at t h e site of t a t t o o s a p p e a r r e l a t e d to t h e sensitizing character o f tattoo material.
References 1. Slater, D. N., and Durrant, T. E.: Tattoos. Light and electron microscopy studies with x-ray microan alysis. Clin. Exp. Dermatol. 9:167, 1984. 2. Blumenthal, G., Okun, Μ. R., and Ponitch, ] . Α.: Pseudolymphomatous reaction to tattoos. Report of three cases. J. Am. Acad. Dermatol. 6:485, 1982. 3. Hanada, K., Chiyoya, S., and Katabira, Y.: Sys temic sarcoidal reaction in tattoo. Clin. Exp. Derma tol. 10:479, 1985. 4. Chan, C . - C , Wetzig, R. P., Palestine, A. G., Kuwabara, T., and Nussenblatt, R. B.: Immunohistopathology of ocular sarcoidosis. Report of a case and discussion of immunopathogenesis. Arch. Oph thalmol. 105:1398, 1987.
Departments of Neurology (J.D.K., L.H.) and Oph thalmology (L.V.L.), Academisch Ziekenhuis Vrije Universiteit Brüssel. Inquiries to Jacques De Keyser, M.D., Department of Neurology, Academisch Ziekenhuis Vrije Universiteit Brüssel, Laarbeeklaan 101, Β 1090 Brussels, Belgium. A 6 5 - y e a r - o l d m a n h a d p o l y c y t h e m i a vera, w h i c h w a s c o n t r o l l e d b y p h l e b o t o m i e s . H e un d e r w e n t a u t o m a t e d p e r i m e t r y b e c a u s e h e saw b l a c k s p o t s . B e c a u s e t h e p e r i m e t r i s t did n o t adjust t h e h e i g h t of t h e c h i n rest, the e x a m i n a tion was c a r r i e d out w i t h t h e h e a d o f t h e p a t i e n t h y p e r e x t e n d e d as s h o w n in t h e F i g u r e . N e a r t h e e n d o f t h e test, w h i c h h a d l a s t e d a p p r o x i m a t e l y 3 0 m i n u t e s , he n o t i c e d a v a g u e p a i n in t h e h i g h , l a t e r a l , right r e g i o n o f h i s n e c k . Five m i n u t e s later the patient suddenly had vertigo, nausea, dysarthria, visual distortion, and an unsteadi n e s s o f gait w i t h a t e n d e n c y to d e v i a t e to t h e right. All s y m p t o m s g r a d u a l l y r e s o l v e d o v e r t h e n e x t t h r e e d a y s . O n e w e e k later, n e u r o l o g i c examination showed no abnormalities. Blood p r e s s u r e was 1 4 0 / 8 0 m m Hg a n d p u l s e w a s 8 0 b e a t s per m i n u t e . C a r d i a c a u s c u l t a t i o n w a s n o r mal. There were no vascular bruits. C o m p u t e d tomography of the head was normal. Intrave n o u s digital s u b t r a c t i o n a n g i o g r a p h y d i s c l o s e d o c c l u s i o n o f t h e right v e r t e b r a l a r t e r y at t h e C 1 - C 2 vertebral level. X-rays of the neck s h o w e d n o t h i n g u n u s u a l . T h e h e m a t o c r i t level was 5 4 . 5 % ; t h e w h i t e b l o o d c e l l c o u n t w a s 1 3 . 9 X l O y m m ' with 8 3 % neutrophils; the platelet c o u n t was 4 9 4 X l O V m m l T h e p a t i e n t h a d p o l y c y t h e m i a v e r a , w h i c h is a s s o c i a t e d with an i n c r e a s e d risk for c e r e b r o vascular thrombosis. However, since hemato crit a n d p l a t e l e t l e v e l s w e r e o n l y m o d e r a t e l y increased, the patient's p o l y c y t h e m i a vera c o u l d n o t b e c o n s i d e r e d t h e c a u s e of t h e c e r e brovascular accident. The temporal relation s h i p to t h e p e r i m e t r i c e x a m i n a t i o n a n d t h e site
Letters to the Journal
Vol. I l l , No. 4
517
Terrien's Marginal Degeneration A s s o c i a t e d W i t h Vernal Conjunctivitis Israel Kremer, M.D. Department of Ophthalmology, Beilinson Medical Center, Petah Tiqva, Sackler School of Medicine, Tel Aviv University. Inquiries to Israel Kremer, M.D., Department of Oph thalmology, Beilinson Medical Center, Petah Tiqva 49100, Israel.
Figure (De Keyser, Herroelen, and Van Langen hove). Perimetry carried out with the head in hyperextension. of the l e s i o n l e a v e l i t t l e d o u b t t h a t the v e r t e b r a l artery occlusion was primarily caused by m e c h a n i c a l i n j u r y or c o m p r e s s i o n o f t h e v e r t e b r a l a r t e r y a c r o s s the c r a n i o v e r t e b r a l j u n c t i o n , caused by cervical hyperextension. Similar c a s e s o f v e r t e b r a l a r t e r y i n j u r y have b e e n d e s c r i b e d after y o g a , ' g y m n a s t i c exercises,^ o v e r head work,' and neck manipulation.'' Clinic personnel should be instructed about the p o t e n t i a l h a z a r d s of c e r v i c a l h y p e r e x t e n sion d u r i n g d i a g n o s t i c p r o c e d u r e s .
References 1. Hanus, S. H., Homer, T. D., and Harter, D. H.: Vertebral artery occlusion complicating yoga exer cise. Arch. Neurol. 34:574, 1977. 2. Nagler, W.: Vertebral artery obstruction by hy perextension of the neck. Report of three cases. Arch. Phys. Med. Rehabil. 54:237, 1 9 7 3 . 3. Okawara, S., and Nibbelinck, D.: Vertebral ar tery occlusion following hyperextension and rotation of the neck. Stroke 5:640, 1974. 4. Mehalic, T., and Farhat, S. M.: Vertebral artery injury from chiropractic manipulation of the neck. Surg. Neurol. 2:125, 1974.
T e r r i e n ' s d i s e a s e o f the p e r i p h e r a l c o r n e a is characterized by a slowly progressive, nonin flammatory, marginal corneal furrowing and e c t a s i a o f the s u p e r i o r p e r i p h e r a l c o r n e a . ' S u v e g e s , L e v a i , a n d A l b e r t ' n o t e d p h a g o c y t o s i s of corneal stroma by cells resembling histiocytes a s s o c i a t e d with p e r i p h e r a l c o r n e a l b l o o d v e s s e l s in the e c t a t i c a r e a s . T h e o r i g i n o f T e r r i e n ' s d i s e a s e is still u n k n o w n , but the p r e s e n c e o f lipid a s s o c i a t e d w i t h the f u r r o w i n g s u g g e s t s a degenerative process. Patients with Terrien's disease are usually asymptomatic, unless they have severe irregu lar a s t i g m a t i s m . M o s t p a t i e n t s do n o t have significant associated ocular inflammation. A u s t i n a n d Brown,^ h o w e v e r , d e s c r i b e d six p a tients with a combination of severe recurrent e p i s o d e s o f painful o c u l a r i n f l a m m a t i o n a n d c o r n e a l findings t y p i c a l o f T e r r i e n ' s d i s e a s e . Binder, Zavala, and S t a i n e r ' s i m i l a r l y described a p a t i e n t w h o h a d b o t h t h e c o r n e a l c h a n g e s of Terrien's degeneration and moderately severe ocular inflammation. I treated a patient who had chronic limbal vernal conjunctivitis and developed Terrien's degeneration. A 40-year-old man had severe vernal con junctivitis, both palpebral and limbal, during childhood. He was treated with corticosteroid a n d d i s o d i u m - c r o m o g l y c a t e e y e d r o p s for al m o s t ten y e a r s , a n d at t h e a g e of 1 7 y e a r s , h e w a s free of s y m p t o m s . S u b s e q u e n t l y , h e b e g a n having visual disturbances. Refraction dis c l o s e d 4 d i o p t e r s of a g a i n s t the r u l e a s t i g m a tism in a d d i t i o n to — 4 . 0 s p h e r e s in b o t h e y e s . S l i t - l a m p e x a m i n a t i o n d i s c l o s e d p e r i p h e r a l su p e r i o r c o r n e a l o p a c i f i c a t i o n w i t h m i l d , superfi cial v a s c u l a r i z a t i o n . C o r n e a l t h i n n i n g w a s a l s o n o t e d in t h a t a r e a . T h e c o r n e a l findings p r o g r e s s e d d u r i n g t h e f o l l o w i n g y e a r s , a n d the superior stromal thinning continued gradually, extending peripherally and centrally (Figure), w h i c h l e d to e c t a s i a , i n c r e a s e d a g a i n s t the rule astigmatism, and diminution of visual acuity.
AMERICAN JOURNAL OF OPHTHALMOLOGY
April, 1991
5. Buechner, S. Α., Winkelmann, R. Κ., and Banks, P. M.: T-cell subsets in cutaneous sarcoidosis. Arch. Dermatol. 119:728, 1 9 8 3 .
Vertebral Artery Occlusion Complicating Perimetry Jacques De Keyser, M.D., Luc Herroelen, M.D., and Luc Van Langenhove, M . D . Fig. 2 (Mansour and Chan). Granuloma around black tattoo pigments (hematoxylin and eosin, x 100).
a n d t i t a n i u m . T h e h i s t o l o g i c p a t t e r n of r e a c t i o n to t a t t o o s i n c l u d e s diffuse l y m p h o h i s t i o c y t i c infiltrate, l i c h e n o i d r e a c t i o n , a n d s a r c o i d a l granuloma.^ H a n a d a , C h i y o y a , a n d K a t a b i r a ' d e s c r i b e d the findings in a 3 1 - y e a r - o l d m a n w h o d e v e l o p e d s y m p t o m s s i m i l a r to t h o s e o f s y s t e m i c s a r c o i d o s i s after e x t e n s i v e t a t t o o i n g . These included uveitis and noncaseating gran u l o m a t o u s r e a c t i o n in skin t a t t o o s , l y m p h nodes, and lung tissue. This case demonstrated granuloma formation with p r e d o m i n a n c e o f m o n o n u c l e a r c e l l s . T h e h i g h r a t i o of Β l y m p h o c y t e s a n d m a c r o p h a g e s and equal number of T-helper and T-suppressor s u p p r e s s o r cells are i n d i c a t i v e o f d e l a y e d h y p e r s e n s i t i v i t y r e a c t i o n , u n l i k e that o f s a r c o i d o sis."'^ T h e c o n c u r r e n t u v e i t i s a n d skin i n d u r a tion at t h e site of t a t t o o s a p p e a r r e l a t e d to t h e sensitizing character o f tattoo material.
References 1. Slater, D. N., and Durrant, T. E.: Tattoos. Light and electron microscopy studies with x-ray microan alysis. Clin. Exp. Dermatol. 9:167, 1984. 2. Blumenthal, G., Okun, Μ. R., and Ponitch, ] . Α.: Pseudolymphomatous reaction to tattoos. Report of three cases. J. Am. Acad. Dermatol. 6:485, 1982. 3. Hanada, K., Chiyoya, S., and Katabira, Y.: Sys temic sarcoidal reaction in tattoo. Clin. Exp. Derma tol. 10:479, 1985. 4. Chan, C . - C , Wetzig, R. P., Palestine, A. G., Kuwabara, T., and Nussenblatt, R. B.: Immunohistopathology of ocular sarcoidosis. Report of a case and discussion of immunopathogenesis. Arch. Oph thalmol. 105:1398, 1987.
Departments of Neurology (J.D.K., L.H.) and Oph thalmology (L.V.L.), Academisch Ziekenhuis Vrije Universiteit Brüssel. Inquiries to Jacques De Keyser, M.D., Department of Neurology, Academisch Ziekenhuis Vrije Universiteit Brüssel, Laarbeeklaan 101, Β 1090 Brussels, Belgium. A 6 5 - y e a r - o l d m a n h a d p o l y c y t h e m i a vera, w h i c h w a s c o n t r o l l e d b y p h l e b o t o m i e s . H e un d e r w e n t a u t o m a t e d p e r i m e t r y b e c a u s e h e saw b l a c k s p o t s . B e c a u s e t h e p e r i m e t r i s t did n o t adjust t h e h e i g h t of t h e c h i n rest, the e x a m i n a tion was c a r r i e d out w i t h t h e h e a d o f t h e p a t i e n t h y p e r e x t e n d e d as s h o w n in t h e F i g u r e . N e a r t h e e n d o f t h e test, w h i c h h a d l a s t e d a p p r o x i m a t e l y 3 0 m i n u t e s , he n o t i c e d a v a g u e p a i n in t h e h i g h , l a t e r a l , right r e g i o n o f h i s n e c k . Five m i n u t e s later the patient suddenly had vertigo, nausea, dysarthria, visual distortion, and an unsteadi n e s s o f gait w i t h a t e n d e n c y to d e v i a t e to t h e right. All s y m p t o m s g r a d u a l l y r e s o l v e d o v e r t h e n e x t t h r e e d a y s . O n e w e e k later, n e u r o l o g i c examination showed no abnormalities. Blood p r e s s u r e was 1 4 0 / 8 0 m m Hg a n d p u l s e w a s 8 0 b e a t s per m i n u t e . C a r d i a c a u s c u l t a t i o n w a s n o r mal. There were no vascular bruits. C o m p u t e d tomography of the head was normal. Intrave n o u s digital s u b t r a c t i o n a n g i o g r a p h y d i s c l o s e d o c c l u s i o n o f t h e right v e r t e b r a l a r t e r y at t h e C 1 - C 2 vertebral level. X-rays of the neck s h o w e d n o t h i n g u n u s u a l . T h e h e m a t o c r i t level was 5 4 . 5 % ; t h e w h i t e b l o o d c e l l c o u n t w a s 1 3 . 9 X l O y m m ' with 8 3 % neutrophils; the platelet c o u n t was 4 9 4 X l O V m m l T h e p a t i e n t h a d p o l y c y t h e m i a v e r a , w h i c h is a s s o c i a t e d with an i n c r e a s e d risk for c e r e b r o vascular thrombosis. However, since hemato crit a n d p l a t e l e t l e v e l s w e r e o n l y m o d e r a t e l y increased, the patient's p o l y c y t h e m i a vera c o u l d n o t b e c o n s i d e r e d t h e c a u s e of t h e c e r e brovascular accident. The temporal relation s h i p to t h e p e r i m e t r i c e x a m i n a t i o n a n d t h e site
Letters to the Journal
Vol. I l l , No. 4
517
Terrien's Marginal Degeneration A s s o c i a t e d W i t h Vernal Conjunctivitis Israel Kremer, M.D. Department of Ophthalmology, Beilinson Medical Center, Petah Tiqva, Sackler School of Medicine, Tel Aviv University. Inquiries to Israel Kremer, M.D., Department of Oph thalmology, Beilinson Medical Center, Petah Tiqva 49100, Israel.
Figure (De Keyser, Herroelen, and Van Langen hove). Perimetry carried out with the head in hyperextension. of the l e s i o n l e a v e l i t t l e d o u b t t h a t the v e r t e b r a l artery occlusion was primarily caused by m e c h a n i c a l i n j u r y or c o m p r e s s i o n o f t h e v e r t e b r a l a r t e r y a c r o s s the c r a n i o v e r t e b r a l j u n c t i o n , caused by cervical hyperextension. Similar c a s e s o f v e r t e b r a l a r t e r y i n j u r y have b e e n d e s c r i b e d after y o g a , ' g y m n a s t i c exercises,^ o v e r head work,' and neck manipulation.'' Clinic personnel should be instructed about the p o t e n t i a l h a z a r d s of c e r v i c a l h y p e r e x t e n sion d u r i n g d i a g n o s t i c p r o c e d u r e s .
References 1. Hanus, S. H., Homer, T. D., and Harter, D. H.: Vertebral artery occlusion complicating yoga exer cise. Arch. Neurol. 34:574, 1977. 2. Nagler, W.: Vertebral artery obstruction by hy perextension of the neck. Report of three cases. Arch. Phys. Med. Rehabil. 54:237, 1 9 7 3 . 3. Okawara, S., and Nibbelinck, D.: Vertebral ar tery occlusion following hyperextension and rotation of the neck. Stroke 5:640, 1974. 4. Mehalic, T., and Farhat, S. M.: Vertebral artery injury from chiropractic manipulation of the neck. Surg. Neurol. 2:125, 1974.
T e r r i e n ' s d i s e a s e o f the p e r i p h e r a l c o r n e a is characterized by a slowly progressive, nonin flammatory, marginal corneal furrowing and e c t a s i a o f the s u p e r i o r p e r i p h e r a l c o r n e a . ' S u v e g e s , L e v a i , a n d A l b e r t ' n o t e d p h a g o c y t o s i s of corneal stroma by cells resembling histiocytes a s s o c i a t e d with p e r i p h e r a l c o r n e a l b l o o d v e s s e l s in the e c t a t i c a r e a s . T h e o r i g i n o f T e r r i e n ' s d i s e a s e is still u n k n o w n , but the p r e s e n c e o f lipid a s s o c i a t e d w i t h the f u r r o w i n g s u g g e s t s a degenerative process. Patients with Terrien's disease are usually asymptomatic, unless they have severe irregu lar a s t i g m a t i s m . M o s t p a t i e n t s do n o t have significant associated ocular inflammation. A u s t i n a n d Brown,^ h o w e v e r , d e s c r i b e d six p a tients with a combination of severe recurrent e p i s o d e s o f painful o c u l a r i n f l a m m a t i o n a n d c o r n e a l findings t y p i c a l o f T e r r i e n ' s d i s e a s e . Binder, Zavala, and S t a i n e r ' s i m i l a r l y described a p a t i e n t w h o h a d b o t h t h e c o r n e a l c h a n g e s of Terrien's degeneration and moderately severe ocular inflammation. I treated a patient who had chronic limbal vernal conjunctivitis and developed Terrien's degeneration. A 40-year-old man had severe vernal con junctivitis, both palpebral and limbal, during childhood. He was treated with corticosteroid a n d d i s o d i u m - c r o m o g l y c a t e e y e d r o p s for al m o s t ten y e a r s , a n d at t h e a g e of 1 7 y e a r s , h e w a s free of s y m p t o m s . S u b s e q u e n t l y , h e b e g a n having visual disturbances. Refraction dis c l o s e d 4 d i o p t e r s of a g a i n s t the r u l e a s t i g m a tism in a d d i t i o n to — 4 . 0 s p h e r e s in b o t h e y e s . S l i t - l a m p e x a m i n a t i o n d i s c l o s e d p e r i p h e r a l su p e r i o r c o r n e a l o p a c i f i c a t i o n w i t h m i l d , superfi cial v a s c u l a r i z a t i o n . C o r n e a l t h i n n i n g w a s a l s o n o t e d in t h a t a r e a . T h e c o r n e a l findings p r o g r e s s e d d u r i n g t h e f o l l o w i n g y e a r s , a n d the superior stromal thinning continued gradually, extending peripherally and centrally (Figure), w h i c h l e d to e c t a s i a , i n c r e a s e d a g a i n s t the rule astigmatism, and diminution of visual acuity.