Vol. 114, No. 3

Letters to The Journal

tal jerk nystagmus does not fall into a described classification. One condition, benign paroxys­ mal positional vertigo, can have associated in­ termittent nystagmus, but vertigo was not a component in our patient. Baclofen has shown promise in the treatment of acquired periodic alternating nystagmus. This form of spontaneous nystagmus beats in one direction for one to two minutes, followed by a null period, and continuation of nystagmus in the opposite direction for a similar length of time. Baclofen is an analogue of aminobutyric acid. Its mode of action is not fully understood; however, it inhibits monosynaptic and polysynaptic transmission at the spinal level, and also depresses the central nervous system. It is used for the symptomatic relief of muscular spasm caused by conditions such as multiple sclerosis and lesions of the spinal cord. 14 Our trial sug­ gests that baclofen may be a useful drug in the treatment of acquired nystagmus other than periodic alternating nystagmus.

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A 66-year-old woman with chronic openangle glaucoma was admitted to our service in order to control her intraocular pressure. Topi­ cal therapy with timolol maleate and dipivefrin had been insufficient. Oral administration of acetazolamide, 250 mg every six hours, was started. After the first dose the patient devel­ oped an anaphylactic shock with associated laryngeal edema and respiratory distress syn­ drome. Despite intensive care, the patient died. She had been taking no other medication and had no history of allergy or hypersensitivity. There have been other reports of adverse effects of acetazolamide. 1 · 2 The reaction in the patient we have described could have been attributable to a sulfonamide hypersensitivity caused by a cross-sensitivity with other drugs of this family, probably those used as bacteriostatics, since these pharmacologie agents were profusely used in our country for decades.

References References 1. Troost, B. T., Janton, F., and Weaver, R.: Period­ ic alternating oscillopsia. A symptom of alternating nystagmus abolished by baclofen. J. Clin. Neuro. Ophthalmol. 110:273, 1990. 2. Dibartolomeo, J. R., and Yee, R. D.: Periodic alternating nystagmus. Otolaryngol. Head Neck Surg. 99:552, 1988. 3. Carlow, T. J.: Medical treatment of nystagmus and ocular motor disorders. Int. Ophthalmol. Clin. 26:251, 1986. 4. Duncan, G. W., Shahani, B. T., and Young, R. R.: An evaluation of baclofen treatment for certain symptoms in patients with spinal cord lesions. Neu­ rology 26:441, 1976.

Anaphylactic Shock and Death After Oral Intake of Acetazolamide Jesus Peralta, M.D., José Abelairas, M.D., and José Fernândez-Guardiola, M.D. Service of Ophthalmology, Hospital La Paz. Inquiries to Jesus Peralta, M.D., Service of Ophthalmology, Hospital La Paz, 28046, Madrid, Spain.

1. Stock, J. G.: Sulfonamide hypersensitivity and acetazolamide. Arch. Ophthalmol. 108:634, 1990. 2. Spaeth, G. L.: Can the risk of acetazolamideinduced aplastic anemia be decreased by periodic monitoring of blood cell counts? Am. J. Ophthalmol. 105:325, 1988.

Lateral Tarsorrhaphy for a Noncompliant Patient With Floppy Eyelid Syndrome Charles S. Bouchard, M.D. Department of Ophthalmology, Loyola University Medical Center. Presented at the annual meeting of the Ocular Microbiology and Immunology Group, Anaheim, California, Oct. 12, 1991. Inquiries to Charles S. Bouchard, M.D., Department of Ophthalmology, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60153. Floppy eyelid syndrome is characterized by a chronic diffuse papillary conjunctivitis, easily everted upper eyelids, and nocturnal eyelid eversion. 1 Typically, overweight young men are affected. Treatment generally includes an eye shield at bedtime with topical lubricants, corticosteroids, or antibiotics. Horizontal full-thickness

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eyelid tightening procedures have also been advocated. 2,3 A 30-year-old, obese man was initially seen on Feb. 5, 1990, because of redness, tearing, and discharge in his left eye for one year. His visual acuity at that time was R.E.: 20/25 and L.E.: 20/60. The initial diagnosis was bacterial conjunctivitis. Despite several regimens with topical antibi­ otics and corticosteroide, the patient's symp­ toms persisted. On May 29,1990, a diagnosis of floppy eyelid syndrome was made. The patient was initially treated with eyelid taping at bed­ time. A Fox shield at bedtime and later prednisolone acetate and sulfacetamide drops were added to the regimen. His symptoms persisted. On Dec. 10, 1990, the patient underwent a pentagonal resection of the lateral third of his left upper eyelid. A characteristic chronic in­ flammatory infiltrate, decreased goblet cells, and keratinized stratified squamous epithelium were present. On March 19, 1991, the patient developed a superior corneal infiltrate. This was initially treated with polymyxin/trimethoprim drops six times a day. When the infiltrate progressed, he was referred to the Cornea Service. On initial examination on March 22, 1991, the patient had a 2.7 x 4.0-mm superior paralimbal infiltrate with an overlying epithelial defect (Fig. 1). His persistent eyelid distensibility was also still evident (Fig. 2). His visual acuity in the left eye was 20/200. He also had rosacea. Corneal cultures grew three colonies of coagulase-negative staphylococcal species. One colony was resistant to all the screening antibiotics except vancomycin.

Fig. 2 (Bouchard). Persistent eyelid distensibility three months after a pentagonal resection of the lateral third of the left upper eyelid. The superior corneal infiltrate is visible. Because of suspected noncompliance with the topical medications, the patient was eventually admitted three times between April 3 and May 20, 1991. During his hospitalization, the infil­ trate improved with frequent topical 2% vanco­ mycin drops and erythromycin ointment. The infiltrate recurred after each hospital discharge. Doxycycline was prescribed for his rosacea blepharoconjunctivitis. On May 20, 1991, a lateral tarsorrhaphy was performed. The decision to perform a tarsor­ rhaphy was made after multiple episodes of finding the patient sleeping on the affected side with his eyelid mechanically opened. His pal­ pebrai conjunctiva and globe were in direct contact with the pillow. The patient was last examined on Nov. 12, 1991. At that time the tarsorrhaphy was in place, and his visual acuity was 20/25 — 3. His cornea had a superior, white subepithelial and minimally vascularized scar. His tarsal con­ junctiva was still rubbery and diffusely mildly injected and smooth. His medications included erythromycin ointment at bedtime and fluorometholone, one drop a day.

References

Fig. 1 (Bouchard). A 2.7 x 4.0-mm superior corneal infiltrate with overlying epithelial defect.

1. Culbertson, W. W„ and Ostler, H. B.: The flop­ py eyelid syndrome. Am. J. Ophthalmol. 92:568, 1981. 2. Dutton, J. J.: Surgical management of floppy eyelid syndrome. Am. J. Ophthalmol. 99:557, 1985.

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3. Moore, M. B., Harrington, J., and McCulley, J. P.: Floppy eyelid syndrome management including surgery. Ophthalmology 93:184, 1986.

Fungal Keratitis After Radial Keratotomy Steven L. Maskin, M.D., and Eduardo Alfonso, M.D. Bascom Palmer Eye Institute, Department of Oph­ thalmology, University of Miami School of Medicine. Inquiries to Eduardo Alfonso, M.D., Bascom Palmer Eye Institute, P.O. Box 016880, Miami, FL 33101. A 35-year-old woman had a history of Crohn's disease that was treated with sulfasalazine. The patient had six-incisional radial kera­ totomy of both eyes; the right eye in October 1990, and the left eye in January 1991. Postoperatively the right eye had done well. However, two weeks postoperatively, the left eye became red and irritated while on a regimen of antibiot­ ic and corticosteroid drops. The surgeon noted an infiltrate in the central aspect of the 5 o'clock incision. The patient was treated with topical fortified cefazolin, fortified tobramycin, and dexamethasone without improvement. Cul­ tures yielded no growth. On March 6, 1991, the patient was referred to a corneal specialist be­ cause of continued irritation and pain. A diag­ nosis of crystalline keratopathy was made. The wound at the 5 o'clock incision was irrigated with vancomycin (50 mg/ml). Vancomycin (50 mg) and gentamicin (40 mg) were injected subconjunctivally, and the patient was given topi­ cal fortified cefazolin, fortified tobramycin, Neosporin, and fluorometholone 0.25%. Re­ peat cultures yielded no growth. On March 18, 1991, she was referred to Bascom Palmer Eye Institute for examination and treatment of per­ sistent keratitis. Visual acuity was 20/30 in the left eye. There was moderate bulbar conjunctival injection with ciliary flush. The 5 o'clock incision had a mid to deep stromal feathery white infiltrate with overlying epithelial defect (Figure). There were small keratic precipitates on the underlying endothelium. The anterior chamber was not inflamed. Tension was 16 mm Hg by pneumotonometry. The posterior seg­ ment was normal. The patient was admitted to the hospital after undergoing corneal scraping for smears and culture. Topical ciprofloxacin

Figure (Maskin and Alfonso). Stromal infiltrate with overlying epithelial defect at the 5 o'clock inci­ sion, three months after radial keratotomy. every 30 minutes was started. Cultures were positive for Candida parapsilosis. The patient was then treated with topical amphotericin B (0.5%), one drop every 30 minutes, and ketoconazole, 200 mg orally three times a day. The patient had daily epithelial scrapings while in the hospital to provide optimal penetration of the amphotericin B to the deep corneal stroma. By the fourth day of therapy, there was marked improvement in symptoms, as well as a de­ crease of the infiltrate. On follow-up examina­ tion, approximately one month later, she was symptom-free, with a best-corrected visual acuity of 20/20. The infiltrate was less dense with an intact epithelium. Amphotericin B, 0.5%, was tapered to every four hours and she continued the ketoconazole, 200 mg orally three times a day. Infectious keratitis is one of the most visually significant complications to occur after radial keratotomy surgery. Maintenance of good vi­ sion (greater than 20/40) relies on early identi­ fication and institution of appropriate thera­ py.1,2 Bacterial keratitis may occur early, within the first few postoperative weeks, or late.1,2 Early-onset cases are mainly caused by grampositive cocci (60%), whereas the majority of late-onset cases (62%) are caused by gramnegative rods. 2 The early onset of fungàl keratitis after radial keratotomy in our patient suggests the inoculum occurred during the in­ traoperative or early postoperative period. The routine use of postoperative topical corticosteroids may dispose the wounded cornea to growth of fungal organisms. Our patient had no

Lateral tarsorrhaphy for a noncompliant patient with floppy eyelid syndrome.

Vol. 114, No. 3 Letters to The Journal tal jerk nystagmus does not fall into a described classification. One condition, benign paroxys­ mal position...
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