504
October, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
References
Fig. 2 (Gupta and Basti). Healed scierai defect and resolved corneal infiltrate. steroids continuously for a month, the disk margins became more distinct, and the macular edema progressively decreased. When the pa tient was last seen, her visual acuity in the left eye was 20/70, improving to 20/30 with pinhole. The eye was not inflamed, the scierai and corneal lesions had healed (Fig. 2), and intraoc ular pressure was 10 mm Hg. Ophthalmoscopy disclosed clear vitreous, a normal-appearing disk and macula, and trace edema over the superior and inferior peripapillary retina. We started anti-infective agents under the presumptive diagnosis of an infective cause. Retrospectively, lack of response to this treat ment and failure to isolate any organisms prompted us to consider a toxic origin. This contention was supported by rapid improve ment after instillation of corticosteroids. The corneal haze precluded accurate assessment of the fundus. Clearing of the haze permitted diagnosis of the fundus findings. We postulated that the area of extreme scierai thinning caused by mitomycin was the portal through which mitomycin entered the vitreous cavity. Its toxic ity on the ciliary body, vitreous, and retina probably caused the hypotony, vitreitis, macu lar edema, and disk changes. Although anterior segment complications have been seen clinically after mitomycin C therapy, 13 its ciliary body and vitreoretinal tox icity has been described in studies on rabbits. 4,5 Considering the disastrous consequences that can ensue with misuse, application of mitomy cin intraoperatively at the site of pterygium excision appears to be safer than its postopera tive use.
1. Singh, G., Wilson, M. R., and Foster, C. S.: Mi tomycin eye drops as treatment for pterygium. Oph thalmology 95:813, 1988. 2. Hayasaka, S., Noda, S. N., Yamamoto, Y., and Setogawa, T.: Postoperative instillation of low-dose mitomycin C in the treatment of primary pterygium. Am. J. Ophthalmol. 106:715, 1988. 3. Dunn, J. P., Seamone, C. D., Ostler, B. H., Nick el, B. L., and Beallo, A.: Development of scierai ulcération and calcification after pterygium excision and mitomycin therapy. Am. J. Ophthalmol. 112:343, 1991. 4. Peyman, G. A., Greenberg, D., Fishman, G. A., Fiscella, R., and Thomas, A.: Evaluation of toxicity of intravitreal antineoplastic drugs. Ophthalmic Surg. 15:411, 1984. 5. Derick, R. J., Pasquale, L., Quigley, H. A., and Jampel, H.: Potential toxicity of mitomycin C\ Arch. Ophthalmol. 109:1635, 1991.
Pure Ocular Blast Injury Itzchak Beiran, M.D., and Benjamin Miller, M.D.
Department of Ophthalmology, Rambam Medical Center (LB., B.M.) and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology (B.M.). Inquiries to Benjamin Miller, M.D., Department of Ophthalmology, Rambam Medical Center, P.O.B. 9602, 31096 Haifa, Israel. The term "blast injury" refers to damage caused to body organs by a shock wave origi nating in an explosion and propagating in a given medium. When the shock wave moves between body spaces, it produces spelling in the interphases inside the body, which causes the expulsion of blood through the capillary wall. Explosion damage is dependent upon dis tance: wave intensity is decreased to a third power of the distance from its source. 1 A 20-year-old healthy man was admitted to our department after being exposed to an ex plosive powder explosion, estimated at 500 kg, from a distance of about 90 m. The patient remained fully conscious and on his feet throughout the explosion event. Three persons standing near him suffered blast injury to their ears and could testify that there was clearly no additional traumatic impact on the patient's
Vol. 114, No. 4
Letters to The Journal
eye. On admission (half an hour after expo sure), the patient complained of mild blurring of vision in his left eye. Visual acuity was R.E.: 20/20 and L.E.: 20/30. The right eye was nor mal. The left eye had conjunctival and ciliary injection. Intraocular pressure was 10 mm Hg. The cornea was clear, with Descemet's folds. The anterior chamber was of normal depth, with a hyphema 3 mm high and multiple float ing erythrocytes. The pupil was round, regular, and reactive to light. The lens was in place and clear. The fundus was normal. Results of computed tomography of both or bits and the brain were normal. During hospitalization, when the patient got up for slit-lamp examination, three events of rebleeding oc curred from a vessel at the root of the iris, located at the 11 o'clock meridian. After eight days of strict bed rest, no rebleeding was ob served. The patient was discharged after 18 days' hospitalization. The only medications were locally applied corticosteroids adminis tered during hospitalization and thereafter. At discharge from the hospital, visual acuity in the patient's left eye was 20/20. Intraocular pressure was 16 mm Hg. A blood clot was observed temporally on the iris, the pupil was nearly round, and pigment particles were seen on the anterior surface of the lens. Results of the remainder of the examination were normal. During a three-month follow-up, the blood clot disappeared, and angle recession of nearly 180 degrees of the lower circumference was observed. In all patients reported to suffer from hy phema, or angle recession, or both, after being exposed to nearby explosion, foreign bodies were found in cornea or eyelids, or corneal lacerations were observed.2"4 The resulting damage in these cases was thought to be a consequence of both the pressure wave and the effect of the foreign body. 4 In a case report 5 of injuries caused to various parts of the eye by exploding letter bombs, propagation of high-pressure wave in the ante rior chamber was believed to cause damage, although in all three patients foreign bodies, or contusion of the eyeball by a solid object, or both, were clearly evident, and there was no way to differentiate the effect of the blast from the contribution of the foreign body/contusion to the ocular damage. Our case is unique because the ocular damage in this instance was the result of blast injury alone. No foreign body or blunt trauma to the
505
eye by any solid object was found. The presence of blast wave was clearly proven by the auditory blast injury caused to three other persons standing close to our patient at the moment of explosion.
References 1. Wiener, S. L., and Barrett, J. (eds.): Explosions and explosive device-related injuries. In Trauma Management for Civilian and Military Physicians. Philadelphia, W. B. Saunders, 1986, pp. 13-26. 2. Moore, A. T„ Cheng, H., and Boase, D. L.: Eye injuries from car battery explosions. Br. J. Ophthalmol. 66:141, 1982. 3. Vernon, S. A.: Fireworks and the eye. J. R. Soc. Med. 81:569, 1988. 4. Queie, M. A., Bouchât, } . , and Cornand, G.: Ocular blast injuries. Am. J. Ophthalmol. 67:64, 1969. 5. Jamra, F. A., Halasa, A., and Salman, S.: Letter bomb injuries. A report of three cases. J. Trauma 14:275, 1974.
Mild Frosted Branch Periphlebitis D a v i d J. Browning, M.D. Inquiries to David }. Browning, M.D., 1600 E. Third St., Charlotte, NC 28204. In 1976, frosted branch periphlebitis was first described as a bilateral retinal vasculitis in a 6-year-old boy. 1 Subsequent reports have de fined the syndrome as involving otherwise healthy young patients with variable degrees of iritis and vitreitis, dramatic venous sheathing, variable degrees of retinal hemorrhage and edema, optic disk edema, and marked permea bility of retinal veins on fluorescein angiography. 2,3 Laboratory study results are generally normal. Sugin and associates 4 enlarged the de scription of the syndrome by reporting two unilateral cases. All of these authors1"4 have treated and emphasize the need to treat pa tients with systemic corticosteroids to reverse and prevent possible visual loss. I encountered a unilateral case in which no systemic cortico steroids were used and in which the outcome was excellent, suggesting a broader spectrum of severity than previously reported in this dis ease.
October, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
References
Fig. 2 (Gupta and Basti). Healed scierai defect and resolved corneal infiltrate. steroids continuously for a month, the disk margins became more distinct, and the macular edema progressively decreased. When the pa tient was last seen, her visual acuity in the left eye was 20/70, improving to 20/30 with pinhole. The eye was not inflamed, the scierai and corneal lesions had healed (Fig. 2), and intraoc ular pressure was 10 mm Hg. Ophthalmoscopy disclosed clear vitreous, a normal-appearing disk and macula, and trace edema over the superior and inferior peripapillary retina. We started anti-infective agents under the presumptive diagnosis of an infective cause. Retrospectively, lack of response to this treat ment and failure to isolate any organisms prompted us to consider a toxic origin. This contention was supported by rapid improve ment after instillation of corticosteroids. The corneal haze precluded accurate assessment of the fundus. Clearing of the haze permitted diagnosis of the fundus findings. We postulated that the area of extreme scierai thinning caused by mitomycin was the portal through which mitomycin entered the vitreous cavity. Its toxic ity on the ciliary body, vitreous, and retina probably caused the hypotony, vitreitis, macu lar edema, and disk changes. Although anterior segment complications have been seen clinically after mitomycin C therapy, 13 its ciliary body and vitreoretinal tox icity has been described in studies on rabbits. 4,5 Considering the disastrous consequences that can ensue with misuse, application of mitomy cin intraoperatively at the site of pterygium excision appears to be safer than its postopera tive use.
1. Singh, G., Wilson, M. R., and Foster, C. S.: Mi tomycin eye drops as treatment for pterygium. Oph thalmology 95:813, 1988. 2. Hayasaka, S., Noda, S. N., Yamamoto, Y., and Setogawa, T.: Postoperative instillation of low-dose mitomycin C in the treatment of primary pterygium. Am. J. Ophthalmol. 106:715, 1988. 3. Dunn, J. P., Seamone, C. D., Ostler, B. H., Nick el, B. L., and Beallo, A.: Development of scierai ulcération and calcification after pterygium excision and mitomycin therapy. Am. J. Ophthalmol. 112:343, 1991. 4. Peyman, G. A., Greenberg, D., Fishman, G. A., Fiscella, R., and Thomas, A.: Evaluation of toxicity of intravitreal antineoplastic drugs. Ophthalmic Surg. 15:411, 1984. 5. Derick, R. J., Pasquale, L., Quigley, H. A., and Jampel, H.: Potential toxicity of mitomycin C\ Arch. Ophthalmol. 109:1635, 1991.
Pure Ocular Blast Injury Itzchak Beiran, M.D., and Benjamin Miller, M.D.
Department of Ophthalmology, Rambam Medical Center (LB., B.M.) and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology (B.M.). Inquiries to Benjamin Miller, M.D., Department of Ophthalmology, Rambam Medical Center, P.O.B. 9602, 31096 Haifa, Israel. The term "blast injury" refers to damage caused to body organs by a shock wave origi nating in an explosion and propagating in a given medium. When the shock wave moves between body spaces, it produces spelling in the interphases inside the body, which causes the expulsion of blood through the capillary wall. Explosion damage is dependent upon dis tance: wave intensity is decreased to a third power of the distance from its source. 1 A 20-year-old healthy man was admitted to our department after being exposed to an ex plosive powder explosion, estimated at 500 kg, from a distance of about 90 m. The patient remained fully conscious and on his feet throughout the explosion event. Three persons standing near him suffered blast injury to their ears and could testify that there was clearly no additional traumatic impact on the patient's
Vol. 114, No. 4
Letters to The Journal
eye. On admission (half an hour after expo sure), the patient complained of mild blurring of vision in his left eye. Visual acuity was R.E.: 20/20 and L.E.: 20/30. The right eye was nor mal. The left eye had conjunctival and ciliary injection. Intraocular pressure was 10 mm Hg. The cornea was clear, with Descemet's folds. The anterior chamber was of normal depth, with a hyphema 3 mm high and multiple float ing erythrocytes. The pupil was round, regular, and reactive to light. The lens was in place and clear. The fundus was normal. Results of computed tomography of both or bits and the brain were normal. During hospitalization, when the patient got up for slit-lamp examination, three events of rebleeding oc curred from a vessel at the root of the iris, located at the 11 o'clock meridian. After eight days of strict bed rest, no rebleeding was ob served. The patient was discharged after 18 days' hospitalization. The only medications were locally applied corticosteroids adminis tered during hospitalization and thereafter. At discharge from the hospital, visual acuity in the patient's left eye was 20/20. Intraocular pressure was 16 mm Hg. A blood clot was observed temporally on the iris, the pupil was nearly round, and pigment particles were seen on the anterior surface of the lens. Results of the remainder of the examination were normal. During a three-month follow-up, the blood clot disappeared, and angle recession of nearly 180 degrees of the lower circumference was observed. In all patients reported to suffer from hy phema, or angle recession, or both, after being exposed to nearby explosion, foreign bodies were found in cornea or eyelids, or corneal lacerations were observed.2"4 The resulting damage in these cases was thought to be a consequence of both the pressure wave and the effect of the foreign body. 4 In a case report 5 of injuries caused to various parts of the eye by exploding letter bombs, propagation of high-pressure wave in the ante rior chamber was believed to cause damage, although in all three patients foreign bodies, or contusion of the eyeball by a solid object, or both, were clearly evident, and there was no way to differentiate the effect of the blast from the contribution of the foreign body/contusion to the ocular damage. Our case is unique because the ocular damage in this instance was the result of blast injury alone. No foreign body or blunt trauma to the
505
eye by any solid object was found. The presence of blast wave was clearly proven by the auditory blast injury caused to three other persons standing close to our patient at the moment of explosion.
References 1. Wiener, S. L., and Barrett, J. (eds.): Explosions and explosive device-related injuries. In Trauma Management for Civilian and Military Physicians. Philadelphia, W. B. Saunders, 1986, pp. 13-26. 2. Moore, A. T„ Cheng, H., and Boase, D. L.: Eye injuries from car battery explosions. Br. J. Ophthalmol. 66:141, 1982. 3. Vernon, S. A.: Fireworks and the eye. J. R. Soc. Med. 81:569, 1988. 4. Queie, M. A., Bouchât, } . , and Cornand, G.: Ocular blast injuries. Am. J. Ophthalmol. 67:64, 1969. 5. Jamra, F. A., Halasa, A., and Salman, S.: Letter bomb injuries. A report of three cases. J. Trauma 14:275, 1974.
Mild Frosted Branch Periphlebitis D a v i d J. Browning, M.D. Inquiries to David }. Browning, M.D., 1600 E. Third St., Charlotte, NC 28204. In 1976, frosted branch periphlebitis was first described as a bilateral retinal vasculitis in a 6-year-old boy. 1 Subsequent reports have de fined the syndrome as involving otherwise healthy young patients with variable degrees of iritis and vitreitis, dramatic venous sheathing, variable degrees of retinal hemorrhage and edema, optic disk edema, and marked permea bility of retinal veins on fluorescein angiography. 2,3 Laboratory study results are generally normal. Sugin and associates 4 enlarged the de scription of the syndrome by reporting two unilateral cases. All of these authors1"4 have treated and emphasize the need to treat pa tients with systemic corticosteroids to reverse and prevent possible visual loss. I encountered a unilateral case in which no systemic cortico steroids were used and in which the outcome was excellent, suggesting a broader spectrum of severity than previously reported in this dis ease.
