366
AMERICAN JOURNAL OF OPHTHALMOLOGY
20/25 with a manifest refraction of +1.50 + 2.50 x 45 degrees. Descemet's membrane detachment is a welldescribed, unusual complication of cataract ex traction.1"3 Previously described maneuvers 4,6 to hasten the reattachment of Descemet's mem brane were unsuccessful in this case. The exten sive corneal edema that persisted after sutures were used to reappose Descemet's membrane prompted surgical intervention with penetrat ing keratoplasty. The exact mechanism of detachment of Des cemet's membrane in this case is unclear. The advent of small incision cataract surgery has allowed for rapid visual rehabilitation in many patients. However, a small incision may predis pose the patient to trauma at the edge of Desce met's membrane. The use of a foldable intraoc ular lens with an injector delivery device may increase the risk of Descemet's detachment from an internal corneal lip incision when there is a snug fit requiring some force on the part of the surgeon to introduce the instrument or the implant into the eye. Many small localized Descemet's detachments will spontaneously reattach. The use of a small incision with an internal corneal lip may make the risk of a localized Descemet's detachment more likely. A slight extension of the interior incision may decrease the incidence of trauma to Descemet's membrane.
References 1. Morrison, L. K., Talley, T. W., and Waltman, S. R.: Spontaneous detachment of Descemet's mem brane. Case report and literature review. Cornea 8:303, 1989. 2. Scheie, H. G.: Stripping of Descemet's mem brane in cataract extraction. Trans. Am. Ophthalmol. Soc. 62:140, 1964. 3. Merick, C: Descemet's membrane detachment treated by penetrating keratoplasty. Ophthalmic Surg. 22:753, 1991. 4. Sparks, G. M.: Descemetopexy. Surgical reat tachment of stripped Descemet's membrane. Arch. Ophthalmol. 78:31, 1967. 5. Donzis, P. B., Carzioglou, L. A., and Ensler, M. S.: Sodium hyaluronate in the surgical repair of Descemet's membrane detachment. Ophthalmic Surg. 17:735, 1987.
September, 1992
Treatment of Acquired Intermittent Horizontal Jerk Nystagmus With Baclofen Bruce A. M i l l e r , M.D., Deirdre A. Younger, B.S., and D a v i d S. Friendly, M.D. Department of Ophthalmology, George Washington University Medical Center (B.A.M., D.S.F.); and Children's National Medical Center (D.A.Y., D.S.F:). Inquiries to Bruce A. Miller, M.D., 3358 Second St. S., Arlington, VA 22204. A 6-year-old boy had a one-month history of "shaking eyes," according to his mother. The episodes occurred two to three times per day and lasted from seconds to over an hour. There did not seem to be an inciting event and the nystagmus resolved only after rest. Medical history included excision of a posterior fossa ependymoma in 1989 (two years before the onset of nystagmus) followed by adjuvant chemotherapy and radiotherapy. The patient was asymptomatic and tumor-free, as evi denced by recent magnetic resonance imaging scans. Examination during a recurrence of the nys tagmus disclosed a right beating, horizontal jerk nystagmus. A right face turn with left gaze was assumed by the patient to obtain a relative null zone. Binocular visual acuity was 20/40 + while nystagmus was present and 20/25 when it was absent. The direction of beating and the face turn were always the same. When the nystagmus was not present, the eye was normal in all respects. Because the patient's parents strongly de sired a trial of treatment, baclofen 1 ' 3 (which has been successful in the treatment of some forms of acquired nystagmus) was initiated. A total daily dose of 20 mg in four equally divided portions seemed to be best in a preliminary trial. The apparent success prompted a place bo-controlled trial involving 30 days of drug, 30 days of placebo, and appropriate washout periods. The patient's mother kept a detailed log of the number of episodes of nystagmus per day, including the duration and intensity of each episode. All three factors markedly de creased during the baclofen phase of the study when compared to the placebo phase. Horizontal jerk nystagmus is indicative of a disorder involving the vestibular system, but this particular acquired intermittent, horizon-
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.
367
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
AMERICAN JOURNAL OF OPHTHALMOLOGY
20/25 with a manifest refraction of +1.50 + 2.50 x 45 degrees. Descemet's membrane detachment is a welldescribed, unusual complication of cataract ex traction.1"3 Previously described maneuvers 4,6 to hasten the reattachment of Descemet's mem brane were unsuccessful in this case. The exten sive corneal edema that persisted after sutures were used to reappose Descemet's membrane prompted surgical intervention with penetrat ing keratoplasty. The exact mechanism of detachment of Des cemet's membrane in this case is unclear. The advent of small incision cataract surgery has allowed for rapid visual rehabilitation in many patients. However, a small incision may predis pose the patient to trauma at the edge of Desce met's membrane. The use of a foldable intraoc ular lens with an injector delivery device may increase the risk of Descemet's detachment from an internal corneal lip incision when there is a snug fit requiring some force on the part of the surgeon to introduce the instrument or the implant into the eye. Many small localized Descemet's detachments will spontaneously reattach. The use of a small incision with an internal corneal lip may make the risk of a localized Descemet's detachment more likely. A slight extension of the interior incision may decrease the incidence of trauma to Descemet's membrane.
References 1. Morrison, L. K., Talley, T. W., and Waltman, S. R.: Spontaneous detachment of Descemet's mem brane. Case report and literature review. Cornea 8:303, 1989. 2. Scheie, H. G.: Stripping of Descemet's mem brane in cataract extraction. Trans. Am. Ophthalmol. Soc. 62:140, 1964. 3. Merick, C: Descemet's membrane detachment treated by penetrating keratoplasty. Ophthalmic Surg. 22:753, 1991. 4. Sparks, G. M.: Descemetopexy. Surgical reat tachment of stripped Descemet's membrane. Arch. Ophthalmol. 78:31, 1967. 5. Donzis, P. B., Carzioglou, L. A., and Ensler, M. S.: Sodium hyaluronate in the surgical repair of Descemet's membrane detachment. Ophthalmic Surg. 17:735, 1987.
September, 1992
Treatment of Acquired Intermittent Horizontal Jerk Nystagmus With Baclofen Bruce A. M i l l e r , M.D., Deirdre A. Younger, B.S., and D a v i d S. Friendly, M.D. Department of Ophthalmology, George Washington University Medical Center (B.A.M., D.S.F.); and Children's National Medical Center (D.A.Y., D.S.F:). Inquiries to Bruce A. Miller, M.D., 3358 Second St. S., Arlington, VA 22204. A 6-year-old boy had a one-month history of "shaking eyes," according to his mother. The episodes occurred two to three times per day and lasted from seconds to over an hour. There did not seem to be an inciting event and the nystagmus resolved only after rest. Medical history included excision of a posterior fossa ependymoma in 1989 (two years before the onset of nystagmus) followed by adjuvant chemotherapy and radiotherapy. The patient was asymptomatic and tumor-free, as evi denced by recent magnetic resonance imaging scans. Examination during a recurrence of the nys tagmus disclosed a right beating, horizontal jerk nystagmus. A right face turn with left gaze was assumed by the patient to obtain a relative null zone. Binocular visual acuity was 20/40 + while nystagmus was present and 20/25 when it was absent. The direction of beating and the face turn were always the same. When the nystagmus was not present, the eye was normal in all respects. Because the patient's parents strongly de sired a trial of treatment, baclofen 1 ' 3 (which has been successful in the treatment of some forms of acquired nystagmus) was initiated. A total daily dose of 20 mg in four equally divided portions seemed to be best in a preliminary trial. The apparent success prompted a place bo-controlled trial involving 30 days of drug, 30 days of placebo, and appropriate washout periods. The patient's mother kept a detailed log of the number of episodes of nystagmus per day, including the duration and intensity of each episode. All three factors markedly de creased during the baclofen phase of the study when compared to the placebo phase. Horizontal jerk nystagmus is indicative of a disorder involving the vestibular system, but this particular acquired intermittent, horizon-
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.
367
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
