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Purpose To describe two patients who developed scleral thinning as a late complication of scleral tunnel incision for cataract extraction. Design Observational case report and interventional case report. Methods A 75-year-old man had an asymptomatic gray-brown subconjunctival nodule in the location of the healed scleral tunnel incision for cataract surgery. A 62-year-old man had a biopsy of a brown conjunctival nodule at the site of a scleral tunnel incision for cataract surgery. Results The 75-year-old patient with prolapsed uveal tissue was followed up for 4 years without change in the wound defect. The 62-year-old patient had a biopsy because the exposed ciliary body mimicked a melanoma. Conclusions Scleral defects with herniated uveal tissue as a late sequela of scleral tunnel incision for cataract surgery should be differentiated from melanoma and can be safely observed for years when covered by conjunctiva.

Purpose To determine the feasibility of a case-control study of phosphodiesterase (PDE)-5 inhibitors and nonarteritic ischemic optic neuropathy (NION). Design Retrospective cohort study using the National Veterans Health Administration's pharmacy and clinical databases. Methods setting: National database. patient population: Male veterans 50 years of age and older with newly diagnosed NION or "possible" NION. interventional procedure: Dispensed prescription for a PDE-5 inhibitor. outcome measure: Incidence of NION and "possible" NION based on exposure to PDE-5 inhibitors. Results The relative risk of NION among men prescribed a PDE-5 inhibitor was 1.02 (95% confidence interval [CI]: 0.92 to 1.12). The relative risk of possible NION among men prescribed a PDE-5 inhibitor was 1.34 (95% CI: 1.17 to 1.55). Conclusions The collective risk of NION and possible NION was marginally significant (relative risk [RR] 1.10 95% CI: 1.02 to 1.20). A case-control study, in which the dependent variable is NION and the effect size of the PDE-5 inhibitor is assumed small, is feasible.

Purpose To determine if topical gel is superior to subconjunctival injection of lidocaine in relieving pain of intravitreous injection of corticosteroid. Design Randomized clinical trial. Methods patient population: One hundred patients receiving intravitreous injection of triamcinolone. interventional procedure: Topical lidocaine 2% gel and subconjunctival lidocaine 2% injection. outcome measure: Analog pain score assessment, conducted by technician masked to treatment. Results There was no statistically significant difference in pain scores between the treatment groups ( P = .1). Conclusions The effective relief of pain with lidocaine for intravitreous injection is independent of its mode of application (gel vs subconjunctival injection).

PURPOSE: To describe the circumstances associated with eye injury from an ocular examination of two patients with Tourette syndrome. DESIGN: Case reports. METHODS: A 21-year-old man and a 24-year-old man had sudden and unpredictable movement during an eye examination, causing conjunctival laceration and hemorrhage abrasion in the first patient and a corneal abrasion in the second patient. RESULTS: With topical antibiotics for both patients and patching of the eye for the 24-year-old patient, healing was uncomplicated. CONCLUSIONS: Patients with Tourette syndrome are at risk of eye injury when an unanticipated tic movement occurs during eye examination. Physician precautions, particularly mental preparedness for sudden jerking movement, should be taken when examining patients with Tourette syndrome.

PURPOSE: To describe the capsular bag distention syndrome after combined cataract extraction with posterior lens implant and aqueous drainage device. METHODS: Case report. RESULTS: A persistently shallow anterior chamber and low intraocular pressure developed after combined cataract extraction with posterior chamber lens implant and Ahmed aqueous drainage device. An optically empty space between the lens implant and posterior capsule was detected 18 days after surgery. The anterior chamber deepened within minutes after Nd:YAG posterior capsulotomy. CONCLUSION: The capsular bag distention syndrome needs to be included in the differential diagnosis of shallow anterior chamber with low intraocular pressure after combined cataract extraction and glaucoma valve implant surgery.

PURPOSE: To determine interobserver agreement for classifying choroidal neovascular membranes in age-related macular degeneration. METHODS: Six fluorescein angiograms of choroidal neovascular membranes were interpreted by 21 retina specialists. Reliability was measured by percent agreement and kappa coefficient. RESULTS: Interobserver agreement of membrane types ranged from perfect concordance for a small, classic membrane to near-random classification for a complex pattern. Mean kappa coefficient was .64. Interobserver agreement of membrane size was most variable for intermediate size lesions (mean kappa coefficient = .40). CONCLUSION: Fluorescein angiographic interpretation of choroidal neovascular membrane type and size can vary considerably. Interobserver agreement is better for membrane type than for membrane size.

Objective To test the hypothesis that a subset of conjunctival melanocytic proliferations exists that cannot be reproducibly classified as benign, malignant, or indeterminate. Methods Three groups of excisional biopsy specimens of conjunctival melanocytic proliferations were evaluated by a panel of 5 ophthalmic pathologists. These groups included lesions that we considered to represent benign (group 1 [n=5]), malignant (group 2 [n=5]), and indeterminate melanocytic proliferations (group 3 [n=5]). The panel classified the same sections in all 3 groups in a randomized, masked fashion, first without and then with a clinical history of patient age, sex, and race. The κ statistic was used to quantify the degree of agreement among observers. Results There was strong concordance among the panel members for both group 1 (benign [κ=0.76]) and group 2 (malignant [κ=0.70]) melanocytic proliferations. There was no concordance of the panel for group 3 (indeterminate) lesions (κ=−0.045). The concordance for groups 1 and 2 and lack of concordance for group 3 lesions were independent of knowledge of clinical history of age, sex, and race. Conclusion A subset of melanocytic proliferations of the conjunctiva exists that cannot be reproducibly classified by pathologists as benign, malignant, or indeterminate.

PURPOSE: To describe four patients who developed cystoid macular edema shortly after onset of treatment with latanoprost. METHOD: Retrospective review of medical records of patients with open-angle glaucoma who developed cystoid macular edema shortly after starting latanoprost. RESULTS: The use of topical latanoprost was temporally related to the development of cystoid macular edema in four patients (six eyes; two aphakic eyes and four pseudophakic eyes). Cystoid macular edema resolved in all patients after latanoprost was discontinued. CONCLUSIONS: Cystoid macular edema is a potential complication of latanoprost therapy. Further observations are needed to determine if the risk of cystoid macular edema is limited to or greatest in patients who are pseudophakic or aphakic.

Purpose To report the anatomic location of bilateral dome-shaped posterior pole hemorrhages in a patient with Terson syndrome. Methods Case report. We performed bilateral vitrectomy for vitreous hemorrhage in a patient with Terson syndrome. After removal of vitreous hemorrhage, the tissue overlying a large discrete hemorrhage in the posterior pole was removed, and the tissue from one eye was examined histologically. Result The discrete dome-shaped hemorrhage in the posterior pole was confined to the retina anteriorly by the internal limiting membrane. Conclusion Large dome-shaped retinal hemorrhages with Terson syndrome can be located beneath the internal limiting membrane of the retina.

Purpose To describe the ocular involvement in xanthoma disseminatum. Design Case report and literature review. Methods Histopathologic study of excised conjunctival tumor and clinical follow-up. Results A 29-year-old woman with normal serum lipoproteins developed widespread xanthomas of the skin, throat, and episclera. There were no signs of recurrence 12 months after removal of the conjunctival xanthomas. Conclusions Xanthoma dissseminatum is a rare condition for which there is no medical treatment. The distinction between the normolipemic xanthomatoses awaits a better understanding of their pathogenesis. Surgical removal of episcleral xanthomas can be successful, but long-term follow-up of such patients has been limited.

To describe the clinical and histopathologic findings in four eyes of three patients who became blind because of multifocal choroiditis and massive subretinal fibrosis.Clinicopathologic correlative study.During a period of several years, three healthy elderly patients developed severe visual loss only partly explained by multifocal chorioretinitis and massive subretinal fibrosis. Histopathologic examination of four eyes from these patients disclosed widespread destruction of the outer retina and retinal pigment epithelium, massive areas of subretinal fibrous tissue proliferation, granulomatous inflammation centered around degenerated and fragmented Bruch's membrane, and chronic uveitis. No infectious organisms were identified by special stains or electron microscopy in one eye.Clinical and histopathologic findings in these three patients were consistent with an autoimmune disease process directed at the retina, retinal pigment epithelium, inner choroid, or all three. Cellular injury in this location can result in massive subretinal fibrosis. Subretinal fibroplasia, however, is probably a nonspecific reparative response to injury. The pathogenesis of this blinding disorder in elderly patients may be similar to the less severe disease usually occurring in younger patients with multifocal choroiditis, panuveitis, and punctate inner choroiditis.

Anatomic features unique to periocular tissues alter the clinical appearance of angioedema, making it difficult to distinguish from cellulitis and other inflammatory conditions. Two patients had prominent periocular manifestations of chronic angioedema with necrotizing vasculitis, a systemic disease often associated with multiorgan involvement. The diagnosis was established by exclusion of other inflammatory disorders and confirmed by biopsy. The scarcity of reports in the ophthalmic literature on chronic angioedema of the eyelids may be caused by its underrecognition. The distinction between chronic angioedema and typical angioedema or urticaria is important because of differences in their diagnostic evaluation, treatment, and prognosis.

plaque was gritty and firmly adherent to the underlying sclera. The adjacent conjunctiva was slightly raised and injected. The cornea was clear. Results of the remainder of the ocular examination were normal. The plaque was removed under local anesthe­ sia. The underlying sclera was intact and the area healed uneventfully. Histopathologically the plaque stained with Alizarin red, suggest­ ing that it was calcific. Mitomycin inhibits the synthesis of DNA, RNA, and protein. Several studies have demon­ strated that topical mitomycin reduces recur­ rence rates after pterygium excision.v" Compli­ cations include pain, photophobia, lacrimation, foreign-body sensation, and noninfectious scleral ulceration. Regimens of mitomycin 0.02%, twice daily for five days," or 0.04% four times daily for two weeks," have been reported to reduce recurrence rates with only mild and temporary side effects. Scleral calcification attributable to mitomycin has been previously described in the Japanese literature." Intramural bladder calcification was reported after bladder irrigation with mitomy­ cin for treatment of superficial bladder cancer.' Although the pathogenesis of calcification is not known, it may represent an extreme form of mitomycin-induced degenerative changes in the tissue. We report this case to alert ophthalmologists to another potential complication of topical mitomycin therapy after pterygium excision.

PURPOSE: To determine the accuracy, specificity, and sensitivity of the clinical diagnosis of malignant tumor of the eyelid. METHOD: Analysis of consecutively submitted biopsy specimens of the eyelid for 1 year to a regional ophthalmic pathology laboratory. RESULTS: Agreement was noted between clinical and histopathologic diagnoses on 72 (84%) of 86 eyelid biopsy specimens received over 12 months. Ten (11.6%) clinical diagnoses of suspected malignant eyelid tumor showed benign skin conditions, and four (4.6%) clinical diagnoses of presumed benign conditions proved to be malignant. CONCLUSIONS: The clinical assessment of eyelid malignancy by ophthalmologists is reasonably good when evaluated in terms of sensitivity (87.5%) and specificity (81.5%) of diagnosis. Lesions giving rise to the false-negative diagnosis of malignancy tend to be nodules with unremarkable surface features.

Purpose: To describe a patient with an acute conjunctival and periocular reaction after blood transfusion. Methods: Case report and literature review. Results: A 67-year-old woman sustained a self-limited periocular reaction characterized by bilateral turgescence and redness of the conjunctiva and eyelids after blood transfusion. More than 100 similar reactions of this type have been reported by the Centers for Disease Control and Prevention. Conclusions: The cause of this periocular transfusion reaction is unclear, but this type of reaction is being investigated by the Centers for Disease Control and Prevention. This case suggests that mild transfusion complications, even if unusual, may be under-reported.

Purpose To report a case of an acquired capillary hemangioma of the eyelid in an adult. Methods A 38-year-old man developed a discrete blue nodular mass in the lower eyelid. The lesion grew slowly for 6 months and then remained stable in size. Excisional biopsy was performed. Result Histopathologic examination of an excisional biopsy specimen of the nodular mass disclosed a capillary hemangioma. Conclusions Capillary hemangioma of the eyelid can occur in adults but should be distinguished from other acquired vascular lesions, including angiosarcoma.

September 1992, visual acuity was 20/30, and there was no vitreous activity. Organ transplantation and subsequent immunosuppression are associated with an increased incidence of malignancy. I A number of lymphoproliferative disorders may occur after transplant, with B-celllymphoma the commonest. The mechanism for this is not understood, but Epstein-Barr virus has been implicated. Lymphomas develop quicker after transplantation in patients treated with cyclosporine," but less often involve the central nervous system. Intraocular malignant B-cell lymphoma is rare, with involvement usually occurring in the form of primary lymphoma of the central nervous system. In many cases, tumor cells in the vitreous masquerade as intraocular inflammation. Bilateral disease occurs in 80%, with central nervous system lymphoma developing in 15% to 80% of patients. Although lymphoma (reticulum cell sarcoma) has been documented in a renal transplant patient with an unresponsive vitreitis," there has been a report of posttransplant intraocular lymphoma as a result of cyclosporine immunosuppression.' This event occurred in a cardiac transplant patient in whom the diagnosis was made at autopsy. Benign lymphoproliferation, in the form of bilateral iris tumors associated with a granulomatous iridocyclitis, has also been described in a liver transplant patient on a regimen of cyclosporine.'