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Sarcoid-like granulomas are a rare adverse effect of TNF-α inhibitors that are becoming increasingly reported in the literature. A retrospective study in France estimated this adverse effect to occur in 0.04% patients. We report an important reversible cause that is more commonly being seen.A 70 year old lady presented with multiple lesions on her lids in the ophthalmology clinic. Histology confirmed that they were sarcoid-like granulomas. The patient had been started on etanercept (anti-TNF agent) a few months prior for rheumatoid arthritis. Investigations were undertaken to rule out differentials such as autoimmune conditions and infective causes like tuberculosis.After ruling out an active inflammatory disease and an autoimmune cause, etanercept induced granulomas were considered. Etanercept was stopped. This resulted in the resolution of granulomas over the course of a few months.Etanercept induced granulomas resolve when the anti-TNF agent is discontinued; however, some patients may require treatment with steroids.As this case demonstrates, ophthalmologists should be aware that anti-TNF agents can cause non-caseating granulomas, which can be cutaneous or pulmonary. This can help to result in more prompt diagnoses and appropriate treatment.

Rosalind MK Stewart1, Say Aun Quah1, Dan Q Nguyen2, Stephen B Kaye11Royal Liverpool University Hospital, Liverpool, UK; 2Bristol Eye Hospital, Bristol, UKPurpose: To report a case of severe conjunctival-corneal melt in association with carotid artery stenosis.Methods: Observational case report.Results: A 76-year-old man with a history of bilateral severe carotid artery occlusion and nonarteritic ischemic optic neuropathy developed a spontaneous bulbar conjunctival defect. Despite intensive lubrication, and attempts at surgical closure including an amniotic membrane patch graft, it progressed with subsequent adjacent corneal perforation. Thorough investigations revealed no underlying disease, except markedly delayed episcleral vessel filling on anterior segment fluorescein angiography.Conclusions: Neovascularisation is a known factor in the inhibition of ulceration. In light of the findings in this report, ocular ischemia should be considered as a cause or contributing factor in the differential diagnosis of conjunctival-corneal melt.Keywords: conjunctival melt, corneal melt, ocular ischemia, carotid artery stenosis

Purpose To report two cases of refractory vernal ulcers in which the fitting of a large-diameter (22 mm) hydrogel (Contaflex T75) bandage contact lens (BCL) ameliorated the signs and symptoms of the condition. Methods Two patients with refractory vernal ulcers are described. Mechanisms of the effect of a large-diameter lens across the ocular surface are discussed in this condition. Results The first patient is a 10-year-old boy who had been treated unsuccessfully for a left vernal corneal ulcer with topical prednisolone 0.5% and olopatadine. The vernal ulcer resolved 2 weeks after the fitting of a large-diameter BCL. The second patient is a 4-year-old boy who had been intolerant of all his previous topical medications partly because of his ocular discomfort in association with the right vernal ulcer. A large-diameter BCL was fitted in his right eye. The BCL was removed 2 weeks later with complete healing of the corneal vernal ulcer. Owing to his improved comfort, the patient was able to tolerate topical prednisolone 0.5% drops. Conclusions Large-diameter BCLs may be a useful treatment option in the management of refractory vernal ulcers.

A 35-year-old man presented with keratoconus; his best corrected visual acuities were −18.00/+10.00 ×180 (6/60) oculus dexter and −10.00/+8.00 ×5 (6/36) oculus sinister. Bilateral steep central corneal thinning, paracentral ectasia and Vogts striae were present. Normal fundi. Corneal topography disclosed 7.4 dioptres of irregular astigmatism in the central 3 mm with thinning (335 μm). Electroretinography (ERG) showed no response. There were no medical or environmental influences for his keratoconus. Occurrence of keratoconus and congenital stationary night blindness (CSNB) in the patient may represent a chance association, but keratoconus has not been previously linked with CSNB1 either as a chance or true association though both show genetic predisposition.

A 35-year-old man with best corrected visual acuities of −18.00/+10.00×180 (6/60) OD and −10.00/+8.00×5 (6/36) OS. Bilateral steep central corneal thinning, paracentral ectasia and Vogts striae were present; normal fundi. Corneal topography disclosed 7.4 dioptres of irregular astigmatism in the central 3 mm with thinning (335 μm). Electroretinography (ERG) showed no response. There were no medical or environmental influences for his keratoconus. Occurrence of keratoconus and CSNB in the patient may represent a chance association, but keratoconus has not been previously linked with CSNB1 either as a chance or true association though both show genetic predisposition.

A 62-year-old man presented with bilateral diffuse uveal melanocytic proliferations (BDUMP) and painful flexor contractures of the fingers of both hands. All these features were considered paraneoplastic but extensive and repeated investigations revealed no underlying malignancy. Oral steroids and orbital radiotherapy were ineffective. The diagnosis was confirmed by trans-scleral biopsy of the right choroid. Rapidly progressive cataracts were treated by phacoemulsification. Severe exudative retinal detachment with rubeosis and neovascular glaucoma in the left eye were treated successfully by partial choroidectomy. Fifteen months after presentation, investigations detected a 22 mm, poorly differentiated adenocarcinoma, which was resected without complication. The ocular tumours in both eyes regressed, without improvement in vision of Light Perception, and the palmar fasciitis also improved. The patient remained free of tumour recurrence until sudden death from myocardial infarction five years after he first presented.

PURPOSE To determine binocular visual field (BVF) changes after strabismus surgery in children with large angle esotropia, and whether these changes can be predicted, using a prism to correct the preoperative angle of deviation. METHODS Monocular visual field (MVF) and BVF were measured by Goldmann perimetry in healthy adults (n = 6) using a range of prisms. Visual fields were then measured in normal children (n = 19) and in children with large angle esotropic amblyopia (n = 28). The visual field was measured preoperatively with and without a prism equal to the angle of esotropia. A further evaluation was made at 2 and 18 months postoperatively. RESULTS In healthy adults, prisms had no significant effect on the extent of MVF or BVF. There was no significant difference in the MVF in children with and without strabismus. There was a significant reduction in the BVF and in the ratio of the BVF to MVF between normal children (138 degrees, 0.59; P = 0.01) and children with esotropic amblyopia (120 degrees, 0.57; P = 0.02). Postoperatively, there was a significant improvement in the BVF (P = 0.02), which was maintained at 18 months. The increase in BVF was significantly greater than the variation in repeat fields (P = 0.04), with 8 of 13 children showing an increase in the BVF above the 95% CI of the repeatability measurements. There was a good linear correlation between the size of the preoperative BVF in the presence of a prism and the postoperative BVF (r = 0.90 P = 0.001). CONCLUSIONS Children with esotropic amblyopia demonstrate a significant reduction in their BVF. Prisms correcting the preoperative angle could be used to predict the potential increase in the BVF after surgery. Patients with a BVF/MVF approaching that found in normal children, however, may not show an improvement in the size of their BVF after surgery.

Selective serotonin reuptake inhibitors (SSRIs) such as citalopram are widely used in the treatment of depression. Advantages over tricyclic antidepressants and monoamine oxidase inhibitors include a more acceptable side-effect profile as well as reduced morbidity and mortality in case of an overdose. We report an unusual complication of the use of citalopram in a patient suffering from low mood.

There are a few reports of the use of voriconazole for the treatment of fungal keratitis.1–5 We report another case of its apparent success in Aspergillus fumigatus keratitis and discuss the dilemma of prescribing an expensive drug in the absence of defined ophthalmic therapeutic levels. A 51 year old diabetic man presented a week after being poked in his eye by a child’s finger, with a 3.0×3.5 mm central corneal ulcer overlying full thickness stromal infiltrate with associated hypopyon (fig 1). Pinhole visual acuity was 2/60 in this eye. Topical ciprofloxacin 0.3% was started. Aspergillus fumigatus was isolated after 48 hours’ incubation and topical amphotericin B 0.15%, voriconazole 1% hourly, and …