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function and not frontalis muscle func tion. Proper assessment of the functioning of the levator muscle is important in plan ning surgical correction of blepharoptosis. If good levator muscle function is present, a levator muscle resection type of approach can be attempted. With little or no levator muscle function a sling procedure is often necessary. There is a physiologic reflex in infants that can be useful in this regard. Referred to either as the "eye popping reflex of infants" 2 or "nonpathologic lid retrac tion," 3 this phenomenon is seen in more than three fourths of all infants between 14 and 18 weeks of age. 2 The reflex con sists of retraction of both upper eyelids and a slight downturning of both eyes in response to decreased ambient illumina tion. 2,3 The reflex is seen in only 20.7% of infants aged 2 to 6 weeks, increasing to 77.9% in infants 14 to 18 weeks old, and gradually decreasing in frequency there after. 2 We have used this reflex to examine a 7V2-week-old girl who had had blepharoptosis of the left upper eyelid since birth (Fig. 1). When the room illumination was abruptly reduced, the right upper eyelid retracted with little or no change in the left upper eyelid (Fig. 2). The observed
Fig. 2 (Rubin and Calhoun). In reduced light the right upper eyelid retracted. Little change occurred in the left eyelid.
change from high to low illumination is the difference in upper eyelid excursion. Noting that the brow heights are similar in both illustrations and that congenital unilateral frontalis muscle weakness is not a known entity, we are interpreting this observation to indicate poor levator muscle function. A frontalis muscle sling procedure was then recommended to the parents. REFERENCES 1. Beard, C : Ptosis, 3rd ed. St. Louis, C. V. Mosby, 1981, p. 81. 2. Perez, R. B.: The eye popping reflex of infants. J. Pediatr. 81:87, 1972. 3. Flynn, J. T.: Neonatal ophthalmology. Evalua tion of visual function in the neonate and infant. In Harley, R. D.: Pédiatrie Ophthalmology. Philadel phia, VV. B. Saunders, 1983, vol. 1, p. 11.
CORNE AL WHITE PLAQUES CAUSED BY SULFACETAMIDE EYEDROPS K H A L I D F. TABBARA, M.D., AND E V E R E T T R. V E I R S , M . D .
Fig. 1 (Rubin and Calhoun). A 7Va-week-old girl with blepharoptosis of the left upper eyelid.
Proctor Foundation and the Department of Ophthalmology, University of California, San Francisco; and the King Khaled Eye Specialist Hospital, Riyadh. This study was supported in part
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LETTERS TO THE JOURNAL
by the Heintz Fund of the Proctor Foundation and by a fund from the Research Department of the King Khaled Eye Specialist Hospital. Inquiries to KJialid F. Tabbara, M. D., Proctor Foundation, Room S-315, University of California, San Francisco, CA 94143.
Dry-eye syndrome is a common ocular disorder that may be caused by a variety of ocular diseases. Depletion of tears de prives the ocular surface of certain pro tective mechanisms against ocular infec tions, and recurrent ocular infections of the eyelids and conjunctiva are common ly encountered among patients with dryeye syndrome. This requires topical ap plication of antimicrobial agents to combat the offending microorganisms. Such a therapeutic measure, however, carries certain risks. The dry eye has no ability to dilute the topically applied medication and such agents may concen trate on the surface of the eye. The ingredients of topically applied medica tions may be harmful to the corneal and conjunctival epithelial cells. 1 A 53-year-old man who came to us had a history of decreased vision in both eyes. The patient was known to have StevensJohnson syndrome, maintained on artifi cial tears eyedrops. Three months earli er, he had developed redness of the eyes associated with discharge. This was treat ed with topical sulfacetamide 10% eyedrops to both eyes three times daily. The patient discontinued the use of artificial tears and kept using the sulfacetamide drops for three more months. Our exami nation disclosed a visual acuity of R.E.: counting fingers at 2 feet and L.E.: hand motions. Results of a Schirmer test per formed without anesthesia were 3 mm in the right eye and 1 mm in the left eye. The bulbar conjunctivas in both eyes showed evidence of keratinization and the cornea in each eye showed white, elevated corneal plaques (Fig. 1). The white corneal plaques were removed by superficial excision. Analysis of the
Fig. 1 (Tabbara and Veirs). The left eye of the patient showing white sulfacetamide corneal plaque. Note similar deposits over the medial canthal area.
plaques by microscopy disclosed sulfacet amide crystals; stain for calcium was neg ative. The patient was given a regimen of topical balanced salt solution to both eyes every 15 minutes, and a lubricating oph thalmic ointment to both eyes at bed time. Visual acuity improved to R.E.: 20/100 and L.E.: counting fingers at 6 feet. One drop of topical sulfacetamide 10% was placed on a clean glass slide once daily for a period of ten days. The drops were allowed to air-dry, and white sulfa crystals were noted on the slide, similar to those seen on the patient's cornea (Fig. 2). It is evident from this case that the topical use of ocular medications in pa tients with severe dry-eye syndrome may predispose to the concentration of the ingredients on the surface of the eye. Patients with severe dry-eye syndrome lack the flushing and dilution effects of
Fig. 2 (Tabbara and Veirs). Ten drops of sulfaceta mide 10% eyedrops on a glass slide and allowed to air dry.
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tears, and therefore the use of topical eyedrops should be carefully monitored. Certain preservatives, such as benzalkonium chloride, could be detrimental to the ocular surface and cause damage to the superficial epithelial cells. 2 The fre quency and dosage of any medication used in patients with tear deficiency should be carefully selected. Sulfacetamide crystals can be irritating, and, in our patient, they caused precipitation on the cornea and decrease in vision. We, therefore, urge the practicing oph thalmologist to be especially careful in the selection of topical eyedrops in the treatment of patients with severe dry-eye syndrome. REFERENCES 1. Wilson, F. M., II.: Adverse external ocular effects of topical ophthalmic medications. Surv. Ophthalmol. 24:57, 1979. 2. Pfister, R. R., and Bumstein, N.: The effects of ophthalmic drugs, vehicles, and preservatives on corneal epithelium. A scanning electron microscopic study. Invest. Ophthalmol. 15:246, 1976.
ACCIDENTAL HEAT DESTRUCTION OF CORNEAL GRAFT TISSUE
Fig. 1 (Mosteller, Goosey, and Kaufman). The Teflon Kaufman corneal cutting block with metal cover.
Hal side up and trephined with a blade of the appropriate diameter. Then a metal cover is placed over the tissue to protect it while the recipient bed is prepared (Fig. 1). During a recent penetrating keratoplasty, we prepared the donor tissue as described above. However, an assistant accidentally covered the tissue with a recently autoclaved metal cover that was still hot. After the recipient bed was
MATTHEW W. MOSTELLER, M.D., JOHN D. GOOSEY, M.D., AND HERBERT E. KAUFMAN, M.D. Lions Eye Research Laboratories, LSU Eye Center, Louisiana State University Medical Center School of Medicine. Inquiries to Matthew W. Mosteller, M.D., LSU Eye Center, 136 S. Roman St., New Orleans, LA 70112.
A Teflon corneal cutting block is rou tinely used in the trephination of donor corneal tissue. The whole cornea with a 3- to 4-mm scierai rim is placed endothe-
Fig. 2 (Mosteller, Goosey, and Kaufman). De stroyed donor corneal tissue that was caused by recently autoclaved corneal cutting block.