Multimodal Imaging for Subacute Sclerosing Panencephalitis: Including Anterior Segment.

Subacute sclerosing panencephalitis (SSPE) is an irreversible and progressive neurological disorder. A 20-year-old woman with SSPE presented with a decline in visual acuity. Anterior segment was evaluated with slit lamp and in vivo confocal microscopy, revealing the presence of dendritiform keratic precipitates and +2 cells in the anterior chamber. In fundus examination, white-yellowish lesions involving the macula and periphery were observed, which gradually progressed into atrophy over time. Optical coherence tomography (OCT) imaging showed progression to atrophy of moth-eaten shaped cavities including all retinal layers due to necrotizing retinitis. OCT angiography (OCTA) further revealed reduced vessel densities and flow void areas. Notably, to the best of our knowledge, this is the first case documenting anterior segment findings in SSPE in detail. [Ophthalmic Surg Lasers Imaging Retina 2024;55:344-348.].

Evaluation of Keratoconus Disease with Tear Cytokine and Chemokine Levels Before and After Corneal Cross-Linking Treatment.

OBJECTIVES: To compare tear cytokine and chemokine levels of keratoconus (KC) patients with controls to perceive etiology distinctly and to clarify the molecular changes after cross-linking (CXL). METHODS: Tear samples were gathered from 34 participants in this prospective study. Participants underwent anterior and posterior segment examinations with slit-lamp biomicroscopy. Patients were assessed by corneal topography before and 3 months after CXL. Flat (K1), steep (K2), and average keratometry (Kmean), cylinder (CYL), and central corneal thickness (CCT) values were evaluated. After 3 months from CXL, samples were re-collected, and comparisons were made with preoperative values. RESULTS: Levels of IFN-gamma, IL-8, IL-12, IL-17, TNF-α, IL-4 and IL-13 were detected higher in KC patients (p= 0.008, p= 0.047, p= 0.001, p= 0.001, p= 0.001, p= 0.001, p= 0.027, respectively). After CXL IL-4, IL-5, IL-6, IL-7, IL-8, TNF-α levels showed significant decrease (p= 0.005, p= 0.045, p= 0.010, p= 0.022, p= 0.001, p=0.002, respectively). As for the topographic measurements, postoperative CCT values were increased whereas Kmean reduced after CXL (p < 0.001, p = 0.015, respectively). (p= 0.001, p= 0.027, respectively).Our findings imply that inflammation plays a key role in the development of KC and that this link is influenced by CXL therapy.

Outcomes and success of amniotic membrane transplantation for the treatment of corneal diseases.

PURPOSE: The amniotic membrane (AM), the inner layer of the placenta, is a semitransparent, avascular, and thin tissue that is useful due to its structure. Amniotic membrane transplantation (AMT) avoids the need for keratoplasty to prevent corneal perforating. The purpose of the study was to evaluate the visual (gain of or no change in visual acuity) and corneal outcomes (closure of the ulcer or corneal healing) of AMT in patients with ocular surface diseases. MATERIALS AND METHODS: This was a retrospective case control study (success or failure of the surgery). It was undertaken at a single academic center. The study cohort consisted of subjects with ocular surface diseases. Patients were treated with AMT for refractory ocular surface diseases. They were divided into five subgroups according to the preoperative diagnosis. The technique of AMT used was the onlay method with two layers of AM. Primary outcome measures included best corrected visual acuity (BCVA), the number of AMTs, and reepithelization of the corneal epithelium at the end of the treatment. Two weeks to six months were given to consider epithelial closure. Treatment success was defined as corneal healing within 6 months. RESULTS: A total of the 66 eyes of 66 patients (39 male/27 female) with a mean age of 44 ± 23 years (range 1-88 years) were included in the study. A single AMT procedure achieved epithelial closure in 74.2% (n = 49) of the eyes (53% in <15 days, 19.6% in 15-30 days, and 1.5% in 1-6 months). The fastest reepithelization occurred in neurotrophic keratopathy, 76.9% of which cases occurred within 15 days after the AMT procedure. Treatment failure was observed in five patients (7.5%), four with keratitis and one with neurotrophic keratopathy. The highest closure rates were found in persistent epithelial defects, graft-versus-host disease (GvHD), and bullous keratopathy, although there was no statistically significant difference in BCVA. Pairwise comparisons were made of neurotropic keratoplasty versus bullous keratopathy (P = 0.025), neurotrophic keratopathy versus keratitis (P = 0.004), GVHD versus keratitis (P = 0.003), and lastly, GvHD versus bullous keratopathy (P = 0.023). CONCLUSIONS: AMT is a safe, valuable, and fast treatment technique to treat corneal epithelial defects stemming from different etiologies that are refractory to conventional treatment.

Short-term effect of macular edema on the peripapillary retinal nerve fiber layer in patients with wet age-related macular degeneration and diabetic macular edema: A comparative study.

BACKGROUND: The combined presence of glaucoma and age-related macular degeneration (ARMD), or glaucoma and diabetes mellitus (DM), occur fairly frequently, especially in elderly patients. This study was intended to compare the effect of resolving macular edema due to DM and wet ARMD on peripapillary retinal nerve fiber layer (RNFL) thickness. METHODS: This cross-sectional study included 76 patients with macular edema secondary to DM (n = 40, 52.6%) or wet ARMD (n = 36, 47.4%). The control group was comprised of 34 age and sex-matched healthy subjects. All study participants underwent evaluation of central macular thickness (CMT) and the peripapillary RNFL using spectral domain-optical coherence tomography (SD-OCT). Data from eyes that received an anti-VEGF injection were obtained one month after the procedure and were compared with pre-injection data. RESULTS: The average initial thickness of the global peripapillary RNFL was 98.9 ± 16.7 (61-163) µm in the macular edema group and 92.0 ± 16.0 (84-115) µm in the control group (p = 0.045). The post-injection global peripapillary RNFL thickness was 97.3 ± 19.0 (61-163) µm in the macular edema group and 92.2 ± 18.0 (81-126) µm in the control group (p = 0.187). In the DM group, the changes in global RNFL thickness, as well as central and temporal quadrant thicknesses, were found to correlate significantly with the change in CMT (r = 0.356, p = 0.024; r = 0.545, p < 0.001, respectively). CONCLUSIONS: Macular edema in wet ARMD appeared not to affect RNFL thickness. Differences in the etiology of macular edema can have varied effects on peripapillary RNFL. It is recommended that peripapillary RNFL thickness be evaluated cautiously in DM patients receiving intravitreal anti-VEGF therapy.

The functional and structural evaluation of small fibers in asymptomatic carriers of TTR p.Val50Met (Val30Met) mutation.

Therapeutic advances in hereditary amyloid transthyretin (ATTRv) amyloidosis with polyneuropathy extended life expectancy and delayed symptom progression especially in patients with early disease. Thus, detection and monitoring of asymptomatic carriers gained importance. However, there is still limited consensus on genetic screening of ATTRv-polyneuropathy patients' family members and diagnostic tests that must be done in the follow-up. In this study, we followed prospectively five asymptomatic carriers of a family with ATTRV30M (p.Val50Met) mutation by different diagnostic tests for three years. The carriers were followed by neurological examination, nerve conduction studies, sympathetic skin response test, heart rate variability, SFN-SIQ and DN4 questionnaires, quantitative sensory testing (QST), skin biopsy and in vivo corneal confocal microscopy. Nerve conduction studies, sympathetic skin response test and heart rate variability were normal in all for three years. Baseline QST and SFN-SIQ were normal but became abnormal during follow-up of two individuals who developed small fiber neuropathy symptoms. Baseline intraepidermal nerve fiber density was low in three carriers and decreased to below normative values in all during follow-up, while corneal sub-basal nerve density was low in all carriers compared to controls during the entire follow-up. Thus, our study showed that SFN-SIQ and QST are useful diagnostic tools to detect the transition to symptomatic ATTRv-polyneuropathy.

The effects of systemic aromatase inhibitors on meibomian glands and corneal structure.

OBJECTIVES: To evaluate the ocular surface, meibomian glands and corneal structural changes using in vivo confocal microscopy (IVCM) in patients receiving aromatase inhibitor (AI) therapy due to the breast cancer. METHODS: This prospective observational study included 13 patients undergoing AI therapy. The patients were evaluated before the treatment, at 3- and 6-month timepoints of AI therapy. To examine the ocular surface and tear film, corneal sensitivity (CS) measurement with Cochet-Bonnet Aesthesiometer, tear film break-up time (TBUT), lissamine green (LG) staining, Schirmer I test with anaesthesia (ST) and the ocular-surface disease index (OSDI) questionnaire were performed consecutively. Corneal cell densities and sub-basal nerve plexus were evaluated with IVCM (ConfoScan 4, Nidek, Japan). Finally, quantitative MG drop-out assessment was made using infrared meibography. Shapiro Wilk, Friedman's and Post-hoc Dunn tests were used for the statistical analysis. RESULTS: TBUT, ST scores, basal epithelium, anterior and posterior keratocytes and endothelial cell densities, long and total sub-basal nerve densities were found to be decreased (p < 0.001, p = 0.023, p < 0.001, p = 0.01, p = 0.002, p = 0.004, p < 0.001, p < 0.001), and meiboscore, CS, OSDI scores and sub-basal nerve tortuosity values were increased (p < 0.001, p = 0.015, p = 0.001, p = 0.004) during the treatment. Endothelial pleomorphism rates were lower at the 3- and 6-month timepoints compared to before the treatment (p = 0.04). CONCLUSION: This study showed that aromatase inhibitor therapy causes deteriorations in many of the ocular-surface parameters and corneal structural changes in relation with the duration of treatment. These patients should be observed during the therapy in terms of the ocular-surface side effects.

Changes in the Anterior Lens Epithelium and Basement Membrane in Pseudoexfoliation Syndrome undergoing Surgery for Senile Cataracts: A Transmission Electron Microscopic Study.

OBJECTIVE: To compare the electron microscopic lens findings with and without pseudoexfoliation syndrome (XFS), in patients undergoing surgery for senile cataract. STUDY DESIGN: A descriptive study. Place and Duration of the Study: Ophthalmology Department, Hacettepe University Hospital between December 2019 and March 2020. METHODOLOGY: Anterior lens capsules (basement membrane and lens epithelial cells) taken from 20 eyes of 20 patients with senile cataract were examined. XFS was detected by slit-lamp examination in 10 of 20 patients. Remaining 10 were included in the control group. All patients and controls were of similar age and had no systemic disease. The anterior lens capsules were obtained from cataract surgery and prepared for observation under a transmission electron microscope. RESULTS: The mean age of individuals in the XFS and control groups was 69.4 ± 6.9 (56-82) years and 65.2 ± 6.9 (54-73) years, respectively. The best-corrected visual acuity in the XFS and control groups was 0.7 ± 0.4 (0.3-1.3) logMAR and 0.9 ± 0.4 (0.4-1.3) logMAR, respectively. Marked ultrastructural changes were observed in the anterior lens capsules of all eyes with pseudoexfoliation. Degenerative changes and thinning in lens epithelial cells were observed in all samples. The lens epithelial cells were loosely attached to the basement membrane in places. Numerous apoptotic cells with pyknotic nuclei were observed in lens epithelial cells, and many vacuoles within the cytoplasm in different areas were detected. CONCLUSION: Transmission electron microscopic examination revealed ultrastructural abnormalities in the XFS epithelium of all patients in the XFS group. Many aspects of the pathogenetic process of XFS remain uncertain, hence requiring further exploration. Key Words: Capsule, Electron microscopy, Epithelium, Pseudoexfoliation syndrome.

Ocular Surface, Meibomian Gland Alterations, and In Vivo Confocal Microscopy Characteristics of Corneas in Chronic Cigarette Smokers.

PURPOSE: To evaluate the ocular surface, meibomian gland alterations, and in vivo confocal microscopy (IVCM) parameters through correlation with nicotine dependency level (NDL) and duration of smoking (DS) in chronic smokers. METHODS: This cross-sectional study included 50 eyes of 50 chronic smokers, and 50 eyes of 50 age- and gender-matched healthy nonsmokers. To examine the ocular surface and tear film, corneal sensitivity (CS) measurement with Cochet-Bonnet esthesiometer, tear film break-up time (TBUT), lissamine green (LG) staining, Schirmer I test with anesthesia, and Ocular Surface Disease Index (OSDI) questionnaire were performed consecutively. Basal epithelial cell, keratocyte, and endothelial cell density, the percentage of endothelial polymegethism/pleomorphism, and subbasal nerve plexus were evaluated using IVCM. Meibomian gland density was evaluated with a meibography unit. The Fagerström test was used to measure NDL, and DS was recorded. RESULTS: In the chronic smokers group, the basal epithelial cell density, anterior and posterior keratocytes, endothelial cell density, and long and total subbasal nerve numbers were lower, and LG staining, meiboscore, and OSDI scores were higher, compared with the control group, whereas other parameters were similar. The percentage of polymegethism was higher and the percentage of pleomorphism was lower in the chronic smokers group. In the correlation analysis, no significant relationship was found between the DS, NDL and ocular surface, and IVCM findings. CONCLUSION: Decreased corneal basal epithelium, anterior and posterior keratocytes, endothelial cell density, meibomian gland density, and subbasal nerve numbers were found in chronic smokers. The results of the study show that smoking has an adverse effect on ocular surface parameters.

Ocular surface alterations and in vivo confocal microscopic characteristics of corneas in patients with myasthenia gravis.

PURPOSE: To evaluate ocular surface alterations and characteristics of corneal basal epithelium and subbasal nerves in patients with myasthenia gravis. MATERIALS AND METHODS: Myasthenia gravis patients (n = 21) and healthy controls (n = 20) were enrolled. All participants underwent ocular surface testing in the following order: tear break-up time, lissamine green staining, Schirmer I test with anesthesia, and Ocular Surface Disease Index questionnaire. The Cochet-Bonnet esthesiometer was used to measure corneal sensitivity. Basal epithelial cells and subbasal nerves were evaluated using in vivo confocal microscopy. RESULTS: Myasthenia gravis patients had higher Ocular Surface Disease Index score (13.9 ± 15.0 vs 1.4 ± 2.2, p < 0.001) and lissamine green staining score (0.6 ± 0.4 vs 0.2 ± 0.4, p = 0.007). Break-up time score (9.3 ± 3.0 vs 9.9 ± 1.9, p = 0.481) and Schirmer I test score (16.5 ± 9.2 vs 19.3 ± 8.4, p = 0.323) did not differ significantly. Corneal sensation was 0.4 g/mm2 in all eyes. Patients with myasthenia gravis had lower basal epithelial cell density (3775.7 ± 938.1 vs 4983.1 ± 608.5, p < 0.001) and total nerve density (1956.1 ± 373.3 vs 2277.9 ± 405.0, p = 0.012) and higher subbasal nerve tortuosity (1.9 ± 0.8 vs 1.6 ± 0.7, p = 0.007) than controls. A significant increase in Ocular Surface Disease Index scores was found with decreasing basal epithelial cell density (rho = -0.518, p = 0.001). There was a significantly moderate negative correlation between the duration of myasthenia gravis and the number of corneal nerves (rho = -0.497, p = 0.022). CONCLUSION: Significant alterations of basal epithelial cells and subbasal nerves were demonstrated in myasthenia gravis patients although there was no difference of corneal sensitivity between myasthenia gravis patients and healthy controls. Thus, it should be borne in mind that myasthenia gravis patients deserve further evaluation with regard to ocular surface disease.

Efficacy of 180° Cyclodiode Transscleral Photocoagulation for Refractory Glaucoma

Objectives: To evaluate the efficacy and safety of transscleral cyclophotocoagulation (TS-CPC) limited to 180° of ciliary body ablation in patients with various forms of refractory glaucoma. Materials and Methods: Thirty eyes with refractory glaucoma treated with 180° TS-CPC were retrospectively analyzed for intraocular pressure (IOP) reduction and success rates. Patients' age, gender, type of glaucoma, number of diode laser treatment sessions, postoperative complications, number of hypotensive medications required to control IOP, and best corrected visual acuity (BCVA) were evaluated. The criteria for success were defined as postoperative IOP <21 mmHg or >20% decrease in IOP with or without additional medical treatment. Results: The mean age of all patients was 51.3±26.9 years (range,1-84 years). The mean postoperative IOP level (23.9±8.5 mmHg) was significantly lower than preoperative IOP (39.2±8.9 mmHg) (p<0.001). The success rate was 66.6% after the first laser treatment and reached 86.7% following repeat laser treatments over an average follow-up period of 22.2±19.9 months. The need for topical hypotensive medications decreased from 2.8±1.0 preoperatively to 2.4±1.3 following TS-CPC (p=0.048). Two patients (6.6%) had a one-line decrease in their BCVA following TS-CPC. Transient hypotony and hyphema developed in 4 patients (13.3%). Total laser energy delivered did not correlate with either preoperative (rho=0.10; p=0.594) or postoperative IOP (rho=0.21; p=0.260). Conclusion: TS-CPC limited to 180° of ciliary body ablation is associated with a reasonable success rate and low incidence of adverse effects in patients with refractory glaucoma.

Ocular Surface Alterations in the Context of Corneal In Vivo Confocal Microscopic Characteristics in Patients With Fibromyalgia.

PURPOSE: To quantify the morphology of corneal basal epithelium and subbasal nerves and to evaluate the ocular surface alterations in patients with fibromyalgia (FM). METHODS: Patients with FM (n = 34) and healthy controls (n = 42) were enrolled. All participants underwent ocular surface tests in the following order: corneal sensitivity, tear film breakup time, lissamine green staining, Schirmer test, and the Ocular Surface Disease Index questionnaire. Basal epithelial cells and subbasal nerves were evaluated using in vivo confocal microscopy (IVCM). Demographic characteristics, Visual Analog Scale for Pain (VAS), American College of Rheumatology 1990, the Widespread Pain Index (WPI), and the Symptom Impact Questionnaire (SIQR) scores of patients with FM were obtained. RESULTS: Corneal sensitivity was 0.4 g/mm (fiber length: 6.0 cm) in all eyes. Patients with FM had a higher Ocular Surface Disease Index (42.2 ± 18.9 vs. 1.2 ± 1.7, P < 0.001), higher lissamine green staining scores (0.5 ± 0.5 vs. 0.05 ± 0.2, P < 0.001), and lower tear breakup time scores (9.0 ± 3.6 vs. 10.3 ± 1.5, P = 0.003) than the controls. Basal epithelial cell density (2709 ± 494 vs. 4491 ± 724), total nerve density (1563 ± 620 vs. 2545 ± 973), long nerve fibers (3.4 ± 1.3 vs. 4.5 ± 1.0), and the number of nerves (5.0 ± 1.8 vs. 10.3 ± 2.1) were all lower in patients with FM compared with those of the controls (P < 0.001 for all). There was a statistically significant negative correlation between the WPI score and Schirmer test results (rho = -0.374, P = 0.03) and between WPI and total nerve density (rho = -0.334, P = 0.054). CONCLUSIONS: To the best of our knowledge, this is the first study that evaluated ocular surface alterations in the context of corneal IVCM characteristics. Patients with FM should be evaluated in terms of ocular surface diseases. IVCM may be used in FM to assess small fiber neuropathy.

Ocular Surface Alterations and In Vivo Confocal Microscopic Features of Corneas in Patients With Newly Diagnosed Graves' Disease.

PURPOSE: To evaluate the ocular surface characteristics and corneal microstructure in patients with newly diagnosed Graves disease (GD) with no evidence of active thyroid eye disease (TED). METHODS: Eighty eyes of 40 patients with newly diagnosed GD and 40 age-matched control subjects were recruited in this cross-sectional study. All participants underwent ocular surface tests in the order of tear break-up time (BUT), lissamine green (LG) staining, Schirmer I test with anesthesia, and ocular surface disease index (OSDI) questionnaire. Basal epithelial cell, keratocyte, and endothelial cell densities and subbasal nerves were evaluated using in vivo confocal microscopy (IVCM). Independent sample t test, χ test, and Mann-Whitney U test were used for statistical analysis. RESULTS: Patients with GD had higher OSDI (5.9 ± 6.6 vs. 1.7 ± 2.4, respectively, P ≤ 0.001) and LG staining scores (0.5 ± 0.6 vs. 0.2 ± 0.4, respectively, P = 0.003), and lower BUT scores (7.3 ± 2.5 vs. 9.9 ± 1.7, respectively, P < 0.001) compared with those of control subjects. Patients with GD had lower mean basal epithelial cell density (3928 ± 657 cells/mm² vs. 4771 ± 622 cells/mm², respectively) and total subbasal nerve density (958 ± 394 cells/mm² vs. 1416 ± 744 cells/mm², respectively) and higher subbasal nerve tortuosity (2.7 ± 0.8 vs. 1.6 ± 0.6, respectively) compared with those of control subjects (P < 0.001). There was a statistically significant negative correlation between the duration of symptoms of hyperthyroidism and BUT (rho = -0.273, P = 0.014) and a positive correlation between LG staining scores (rho = 0.329, P = 0.003). A significant reduction in BUT (rho = -0.238, P = 0.003) and epithelial cell density (rho = -0.174, P = 0.029) and an increase in OSDI scores (rho = 0.328, P = 0.003) were found with increasing exophthalmometry measurements. CONCLUSIONS: Ocular surface alterations begin early in the course of Graves disease before the onset of overt TED.

In vivo confocal microscopic characteristics of crystalline keratopathy in patients with monoclonal gammopathy: report of two cases.

In this paper, we report two cases of a 62-year-old patient presented with blurred vision and a 45-year-old male diagnosed with multiple myeloma who was referred from the Department of Oncology. Slit-lamp examination, in vivo confocal microscopy (IVCM), systemic work-up and serum protein electrophoresis were obtained. In both patients, slit-lamp findings revealed bilateral diffuse subepithelial and anterior stromal crystals and IVCM showed highly reflective deposits in the corneal epithelium and stroma. The first patient was eventually diagnosed with monoclonal gammopathy of undetermined significance following bone marrow biopsy and systemic evaluation. Unusual corneal deposits may constitute the first sign of monoclonal gammopathies. IVCM may be helpful in showing the crystalline nature of the corneal deposits and guiding the clinician to the diagnosis of gammopathies. Both ophthalmologists and oncologists should be aware that corneal deposits may herald a life-threatening hematologic disease.

In vivo confocal microscopic features of corneal pseudodendritic lesions in tyrosinemia type II.

PURPOSE: To report the clinical and in vivo confocal microscopic (IVCM) findings of corneal deposits in a patient with tyrosinemia type II. METHODS: The pretreatment and 1-month posttreatment slit-lamp examination and IVCM findings of a patient with tyrosinemia type II are described. RESULTS: A 12-year-old girl diagnosed with tyrosinemia type II was evaluated for photophobia and bilateral ocular discomfort of 1-year duration. The patient had been placed on topical acyclovir treatment with the diagnosis of recurrent bilateral herpetic keratitis during the previous 12 months. Slit-lamp examination revealed bilateral dendritiform epithelial lesions in the central cornea, which stained poorly with fluorescein. IVCM highlighted multiple hyperreflective linear crystalline deposits at the level of superficial epithelium. One month after discontinuation of acyclovir treatment and initiation of a protein-restricted diet therapy, improvement in the patient's symptoms and regression of corneal epithelial lesions was noted. Reduction in the extent of corneal deposits was also confirmed with IVCM. CONCLUSIONS: Corneal involvement, secondary to hereditary tyrosinemia type II, is characterized by pseudodendritic epithelial lesions on slit-lamp examination and hyperreflective linear deposits in the superficial epithelium using IVCM. These lesions may regress expeditiously with a low-protein diet. IVCM may be a useful tool in the differential diagnosis of this disorder by highlighting the crystalline structures in the superficial epithelial layers and also in evaluating the response to the treatment in patients with tyrosinemia type II.

Langerhans cell histiocytosis of the caruncle.

A 37-year-old man presented with the complaint of a small non-tender mass growing steadily on the left caruncle for 3 months. This was a soft, reddish-yellow tumour, occupying the whole left caruncular area without impinging on the conjunctiva. Histopathological evaluation of the excisional biopsy specimen showed that the tumour was largely composed of Langerhans cells mixed with eosinophils and mature lymphocytes. There were strong CD1a and S-100 positivity on immunohistochemical studies. Langerhans cell histiocytosis is an exceedingly rare tumour of the caruncle in the adult and this lesion cannot be distinguished from other amelanotic lesions on clinical grounds alone. Simple excision of the lesion provided a 4-year disease-free period.

Severe pseudo-preseptal cellulitis following sub-Tenon's carboplatin injection for intraocular retinoblastoma.

Sub-Tenon or subconjunctival administration of carboplatin is used to consolidate tumor regression by achieving high intraocular concentrations, without incurring systemic toxicity, in selected patients with intraocular retinoblastoma. Mild transient periocular edema is a common side effect of this treatment. We describe four patients with severe local soft-tissue toxic reaction mimicking preseptal cellulitis following subtenon carboplatin injections. The development of this complication after injecting through the inferior conjunctiva and unexpectedly severe signs are the unusual features of these patients. We did not encounter this complication after injections through the superior conjunctiva in 22 other patients using the same technique and identical drug dosage.

Conjunctival Splendore-Hoeppli phenomenon in a 3-year-old child.

A case of benign granulomas of the conjunctiva in a 3-year-old girl is reported. Histologic features of the excised conjunctival lesions were consistent with Splendore-Hoeppli phenomenon. This phenomenon is thought to be a granulomatous reaction to an antigen-antibody precipitate related to parasites or fungi. No causative agent is identified in our patient. Immunohistochemical analysis showed no immunoreactivity for immunoglobulin G (IgG), IgM, IgA, or the C3 component of the complement. We propose that the presence of small amelanotic nodular conjunctival tumors should arouse suspicion related to the Splendore-Hoeppli phenomenon even in early childhood.