Jellyfish Sting of the Cornea

Vol. 100, No.5 Letters to The Journal 739

changes in intraocular pressure with variouspostures.!" Recent studies have emphasizedthe increased intraocular pressures associatedwith an inverted body position and proposedthat individuals who assume this position forlong periods may be at increased risk for devel­opment of glaucomatous visual field loss.v'Although the long-term effects of repeatedlyassuming a head-down or inverted position onthe normal and glaucomatous nerve head havenot been adequately elucidated, it seems pru­dent to discourage such activity in patientswho have manifest or suspected glaucoma. Ourpatient was cautioned that daily inverted­posture exercises may be inadvisable becauseof his visual field changes and asymmetriccupping on the right side. He complied withour recommendation and his ocular status hasbeen stable at careful follow-up examinations.

References

1. Anderson, D. R., and Grant, W.: The influenceof position in intraocular pressure. Invest. Ophthal­mol. 12:204, 1967.

2. Tarkkanen, A., and Leikola, J.: Postural varia­tions of the intraocular pressure as measured withthe Mackay-Marg tonometer. Acta Ophthalmol.45:569, 1967.

3. Krieglstein, G. H., and Langtham, M. E.: Influ­ence of body position on the intraocular pressure ofnormal and glaucomatous eyes. Ophthalmologica171:132,1975.

4. Mansour, A. M., Feghali, J. G., To'rney, K., and[aroudi, N.: Increased intraocular pressure withhead-down position. Am. J. Ophthalmol. 98:114,1984.

5. Weinreb, R. N., Cook, J., and Friberg, T. R.:Effect of inverted body position on intraocular pres­sure. Am. J. Ophthalmol. 98:784, 1984.

Jellyfish Sting of the Cornea

Stephen K. Wong, M.b.,and Alice Matoba, M.D.Ophthalmology Service, Veterans AdministrationHospital, and the Cullen Eye Institute, Baylor Col­lege of Medicine.Inquiries to Stephen K. Wong, M. D., Cullen Eye Insti­tute, 6501 Fannin St., Houston, TX 77030.

Jellyfish stings, a frequent occurrence in thewaters of the Gulf of Mexico, result primarily incutaneous injuries. Only one case of jellyfishsting to the cornea has been reported in the

English literature.! We wish to report a secondcase.

A 34-year-old man was stung by a jellyfishwhile swimming in the Gulf of Mexico. Hereported an immediate "fire-like" pain alonghis right leg, right arm, and around his righteye. Within ten minutes an urticarial rash withlarge wheals appeared in the affected areas,and the patient noted a foreign-body sensationand photophobia in his right eye. Methanoland meat tenderizer applied topically to hisskin lesions produced prompt subsidence ofpain. Twenty-four hours later he was examinedfor persistence of his ocular symptoms.

His visual acuity was R.E.: 20/30 and L.E.:20/20. There was a slight hyperemia of themargin of his right upper and iower eyelids.The corneal epithelium was irregular, withsmall pinpoint epithelial defects in an areaextending from the 2 to 5 o'clock meridians,and 4 mm from the corneoscleral limbus to­ward the visual axis. The stroma was hazy andedematous in that area with some endothelialcell swelling. the border of the affected areawas irregular but there was a sharp demarca­tion from affected cornea to normal cornea. Theadjacent conjunctiva was injected and chemo­tic. The anterior chamber showed trace flare butno cells.

The patient was treated with prednisoloneacetate 1% four times a day and hyoscine 0.25%three times a day. During a ten-day course oftreatment, the stromal and endothelial changesresolved. The corneal epithelium returned tonormal and visual acuity in the affected eyeimproved to 20/20.

Jellyfish envenomation occurs from the injec­tion of toxin-coated nematocyst threads intothe victim from the tentacles of the jellyfish.This usually results in severe burning pain witherythema and urticaria of the skin. The toxin isa combination of polypeptides and degradativeenzymes. Previous treatment measures includ­ed removal of residual tentacles from the victimand topical administration of alcohol, vinegar,ammonia, acetone, baking soda, antihista­mines, meat tenderizer, or papain. The ration­ale is either to prevent nematocyst firing or toinactivate the toxin.v"

In the treatment of jellyfish sting to the cor­nea we do not advocate administration of theabove agents to the eye. They are likely tocause further tissue damage. Our patient'scourse and the previously reported case sug­gest that a jellyfish sting to the cornea leads to aself-limited injury with complete resolution intime with conservative therapy.

740 AMERICAN JOURNAL OF OPHTHALMOLOGY November, 1985

References

1. Hercus, J.: An unusual eye condition. Med. J.Aust. 1:98, 1944.

2. Halstead, B. W.: Poisonous and Venomous Ma­rine Animals of the World. Princeton, Darwin Press,1978, pp. 105-114.

3. Burnett, J. W., Rubinstein, H., and Calton, G. J.:First aid for jellyfish envenomation. South. Med. J.76:870, 1983.

Demonstration of Scotoma on anAmsler Grid Examination

Martin E. Lederman, M.D.Inquiries to Martin E. Lederman, M.D., 10 Chester Ave.,White Plains, NY 10601.

The Amsler grid is useful in determining thepresence of central and paracentral scotomas incooperative patients.

It is sometimes difficult, particularly withchildren less than 10 years old, for the exami­ner to explain what is required. Often the childdoes not know how to describe what is beingseen.

A useful technique is to shine a pen light intoone eye (the eye thought to be sound, if possi­ble, to avoid generating an afterimage that lastsoverly long) from a distance of 2 to 3 em awayfrom the eye. The afterimage generated is read­ily identified by the patient. After the generat­ed afterimage fades, the pathologic scotoma, ifpresent, is more easily found and described.

The generated afterimage is also useful as ateaching device in that a resident can view acentral or paracentral "scotoma" (dependingon whether the viewer looks directly at the penlight or looks 5 to 10 degrees to the side). Theresident observing the afterimage fade is alsobetter equiped to help the patient describewhat is being seen.

Muscle Inclusion Cyst as aComplication of Strabismus Surgery

Gerhard W. Cibis, M.D.,and Joanne M. Waeltermann, M.D.Children's Mercy Hospital.Inquiries to Gerhard W. Cibis, M.D., 4620 J. C. NicholsParkway, Suite 421, Kansas City, MO 64112.

In extraocular surgery inclusion cysts arecommon at conjunctival incision sites. Theseare of little consequence and are generally re­moved by amputation. We found a squamousinclusion cyst within the substance of an extra­ocular muscle at the time of strabismus sur­gery.

The patient was a 30-year-old man with con­secutive exotropia. He had undergone threeprevious extraocular muscle operations for eso­tropia.

His visual acuity was 20/20 in both eyes. TheWorth four-dot test showed suppression and hehad 65 diopters of exotropia. Extraocular motil­ity was within normal limits. There was nopattern to the deviation or lateral incomitance.External, slit-lamp, and ophthalmoscopicfindings were normal. Intraocular pressure waswithin normal limits.

At surgery the medial rectus muscle wasexposed by a standard limbal incision. As themuscle was cleaned of its check ligaments andscar tissue, a large cyst (Figure) was notedapproximately 6 mm from the corneosclerallimbus and 2 mm from the insertion of themedial rectus muscle. The cyst was firmly em­bedded in the muscle and was clear in appear­ance with a solid consistency. A suture wasplaced posterior to the cyst and the cyst wasincluded in the resection specimen. The post­operative course was uneventful with goodcosmesis, no diplopia, and some limitation ofabduction of the right eye.

The pathologic report described an oval pink­brown cyst 9 x 5 x 3 mm in size. Histological-

Figure (Cibis and Waeltermann). The cyst embed­ded in the substance of the medial rectus muscle.