Vol. 102, No. 2 Letters to The Journal 279

upon hemagglutination of sensitized sheeperythrocytes rather than fluorescence.

References

1. O'Connor, G. R.: Uveitis of microbial origin.Current and future trends. Trans. Pacific Coast Oto­Ophthalmol. Soc. 57:223, 1976.

2. Mendelsohn, A. D., and [ampol, L. M.: Syphi­litic retinitis. A cause of necrotizing retinitis. Retina4:221, 1984.

3. Morgan, C. M., Webb, R. M., and O'Connor,G. R.: Atypical syphilitic chorioretinitis and vasculi­tis. Retina 4:225, 1984.

4. Hunter, E. F., Deacon, W. E., and Meyer, P. E.:An improved FTA test for syphilis, the absorptionprocedure (FTA-ABS). Pub. Health Rep. 79:410, 1964.

Corneal Subepithelial Deposits AfterUse of Sodium Chondroitin

Mark R. Coffman, M.D.,and Paul Michael Mann, M.D.Mann Eye Clinic.Inquiries to Mark R. Coffman, M.D., Mann Eye Clinic,18850 S. Memorial Blvd., Humble, TX 77338.

We used sodium chondroitin in cataract ex­traction and intraocular lens surgery in 21 eyesof 19 patients from November 1985 throughJanuary 1986. In six of these eyes, white depos­its in the corneal stroma were noted within 24hours of surgery. These deposits appeared tomigrate anteriorly within the stroma during thefirst one or two postoperative weeks and as­sumed a subepithelial position. The depositshad fairly distinct borders but varied in density(Figure). There was no subepithelial edema orstromal edema.

Of these six eyes, two had undergonephacoemulsification with implantation of aposterior chamber lens and four had under­gone secondary intraocular lens implantation.Regular BSS was used in all cases. Acetylcho­line was used in only one eye. The postopera­tive medications used were prednisolone (fiveeyes), neomycin sulfate-polymyxin B (one eye),and gentamicin (one eye). In three eyes, thesodium chondroitin came from the same lot butin the other three eyes, the sodium chondroitincame from three separate lots. The sodium

Figure (Coffman and Mann). Subepithelial cornealdeposits after intraocular surgery using sodiumchondroitin.

chondroitin was not aspirated from the eye atthe end of the operation because the manufac­turer suggests that leaving the sodium chon­droitin in the anterior chamber is not deleteri­ous. Intraocular pressure measurements wereobtained on the first postoperative day in all sixeyes and in no case exceeded 30 mm Hg.

The longest follow-up at this point is 20weeks. The subepithelial deposits initially ap­peared to fade slowly, but have stabilized dur­ing the last four to eight weeks. Visual acuity,which ranged from 20/50 to 20/200 one weekpostoperatively in the eyes with the subepithe­lial deposits, improved at eight weeks to 20/20to 20/30 in all but one patient. This patient hascystoid macular edema.

The University of Oregon Drug ReactionCenter has received two reports regardingchondroitin sulfate and corneal deposits. Onereport included 20 cases but minimal additionalinformation. The second report included twocases in which a "calcific band keratopathy"appeared immediately postoperatively wheresodium chondroitin touched the endothelialdeposits. Another investigator reported similarchanges in one patient referred to him (J.Rowsey, oral communication, January 1986).

280 AMERICAN JOURNAL OF OPHTHALMOLOGY August, 1986

According to the manufacturer (Cilco), the sub­epithelial corneal changes have been noted inapproximately 0.5% of cases. Of the surgeonsinvolved as investigators, 4.9% have noted thecorneal changes. Research has shown that thesubepithelial white deposits are probably calci­um phosphate precipitates. The calcium phos­phate tends to precipitate if BSS+ or sodiumcitrate is used with the sodium chondroitin.The precipitate is least likely to occur if BSS isused and at least 50% of the sodium chondroi­tin is aspirated or irrigated from the anteriorchamber. Six months to two years may berequired for the subepithelial deposits to re­solve. The manufacturer recommends no treat­ment if the deposits are outside the visual axisand do not affect visual acuity. If visual acuityis effected, topical EDTA may be used for che­lation.

References

1. Barron, B. A., Busin, M., Page, c., Bergsma,D. R., and Kaufman, H. E.: Comparison of the ef­fects of Viscoat and Healon on postoperative intraoc­ular pressure. Am. J. Ophthalmol. 100:337, 1985.

2. Wilson, M. F. II: Adverse external ocular effectsof topical ophthalmic medications. Surv. Ophthal­mol. 24:47, 1979.

Palmar-Plantar HyperkeratosisAssociated With BilateralKeratopathy

Saul Ullman, M.D.,Leonard B. Nelson, M.D.,and Ming-liang Lee, M.D.Department of Pediatric Ophthalmology, Wills EyeHospital (S.U. and L.B.N.) and Department of Pedi­atrics, Division of Medical Genetics, Rutgers MedicalSchool (M.L.).Inquiries to Leonard B. Nelson, M.D., Wills Eye Hospi­tal, Ninth and Walnut Sts., Philadelphia, PA 19107.

Hyperkeratosis of the volar aspects of thehands and feet is a rare condition that may beassociated with inborn errors of metabolismand ophthalmic disease;' We studied a patientwith palmar-plantar hyperkeratosis associated

with severe corneal epithelial disease and de­velopmental delay.

The patient, a 25-month-old girl, was theproduct of an uneventful full-term pregnancy.When she was first examined at the age of 22months, it was found that she had had severephotophobia, tearing, and blepharospasmsince the age of 6 weeks. The child was beingmonitored for developmental delay and wastaking no medications. The family history wasnoncontributory for ophthalmic or dermato­logic disorders.

The child had extreme photophobia andblepharospasm even in room illumination (Fig.1). The instillation of proparacaine allowed thechild to fix and follow objects bilaterally. Theeyelids, conjunctiva, lens, fundus, and cyclo­plegic refraction were normal. A slit-lamp ex­amination showed a symmetric diffuse superfi­cial punctate keratopathy that stained withfluorescein. No corneal vascularization or infil­trates were apparent.

Physical findings were normal except for se­vere hyperkeratotic lesions on her palms andsoles (Fig. 2). The lesions were not inflamed orpainful. Results of serum amino acid analysis,24-hour urine for amino acids, and chromoso­mal analysis were all normal. After two weeksof ocular lubricants every four hours the pa­tient had a marked improvement in her ocularsymptoms; the corneal examination showedonly mild superficial punctate keratopathy.

Palmar-plantar hyperkeratosis is a rare, het­erogeneous condition sometimes associatedwith distinct clinical entities." The Richner­Hanhart syndrome (tyrosinemia type II) con­sists of hyperkeratosis of the hands and feet,

Fig. 1 (Ullman, Nelson, and Lee). Bilateral blepha­rospasm, tearing, and photosensitivity before theinstillation of proparacaine.