received four applications of DLCC and the crystalline lens sub-luxation was noted 7 weeks following the fourth laser treatment(8 months after the initial DLCC application).5 To our knowledge,however, this is the first reported case of late-onset crystalline lenssubluxation occurring 5 years after DLCC. There was no clinicalevidence of collagen disorders, pseudoexfoliation syndrome orother diseases that can potentially predispose to lens instability.The patient denied any history of ocular trauma including the5-year follow-up period following DLCC. We believe that thediode laser-induced destruction of ciliary processes and the disrup-tion of the zonules is a progressive process and can lead to delayedzonular dehiscence and lenticular subluxation/dislocation.
We recommend that patients should be informed about this rarecomplication especially when repeated treatments are necessary.With the increasing use of DLCC in sighted eyes, cataract surgeonsshould be aware of the potential zonular weakness in this group ofpatients.
In conclusion, dislocation of the crystalline lens may occur as arare complication after DLCC, especially when repeated treatmentsare needed.
Omar H Hadid MRCOphth andChristine R Ellerton FRCOphth
Eye Department, James Cook University Hospital,Middlesbrough, UK
Received 6 June 2008; accepted 30 July 2008.
REFERENCES
1. Pearson PA, Baldwin LB, Smith TJ. Lens subluxation as acomplication of cyclocryotherapy. Ophthalmic Surg 1989; 20:445–6.
2. Sony P, Sharma N, Pangtey MS. Dislocation of the lens: acomplication after cyclocryotherapy. Clin Experiment Ophthalmol2002; 30: 442–3.
3. Ansari E, Gandhewar J. Long-term efficacy and visual acuityfollowing transscleral diode laser photocoagulation in cases ofrefractory and non-refractory glaucoma. Eye 2007; 21: 936–40.
4. Lai JS, Tham CC, Chan JC, Lam DS. Diode laser transscleralcyclophotocoagulation as primary surgical treatment for medi-cally uncontrolled chronic angle closure glaucoma: long-termclinical outcomes. J Glaucoma 2005; 14: 114–19.
5. Rao VJ, Dayan M. Lens subluxation following contact transs-cleral cyclodiode. Arch ophthalmol 2002; 120: 1393–4.
Light emitted by an arc welder is a documented cause of phototoxicmaculopathy1,2 which can also occur on overexposure to sunlight,halogen filaments and operation microscopes.1,3,4 An arc welderemits at both ultraviolet and infrared visible light and the intensenear ultraviolet emissions lead to maculopathy when prolongedlight exposure causes damage to the photoreceptors, retinalpigment epithelium (RPE) and other layers. Acute presentation ofphototoxic trauma includes de-pigmentation of the RPE andoedematous greying of the macula, while there is secondaryinvolvement of the other retinal layers.5 Young apprentice weldersare most at risk of this type of injury owing to vocational inexpe-rience and clear ocular media.2 As these retinal changes are typicallysmall, they are difficult to identify and document clinically. The useof Optical Coherence Tomography, Multifocal Electroretinographyand micro-perimetry have been reported as effective methods fordocumenting the retinal layer changes seen with this type ofinjury.1,2,6
While the retinal changes associated with this type of macul-opathy have been reported,1,2,5–7 the functional vision problemshave not been well documented and are underestimated owing tosmall scotoma and preservation of reasonable distance acuity. Theclinical characteristics and the functional visual implications ofa patient with phototoxic maculopathy from arc welding aredescribed.
A healthy 21-year-old man presented almost 4 years after sus-taining a phototoxic foveal injury from overexposure to an arcwelder. He had been welding with a mask but without the tintedvisor down, while attending a vocational training course. He hadpresented to an ophthalmologist 3 days after the injury and wassuffering with residual visual symptoms several years later when acompensation claim was processed. Best-corrected visual acuity(VA) was 6/12 in each eye with near acuity of n8 but the timerequired for him to read a vision chart was particularly long, withre-fixation needed every few seconds.
Fundus photography 3 years post injury shows a de-pigmentedsub-foveal RPE in both eyes (Fig. 1).
Optical Coherence Tomography examination revealed destruc-tion of the centre of the fovea with absent RPE and photoreceptors(Fig. 2).
(a) (b)Figure 1. Colour fundus photo-graphs of the (a) left and (b) righteye.
As the patient’s symptoms and level of function were not con-sistent with his VA, further investigations were conducted to betterquantify his visual disability. Stereopsis was found to be reducedusing both the ‘Titmus’ (200″ arc) and ‘TNO’ (180″ arc). Colourvision (City University) showed an abnormal result in the chroma 2range, with no specific protan, deutan or tritan loss. Sine Wavecontrast was at the lower end of normal and especially reduced at1.5 and 6 cycles per degree (Fig. 3). Multifocal Electroretinographywas not available.
An ‘Amsler Grid’ defect was noted (Fig. 4) showing the extent ofthe micro-scotoma and the impact of the re-fixation movementsrequired in order to see the centre target. The re-fixation move-ments made by scanning the fixation target allow the patient to seea low quality impression of the target and some of the lines but thisinduces the artefact of the shaded pattern. This X-pattern non-absolute scotoma has a significant impact upon his ability to absorbvisual information and impact upon his functional vision.
In order to further investigate the impact of this injury upon hisvisual functioning, a Visual Functioning Questionnaire (VF-14) wasadministered.8 It comprises 18 questions relating to visual function-ing for daily living skills. The patient responds on a Likert scale anda healthy 21-year-old man would be expected to score 100%. TheVF-14 score of this patient was 43% with ‘mild difficulty’ seeingsteps or curbs; writing cheques; filling in forms and playing sport.He had ‘moderate difficulty’ watching television and driving and ‘agreat deal of difficulty’ reading small print in addition to seeingstreet signs, traffic signs and shop signs.
The incidence of phototoxic maculopathy is uncertain but pos-sibly 0.14%, with 15% of cases caused by welding.5,9 Degenerativeretinal changes as a result of welding are well recognized amongwelders in Eastern Europe; however, phototoxic maculopathy isless recognized as an occupational health issue in Westerncountries.6,7 This is supported by the work of Maier5 who examineda group of welders and found no significant morphological or func-tional differences between welders and non-welders. Maier suggeststhat workers make full use of safety equipment in their workplace –but this is related to the culture of workplace safety and will varyfrom country to country thus making incidence data impossible tocompare. The risk factor in this case was that the patient wore themask which blocks UV light and prevented corneal epithelial injury(‘flash burn’) but not the dark filter to cut the intense blue light.There was thus no pain – just the late awareness of a void in centralvision.
Despite the low incidence and small anatomical defect associ-ated with this injury type, the impact on visual function should notbe underestimated, especially as this case went to trial in theCounty Court of Victoria. Decreased VA associated with OpticalCoherence Tomography-documented photoreceptor abnormalityhas been reported,2,6 but more in-depth measures of visual functionhave not. The impact of this injury on daily activities is high-lighted in this case study and it has been important, from amedico-legal perspective, to quantify the patient’s level of visionimpairment. A 40% impairment to this patient’s visual system, with38% whole-person impairment10 together with in-depth investiga-tion of the patient’s ability to perform daily living tasks includinginvestigation beyond near and distance VA, was accepted by theCourt. The results of the VF-14, although subjective and reliantupon patient response, were still considered as part of this claim.Of particular importance for this patient, as he is employed as acarpenter, are the micro-scotoma that require scanning andre-fixation that greatly prolong reading times and the ability toperform tasks, such as measuring with a tape measure and readingsmall measurements on plans. Thus, the experiences of the patientreported here emphasize the need for documentation of the clini-cal signs and symptoms in addition to thorough investigation of
(a) (b) Figure 2. Optical coherencetomography images of (a) left and(b) right eye.
Figure 3. Sine Wave Contrast Sensitivity Test. The black linerepresents results for the right eye, the red line represents results forthe left eye.
the underlying functional impairment which may not be immedi-ately obvious.
Meri Vukicevic PhD1,2 and Wilson Heriot FRANZCO2
1Department of Clinical Vision Sciences, Division of Allied Health,Faculty of Health Sciences, La Trobe University, and 2Eye Surgery
Associates, Freemasons Medical Centre, East Melbourne, Victoria,Australia
Received 1 June 2008; accepted 28 August 2008.
REFERENCES
1. Denk P, Kretschman U, Gonzalez J, Gelisken F, Knorr M.Phototoxic maculopathy after arc welding: value of multifocalERG. Klin Monatsbl Augenheilkd 1997; 211: 207–10.
2. Lucas R, Harper A, McCombe M, Mainster M, Silney D, ZamirE. Optical coherence tomography findings in welder’smaculopathy. Retin Cases Brief Rep 2007; 1: 169–71.
3. Karp K, Flood T, Wilder A, Epstein R. Photic maculopathyafter pterygium excision. Am J Ophthalmol 1999; 129: 422.
4. Ruiz-del-Rio N, Moriche-Carretero M, Ortega-Canales I,Revilla-Amores R, Peralta-Calvo J. Photic maculopathy and irisdamage in a psychotic patient. Arch Soc Esp Oftalmol 2006; 81:165–8.
5. Maier R, Heilig P, Winker R, Neudorfer B, Hoeranter R, Rue-diger H. Welder’s maculopathy? Int Arch Occup Environ Health2005; 78: 681–5.
6. Jorge R, Costa R, Quirino L et al. Optical coherence tomogra-phy findings in patients with late solar retinopathy. Am J Oph-thalmol 2004; 137: 1139–42.
7. Magnavita N. Photoretinitis: an underestimated occupationalinjury? Occup Med 2002; 52: 223–25.
8. Steinberg E, Tielsch J, Schein O, Javitt J, Sharkey P, Cassard S.The VF-14. An index of functional impairment in patients withcataract. Arch Ophthalmol 1994; 112: 630–38.
9. Stokkermans T, Dunbar M. Solar retinopathy in a hospital-based primary care clinic. J Am Optom Assoc 1998; 69: 625–36.
10. American Medical Association. AMA Guides to the Evaluation ofPermanent Impairment, 4th edn. Chicago: AMA Press, 1995.
A 29-year-old indigenous gentleman from remote Central Australiapresented with pain and redness in the right eye for several days.There was no history of trauma but symptoms had worsened overthe preceding 3 days. He had no previous ocular history of note,but his systemic health problems included: previous soft tissueinjuries to the trunk and limbs, superficial stab wounds, pneumoniaand alcohol abuse. The immune status of the patient was not spe-cifically evaluated.
His ocular examination revealed visual acuities of 6/6 in theaffected eye and 6/4.8 in the left eye. The right conjunctiva wasinjected, and corneal examination demonstrated an inferonasal stel-late epithelial defect. Underlying this was subepithelial and anteriorstromal infiltrate with satellite lesions extending beyond the epithe-lial defect (Fig. 1). The anterior chamber was inflamed with 2+cells, but examination of the lens and posterior segment wasunremarkable. The left eye was healthy.
A corneal scrape was performed and sent for urgent microscopy,culture and sensitivities. The initial gram stain confirmed the pres-ence of 2+ polymorphonuclear cells, tissue cells and possible ele-ments resembling fungal hyphae. Given the uncertainty regardingthe definite presence of fungal elements, the patient was com-menced on hourly ofloxacin 0.3 mg/mL and cyclopentolate 1%three times daily.
There was no change in his symptomatology 24 h later, and athis 48-h review further microbiology results were available. Afungal colony had grown on the Sabouraud’s agar, which was sent toa tertiary institution for identification and sensitivities (Fig. 2).
The patient was empirically commenced on guttae natamycin5% hourly for 48 h and then reduced to six times per day afterhealing of the epithelial defect. The organism was identified asB. australiensis. Antifungal susceptibility testing (Table 1) againstamphotericin B, 5-fluorocytosine, fluconazole, itraconazole, keto-conazole and voriconazole was performed in accordance with theCLSI M38-A reference method for testing of moulds. Natamycin
Figure 4. Amsler Grid. The blackline represents results for the righteye, the red line represents resultsfor the left eye. The patientdescribes the lines of the AmslerGrid as ‘significantly faded wherethe cross is’.
