hyperostosis.4 The direct correlation of hyperostosis relat-ing to malignancy was not convincing, and the likely causefor bone growth would be inflammation related to ISOI. Incases of chronic refractory sinusitis, lytic and blastic formsof osteitis occur, and can result in hyperostosis of the nasaland paranasal bones, which was seen in 64% of patientswith recurrent rhinosinusitis.5 The chronic inflammation ofISOI likely caused a corresponding osteitis, an osteoblastictype in this case, producing hyperostosis and the bonychanges seen in this case.

Diagnosing ISOI is difficult and can further be compli-cated by the unusual finding of hyperostosis. Treatment ofISOI is controversial as studies using steroids, azathio-prine, cyclosporine and radiation have been used withlimited success.1,2 With our patient’s age and the systemiccomplications associated with his mesothelioma, treatmentwas deferred. This case highlights ISOI associated withhyperostosis, and it is important with this presenta-tion that a concomitant work-up for occult malignancy isconsidered.

Son T Ho MD,1 Meredith Lakey MD,2

Byron Crawford MD,2 Philip J Daroca MD2

and Alejandra A Valenzuela MD1

1Department of Ophthalmology, Tulane University Schoolof Medicine, and 2Department of Pathology, Tulane

University School of Medicine, Tulane University,New Orleans, Louisiana, USA

Received 12 July 2012; accepted 18 July 2012.

REFERENCES

1. Pemberton JD, Fay A. Idiopathic sclerosing orbitalinflammation: a review of demographics, clinical pres-

entation, imaging, pathology, treatment, and outcome.Ophthal Plast Reconstr Surg 2012; 28: 79–83.

2. Rootman J, McCarthy M, White V, Harris G, KennerdellJ. Idiopathic sclerosing inflammation of the orbit. Adistinct clinicopathologic entity. Ophthalmology 1994;101: 570–84.

3. Fleming JC, Linder JS, Karcioglu ZA. Orbital hyperos-tosis following exenteration. Ophthal Plast Reconstr Surg2008; 24: 378–82.

4. Cheng WF, Berkman AW. Malignant mesotheliomawith bone metastases. Med Pediatr Oncol 1990; 18: 165–8.

5. Kim HY, Dhong HJ, Lee HJ et al. Hyperostosis mayaffect prognosis after primary endoscopic sinus surgeryfor chronic rhinosinusitis. Otolaryngol Head Neck Surg2006; 135: 94–9.

Bilateral severe anterior uveitisafter unilateral selective lasertrabeculoplastyWe would like to report a case of bilateral anterior uveitisafter unilaterally applied selective laser trabeculoplasty(SLT).

Since its introduction in 1995, SLT has been an alterna-tive or adjunctive therapy, with low complication rates, formedical therapy of open-angle glaucoma.1 Some moregrave complications although rare have been reported likecorneal haze and oedema, and severe uveitis and choroidaleffusion.2,3

A 40-year-old female patient with open-angle glau-coma was admitted to outpatient clinics. Visual acuitywas 6/6 in both eyes, while intraocular pressure was11 mmHg in right eye and 30 mmHg in left eye. Bothanterior segments were quiet during examination, exceptsome pigment on bilateral posterior corneal surfaces(Fig. 1). Gonioscopy revealed open angle with ShafferClassification Grade 4. C/D ratio was 0.5 in the right eyeand 0.8 in the left eye. Retinal nerve fibre layer thick-ness with an Optical coherence tomography (Stratus, CarlZeiss, Germany) was 90 and 54 microns in the right andleft eyes, respectively. Visual field testing with HumphreyField Analyser 30.2 (Carl Zeiss Meditec Inc., Dublin, CA,USA) test revealed a wide visual field constriction in theleft eye. Specular microscopic evaluation of the right eyewas normal, while there were 2–4 dark spots/patches onleft corneal endothelium (Fig. 2). Upon these findings,patient has undergone SLT (54 spots, 600 mJ/spot, 180degree inferior) in the left eye. In the postoperative firstweek visit, intraocular pressure was 12 mmHg in righteye and 13 mmHg in the left eye without any inflamma-tion. In the third week of the SLT, the patient was admit-

Competing/conflicts of interest: No stated conflict of interest.

Funding sources: No stated funding sources.

This study was presented as a poster presentation at the Turkish

Society of Ophthalmology, Annual Congress, 2011, Cyprus.

Figure 2. Photomicrographs showing nodular lymphoid aggre-gates in a background of dense sclerosis diagnostic of idiopathicsclerosing orbital inflammation (H&E, 20¥).

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ted with cloudy vision and photophobia when visualacuity was 6/12 in right eye and 6/15 in the left eye. Therewas bilateral uveitis with +3 cells in the anterior chamber,bilateral posterior synechia and corneal haze (Fig. 1).

Specular microscopy was repeated then, and it demon-strated multiple dark spots/patches bilaterally on cornealendothelium (Fig. 2). Topical prednisolone, cyclopen-tolate HCl and tropicamide were administered. Symptoms

Figure 1. Anterior segment pho-tography of right and left eyebefore selective laser trabeculo-plasty (SLT) (a and b) and 3 weeksafter SLT (c and d).

Figure 2. Specular microscopyof right (a) and left eye (b) beforeselective laser trabeculoplasty(SLT) and right (c) and left (d) eye3 weeks after SLT.

306 Letters to the Editor

© 2012 The AuthorsClinical and Experimental Ophthalmology © 2012 Royal Australian and New Zealand College of Ophthalmologists

resolved in 2 weeks. The entire laboratory testing includ-ing the serologic surveys was normal during the state.

Dark spots/patches seen on the specular microscopyafter SLT has been recently reported by Ong et al.4 Thischange in the corneal endothelium may be due to oedema,subendothelial inflammatory cells or adjacent endothelialcell damage, and they are assumed to resolve after theresolution of the inflammation. The interesting fact aboutour case was that these changes occurred bilaterally after aunilateral SLT procedure. Bilateral effect after unilaterallyapplied SLT was also reported by Rhodes et al.5 Theauthors proposed a significant reduction in the intraocularpressure of the fellow untreated eye after uneventful uni-lateral SLT.

Regina et al. have reported two cases with centralcorneal oedema and haze after SLT.2 They hypothesizedthat may be due to herpetic activation or residual alcoholon the goniolens or inflammatory response in the anteriorchamber. Our patient has developed peripheral cornealhaze and thinning, which might be due to inadvertentapplication of the laser, but this reaction was bilateral.

Kim and Singh have introduced a case with severe iritisand choroidal effusion.3 Their case was also unilaterallyaffected in the treated eye. Our case developed severe bilat-eral anterior iritis and posterior synechia in the third weekof SLT. It is interesting that it may be a period enough forimmunization of the other eye because both eyes wereaffected at the same time.

SLT is usually a safe procedure, but having signs of apast intra-ocular inflammation or pigment on the posteriorsurface of the cornea should also be considered as a relativecontraindication for SLT therapy. The involvement of theuntreated eye needs further investigation for any autoim-mune triggering effect of SLT.

Bengu E Koktekir MD, Sansal Gedik MDand Berker Bakbak MD

Ophthalmology Department, Selcuk University SelcukluFaculty of Medicine, Konya, Turkey

Received 4 August 2012; accepted 6 August 2012.

REFERENCES

1. Latina MA, Park C. Selective targeting of trabecularmeshwork cells; in vitro studies of pulsed and CW laserinteractions. Exp Eye Res 1995; 60: 359–71.

2. Regina M, Bunya VY, Orlin SE, Ansari H. Cornealedema and haze after selective laser trabeculoplasty.J Glaucoma 2011; 20: 327–9.

3. Kim DY, Singh A. Severe iritis and choroidal effusionfollowing selective laser trabeculoplasty. OphthalmicSurg Lasers Imaging 2008; 39: 409–11.

4. Ong K, Ong L. Selective laser trabeculoplasty may com-promise corneas with pigment on endothelium. ClinExperiment Ophthalmol 2012; [Epub ahead of print]doi:10.1111/j.1442-9071.2012.02841.x.

5. Rhodes KM, Weinstein R, Saltzmann RM et al. Intraocu-lar pressure reduction in the untreated fellow eye afterselective laser trabeculoplasty. Curr Med Res Opin 2009;25: 787–96.

Diode laser thermotherapy forconjunctival vascular malformations

Vascular malformations of the conjunctiva are hamartomasof lymphatic, venous and/or arterial origin. They can pro-liferate in disfiguring, recurrent lesions causing sub-conjunctival haemorrhage, serous exudation, astigmatismand obstruction of the visual axis.1 Treatment options arevarious. These include surgical excision,2 cryotherapy withliquid Nitrogen3 and argon laser photocoagulation.4

We report the successful use of diode laser thermo-therapy (DLT) as treatment of disfiguring conjunctival vas-cular malformation in two patients. For both cases, the IrisMedical Oculight SLx 810 nm diode laser (Iridex Corp.,Mountain View, CA, USA) was used.

In the first case, a 20-year-old lady presented with agrossly raised vascular lesion on the lateral aspect of theleft conjunctiva (Fig. 1). The lesion measured 11.1 mm by7.2 mm and 2 mm away from the limbus. The vision was6/36 due to amblyopia. The intraocular pressure (IOP)was recorded at 14 mmHg. The retina and ciliary bodywere both normal. DLT was delivered to the vascularlesion. This was carried out under general anaesthetic onpatient request. The laser was set at 650 mW ¥ 1500 ms(duration) ¥ 500 ms (interval) ¥ 200 microns (spot size) ¥300 burns. The patient received two treatment sessions.Following the second session of treatment, the patient wassatisfied with the cosmetic improvement and was reluctantfor further intervention (Fig. 2).

In the second case, a 21-year-old gentleman presentedwith a 2-year history of a violet-red lesion at the supero-nasal aspect of the right eye (Fig. 3). The malformationmeasured 5.8 mm by 3.1 mm and 2.2 mm away from thelimbus. The visual acuity was 6/6 bilaterally. The IOP wasrecorded at 15 mmHg in both eyes. The retina and ciliarybody were healthy. Treatment with DLT was deliveredunder topical anaesthetic only and using the followingsettings: 400 mW ¥ 1500 ms (duration) ¥ 500 ms (inter-val) ¥ 200 microns spot size ¥ 200 burns. The patientreceived three sessions of laser treatment. Following thethird treatment, the lesion had nearly disappeared to thepatient’s satisfaction (Fig. 4).

Both patients used an antibiotic and steroid drop aftereach treatment session and were reviewed at 8 weeks. At2 years of follow-up, neither patient had conjunctivalpuckering, evidence of neovascularization, recanalizationor recurrence of the original lesion (Figs 2,4). The visualacuity and IOP remained unchanged. The retina and ciliarybody were healthy.

In this treatment modality, diode laser works by elicit-ing photothermal effects on the target tissue. In conjun-ctival vascular malformations, the main light absorbingchromophore is haemoglobin. The long-exposure durationused in our series ensured adequate photothermal effect onthe lesion. Moreover, using the settings earlier, at the level

Competing/conflicts of interest: No stated conflict of interest.

Funding sources: No stated funding sources.

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