BRIEF REPORTS

Blepharoptosis-induced SuperiorKeratoconusTerry Kim, MD, Bobbie Khosla-Gupta, MD, andChristopher Debacker, MD

PURPOSE: This clinical case report demonstrates blepha-roptosis-induced corneal steepening and its subsequentresolution after blepharoptosis surgery.METHODS: A 62-year-old man complaining of blurredvision without apparent cause on clinical examinationunderwent keratometry and computerized corneal topog-raphy, which revealed superior corneal steepening inboth eyes. Bilateral upper eyelid blepharoptosis surgerywas performed.RESULTS: Three months after blepharoptosis surgery,repeat computerized corneal topography revealed normalcorneal contours with improved vision in both eyes.

Figure 1. (Top left) Moderate blepharoptosis is evidenced bythe decreased margin-reflex distance in both eyes. (Bottom leftand right) Computerized corneal topography shows orange-yellow islands corresponding to areas of superior corneal steep-ening (more pronounced in the right eye than in the left eye).

Accepted for publication Mar 23, 2000.Department of Ophthalmology, Duke University, Durham, North

Carolina.Inquiries to Terry Kim, MD, Duke University Eye Center, Box 3802,

Erwin Rd, Durham, NC 27710-3802; fax: (919) 681-7661; e-mail:kim00006@mc.duke.edu

© 2000 BY ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED.232 0002-9394/00/$20.00PII S0002-9394(00)00497-9

CONCLUSIONS: Blepharoptosis is a common conditionthat may induce superior corneal ectasia that is notevident by manifest refraction, slit-lamp examination, orkeratometry. Computerized corneal topography can helpdetect such subtle corneal abnormalities and guide ther-apy. (Am J Ophthalmol 2000;130:232–234. © 2000by Elsevier Science Inc. All rights reserved.)

A62-YEAR-OLD MAN WAS REFERRED WITH COMPLAINTS

of monocular diplopia and blurred vision in each eyeof 3 years’ duration. During this time, previous examina-tions by several ophthalmologists had been nondiagnostic.His medical history included chronic bronchitis and rheu-matoid arthritis, and his ophthalmic history was unremark-able. He had no history of atopy, allergies, scleritis, orcontact lens use. The patient did admit to intermittenteye rubbing in both eyes. His maternal family historywas negative for keratoconus; his paternal family historywas unknown. His visual acuity of 20/50 in both eyes was

corrected to 20/20 in both eyes with a manifest refractionof 12.00 2 1.50 by 90 degrees in both eyes, but hissymptoms of monocular diplopia and blurred imagespersisted.

Keratometry revealed 44.62/45.00 by 135 degrees righteye and 44.37/44.50 by 130 degrees left eye. Intraocularpressure was normal in both eyes. Slit-lamp examinationrevealed moderate blepharoptosis of both upper eyelids(Figure 1) with otherwise normal findings. Specifically,both corneas and lenses were clear. A Fleisher iron linewas not noted. Computerized corneal topography (EyeSysTechnologies, Houston, Texas) was obtained and showedsuperior corneal steepening in both eyes (Figure 1). Supe-rior corneal thinning was not noted. The patient wasreferred to our oculoplastics service for evaluation. Bilat-eral upper eyelid blepharoplasty was performed withoutcomplication.

The patient presented for follow-up 3 months later,noting resolution of his symptoms. His visual acuity had

Figure 2. (Top left) Resolution of blepharoptosis after surgicalrepair in both eyes. (Bottom left and right) Computerizedcorneal topography shows disappearance of the orange-yellowislands corresponding to normalization of corneal curvature inboth eyes.

BRIEF REPORTSVOL. 130, NO. 2 233

improved to 20/20 in both eyes without correction, and hisblepharoptosis was no longer evident (Figure 2). Repeatcorneal topography was performed, which revealed normalcorneal contours (Figure 2).

The term superior keratoconus refers to the rare andatypical presence of superior corneal ectasia evident eitheron clinical examination or corneal topography.1,2 How-ever, it is used here to demonstrate that the commondisorder of blepharoptosis can induce similar changes oncorneal topography that are not evident on slit-lampexamination, manifest refraction, or keratometry. Previousstudies have confirmed changes in astigmatism after sur-gery for blepharoptosis.3

REFERENCES

1. Eiferman RA, Lane L, Law M, Fields Y. Superior keratoconus.Refract Corneal Surg 1993;9:394–395.

2. Prisant O, Legeais J, Renard G. Superior keratoconus. Cornea1997;16:693–694.

3. Holck DE, Dutton JJ, Wehrly SR. Changes in astigmatismafter ptosis surgery measured by corneal topography. OphthalPlast Reconstr Surg 1998;14:151–158.

Air Bag–induced Corneal Flap FoldsAfter Laser In Situ KeratomileusisRichard A. Norden, MD, Henry D. Perry, MD,Eric D. Donnenfeld, MD, andCarlos Montoya, MD

PURPOSE: We describe a case of air bag–induced oculartrauma resulting in folds in the corneal flap 3 weeks afterlaser in situ keratomileusis.METHODS: Case report. Three weeks after laser in situkeratomileusis, a 20-year-old man was involved in amotor vehicle accident and sustained blunt trauma to theright eye, which caused corneal flap folds, corneal edema,anterior chamber cellular reaction, and Berlin retinaledema.RESULTS: Six weeks after laser in situ keratomileusis,persistent flap folds necessitated re-operation with liftingof the flap and repositioning. One week after the proce-dure, the visual acuity improved to 20/20-2, and the foldshad cleared.CONCLUSION: Trauma after laser in situ keratomileusismay produce folds in the corneal flap. With persistence ofthese folds, management by lifting and repositioning thecorneal flap may be necessary to permit recovery of visual

acuity. (Am J Ophthalmol 2000;130:234–235.© 2000 by Elsevier Science Inc. All rights reserved.)

POSTOPERATIVE CORNEAL FLAP COMPLICATIONS ARE

relatively uncommon after laser in situ keratomileu-sis.1–3 We have recently encountered a case of air bag–induced ocular trauma resulting in corneal folds in a laserin situ keratomileusis flap 3 weeks after laser in situkeratomileusis.

CASE REPORT

A 20-YEAR-OLD MAN HAD BEST-CORRECTED VISUAL ACUITY

with spectacles of 20/20 in both eyes with 23.25 20.25axis 30 degrees in the right eye and 21.75 21.75 axis 165degrees in the left eye. The patient underwent an uncom-plicated bilateral laser in situ keratomileusis procedure and9 days later was noted to be plano in the right eye and20.25 in the left eye, with 20/20 vision in each eyeuncorrected.

Two weeks later, the patient was involved in a motorvehicle accident and sustained blunt trauma to the right eyeby air bag inflation. On initial examination, the patient’svisual acuity in the right eye without correction was 20/200,pinhole acuity of 20/60, and 20/20 in the left eye. Slit-lampevaluation showed folds on the flap in the right eye, and theanterior chamber had moderate (21) cells. The retinashowed Berlin retinal edema of the macula. The pachymetryreading was 0.695 mm in the right eye. The patient wastreated with prednisolone acetate 1% (Pred Forte; Allergan

Accepted for publication Mar 27, 2000.Department of Ophthalmology, University of Medicine and Dentistry,

New Jersey (R.A.N.), Newark, New Jersey; North Shore UniversityHospital (H.D.P., E.D.D.), Manhasset, New York; Nassau County Med-ical Center (H.D.P., E.D.D., C.M.), East Meadow, New York.

Inquiries to Richard A. Norden, 1144 East Ridgeway Avenue, Ridge-wood, NJ 07450, lasik@ibm.net

FIGURE 1. Slit-lamp photograph showing corneal folds aftercorneal trauma occurring at 3 weeks after air bag injury to theright eye.

AMERICAN JOURNAL OF OPHTHALMOLOGY234 AUGUST 2000