Bilateral naevus of Ota with choroidal melanoma and diffuse retinal pigmentation in a dark skinned person Naevus of Ota (naevus fusculocoeruleus ophthalmomaxillaris) was described by the Japanese dermatologist, Ota, in 1939 as a dermal melanocytic hamartoma that presents as bluish hyperpigmentation along the ophthalmic, maxillary, and mandibular branches of the trigeminal nerve. It is bilateral in less than 5% cases, occurring frequently in Orientals (0.2%–1%) and darker races and rarely in white people (0.04%). Open angle glaucomas and choroidal mela- noma are the rare ocular involvements. Ota’s naevus is more common in Asians than white people but uveal melanoma occurs predomi- nantly in white populations. 12 Dark skinned patients represent only 1% of all cases of orbital melanomas. 3 The risk of developing uveal melanoma in a patient with naevus of Ota is one in 400 patients in their lifetime. 12 We report a rare case of bilateral naevus of Ota with a right (RE) choroidal melanoma and left (LE) diffuse pigmentation of retina. Case report A 73 year old Anglo-Indian woman was referred with complaints of photopsia. She had black hair and light brown skin. Examination revealed a brownish-black pig- mentation of the conjunctiva, episclera, and periocular skin bilaterally (fig 1). Visual acuity for distance and near was 6/6 and N5, respectively, in each eye. Heterochromia was present, the right iris being a darker brown than the left, which had a sector of light brown colour. Gonioscopy and intra- ocular pressure were normal. The right fundus revealed a pigmented, large, elevated choroidal mass 10 disc diameter (DD) in size, 4 DD superonasal to the disc. Drusen were overlying it. No subretinal fluid was seen. The left eye showed a patchy dark pigmentation 3 DD in size, at the temporal edge of the macula. A ridge-like pigmented elevation, 3 DD long, was also seen along the super- onasal vessels. Both optic discs and maculas were normal. Ultrasound in the right eye showed a 10 mm tumour, 4.2 mm high. Fluorescein angiography confirmed its inde- pendent circulation. A systemic examination found no signs of metastasis. A diagnosis of a bilateral naevus of Ota with low grade, choroidal melanoma in the right eye (fig 2) and retinal pigmentation in the left eye was made. The patient was reluctant to accept the option of enucleation in view of the right vision. A 125 I radioactive plaque was applied (COMS study). A follow up examination 3 years postoperatively showed a flatter, yellow 4 DD6 1.5 DD scarred tumour with mottled pigmentation. The left melanosis remained unchanged. The vision was 6/6 in both eyes 6 years after 125 I treatment and cataract surgery. Comment Ota’s naevus is commonly seen unilaterally (90%). Bilateral involvement is rare. It represents melanocytes that have not migrated completely from the neural crest to the epidermis during the embryonic stage. Orientals and pigmented races have a high prevalence with a predilection for women (1: 4.8). Variable prevalence among different populations suggests genetic influences, although familial cases are rare. Two peak ages of onset in early infancy (50%) and in early adolescence suggest hormonal influ- ence. 1 In addition to the skin, pigmentation may involve oral mucosa, tympanic mem- brane, intranasal mucosa, leptomeninges and ocular structures such as the sclera, retro- bulbar fat, cornea, lens, trabeculum, disc, and retina. Associated malignant melanomas of the uvea, orbit, skin, and CNS have been described. 2 Choroidal melanomas are known to occur in less than 4% of cases and glaucoma has been noticed in less than 10% of cases. 4 Our case reports a rare occurrence of bilateral naevus of Ota with choroidal malig- nant melanoma in the right eye and retinal pigmentation in the left eye in a pigmented person. She was born to Anglo-Indian par- ents but did not know how far back in time the intermarriage had occurred. Ophthalmological follow up care is necessary for patients with increased melanosis. This case illustrates the need for regular ophthal- mic review of all pigmented lesions and the recognition that patients with naevus of Ota may also have the additional complication of melanoma. There is need for close observa- tion of all pigmented lesions of the eye. Regardless of the patient’s race, there is a greater than normal chance that a patient with the naevus of Ota might have a malignant melanoma develop within one of the affected tissues. S Sharan, J R Grigg, F A Billson Save Sight Institute, University of Sydney, Department of Ophthalmology, Sydney Eye Hospital, 8 Macquarie Street, Sydney 2000, Australia Correspondence to: Sapna Sharan, Save Sight Institute, University of Sydney, Department of Ophthalmology, Sydney Eye Hospital, 8 Macquarie Street, Sydney 2000, Australia; sapnasd@yahoo.co.uk doi: 10.1136/bjo.2005.070839 References 1 Hidano A, Kajima H, Ikeda S, et al. Natural history of nevus of Ota. Arch Dermatol 1967;95:187–95. 2 Gonder JR, Shields JA, Albert DM, et al. Uveal malignant melanoma associated with ocular and oculodermal melanocytosis. Ophthalmology 1982;89:953–60. 3 Margo CE, McLean IW. Malignant melanoma of the choroid and ciliary body in black patients. Arch Ophthalmol 1984;102:77–9. 4 Roy PE, Schaeffer EM. Nevus of Ota and choroidal melanoma. Surv Ophthalmol 1967;12:130–40. Treatment of neurotrophic keratopathy with nasal dilator strips Neurotrophic keratopathy, characterised by poorly healing corneal epithelium, occurs in eyes with decreased corneal sensory innerva- tion. Clinical findings include chronic epithe- lial defects and corneal ulceration. Numerous conditions predispose to neurotrophic kerato- pathy including diabetes mellitus, accidental and surgical trauma, herpes simplex and herpes zoster keratitis, leprosy, and topical anaesthetic abuse. Management of neurotrophic keratopathy includes ocular lubrication, pressure patch- ing, autologous serum eye drops, 1 fitting of a bandage contact lens, 2 amniotic membrane grafting, 34 and surgical tarsorrhaphy. Surgical tarsorrhaphy can be very successful in resolving neurotrophic corneal ulceration, 5 but many patients find this option cosmeti- cally unacceptable. We describe a novel method of non- surgical tarsorrhaphy using over the counter adhesive, non-medicated, nasal dilator strips (NDS) (Breathe Right Nasal Strips, Whippany, NJ, USA) applied vertically across the eyelids (fig 1). The adhesive strip consists of parallel bands of plastic imbedded in a pad, and is available in different sizes. The nasal strips were originally developed to treat patients with snoring problems, 6 or to improve nasal congestion. 7 In rhino- logical applications, the strip is typically used Figure 1 Oculodermal pigmentation. Figure 2 Choroidal melanoma. LETTERS PostScript .............................................................................................. Accepted for publication 1 May 2005 Br J Ophthalmol 2005;89:1529–1545 1529 www.bjophthalmol.com on November 28, 2021 by guest. Protected by copyright. http://bjo.bmj.com/ Br J Ophthalmol: first published as 10.1136/bjo.2005.074468 on 18 October 2005. Downloaded from on November 28, 2021 by guest. 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Protected by copyright. http://bjo.bmj.com/ Br J Ophthalmol: first published as 10.1136/bjo.2005.074468 on 18 October 2005. Downloaded from on November 28, 2021 by guest. Protected by copyright. http://bjo.bmj.com/ Br J Ophthalmol: first published as 10.1136/bjo.2005.074468 on 18 October 2005. Downloaded from