Anupama Pherwani Division of Ophthalmology and Visual Sciences, University of Nottingham, Queens Medical Centre, Nottingham, UK Vipul Vakil PBMA’S H V Desai Hospital, Pune, India Habibullah Eatamadi, Ravinder Singh, Harminder S Dua Division of Ophthalmology and Visual Sciences, University of Nottingham, Queens Medical Centre, Nottingham, UK Correspondence to: Professor H S Dua, Division of Ophthalmology, B Floor, Eye ENT Centre, Queens Medical Centre, University Hospital, Nottingham. NG7 2UH, UK; harminder.dua@nottingham.ac.uk References 1 Alaniz-Cancino F. The use of beta radiation in the treatment of pterygium. Ophthalmic Surg 1982;13:1022–5. 2 Meacham CT. Triethylene thiophophoramide in prevention of pterygium recurrence. Am J Ophthalmol 1962;54:751–6. 3 Joselson GA, Muller P. Incidence of pterygium recurrence in patients treated with thiotepa. Am J Ophthalmol 1966;61:891–2. 4 Singh G, Wilson MR, Foster CS. Mitomycin eye drops as treatment of pterygium. Ophthalmol 1988;95:813–21. 5 Hayasaka S, Noda S, Yamamoto Y, et al. Postoperative instillation of low dose mitomycin C in treatment of primary pterygium. Am J Ophthalmol 1988;106:715–8. 6 Kamlesh DS. Intraoperative daunorubicin to prevent the recurrence of pterygium after excision. Cornea 2001;20:172–4. 7 Maldonado MJ, Cano-Parra J, Navea-Tejerina A, et al. Inefficacy of low-dose intraoperative fluorouracil in the treatment of primary pterygium. Arch Ophthalmol 1995;113:1356–7. 8 Prabhasawat P, Barton K, Burkett G, et al. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology 1997;104:974–85. 9 Hirst LW. The treatment of pterygium. Surv Ophthalmol 2003;48:145–80. 10 Blumenkranz MS, Ophir A, Clafin AJ, et al. Fluorouracil for treatment of massive periretinal proliferation. Am J Ophthalmol 1982;94:458–67. 11 Pikkel J, Yair P, Ophir A, et al. Halting pterygium recurrence by postoperative 5-fluorouracil. Cornea 2001;20:168–71. A novel technique to treat traumatic corneal perforation in a case of presumed brittle cornea syndrome The management of corneal perforation can be difficult. We describe a novel technique to manage corneal perforation in brittle cornea syndrome (BCS). Case report A 14-year-old daughter of consanguineous Pakistani parents presented with a history of a bottle cap having struck her left eye. She had a history of multiple trauma to both eyes since childhood. At presentation, there was limbus-to-limbus corneal perforation in the left eye. The right eye had a failed corneal graft (for extensive corneal opacities). An examination under general anaes- thesia showed a collapsed left eye with rolled-in corneal edges, without any scleral injury. There was partial aniridia, aphakia and prolapsed vitreous, with no obvious retinal detachment. She was also noted to have hypermobility of the small joints of her hands, with bilateral campto- dactyly of the fifth fingers and over-riding toes. During primary repair, the cornea was noted to be soft, with cheese-wiring of 10/0 nylon sutures. At review on past-operative day 1, she had a flat anterior chamber, necessitating a second operation. During this operation, suture track leaks were observed with the use of fluorescein. These were successfully tampo- naded with air. To allow sufficient duration of tamponade, a non-expansile (14%) perfluoro- propane (C 3 F 8 ) gas exchange was performed after transcorneal three port vitrectomy to gain maximal gas fill. Postoperatively, the cornea was Siedel negative. The patient was kept supine for 10 days, at the end of which the globe remained formed (fig 1). A month later, the patient received a penetrating corneal injury to the right eye while not using her protective goggles. She underwent primary surgical repair similar to the left eye using C 3 F 8 gas. The final visual acuity was hand movement by both eyes. Discussion The patient’s history suggested an underlying connective tissue disorder affecting the eyes. BCS is a generalised connective tissue disorder characterised by corneal rupture, after a minor trauma, or spontaneously. 1 Other features include keratoconus or keratoglobus, blue sclera, red hair, hyperelasticity of the skin without excessive fragility, and hypermobility of the joints. 2 BCS has been reported mainly in Middle Eastern consanguineous families, although no underlying genetic defect has been identified to date. 3 A differential diagnosis is Ehlers–Danlos syndrome type VI, which is associated with kyphoscoliosis and thin sclera (with rupture after trivial trauma). It is characterised by the absence or mutation of the procollagen lysyl hydroxylase gene on chromosome 1, causing a deficiency of the enzyme lysyl-hydroxylase. 4 This leads to a build-up of urinary hydroxylysyl- pyridinoline. In contrast, BCS has normal total urinary pyridinoline ratios. The urinary test results of this patient showed a normal ratio of total lysyl-pyridinoline to total hydroxylysyl- pyridinoline, suggesting a diagnosis of BCS. Repair of corneal perforations using tissue adhesives and viscoelastic agents, 5 and onlay epikeratoplasty with a donor corneoscleral button to repair a ruptured keratoglobus, 6 has been reported previously. Air tamponade is also com- monplace, but the intraocular gas tamponade we used is a novel technique. Prolonged C 3 F 8 gas contact with the corneal wound prevented aqu- eous egress, allowing sufficient wound integrity while keeping the globe formed. This is the first case report of the use of a non-expansile volume of C 3 F 8 gas to repair the brittle cornea in BCS, which could be generally applied to fragile leaking corneas. Hussin Mohamed Hussin, Suman Biswas, Mohamed Majid, Richard Haynes, Derek Tole Bristol Eye Hospital, Bristol, UK Correspondence to: MrH M Hussin, Bristol Eye Hospital, Lower Maudlin Street, Bristol BS1 2LX; UK; H.M.Hussin@bristol.ac.uk References 1 Izquierdo L Jr, Mannis MJ, Marsh PB, et al. Bilateral spontaneous corneal rupture in brittle cornea syndrome: a case report. Cornea 1999;18:621–4. 2 Zlotogora J, BenEzra D, Cohen T, et al. Syndrome of brittle cornea, blue sclera and joint hyperextensibility. Am J Med Genet 1990;36:269–72. 3 Al-Hussain H, Zeisberger SM, Huber PR, et al. Brittle Cornea Syndrome and its delineation from the kyphoscoliotic type of Ehlers-Danlos Syndrome (EDS VI). Am J Med Genet 2004;124:28–34. 4 Steinmann B, Royce PM, Superti-Furga A. The Ehlers- Danlos Syndrome. In: Royce PM, Steinmann B, eds. Connective tissue and its heritable disorders:molecular, genetic and medical aspects.2nd edn. New York: Wiley-Liss, 2002:431–523. 5 Hirst LW, DeJuan E. Sodium hyaluronate and tissue adhesive in treating corneal perforations. Ophthalmology 1982;89:1250–3. 6 Macsai MS, Lemley HL, Schwartz T. Management of oculus fragilis in Ehlers-Danlos type VI. Cornea 2000;19:104–7. Sympathetic ophthalmia after ruthenium plaque brachytherapy Sympathetic ophthalmia is a rare, bilateral inflammatory process with an incidence of 0.03/100 000 in the UK and Ireland. 1 It usually follows either penetrating eye injury or intrao- cular surgery. Although sympathetic ophthalmia has previously been described after irradiation of ocular melanoma, 23 it has never been reported after simple 106 Ru plaque brachytherapy. We present a case which confirms that there is a risk of developing sympathetic ophthalmia after charged-particle therapy in the absence of a penetrating injury of the uveal tract. Case report A 41-year-old lady was referred by her optician for a slow-growing iris lesion. Fine needle aspiration biopsy confirmed the diagnosis of ciliary body malignant melanoma. Systemic investigations for metastatic disease were negative. The patient underwent routine sur- gery for the insertion and subsequent removal of a 106 Ru plaque. Postoperative recovery was uneventful. At 6 months after surgery, the patient presented with a 1-week history of reduced vision in both eyes to 6/24 OD and 6/36 OS. This was accompanied by photophobia, sore- ness and redness of both eyes. Informed consent was obtained for publication of the person’s details in this report. doi: 10.1136/bjo.2006.101956 Accepted 27 July 2006 Competing interests: None. Figure 1 The left eye after the corneal perforation was repaired. Informed consent was received for publication of this figure. Informed consent was obtained for publication of the person’s details in this report. doi: 10.1136/bjo.2006.102178 Accepted 8 July 2006 Competing interests: None. PostScript 399 www.bjophthalmol.com