Sir,

I read with interest the recently published article by Köksal et al,1 reporting adherent leukoma associated with measles in two patients in Turkey. They rightly pointed out that these corneal changes are seen more commonly in developing and third world countries. However, in the modern and ‘borderless’ Europe, where there are a large number of immigrants and refugees, we are beginning to encounter these patients in this country as well. It is important to recognise the problems in these patients, and they present new clinical challenges to ophthalmologists in the United Kingdom (UK).

Recently, a Turkish refugee aged 51 years was referred by an optician for cataract assessment. He suffered from measles and malnutrition during his childhood in Turkey, but he denied any previous ocular history. He achieved a visual acuity of 6/18 and 6/24 in the left and right eyes, respectively. Anterior segment examinations revealed bilateral mild nuclear cataracts and inferior corneal opacities (leukoma), which were adherent to the underlying iris tissue and distorted pupils (Figure 1). The rest of the ocular examinations were unremarkable. The corneal changes appeared to be chronic, and detailed enquiries showed that he maintains a balanced diet since he came to UK 5 years ago.

Figure 1
figure 1

Corneal scar in the right eye (left figure) is larger than that in the left eye (right figure). Note the underlying iris tissues were dragged towards the corneal scars (adherent leukoma) with pupils being distorted.

Full size image

The options of cataract management in this patient include cataract extraction and intraocular lens implantation alone, with or without corneal graft at a later date, or with penetrating keratoplasty (PK), a triple procedure, at the same time. Using trypan blue during cataract operation in corneal opacities has some positive results; the dye improved visualisation of the anterior capsule and a complete capsulorrhexis could be performed successfully in all eyes in the study.2 As for corneal graft, the evidence is less clear. Dandona et al3 reported adherent leukoma as an indication for PK in 7.5% of its cases in India, but it was unclear with regards to their visual outcome. Yorston et al4 reported a series of PK in Africa and 5% of the grafts being undertaken for corneal scarring caused by trachoma or measles. The visual outcome was worse in the corneal scarring group compared to the keratoconus group. They concluded that penetrating keratoplasty has a limited role in the treatment of blindness from corneal scarring due to trachoma, measles, and vitamin A deficiency for which community-based preventive measures must remain the priority. In this case, it is important to assess for other underlying pathologies like herpetic infection, malnutrition, and vitamin A deficiency, as these may affect the success rate of PK. As mentioned earlier, this is the kind of patients that UK ophthalmologists may encounter more often in the future, but, due to its rarity, they are probably best managed in centres with specialised corneal service.