Correspondence and reprint requests to:Dr. Sheraz DayaCorneoplastic UnitQueen Victoria Hospital NHS TrustHoltye RoadEast GrinsteadWest Sussex RH19 3DZU.K.Tel.: +44 1342 414000Fax: +44 1342 414106E-mail: sdaya@centreforsight.com

Abstractpurpose To report a case of poliosis arising from treatment withtopical medications.

design Interventional case report.

methods A 37-year-old man was treated for fungal endophthalmi-tis arising from Aspergillus fumigatus keratitis with penetrating ker-atoplasty, lensectomy and vitrectomy together with systemic andprolonged topical medications.

results Recovery was complicated by retinal detachment, elevatedintraocular pressure and bullous keratopathy. Unilateral poliosis devel-oped eight months following keratoplasty and has persisted over 21/2years.

conclusions Topical medications are implicated in causing thepoliosis.

Key words Econazole; fungal endophthalmitis; fungal keratitis;latanoprost; poliosis

Introduction Poliosis is a depigmentation of hairs that may affecteyelashes, brow hair, scalp and other body hair. Associations with ophthalmic disease include Vogt-Koyanagi-Harada syndrome (VKH),where it occurs as a characteristic finding in the convalescent stage in4–60% of cases and is often associated with vitiligo.1 Poliosis may alsooccur in cases of sympathetic ophthalmia, although this is a rarefinding.1 Reported associations of poliosis with medication use areuncommon. We present this as a case of localised poliosis occurring in

Poliosis probably due to topical latanoprost 241

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Orbit – 2004, Vol. 23No. 4, pp. 241–244© 2004 Taylor & Francis Ltd.

DOI: 10.1080/01676830490522502

Accepted 15 August 2004

Poliosis associated with treatment offungal endophthalmitis

Adam S. J. Watson, FRANZCO1

Osama Giledi, FRCS2

Sheraz M. Daya, MD, FACP, FACS1,2

1Corneoplastic Unit and 2Centre for Sight, Queen VictoriaHospital NHS Trust, East Grinstead, West Sussex RH19 3DZ,

U.K.

Case report

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Fig. 1. Pre-operative photograph of right fungal keratitis andendophthalmitis showing normallypigmented eyelashes.

a complicated case of fungal endophthalmitis, the poliosis probablybeing caused by topical medications.

Case report A 37-year-old Caucasian male was referred to our unitwith right fungal keratitis and perforated corneal ulcer (Figure 1). Hewas otherwise well. He had a background of an infected corneal foreignbody removed 31/2 months earlier with growth of Aspergillus fumigatusfrom microbiological specimens. Treatment with topical econazole,ciprofloxacin and dexamethasone led to initial improvement but sub-sequent corneal perforation and recurrence of hypopyon occurred.Theperforation was sealed with cyanoacrylate tissue adhesive thatremained intact for 21/2 months until referral. Econazole was stoppedwhile ciprofloxacin and dexamethasone were continued.

Visual acuity at referral was light perception only in the affected eye.The fellow eye was healthy with uncorrected visual acuity of 20/15.Clinically, fungal endophthalmitis was suspected. An urgent right pen-etrating keratoplasty was carried out, combined with lens extractionand subtotal vitrectomy when infective involvement of lens and poste-rior segment was identified at the time of surgery. Five micrograms ofintravitreal amphotericin was administered along with 800mg of sys-temic itraconazole twice daily, and intensive topical econazole, topicalofloxacin, clotrimazole, atropine, timolol 0.5% and systemic acetazo-lamide. Microbiology of the surgical specimen confirmed growth of A. fumigatus.

Intensive (hourly) topical econazole was continued for three weeksfollowed by a slow taper (8 months total). Post-operative recovery wascomplicated by a retinal detachment three weeks following kerato-plasty. This was repaired with a vitrectomy, silicone oil tamponade andfurther intravitreal amphotericin. Subsequent intraocular pressure ele-vation required treatment with topical betaxolol, latanoprost, and oralacetazolamide. Review at 31/2 months following keratoplasty showeddiffuse right lower lid skin depigmentation. Poliosis of right upper andlower lid eyelashes was noted 8 months following keratoplasty.

Subsequent surgery has included silicone oil removal and Ahmedvalve placement for intraocular pressure control following whichlatanoprost, econazole, betaxolol and acetazolamide were discontin-

242 A.S.J. Watson et al.

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Fig. 2. Persistent right upper andlower eyelash poliosis two yearsafter cessation of econazole andlatanoprost. The poliosis is slowlydiminishing.

ued. An amniotic membrane transplant successfully stabilised theocular surface affected by bullous keratopathy secondary to cornealgraft failure. The poliosis affecting the upper and lower lids has per-sisted for 21/2 years of follow-up although fewer lashes are now affected(Figure 2).The eye is comfortable with visual acuity of counting fingers.The fellow eye remains quiet and no other areas of vitiligo or poliosishave developed.

Discussion A MEDLINE search revealed only three reports ofpoliosis associated with medication use. Waheed and Laganowski2

reported a case of bilateral eyelash poliosis and granulomatous ante-rior uveitis with no chorioretinal abnormalities associated with twomonths of topical latanoprost use. The poliosis resolved following ces-sation of latanoprost. Asensio et al.3 described poliosis in two patientsassociated with use of systemic cyclosporin A. One of the patients hadpars planitis, one was treated for iridocyclitis; both had associated tri-chomegaly. Fraga and Honigman reported a single case associated withchloroquine use.4

In VKH and sympathetic ophthalmia, vitiligo and poliosis arise dueto a cellular autoimmune process directed against melanocytes.1

However, there are probably numerous mechanisms that may causeloss of melanocytes.5 The mechanism by which drug-related poliosisarises is speculative. Presumably, inflammation directed at or involvingmelanocytes is responsible, possibly through deposition of immunecomplexes arising from anti-drug antibodies,2,6 or from the drug com-bining with melanin thereby reducing melanin’s ability to scavenge freeradicals.6 Chemically-induced apoptosis of melanocytes has also beensuggested.5

The cause of the poliosis in this case is impossible to determine. It istempting to attribute it to one or more of the topical medications usedin treating the fungal infection and its sequelae. The poliosis involvesonly the lids of the affected eye, suggesting that this is not a systemicdisease process or related to the taking of a systemic drug. Hence, thisis unlikely to represent a VKH or sympathetic uveitis-like phenome-

Poliosis probably due to topical latanoprost 243

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References1 Moorthy RS, Inomata H, Rao NA.

Vogt-Koyanagi-Harada syndrome.Surv Ophthalmol. 1995;39(4):265–292.

2 Waheed K, Laganowski H. Bilateralpoliosis and granulomatous anterioruveitis associated with latanoprostuse and apparent hypotrichosis onits withdrawal (letter). Eye. 2001;15(3):347–349.

3 Asensio V, Del Pozo LJ, Asensio M,Lerida MT. [Megalotrichiasis and

poliosis caused by cyclosporin A.]Med Clin (Barc). 1991;97(1):39.

4 Fraga S, Honigman IJ. [A case ofpoliosis during chloroquine therapy.]An Bras Dermatol. 1966;41(2):57–68.

5 Huang CL, Nordlund JJ, Boissy R.Vitiligo: a manifestation ofapoptosis? Am J Clin Dermatol.2002;3(5):301–308.

6 Moorthy RS, Valluri S, Jampol LM.Drug-induced uveitis. SurvOphthalmol. 1998;42(6):557–570.

244 A.S.J. Watson et al.

non with stimulation of a systemic autoimmune response directedagainst melanocytes.

Poliosis related to topical drug administration seems more likely. Ofthe many candidates, the two most likely are latanoprost, whose usehas been previously reported in association with poliosis, and econa-zole, used intensively and for a prolonged period in this case.We wouldlike to speculate that latanoprost is the more likely causative agentbased on the temporal relationship between starting latanoprost andnoting skin depigmentation (two months). The case reported herediffers from that previously reported associated with latanoprost inthat the poliosis has not resolved although the number of lashesaffected is diminishing. We believe that this case provides further evi-dence that latanoprost may be a rare cause of poliosis.

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