title: Chronic and delayed-onset mustard gas keratitis: report of 48 patients and review of literature.
abstract: OBJECTIVE
  To report the clinical features of 93 eyes of 48 patients with chronic and delayed-onset mustard gas keratitis. Clinicopathologic correlation in 5 eyes and a review of related literature are presented.
  
  
  METHODS
  Retrospective, noncomparative case series.
  
  
  METHODS
  Forty-eight Iranian survivors of Iraqi chemical warfare with chronic or delayed-onset mustard gas keratitis.
  
  
  METHODS
  We reviewed the symptoms, clinical findings, course, and treatment of our patients and reviewed the literature. In 5 patients, histopathologic features of corneal and conjunctival specimens were evaluated.
  
  
  METHODS
  Ocular findings, clinical course, treatment measures, and histopathologic studies.
  
  
  RESULTS
  Of 48 patients, 31 (64.6%) had chronic symptomatology, whereas 17 (35.4%) experienced delayed-onset lesions. Visual acuity at referral ranged from hand motions to 20/20. Ocular surface changes included chronic blepharitis and decreased tear meniscus in all patients, limbal ischemia (81.3%), and conjunctival vascular abnormalities (50%). Corneal signs in order of frequency were: scar or opacity (87.5%), neovascularization (70.8%), thinning (58.3%), lipoid deposits (52.1%), amyloid deposits (43.8%), and epithelial defects and irregularity (31.3%). Many patients received conservative treatment; others underwent allograft stem cell transplantation (20 eyes of 17 patients), penetrating keratoplasty (12 eyes of 12 patients), and lamellar keratoplasty (4 eyes of 3 patients). Conjunctival specimens were evaluated by light microscopy. Decreased goblet cell density, attenuated or thickened epithelium, scarring in the substantia propria associated with plasmacytic and lymphocytic infiltration, and dilated lymphatic vessels were noted. Excised corneal buttons disclosed absence of epithelium and Bowman's layer, fibrovascular pannus, stromal scarring, and vascularization.
  
  
  CONCLUSIONS
  Mustard gas causes chronic and delayed destructive lesions in the ocular surface and cornea, leading to progressive visual deterioration and ocular irritation. The pathophysiologic features of these changes are not clearly identified. Excised conjunctival and corneal specimens revealed a mixed inflammatory response without any specific features. Based on the clinical appearance of the lesions and the histopathologic findings, an immune-mediated component seems possible. This article contains additional online-only material available at.
authors.affiliation: Ophthalmic Research Center and Ophthalmology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran. ma_javadi@yahoo.com
authors.forename: Mohammad-Ali
authors.initials: MA
authors.lastname: Javadi
authors.forename: Shahin
authors.initials: S
authors.lastname: Yazdani
authors.forename: Hamid
authors.initials: H
authors.lastname: Sajjadi
authors.forename: Khosro
authors.initials: K
authors.lastname: Jadidi
authors.forename: Farid
authors.initials: F
authors.lastname: Karimian
authors.forename: Bahram
authors.initials: B
authors.lastname: Einollahi
authors.forename: Mohammad-Reza
authors.initials: MR
authors.lastname: Ja'farinasab
authors.forename: Mohammad
authors.initials: M
authors.lastname: Zare
mesh_terms: D000328:Adult; D000368:Aged; D002057:Burns, Chemical / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D002619:Chemical Warfare Agents / Q000009:adverse effects*; D002908:Chronic Disease; D003228:Conjunctiva / Q000187:drug effects; D003315:Cornea / Q000187:drug effects*; D005126:Eye Burns / Q000139:chemically induced* / Q000175:diagnosis / Q000601:surgery; D006801:Humans; D007492:Iran; D007493:Iraq; D007634:Keratitis / Q000139:chemically induced* / Q000175:diagnosis / Q000601:surgery; D015948:Keratoplasty, Penetrating; D016850:Limbus Corneae / Q000166:cytology; D008297:Male; D008875:Middle Aged; D009151:Mustard Gas / Q000009:adverse effects*; D012189:Retrospective Studies; D033581:Stem Cell Transplantation; D014857:Warfare
chemical_list: D002619:Chemical Warfare Agents; D009151:Mustard Gas