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b

a

Fig. 7.3b  Dust-like or glittering purple granules (a) and marginal keratitis­ (b) related to systemic auranofin use. Photo courtesy of Kanski­ JJ. Clinical Diagnosis in Ophthalmology, Mosby Elsevier, London, 2006.

4. Cornea

a.Keratitis

b.Ulceration

c.Stromal melting 5. Iris and ciliary body

a.Hyperemia

b.Inflammation

c.Cells and flare

Generic names: 1. Auranofin; 2. aurothioglucose; 3. sodium aurothiomalate (gold sodium thiomalate).

Proprietary names: 1. Ridaura; 2. Solganal; 3. Aurolate, Myocrysine.

Primary use

These heavy metals are used in the treatment of active rheumatoid arthritis and non-disseminated lupus erythematosus.

Ocular side effects

Systemic administration

Certain

1. Red, violet, purple or brown gold deposits (Fig. 7.3b)

a.Eyelids

b.Conjunctiva

c.Cornea

d.Surface of lens

2. Eyelids or conjunctiva

a.Allergic reactions

b.Hyperemia

c.Erythema

d.Blepharoconjunctivitis

e.Edema

f.Photosensitivity

g.Symblepharon

h.Angioneurotic edema

i.Urticaria

j.Purpura

3. Photophobia

Probable

1. May activate

a.Herpes infections

b.Guillain-Barre syndrome

Possible

1. Myasthenia gravis

a.Diplopia

b.Ptosis

c.Paresis of extraocular muscles 2. Nystagmus

3. Subconjunctival or retinal hemorrhages secondary to drug-induced anemia

4. Eyelids or conjunctiva

a.Lupoid syndrome

b.Erythema multiforme

c.Stevens-Johnson syndrome

d.Exfoliative dermatitis

e.Lyell’s syndrome

Clinical significance

Patients taking any of the gold agent may show one of two patterns of ocular chrysiasis. The more common pattern is where gold salts are deposited in the conjunctiva, all layers of the cornea and in the crystalline lens. Gold deposition in the cornea may take a Hudson-Stähli line distribution or a vortex distribution, not unlike Fabry’s disease. The gold deposits tend to be increased in areas of corneal scarring. Deep corneal deposition is usually in the posterior half of the cornea and denser inferiorly, while the superior cornea and perilimbal areas are more often spared. Lens deposits of gold are much less frequent than corneal deposits and are of little to no clinical importance. These