Letters Conjunctival Changes Associated with Yellow Nail Syndrome

The yellow nail syndrome (YNS) is a rare clinical entity characterised by slow growing yellow discoloured nails in association with peripheral lymphoedema, pulmonary manifestation (bronchiectasis, pleural effusions), and chronic sinusitis. 1 About 100 cases of YNS have been described in the literature but it has never been associated with ocular manifestations. 2 We report one patient with YNS in whom chronic chemosis and conjunc-tival degenerative lesion was observed. A 61 year old man was referred with a 2 month history of ocular irritation in the left eye. His past medical history was significative for yellowish slow growing nails, chronic maxillary sinusitis, and bronchiectasis for 5 years diagnosed as YNS. On examination, nails of both hands and feet showed yellow discoloration and thickening (Fig 1). He also had oedema over the lower limbs and subacute bronchial infection for 2 months. On ocular examination, corrected visual acuity was 20/20 in both eyes. Slit lamp examination of the left eye revealed an area of conjunctival injection and thickening in the palpebral fissure adjacent to nasal limbus. A mild nasal chemosis and superficial corneal micropan-nus were also observed (Fig 2 top). Tear secretion was normal. Examination of the anterior and posterior segment in both eyes was unre-markable. Treatment with topical cortico-steroid (dexamethasone 0.1%, four times per day) and artificial tears was begun. Two weeks after presentation the patient reported an incomplete resolution of the irritation on the left eye and conjunctival lesion persisted. Computed tomographic scan of the brain and the orbits was normal. A conjunctival biopsy specimen showed multilayered epithelium, nuclear pleomorphism with malpighian differentiation. The underlying connective tissue was normal (Fig 2 bottom). Ocular symptoms improved rapidly and postoperative antibiotic and steroid eye drops where discontinued after 2 weeks. There was no recurrence of the conjunctival lesion but a mild chemosis persist in the left eye and appeared in the right eye. Comment YNS was first described by Samman and White in 1964. 1 The syndrome has been defined as the complete triad of slow growing yellow nails, lymphoedema, and pleural effu-sions but today it is accepted that the presence of two of the three symptoms is sufficient to establish the diagnosis, even though the abnormalities may appear separately with intervals of several years. 2 The aetiology of YNS is obscure, while pathogenesis seems to involve impaired lym-phatic drainage. 3 Ocular involvement has never been described in the YNS. However, conjunctival chemosis …