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A 54-year-old woman with bluish discoloration of her sclera
Digital Journal of Ophthalmology 2010
Volume 16, Number 2
May 8, 2010
DOI: 10.5693/djo.03.2010.02.002
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Isabella Phan, MD | Oregon Health and Science University
Rachel Kaiser, MD, MPH | University of California, San Francisco
Cynthia Chiu, MD | University of California, San Francisco
Differential Diagnosis
1. Drug toxicity from prolonged minocycline use was suspected in this patient because she lacked findings suggestive of scleritis, uveitis, vasculitis, or connective tissues diseases and had a history of prolonged, high-dose minocycline use. Other drugs such as nonsteroidal anti-inflammatory medications, amiodarone, cytotoxic drugs (i.e., busulfan, cyclophosphamide, bleomycin, adriamycin), chloroquine, phenytoin, antipsychotics (i.e., chlorpromazine and related phenothiazines), and heavy metals have been reported to cause scleral hyperpigmentation.(1) However, our patient denied use of these drugs.

2. Scleromalacia is on the differential for sclera hyperpigmentation; however, this patient had no history of autoimmune disease and denied any eye or joint pain. On examination, her sclerae were not thinned and she had no conjunctival injection or uveitis. Rheumatologic work-up was negative for RF and ANA.

3. Choroidal or ciliary body melanomas can cause scleral hyperpigmentation, particularly if they invade through the sclera. Scleral invasion due to choroidal melanoma would be an indication for enucleation; however, retinal examination revealed no choroidal masses in this patient.

4. Addison’s disease can cause a bronze hyperpigmentation of the sclera. Our patient denied any weakness, fatigue, anorexia, or abdominal pain.

5. Ochronosis, or skin discoloration due to alkaptonuria, can cause a bluish-black discoloration of the ear and sclera. The patient denied any black discoloration of her urine, as would be expected in alkaptonuria so no further urine testing was performed. Serum homogentisic acid was normal.
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