Indirect argon laser drainage of subretinal fluid.

We report on a new method of subretinal fluid drainage which uses the indirect ophthalmoscopic delivery of argon laser energy to perforate the choroid. This carries all the theoretical advantages of drainage with the endolaser probe but is simpler and less expensive. We present a prospective series of 31 patients in whom this method was applied. Satisfactory drainage was obtained in 28. There were 4 cases of limited subretinal haemorrhage attributable to the laser, and 1 case of subfoveal haemorrhage. No cases of retinal perforation or incarceration were observed.

Manchineel keratoconjunctivitis.

The Manchineel tree is an evergreen widely distributed in tropical regions. The toxic nature of Manchineel has been known since the early sixteenth century. Contact with its milky sap (latex) produces bullous dermatitis and acute keratoconjunctivitis. We identified 19 patients who had ocular injuries caused by Manchineel between 1985 and 1990 and were able to review 12. All of these patients had been treated by lavage, cycloplegia, and topical antibiotics. Of 20 episodes of exposure 14 affected both eyes. The cornea was damaged in 16 episodes, the extent varying from large corneal epithelial defects to superficial punctate keratitis. The epithelial changes had resolved in a mean period of 3.75 days (range 1 to 14 days). Two episodes caused stromal infiltration to appear and in one of these a stromal opacity remained 5 years later. The final visual acuity was 6/9 or better in all eyes except in one patient who had visual impairment because of glaucoma. Our results suggest that despite the severity of the acute reaction, the long term visual prognosis is excellent in Manchineel keratoconjunctivitis. The historical and toxicological literature on Manchineel is reviewed.

Bilateral Kimura's disease of the eyelids.

A case of Kimura's disease affecting the eyelids bilaterally is reported in a 5-year-old boy of Afro-Caribbean extraction who has been followed for 12 years with repeat biopsies. He initially presented at 5 years of age with swelling of the left upper eyelid, left cervical lymphadenopathy, and eosinophilia. One year later he developed swelling of the right upper eyelid. There has been no change in the clinical appearance over the next 12 years. Repeated biopsies of the eyelids showed a diffuse inflammatory infiltrate with many eosinophils and lymphocytes. A lymph node biopsy showed reactive lymphoid hyperplasia. Immunohistochemistry using lymphoid markers showed a polyclonal pattern. Kimura's disease is a rare cause of eyelid swelling, particularly at such a young age and with bilateral involvement. This case demonstrates that bilateral orbital lymphoid lesions with cervical node involvement do not always imply lymphoma, but may have a benign pathogenesis. The unusually long follow up in this case confirms an excellent prognosis for Kimura's disease with conservative management. Accurate diagnosis in small orbital biopsies may spare the patient unnecessary radical surgery.

Spontaneous subconjunctival haemorrhage--a sign of hypertension?

The relationship between the condition of spontaneous subconjunctival haemorrhage (SCH) and hypertension was investigated. Seventy eight patients with SCH and 78 controls with unrelated ophthalmic conditions were compared. Blood pressure (BP) was significantly higher at presentation in the group with SCH at 149 (SD 27)/89 (SD 15) versus 142 (SD 25)/81 (SD 12). The proportion of hypertensives by WHO criteria (systolic blood pressure > 160 and/or diastolic blood pressure >95) was 46% on presentation compared with 23% of the control group. The morphology of the lesion did not influence the association with hypertension although there was a suggestion that the group with raised haemorrhages had a tendency to higher systolic blood pressure. It is recommended that all patients with SCH have their BP checked; this will result in the diagnosis of a significant number of new hypertensives.

A case of developmental glaucoma presenting with abdominal colic and subnormal intraocular pressure.

A healthy baby boy presented with abdominal colic. He was subsequently noted to have enlarged, edematous corneas. A clinical diagnosis of developmental glaucoma was made despite ocular hypotony. Trabeculectomies were designed to include peripheral cornea. This served as a biopsy to confirm the diagnosis and as a surgical treatment for the condition. Morphological examination of the outflow system revealed findings compatible with a diagnosis of developmental glaucoma: a hypoplastic trabecular meshwork which contained an abundance of abnormal collagenous tissue in the extracellular spaces and the presence of endothelial cells overlying a continuous collagenous membrane. In the iris stroma there were numerous abnormal blood vessels, with a paucity of mural contractile cells.

Etretinate and visual function: a 1-year follow-up study.

Concern has been expressed in the literature that the drug etretinate may be potentially retinotoxic. Four patients are reported who have received long-term treatment with etretinate and who have undergone detailed evaluation for the development of visual dysfunction over a 1-year period. Despite prolonged treatment and high total doses no evidence of ocular toxicity attributable to the drug was found in any of the patients.

The association of Fuchs's corneal endothelial dystrophy with axial hypermetropia, shallow anterior chamber, and angle closure glaucoma.

A series of 24 patients with Fuchs's dystrophy are presented in whom detailed clinical measurement showed an association with axial hypermetropia and shallow anterior chamber. In 14 of these patients one cornea had developed oedema, of which 11 had required penetrating keratoplasty. Comparison of these eyes with the fellow eyes without corneal oedema revealed that the anomalies in measurement were not due to the process of decompensation. These 14 patients were then compared with the remaining 10 patients without corneal oedema in either eye, and a similar profile of anomalous measurements was observed. The whole group of 24 patients were then compared with three separate control groups, and in each case a significant trend towards hypermetropia, short axial length, and shallow anterior chamber was noted. The mean spherical equivalent refractive error in the patients with Fuchs's dystrophy was +2.48 D compared with -0.31 D for controls; corresponding means for axial length were 22.1 mm compared with 23.4 mm; and for anterior chamber depth were 2.2 mm compared with 2.7 mm. Each of these differences was statistically significant, but there was no significant difference for the keratometry measurements between patients and controls. Five of 24 (21%) of the patients had problems related to shallow anterior chambers of whom 3 (12%) had manifest angle closure glaucoma requiring surgical peripheral iridectomy. The aetiology of Fuchs's dystrophy and of ametropia is discussed and possible modes of association outlined. This previously unrecognised association gives a rational basis for the widely accepted practice of combining penetrating keratoplasty with lens extraction and has several other practical implications which are important in the differential diagnosis and treatment of Fuchs's dystrophy and angle closure glaucoma.

Subarachnoid haemorrhage due to upper cervical trauma.

Seventeen cases are reported in which fatal subarachnoid haemorrhage was associated with injury to the upper cervical region. Most of these cases were alcohol-intoxicated, most had sustained their injuries in an altercation, and death was usually but not invariably rapid. It is proposed that trauma to the upper cervical region can cause subarachnoid haemorrhage, by a mechanism involving tracking of blood into the subarachnoid space from a damaged vertebral artery or one of its branches.