Acute angle closure glaucoma following head and orbital trauma.

The case is reported of a 52-year-old woman who suffered a minor head injury and orbital trauma and returned 2 days later with a unilateral headache, vomiting and photophobia. This was initially thought to be secondary to her head injury but, once severe visual impairment and a dilated unreactive pupil developed, the true diagnosis became obvious. A diagnosis of acute angle closure glaucoma was made and she was treated with no complications. This case highlights acute angle closure glaucoma as an important diagnosis to consider in patients who present with unilateral headache and dilated pupil after head injury.

Idiopathic intracranial hypertension: 12 cases treated by venous sinus stenting.

BACKGROUND: The high pressures documented in the intracranial venous sinuses in idiopathic intracranial hypertension (IIH) could be the result of focal stenotic lesions in the lateral sinuses obstructing cranial venous outflow. OBJECTIVE: To explore the relation between venous sinus disease and IIH. METHODS: 12 patients with refractory IIH had dilatation and stenting of the venous sinuses after venography and manometry had shown intracranial venous hypertension proximal to stenoses in the lateral sinuses. Intrasinus pressures were recorded before and after the procedure and correlated with clinical outcome. RESULTS: Intrasinus pressures were variably reduced by stenting. Five patients were rendered asymptomatic, two were improved, and five were unchanged. CONCLUSIONS: The importance of venous sinus disease in the aetiology of IIH is probably underestimated. Lateral sinus stenting shows promise as an alternative treatment to neurosurgical intervention in intractable cases.

Clinical comparison of the Keeler Pulsair 3000 with Goldmann applanation tonometry.

AIM: To confirm the accuracy of the Pulsair 3000 before introducing the instrument into clinical practice. METHOD: A masked study by two experienced tonometrists comparing the mean of the Goldmann intraocular pressure (IOP) readings against the Pulsair 3000 reading (average of four puffs). Results of 150 eyes were compared with an IOP range of 10 mm Hg-44 mm Hg. RESULTS: Correlation between the two Goldmann tonometry results was 0.9830 with a standard deviation of 1.1085 mm Hg. Correlation between the mean of the two Goldmann readings against the Pulsair 3000 reading was 0.982 with a standard deviation of 1.1179 mm Hg. Bland-Altman analysis confirms a satisfactory outcome. CONCLUSION: The Pulsair 3000 provides an accurate and objective method of measuring IOP with many advantages over traditional Goldmann tonometry.

The relationship between obesity and idiopathic intracranial hypertension.

OBJECTIVES: To evaluate the association between obesity and idiopathic intracranial hypertension (IIH) and establish whether there is a relationship with visual outcome. To calculate the prevalence and degree of obesity in a group of patients with IIH. METHODS: 34 patients (31 female and 3 male) were recruited between 1993 - 1997 with a diagnosis of IIH. Assessment included visual acuity, visual field assessment (Humphrey automated and Goldmann manual perimetry), fundus assessment and measurement of body mass index (BMI). Obesity was defined as a BMI of 30 kg/m2. RESULTS: 70.5% of patients were obese. The relative risk for obesity and IIH was significant at 8 (95%CI: 2,29). This increased to 17 (95%CI: 5,62) for obese females aged 16 to 24 years and 10 (95%CI: 3,35.5) for obese females aged 25 to 34 years. Morbid obesity (BMI > 40) was significantly associated with poor visual outcome. Serial obesity measures showed generally little change in weight over time and there was no correlation between weight change and visual improvement. CONCLUSIONS: This study has documented a relationship between obesity and IIH. A high degree of obesity was associated with a poor visual function and identified as a risk factor for poor outcome. Obesity may be an aetiological factor in this condition although it is unlikely to be the sole cause but more probably a precipitating factor. Weight loss is recommended although failure to lose weight is common. Any weight reduction programme must therefore be actively encouraged and monitored.

Assessment of visual function in idiopathic intracranial hypertension: a prospective study.

The visual function of 35 patients with a diagnosis of idiopathic intracranial hypertension was assessed prospectively over a 3 year period. In assessing the visual function of cases of idiopathic intracranial hypertension a number of tests were employed including visual field assessment with Humphrey and Goldmann perimeters and documentation of visual acuity and contrast sensitivity. Loss of visual function is the only serious complication and may occur early or late in the course of the condition. An appropriate and sensitive clinical assessment regime is therefore of importance in the outpatient situation. Visual field assessment was documented as the most sensitive to detection of visual loss, with statistically greater sensitivity in comparison with visual acuity and contrast sensitivity testing. Detection of asymptomatic visual loss indicates the necessity for visual monitoring to ensure detection of insidious visual loss. The types of visual field defects noted in this study were typical of anterior optic nerve pathology of raised intracranial pressure and commonly included arcuate defects, nasal steps and global constriction. Visual loss was noted at presentation and during follow-up in up to 87% of patients using Goldmann perimetry and up to 82% of patients using Humphrey perimetry. The visual status improved significantly throughout the follow-up period and the final visual outcome was excellent or good in 83% of patients.

Intraocular pressure changes after peribulbar injections with and without ocular compression.

AIM: Two prospective studies were carried out in order to investigate (1) the rise in intraocular pressure (IOP) following peribulbar anaesthesia with a fixed volume of anaesthetic agent administered by a single surgeon, and (2) the efficacy of ocular compression with the Honan balloon for lowering IOP. Glaucomatous eyes were excluded from both studies. METHODS: In study group 1, 36 eyes of 36 patients undergoing cataract and/or implant surgery each received peribulbar injections consisting of 5 ml of anaesthetic from an inferotemporal site through the conjunctiva and a further 5 ml from a medial injection through the caruncle. IOP values were measured immediately before and after the injections and then after a variable period of external ocular compression. In study group 2, 20 eyes of 20 patients undergoing cataract surgery received peribulbar injections of local anaesthetic as above. IOP values were measured immediately before and after the injections and after 20 minutes without ocular compression. After a further 20 minute period with ocular compression the IOP was again measured. RESULTS: In study group 1, the mean immediate rise in IOP induced by the injections was 11.44 (95% confidence interval 8.97-13.90) mm Hg. The mean change in IOP after ocular compression was an overall fall of 2.42 (0.49-4.34) mm Hg from the pre-injection value. In study group 2, the mean injection induced rise in IOP was 9.45 (6.90-12.00) mm Hg. The mean fall in IOP during the first 20 minutes without ocular compression was 2.85 (1.20-4.50) mm Hg. During the second 20 minutes with ocular compression the mean fall in intraocular pressure was 11.05 (8.14-14.96) mm Hg. CONCLUSIONS: There is a large and individually variable rise in IOP following peribulbar anaesthesia. Ocular compression with the Honan balloon is effective in reversing this rise even when the initial rise is large.

Indicator-based audit of cataract surgery in four neighbouring hospitals in East Anglia.

To review and compare management and outcomes of patients undergoing cataract surgery in order to improve practice by identifying weaknesses and standardising best practice where appropriate, a concurrent and prospective audit from June to October 1993 was carried out in four neighbouring ophthalmic units in East Anglia. Six hundred and twenty-seven consecutive patients were undergoing cataract surgery in the audit period. The main measures and results were as follows: (1) Patients with visual acuity reduced to 6/60 or less should not wait longer than 3 months from consultation to surgery; 69.5% met standard. (2) Patients with visual acuity reduced to 6/18 or less should not wait longer than 12 months from consultation to surgery; 85.8% met standard. (3) Patients who have had cataract surgery should achieve 6/12 or better corrected visual acuity by 3 months post-operatively; 88.6% met standard. (4) There should be less than 2% sight-threatening complications of surgery; 4.2% suffered sight-threatening complications. (5) There should be no life-threatening complications of surgery; 100% met standard. The audit identified key areas of variation in practice, and analysis of reasons for differences in outcome has led to some changes in the management of patients with cataracts in the four units.

Pressor reactivity to norepinephrine and angiotensin in salt-sensitive hypertensive patients.

The mechanisms responsible for increased blood pressure in response to a high dietary sodium intake in salt-sensitive patients with essential hypertension are only partially understood. The possibility that increased reactivity to pressor hormones might contribute to hypertension in these patients has not been adequately investigated. We studied 11 salt-sensitive and 15 salt-resistant patients with essential hypertension while they were ingesting a diet with 20 meq/day sodium for 9 days or one with 200 meq/day sodium for 14 days. During the last 4 days of each dietary regimen, they received 30 mg/day of slow-release nifedipine. Blood pressure response to increasing doses of norepinephrine and angiotensin II (Ang II) was studied at the end of each of four phases of the study. Salt-sensitive patients exhibited a greater blood pressure response to norepinephrine than salt-resistant patients, irrespective of the dietary sodium intake and whether we took into account the dose infused or the actual plasma levels of norepinephrine achieved during the infusion. The blood pressure response to Ang II, on the other hand, was greater in salt-sensitive than salt-resistant patients during low but not during high sodium intake. The blood levels of norepinephrine achieved during the infusion of this hormone were lower in salt-sensitive than in salt-resistant patients. These studies indicate that an increased reactivity to the pressor action of norepinephrine might contribute to the maintenance of hypertension in salt-sensitive patients. The increased reactivity appears to be specific for norepinephrine. In fact, we observed increased reactivity to Ang II during low but not during high sodium intake.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracerebral metastases from ocular melanoma.

A blind painful eye may harbour an unsuspected malignant melanoma. We report a case of ocular melanoma that presented with confusion owing to direct extension via the optic nerve into the anterior cranial fossa.