Triptans and third nerve paresis: a case series of three patients.

PurposeThe aim of this report is to increase awareness of a possible association between cranial nerve paresis and the use of sumatriptan in migraine sufferers, particularly in patients who have additional vascular risk factors.Patients and methodsWe describe a series of three cases where third nerve paresis developed in patients who were treated with the oral form of sumatriptan. All of the patients had a clear history of repetitive migraine headache and none of them had previous third nerve paresis.ConclusionAmong a variety of medications for the treatment of migraine, there are some drugs with vasoconstrictive effects, particularly triptans. These drugs may be a contributing factor for microvascular damage of the cranial nerves and other organs.

Plusoptix Vision Screener: the accuracy and repeatability of refractive measurements using a new autorefractor.

BACKGROUND: The Plusoptix Vision Screener (PVS) is a new non-cycloplegic videoretinoscopy autorefractor. Refractive accuracy may affect its performance as a screening tool. AIMS: Study 1: To determine the intra- and interobserver variability of PVS measurements. Study 2: To compare PVS measurements with gold-standard manual cycloplegic retinoscopy (MCR). METHODS: Study 1: PVS refraction of 103 children with mean (SD) age 5.5 (0.6) years by two observers. Study 2: PVS and MCR refraction of 126 children with mean (SD) age 5.5 (1.5) years, including 43 children with manifest strabismus >/=5 PD, comparing mean spherical equivalent (MSE) and Jackson cross cylinders J(0) and J(45). RESULTS: Study 1: Repeatability coefficients (observer 1): MSE: 0.63 D, J(0): 0.24 D, J(45): 0.18 D; those of observer 2 were nearly identical. The mean difference (95% limits of agreement) between the two observers for MSE, J(0) and J(45) were, respectively, 0.03 (-0.62 to 0.68 D), -0.008 (-0.25 to 0.23 D) and 0.013 (-0.18 to 0.20) D. Study 2: MSE tended to be lower on PVS than MCR, with differences of up to 8.00 D. Less than 20% of values were within +/-0.50 D of each other. Agreement was better for J(0) and J(45). Strabismus was associated with an odds ratio of 3.7 (95% CI 1.3 to 10.5) of the PVS failing to obtain a reading. CONCLUSIONS: The PVS may underestimate children's refractive error.

Vision screening in children by Plusoptix Vision Screener compared with gold-standard orthoptic assessment.

BACKGROUND/AIMS: To evaluate a new autorefractor, the Plusoptix Vision Screener (PVS), as a screening tool to detect risk factors for amblyopia by comparing it with gold-standard orthoptic vision screening in children. METHODS: Community-based screening study including 288 children age 4-7 years who were screened with the PVS and by orthoptic assessment (distance acuity, cover test, extraocular movements, 20 PD prism test, Lang stereotest). Follow-up comprehensive eye examination of screening-positive children included manual cycloplegic retinoscopy. RESULTS: Testability was high for both methods. Orthoptic screening identified 36 children with reduced vision and/or factors associated with amblyopia (referral rate 12.5%). The PVS identified 16 children with potential vision problems (referral rate 5.6%), indicating only moderate sensitivity (44%; 95% CI 27.9 to 61.9%), but high specificity (100%; 95% CI 98.5 to 100%) to detect factors associated with amblyopia. The PVS underestimated visually significant refractive errors. CONCLUSIONS: Use of the PVS as single screening test in young children may miss a significant number of children with amblyopia or amblyogenic risk factors.

The prevalence and associated features of posterior embryotoxon in the general ophthalmic clinic.

PURPOSE: To estimate the prevalence of posterior embryotoxon (PE) in the general ophthalmic clinic and to identify any features of PE that suggest that it is pathological rather than physiological. METHODS: Over 700 consecutive patients of all ages were examined with the slit lamp during their routine eye clinic appointment. Patients with posterior embryotoxon were invited to return for full ocular examination including keratometry, corneal topography, and gonioscopy. RESULTS: In all, 49 out of 723 patients were found to have PE. This gives a prevalence of 6.8% with an age range of 18 months to 95 years. There was a higher prevalence in the younger age group of 22.5% (age range 18 months to 20 years) compared to 5.9% in the older age range (21-95 years). A total of 29 patients with PE returned for further examination. Six patients had glaucoma (two with Axenfeld's syndrome and one with aniridia), and one had ocular hypertension. In all, 20 patients had bilateral PE on slit-lamp examination, which increased to 24 with gonioscopy. The majority of the PE was seen temporally (97.9%) and limited to a few clock hours. Gonioscopy showed that eight patients with PE had associated inferior pigmentation of schwalbes line. CONCLUSION: This large series found the prevalence of PE the general ophthalmic clinic to be 6.8%. Its presence should prompt careful anterior segment examination, including gonioscopy, to identify any associated abnormalities that may carry a risk of glaucoma. Children should also be assessed for any associated systemic or genetic abnormality.

First day post-operative review following uncomplicated phacoemulsification.

PURPOSE: To determine whether the first day review is essential in management of patients following uncomplicated phacoemulsification with intraocular lens implantation. Patients are routinely seen on the day following surgery. This can produce logistical problems in patient attendance that can necessitate an overnight stay. If the first day review were abandoned this would lead to an increased uptake of day case surgery and a reduction in health care costs. METHODS: A retrospective cohort study was performed on all cases of uncomplicated phacoemulsification with intraocular lens implant surgery over a 6 month period. Slit lamp examination findings on the first post-operative day were reviewed. Visual acuity, corneal clarity, anterior chamber activity, intraocular pressure and configuration of the pupil were recorded. Any cases that failed to meet predetermined criteria underwent full case-note review. The subsequent management of these patients was analysed. RESULTS: Of the 201 cases of uncomplicated surgery, 74 cases (37%) failed to meet the study criteria and underwent review. Of these only 12 (6%) had their management altered as a result of the first day post-operative findings. This was entirely due to raised intraocular pressure. Visual acuity, corneal oedema and activity in the anterior chamber all improved on subsequent follow-up. CONCLUSIONS: The first day review of uncomplicated phacoemulsification with lens implant surgery provides the opportunity to treat raised intraocular pressure. A prospective randomised study is needed to identify means to prevent the post-operative intraocular pressure rise before we are able to consider abandoning the first review.

Ophthalmic manifestations of trisomy 8 mosaic syndrome.

Trisomy 8 mosaicism can present with a varied clinical picture. A significant number of cases have ocular manifestations. The most commonly reported in the literature have been corneal abnormalities and strabismus. We present a case of trisomy 8 mosaic syndrome with very different ophthalmic manifestations, some of which are previously unreported in the literature. The patient who was known to have trisomy 8 mosaic syndrome was referred with concerns about his visual abilities. He had a characteristic facial dysmorphism and other systemic features associated with this condition. Ophthalmic features included bilateral Duane's syndrome, bilateral myopic astigmatism, congenital pendular nystagmus, and macula hypoplasia. Electrodiagnostic tests confirmed extensive abnormality of cone function in both eyes. This case is discussed in relation to a review of the literature.

Ocular ultrasound in Alagille syndrome: a new sign.

BACKGROUND: Alagille syndrome (AS) is one of six forms of familial intrahepatic cholestasis, all of which present with neonatal jaundice and paucity of intrahepatic bile ducts. Differentiation of these individual syndromes is crucial as their treatments and prognoses vary. It is the ophthalmic features, posterior embryotoxon on particular, that distinguish AS. METHODS: The authors performed full ocular examination, including A- and B-scan ultrasound, refraction, and, where possible, fluorescein angiography in 20 unrelated children with AS and 8 with non-AS-related cholestasis. RESULTS: There was ultrasound evidence of optic disc drusen in at least one eye in 95% and bilateral disc drusen in 80% of patients with AS but in none of the patients who were non-AS at the time of examination. Independent review of hard-copy scans suggested drusen in at least one eye in 90% of the cases and bilateral drusen in 50%, although this latter figure rose to 65% on review of the angiograms. This is markedly higher than the incidence in the normal population (0.3%-2%). Axial lengths were shorter than expected for the older age group (older than 10 years of age), but this was not associated with gross ametropia. CONCLUSION: This strong association of AS and optic disc drusen has not been reported previously and represents not only the first significant association between a systemic condition and disc drusen but also a possibly useful tool in the diagnosis of AS, especially in young children.

Alagille syndrome: family studies.

Alagille syndrome (AGS) is one of the major forms of chronic liver disease in childhood with severe morbidity and a mortality of 10 to 20%. It is characterised by cholestasis of variable severity with paucity of interlobular bile ducts and anomalies of the cardiovascular system, skeleton, eyes, and face. Previous studies suggest a wide variation in the expression of the disease and a high incidence of new mutations. To determine more accurately the rate of new mutations and to develop criteria for detecting the disorder in parents we systematically investigated parents in 14 families with an affected child. Clinical examination was supplemented by liver function tests, echocardiography, radiographic examination of the spine and forearm, ophthalmological assessment, and chromosome analysis. Six parents had typical anomalies in two or more systems pointing to the presence of autosomal dominant inheritance. Systematic screening of parents for the features defined in this study should improve the accuracy of genetic counselling.

Familial posterior lenticonus.

Posterior lenticonus tends to be unilateral and there is no evidence that this is a familial condition. We report three cases of bilateral posterior lenticonus in boys. The mothers of all three cases had posterior lenticular changes, less severe than their sons. We suggest that bilateral posterior lenticonus may be inherited in an X-linked fashion.