SPONTANEOUS ONSET OF CILIARY BLOCK GLAUCOMA IN ACUTE HYDROPS IN DOWN'S SYNDROME

A flat anterior chamber and raised intraocular pressure are unusual complications of acute hydrops. We report a case in which a patient with Down's Syndrome developed a flat anterior chamber, together with raised intraocular pressure, several weeks after the onset of acute hydrops.     

ARGON LASER TRABECULOPLASTY FIVE YEARS ON

The results of argon laser trabeculoplasty (ALT) in a series of 252 patients are presented with follow-up of up to five years. The procedure is effective in chronic open-angle glaucoma (COAG), ocular hypertension and pseudoexfoliative (PXF) glaucoma. Most cases were treated initially over 180° of the angle and repeat treatment of the remaining 180° usually resulted in an additional fall in IOP which was maintained at two, three and four year follow-up with only a small number of these retreated cases having no fall on later follow-up. ALT was not very effective in further lowering IOP in eyes with IOP controlled to a low level before treatment or in low tension glaucoma. It was effective in most of a number of miscellaneous glaucomas including pigmentary glaucoma. Apart from the immediate high rise in IOP the main complication was a late high rise in IOP which was serious in degree and appeared mainly in PXF but also in two cases of ocular hypertension. The presence of a concomitant fall in IOP in the fellow untreated eye is important and probably due to better compliance with treatment. Almost all cases required medical treatment for glaucoma which could not be ceased after ALT. ALT should be seen as an adjunct to, but not a substitute for, medical treatment.     

THE VICRYL TIE TECHNIQUE FOR INSERTING A DRAINING IMPLANT IN THE TREATMENT OF SECONDARY GLAUCOMA

We have reviously described surgical techniues for draining severe cases of secondary glaucoma by means of an artificial implant. Wherever possible these implants have been inserted in two stages The technique involved suturing the episcleral plates of the implant to the sclera without connecting them to the chamber as the first procedure Following this procedure the presence of the plates cause the surrounding tissue to form a thin fibrous envelope called a preformed bleb cavity After a suitable interval of between six and eight weeks the connecting tube of the implant was inserted into the anterio chamber so as to drain aqueous into this preformed bleb cavity This manoeuvre drastically reduced the incidence of postoperative hypotony and has proved a safe and effective technique
This communication reports an improvement on this technique in which the connecting tube of the implant is occluded by a ligature of 5–0 vicryl before inserting the tube into the anterior chamber through a fine needle puncture, at the same time as the episcleral plates of the implant are sutured to the sclera The effect of this procedure is thus to prevent any drainage of aqueous until three to five weeks after operation when the vicryl suture material dissolves, allowing aqueous to drain into the preformed bleb system lined by a thin layer of dense fibrous tissue. This technique provides the advantages of the previous two-stage technique without the need for a second operation.
The surgical technique is described together with the results of treating a series of 20 eyes with severe secondary glaucoma     

OCULAR LEUKAEMIA IN ACUTE LYMPHOBLASTIC LEUKAEMIA OF CHILDHOOD

Abstract Modern cytotoxic drugs increase the survival rate of children with Acute Lymphoblastic Leukaemia (ALL): But the eye is a pharmacological sanctuary and after clinical “cure” of the haematological disease the child may be blinded by leukaemic ocular infiltration. Should this prophylactic irradiation of the posterior segment of the eye and optic nerve be repeated on diagnosis of CNS leukaemia and at specified intervals thereafter with recurrence of CNS leukaemia? This is the history of a child who had had no recurrence of haematological leukaemia for four and a half years but following remission developed central nervous system (CNS) leukaemia followed by leukaemic iridocyclitis in the right eye after 20 months and in the left eye after three years three months from the initial diagnosis of ALL Prophylactic cranial irradiation is performed on initial haematological diagnosis of ALL This includes prophylactic irradiation of the posterior segment of the eye and optic nerve.     

THE DETECTION AND MANAGEMENT OF THE ACUTE RISE IN INTRAOCULAR PRESSURE FOLLOWING LASER TRABECULOPLASTY

A series of 64 patients undergoing laser trabeculoplasty had pressures estimated immediately before treatment and at one, two and three hours and in some patients at four, 24 and 48 hours after treatment. Pilocarpine 4% was given topically to 33 patients in order to assess its effect in preventing a pressure rise. The mean pressure rise for the whole series was 4 mmHg, for those not using pilocarpine it was 4.9 mmHg, and for those using pilocarpine it was 3.2 mmHg. A significant pressure rise of 5 mmHg or more was usually apparent by two hours, and patients with no rise or a fall at two hours were very unlikely to develop a rise in pressure.
Patients with an initial pressure greater than 20 mmHg, pseudoexfoliation of the lens capsule, and a shallow anterior chamber seemed more susceptible to a pressure rise while those with an initial pressure of 17 mmHg or less and only a slight reaction in the anterior chamber seemed very unlikely to develop a pressure rise. Treatment with acetazolamide, fluorometholone drops and hypotensive drops was usually successful in controlling the raised pressure.     

原发性急性闭角型青光眼铜蓝蛋白变化和氧化损伤的初步观察

目的探讨原发性急性闭角型青光眼患者血浆铜蓝蛋白和氧化损伤的变化。设计实验研究。研究对象50例年龄45~70岁原发性急性闭角型青光眼患者及20例年龄和性别相匹配的健康成年人对照者。方法采用总抗氧化能力和铜蓝蛋白含量试剂盒,测定血浆总抗氧化能力和铜蓝蛋白含量的变化及丙二醛(MDA)含量和超氧化物歧化酶(SOD)活性。主要指标总抗氧化能力、铜蓝蛋白含量、MDA含量和SOD活性。结果原发性急性闭角型青光眼患者总抗氧化能力、SOD活性较正常对照组明显下降,分别为(5.37±1.29)、(9.28±0.98)kU/L;(58.45±20.21)、(79.26±18.02)U/ml;P均<0.05;而铜蓝蛋白含量、MDA含量较对照组明显增加,分别为(76.72±19.32)、(52.38±13.53)mg/dl;(689.76±189.34)、(472.21±181.72)nmol/ml;P均<0.05。结论原发性急性闭角型青光眼患者存在氧化损伤、铜蓝蛋白增加与抗氧化能力下降,可能与青光眼的视功能损害有关。     

Is exfoliation syndrome a sign of systemic vascular disease?

Exfoliation syndrome (ES) is an age‐related disorder in which greyish‐white flakes accumulate in different tissues in the anterior eye. Its pathogenesis is not completely known, but it results in electron‐dense microfibrils. The finding that these can be seen outside the eye in many visceral organs inspired the theory that ES might be a part of a generalized disorder. It was postulated that ES might contribute to increased morbidity, mainly of systemic vascular diseases. This review is a summary of the existing knowledge. The prevalence of arterial hypertension (AHT) in elderly populations is > 30%. No differences have been found in the frequency of AHT among patients with ES or exfoliative glaucoma (EG) compared with those with primary open‐angle glaucoma (POAG) or no ES. There are conflicting reports of frequencies of ischaemic heart disease (IHD). A recent registry‐based study that used uniform criteria for IHD found no difference in the rate of IHD between patients with EG and those with POAG. However, findings of elevated homocysteine levels in the plasma and aqueous humour of patients with ES or EG suggest an increased vascular risk. No studies have yet been conducted to assess possible links between ES and systemic vascular diseases. In a single‐blind study, ES was associated with abdominal aortic aneurysm, but this was not found in a large, cross‐sectional investigation. The frequency of ES in patients with diabetes mellitus (DM) is only about half of that when compared in patients with no ES or with POAG. This finding warrants further studies. Molecular genetics research has found no common denominator for ES and the vascular diseases. There is no evidence that ES or EG are related to increased mortality for cardiovascular diseases. Further large‐scale, randomized clinical studies are required. At present there are no known medical indications that infer an increased systemic vascular risk or imply a need for the complete internal medical examination of a symptom‐free patient with newly diagnosed ES in the eye.     

RETROSPECTIVE STUDY OF ALKALI BURNS OF THE EYE

This report examines the epidemiology, management and morbidity of 159 cases of alkali burns of the eye admitted to The Royal Victorian Eye and Ear Hospital from 1972 to 1981. It was intended to use this as a basis for future accurate assessment and management of this problem. Grading of burns on information provided within the histories was according to Hughes' classification as modified by Ballen. Aspects examined were type of alkali, nature of accident, treatment, complications and follow-up. Results showed that the majority of burns were grade 1 or 2; only a few grade 1 and slightly more grade 2 burn patients suffered any complications, and none of these resulted in loss of vision. All patients with grade 3 and 4 burns suffered severe complications. It would appear that grade 3 and 4 burns need a more specific and energetic plan of treatment. Lime was the most common agent, and the largest group involved comprised male workers who suffered injuries at work. On the basis of the findings of the study the following points are raised: (i) a protocol for future study is suggested; (ii) there is a need tor a more discriminate use of EDTA: (iii) do grade 1 burns require hospital admission?; (iv) treatment of grade 3 and 4 burns is still unsatisfactory; (v) the public must be made aware of the existing dangers of alkali burns and their prevention.     

VISUAL ACUITY IN THE PRIMARY SCHOOL CHILD AGED FOUR TO TWELVE YEARS: A REVIEW OF AMBLYOPIA TREATMENT IN THIS AGE GROUP AT PRINCESS MARGARET HOSPITAL

A survey of the incidence in Western Australia of amblyopia assessed through the school vision screening programme and Princess Margaret Hospital (PMH) eye clinics shows the figure to be 0.12%, being new cases detected in primary school children each year. Occlusion methods of treatment for amblyopia acceptable in the younger age-group are much less tolerated by both parents and child in the school-age group. The PMH series involving 240 children between the ages of four and 12 years showed that an amblyopic eye with macula or paramacula fixation can be successfully treated up to the age of 10 years without constant occlusion. Also, eccentric fixation can be cured up to the 7th birthday, but no alternative has been found for the mandatory constant occlusion. Medical, developmental and behavioural problems can influence the management and response in the four to twelve-year-old child; if these are not recognized and the child treated as a whole during the critical stages of natural development of the visual system, these children can be left with an unnecessary visual disadvantage for the next 70 years of their life.