THRESHOLD PERIMETRY AND THE DIAGNOSIS OF GLAUCOMA

Visual field examinations are one of the commonest, presumably most sensitive practical indices of optic nerve dysfunction in glaucoma. Given the difficulties in training and retaining good technicians, and presumed vagaries of the Goldmann-type isopter examination technique, interest has turned to computer-controlled automated suprathreshold and threshold static perimetry. Despite the enthusiasm for these approaches, we lack rigorous tests of their value, criteria of abnormality and progressive deterioration, and even normal standards. These important issues are now being addressed. In the interim ophthalmologists must be cautious in their use and interpretation.     

CONTUSION INJURIES OF THE OPTIC NERVE

Indirect trauma to the optic nerve with secondary optic atrophy may result from minor trauma and has traditionally been associated with a poor visual prognosis. The case of a 32-year-old man who suffered a blow to his left supraorbital region and eyebrow in an automatic closing door is reported to draw attention to the uncommon but trivial nature of this injury which may result in profound visual loss. He suffered an initial inferonasal visual field loss which was related to vascular changes in the optic nerve head. Over the ensuing year there was deterioration in his central vision and visual field due to arachnoiditis.
Current trends in the management of optic nerve contusion injuries are discussed. There is currently a move towards primary medical management with high-dose corticosteroids as in this case; surgery is reserved for those patients who fail to respond to steroids or deteriorate as the steroid dose is reduced.     

DYSPLASTIC OPTIC DISCS IN ASSOCIATION WITH TRANSSPHENOIDAL ENCEPHALOCELE AND HYPOPITUITARY DWARFISM: A CASE REPORT

A patient with a basal encephalocele, dysplastic optic discs and hypopituitary dwarfism is described. The importance of identifying associated structural defects and endocrine dysfunction in patients with dysplastic optic discs is emphasised.     

MANAGEMENT OF UNCONTROLLED GLAUCOMA WITH THE MOLTENO SYSTEM

In glaucomatous eyes refractory to medication, laser techniques and conventional drainage surgery, intraocular pressure is often high, and visual loss rapid. In this situation a reliable, robust artificial outflow system is required. Molteno has evolved a plastic tube and plate device combined with a fibrosis suppression medication regimen. Thirty-eight eyes of 32 patients with uncontrolled glaucoma were treated with the Molteno system. Six months after operation mean intraocular pressure had been reduced from 41.0 ± 13.6 to 16.2 ± 5.6 mmHg. Eighteen eyes had pressures of 20 mmHg or less on no hypotensive therapy, 17 on reduced treatment. Three eyes had a pressure of 21 to 35 mmHg on treatment at six months. The 13 aphakic eyes responded as well as 25 phakic eyes. Five eyes with rubeotic glaucoma demonstrated pressures of less than 20 mmHg without therapy, four eyes with traumatic glaucoma required continuing medication with three having pressures below 22 mmHg. Of the seven eyes with uveitic glaucoma, one was lost, two required maintenance therapy; five of six surviving eyes had pressures below 20 mmHg. Fifteen eyes with congenital or juvenile glaucoma achieved pressures below 20 mmHg, three of these with timolol drops, three with timolol and acetazolamide, and nine with no treatment. While seven of seven eyes with refractory primary open-angle glaucoma attained pressures below 20 mmHg. all seven needed continuing mild hypotensive therapy. Eleven eyes underwent a one-stage procedure, while 27 eyes required a two-stage operation. Twenty-eight eyes received fibrosis suppression medication after the second stage, and 24 maintained or improved their preoperative visual acuity. Results have been encouraging: in general the Molteno system is recommended as the second drainage operation in all glaucomatous eyes in which conventional therapy has failed, and as the primary surgical procedure (after laser techniques) in eyes with rubeotic and uveitic glaucoma. Ciliary body destructive procedures should be restricted to control of symptoms in blind eyes.     

COMBINED HAMARTOMA OF THE RETINA AND RPE: AN UNUSUAL CAUSE OF THE DRAGGED DISC APPEARANCE

Combined hamartoma of the retina and retinal pigment epithelium (RPE) is a rare, benign, congenital fundal lesion which contains a mixture of glial tissue, blood vessels and pigment epithelium. Such turnours are variably pigmented and may be wrongly diagnosed as malignant melanoma or retinoblastoma. We report two cases which were located in the periphery of the fundus and which produced a dragged disc appearance.     

VITRECTOMY AND PHOTOCOAGULATION IN THE MANAGEMENT OF SEROUS DETACHMENT ASSOCIATED WITH OPTIC NERVE PITS

Two cases of serous detachment of the retina associated with congenital pits of the optic nerve were successfully treated with photocoagulation, vitrectomy and gas tamponade. The rationale of management and the results are discussed. It is suggested that this treatment deserves further study to see if early intervention will favourably affect the return of macular function, particularly in cases of optic nerve pits where the serous detachment is of short duration and fixed structural changes at the macula have not occurred.     

RETINOPATHY OF PREMATURITY: REVIEW OF A FIVE-YEAR PERIOD, EXAMINATION TECHNIQUES AND RECOMMENDATIONS FOR SCREENING

The reported resurgence of retinoathy of prematurity prompted analysis of the prevalence of retinopathy among premature infants born at Christchurch Women's Hospital over a five-year period. Of the 129 surviving very-low-birth weight infants, 65 (50.4%) underwent ocular screening during the review period. Retinopathy was detected in 17.1% (22/129) of surviving infants, or 34% (22/65) of selected infants referred by paediatricians for ocular screening. Five infants had severe or blinding retinopathy and these premature infants were of significantly lower birthweight and born after shorter gestation periods than those found to have no retinopathy. Examination techniques for eyes of premature infants are discussed, and recommendations for screening for retinopathy of prematurity made.     

A STUDY OF THE INTRAOCULAR PRESSURE LOWERING EFFECT OF TIMOLOL AND DIPIVALYL EPINEPHRINE

A double masked cross-over study was carried out to compare the intraocular pressure lowering effect of Timolol maleate 0.25% and Dipivalyl epinephrine (DPE) 0.1% eye drops. Timolol showed a greater effect in reducing intraocular pressure, with a mean reduction of 8.0 mm/Hg than did DPE, with a mean reduction of intraocular pressure of 4.3 mm/Hg.     

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     

LASER TRABECULOTOMY OR TRABECULOPLASTY: EARLY EXPERIENCE WITH A NEW NON-INVASIVE SURGICAL TECHNIQUE FOR GLAUCOMA

A series of 38 laser trabeculoplasty operations in 32 eyes of 29 patients is described. An average fall of 5.32 mmHg intraocular pressure was obtained; if secondary glaucomas were excluded the average fall was 7.39 mmHg. If a fall of 10 mmHg or more is considered a good result then eight eyes obtained a good result, five of these eyes having pseudoexfoliative glaucoma. A fall of 3–9 mmHg was considered a moderate result and 12 eyes obtained this, 11 of them having chronic simple open-angle glaucoma, the other being the only other case of pseudoexfoliative glaucoma in the series. Five eyes with chronic simple open-angle glaucoma and seven eyes with secondary glaucoma all obtained no significant fall. It is stressed that in chronic simple open-angle glaucoma there was often only a small fall or no fall at all, so that it seems unwise to temporise if there is a high uncontrolled pressure in this condition. Great care is also needed in advanced chronic simple open-angle glaucoma because of the occasional occurrence of a high rise of pressure soon after operation. The procedure works well in pseudoexfoliative glaucoma.     

MORNING GLORY SYNDROME: A REPORT OF TWO CASES

Two cases of Morning Glory Syndrome are presented to draw attention to the occurrence of this rare syndrome in Australia. The typical case shows an enlarged excavated optic nerve head surrounded by peripapillary pigment disturbance. There is early branching of the retinal vessels and a central tuft in the cavity. Some management guidelines are suggested.     

EVALUATION OF SODIUM CROMOGLYCATE AND MEDRYSONE IN THE MANAGEMENT OF ATOPIC KERATOCONJUNCTIVITIS: A DOUBLE MASKED CLINICAL STUDY

The efficacy of topical sodium cromolycate and medrysone was evaluated in 38 patients suffering from atopic keratoconjunctivitis. It was found that medrysone (1%) signifmntly improved the symptoms of itching, watering. photophobia and hyperaemia, while sodium cromoglycate (2%) was found to be ineffective. Tear prostaglandin E₂ and histamine levels did not decrease significantly after sodium cromoglycate therapy. The findings of the present study reveal that sodium cromoglycate has no significant role in the management of atopic keratoconjunctivitis.     

INTRAOCULAR LENS IMPLANTATION: A MODEL FOR THE THIRD WORLD

Intracapsular cataract extraction has long been thought of as the appropriate technique to deal with the backlog of Third World cataract blindness. However, this operation may not be as sight effective as many believe. The authors offer their experience of intraocular lens implantation in the Torres Strait as a model for a more visually appropriate surgical cure for Third World cataract.     

AN OPERATION FOR ENTROPION AND TRICHIASIS:A COMPOSITE OF METHODS FOR LID MARGIN ROTATION

Abstract
An operation for entropion/trichiasis is presented which is applicable to both upper and lower lids, and for grades of distortion from mild to severe. It is suitable for gross trachomatous lid disease in Aboriginal patients, and also for the discomfort of chronic cicatricial trichiasis in aged Caucasians.
No new procedure is proposed. The method combines features of several well tried operations to free the inturned lid margin and resuture it in proper apposition.     

TIMOPTOL—THREE YEARS ON: A STUDY OF TIMOLOL MALEATE DROPS OVER A LONGER PERIOD

A group of 130 patients with chronic glaucoma has been followed from one to more than three years on timolol maleate drops; this confirms that these drops remain effective in long-term therapy though added therapy is usually needed. Of 54 patients originally controlled by timolol alone or in combination, only four were not controlled more than three years later, though some needed further additional therapy. Of 35 patients followed for two to three years, only six could not be controlled by timolol alone or in combination; and of 41 followed for one to two years, 18 were controlled on timolol alone while 23 needed additional therapy. Attention is drawn to side effects including a mild keratopathy and in particular the occurrence of bronchospasm or other severe respiratory disease in 10 patients, not all of whom had a previous history of respiratory disease. Great care should be exercised with timolol in the presence of present or past respiratory disease as the complication is not generally recognised and it falls to the ophthalmologist to act to stop the drop.     

A FAMILY OF SQUINTS: THE DIFFERING EFFECTS OF HYPERMETROPIA ON FOUR SIBLINGS

Four siblings in a famil of five were found to be affected with hypermetropia in differing degrees and with differing effects. dese were (i) unilateral hypermetropia, producing amblyopia; (ii) hypermetropia inducing an accommodative esotropia with minimal amblyopia and fully controlled with glasses; (iii) hypermetropia producing an accommodative esotropia with a high AC/A ratio, fully controlled with bifocals; and (iv) hypermetropia producing esotropia which was only partially corrected with glasses, therefore partially accommodative, with a residual squint which required surgery.
This family of four nicely demonstrates all the permutations and combinations possible in accommodative-type esotropia and the piifalls therein.     

UNTREATED HANSEN'S DISEASE OF THE EYE: A CLINICOPATHOLOGICAL REPORT

A Maltese immigrant presented with intermittent bilateral anterior uveitis for which no cause could be found. The inflammation did not respond to topical treatment and ultimately the left eye developed a hypopyon and was enucleated. Histological examination revealed granulomatous inflammation and large numbers of Mycobacterium leprae throughout the anterior segment. Occasional foci of inflammation containing Mycobacterium leprae were found in the vitreous extending to the retina at the posterior pole. These findings in the posterior segment have rarely been reported. Eye infection in Hansen's disease is frequent and delays in diagnosis are common.     

THE RELATIONSHIP BETWEEN TOXOCARA ELISA ABSORBANCE VALUES AND TOXOCARA ELISA TITRES: A COMPARATIVE STUDY

Enzyme-linked immunosorbent assays (ELlSAs) may be made by a variety of techniques at one or several serum dilutions which is very confusing for clinicians This study compares the ELlSA results from two centres on sera from 12 patients investigated for ocular toxocarrasis by two common ELSA methods —the absorbance and titration techniques With one exception, ELSA results by the two methods correlated well For reasons outlined, the absorbance ELlSA method is likely to remain the preferred method in New Zealand and Australia Attention is drawn to the implications of the serum response to Toxocara canis larvae. and the need to evaluate ELlSA results against clinical findings is emphasized.