Lacrimal canalicular obstruction associated with topical ocular medication

Purpose: To describe the association between the use of various types of topical ocular medications and acquired lacrimal canalicular obstruction in 14 patients. Methods: The records of all patients in the author's practice with either lacrimal canalicular or punctal occlusion associated with the use of topical ocular medication were reviewed. Results: Fourteen cases were identified. The obstructions occurred at any point from the punctum to the common canaliculus, but most commonly occurred 2–5 mm from the lacrimal punctum. There was an association with various degrees of clinically apparent subconjunctival scaring maximal at the inner canthus, rarely to a severe degree, with symblepharon, medial canthal keratinization and cicatricial medial entropion. In some cases, no subconjunctival scarring could be clinically detected. Topical medications used were often multiple and included prednisolone acetate/phenylephrine hydrochloride (n= 5), timolol maleate (n= 5), pilocarpine (n= 3), dipivefrine hydrochloride or adrenaline (n= 3), chloramphenicol (n= 3), tobramycin (n= 3), indomethacin (n= 2), ecothiopate iodide (n= 1), betaxolol (n= 1), dexamethasone (n= 1), tropicamide (n= 1) and the long-term use of naphazoline and various artificial tear preparations (n= 1). The duration of exposure ranged from 3 weeks to 20 years, with seven patients having used drops for 3–6 weeks. Seven patients had surgical repair, three by dacryocystorhinostomy (DCR) and glass by-pass tube (all successful), three by canalicular repairs (one failed) and one by DCR and canalicular repair that restenosed at the puncta, who then had successful punctoplasty and silicone intubation. Conclusions: Lacrimal canalicular obstruction may occur after relatively short-term exposure to topical ocular medications or as part of a more widespread cicatricial reaction in patients on long-term medication. While a direct causal relationship cannot be confirmed, there appears to be a strong association and the site of the obstructions makes other causes unlikely.     

Midbrain angioma with disconjugate vertical gaze palsy

Loss of depression in one eye with contralateral loss of elevation is rare. It has been attributed to a subnuclear lesion of the oculomotor nerve nuclear complex. We present a patient with these signs who has an arteriovenous malformation occupying his rostral midbrain. We argue that attributing these findings to a subnuclear lesion of the oculomotor nerve complex does not take into consideration the secondary, vertical action of the obliques.     

Pterygium surgery in Victoria: A survey of ophthalmologists

Aim: To determine the surgical approaches and adjunctive therapies currently used by Victorian ophthalmologists for the treatment of primary and recurrent pterygia. Method: Ophthalmologists practising in Victoria were asked to complete a written survey relating to their experience with pterygium surgery. Results: Responses were received from 142 of 165 ophthalmologists surveyed (86%). Of these, 107 (75%) had performed at least one pterygium operation during the preceding 2 years. Excision followed by beta irradiation was the most commonly performed procedure for both primary (57%) and recurrent (35%) pterygia. The next most commonly performed procedure for primary pterygia was excision leaving bare sclera (15%) and, for recurrent pterygia, excision with autologous conjunctival transplantation (26%). Considerable variation was observed in surgical technique, choice of adjunctive therapy, postoperative care and in the surgeons' estimates of the frequency of major complications. Conclusion: Although there is little consensus regarding the surgical management of pterygium, beta irradiation remains the most commonly used adjunctive therapy in Victoria.     

Identification of the lower end of the nasolacrimal duct with a fibre-optic light 'pipe'

Purpose: To report a method of identifying the lower end of the nasolacrimal duct when more usual methods have failed. Methods: A vitreoretinal fibre-optic light pipe was used to identify the lower end of the nasolacrimal duct in a child with unusual congenital nasolacrimal duct obstruction. Results: This intraluminal light source enabled easy cut down onto the ‘blind’ end of the lacrimal drainage apparatus and subsequent intubation with silicone tubing to overcome the obstruction. Conclusion: This technique may prove useful in the rare cases in which it is not possible to identify the lower end of the nasolacrimal duct with a probe and nasal endoscope alone.     

The significance of reactions to betaxolol reported by patients

Abstract
Some patients may experience respiratory side effects on betaxolol in spite of the greater safety which is claimed for this ocular hypotensive drug compared with timolol. Six of 29 patients using betaxolol complained of wheeze or respiratory distress and five of these patients were rechallenged with betaxolol and a placebo in a double-masked clinical study, respiratory function being measured before and after each medication according to the American Thoracic Society guidelines. No patient showed any change in respiratory function either with betaxolol or the placebo. The findings further support the safety of betaxolol even in patients with respiratory disease, though some caution should be observed.     

DEEP CORNEAL STROMAL OPACITIES WITH CONTACT LENSES

Two patients with deep corneal stromal opacities occurring after prolonged contact lens wear are described. The opacities were associated with folds or striae in Descemet's membrane which they overlay. Development of the opacities was associated with ocular discomfort, photophobia, reduced vision and a history of prolonged daily wearing times. Although the corneal endothelial cell counts were within the normal range, the count was reduced in the affected eye in the patient with the unilateral deep stromal opacity and there was mild polymegathism of the endothelial cells. It is possible that the long-term effects of subtle endothelial cell changes may cause a keratopathy with later scarring and opacification. Poor oxygen trans-missibility, carbon dioxide build-up, or suction effects by the lens may all be aetiological factors. Early recognition and treatment, particularly with a better fitting lens of high oxygen transmissibility is important, as once developed the opacities regress only slowly and may result in permanent visual impairment.     

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.     

Surgical management of oculomotor nerve palsy with lateral rectus transplantation to the medial side of globe.

An operation for complete third nerve paralysis involving lateral rectus muscle transplantation to the medial side of the globe as a basic procedure is described. An inferior rectus muscle recession plus resection of an apparent completely paralysed medial rectus was subsequently performed at a second stage operation. The results appeared to be an improvement on previous surgery, particularly in terms of ocular motility, with almost full adduction of the operated eye being achieved. This adduction movement occurred as part of a normal conjugate movement of the two eyes, and the question arises as to the responsible muscles, with some evidence to suggest that relearned action of the transplanted lateral rectus muscle may be implicated. Finally, a Fasanella-Servat procedure as a third stage operation appeared to be adequate to correct the ptosis.