AIMS:There is increasing evidence that pseudoexfoliation (PXF) not only affects ocular anterior segment structures, but may also be a systemic disease. This study was undertaken to assess the relationship between PXF and sensorineural hearing loss.METHODS:Patients with PXF were identified from hospital records and underwent complete ocular examination. The sum of pure-tone hearing thresholds measured at 1, 2 and 3 kHz (HTL1,2,3) in each ear was compared with the ISO 7029 standard sex-matched, median age-associated hearing loss summed over the same frequencies (AAHL1,2,3). The proportion of ears with thresholds higher than the ISO 7029 median AAHL1,2,3 on the same side as eyes without PXF was compared with the proportion of ears ipsilateral to eyes with PXF but without glaucoma and similarly the proportion of ears on the same side as eyes with PXF and glaucoma.RESULTS:In total, 69 patients were studied, of whom 39 were male (56.5%). The mean age of the male patients was 75.8 years, while that of the female group was 75.1 years. All patients had PXF affecting at least one eye. Overall 101 ears (73.7%) had a higher HTL1,2,3 than the ISO 7029 median AAHL1,2,3 which included 56 ears of 78 in the male group (71.8%) and 45 ears of 59 in the female group (76.3%). There was no significant difference between the proportion of ears with HTL1,2,3 higher than the ISO 7029 median AAHL1,2,3 on the same side as eyes without PXF, with PXF but not glaucoma and with PXF and glaucoma, in either the male or female groups.CONCLUSIONS:A large proportion of patients with PXF have sensorineural hearing loss in comparison to age-matched controls, regardless of whether or not there is associated glaucoma. This finding supports the theory that PXF may be a systemic condition.

Background/aims-The autonomic pupillary changes in type I and II diabetic patients without clinical evidence of diabetic autonomic neuropathy (DAN) were compared with age matched controls. The relation between pupillary and cardiovascular autonomic function was assessed in the diabetic patients.Methods-A case-control study was performed with diabetics grouped according to type and duration of diabetes. Static infrared pupillography was used to compare mean dark adapted pupil size and mean percentage changes in pupil size with pilocarpine 0.1% and cocaine 4% in the diabetic and control groups. All diabetic patients underwent cardiovascular autonomic function assessment using the Valsalva ratio, the 30:15 ratio, and testing for orthostatic hypotension.Results-In total, 72 type I and 69 type II diabetic patients were compared with 120 controls. Mean dark adapted pupil size was significantly smaller in diabetic groups than controls. Except for type I diabetics with disease for less than 5 years, all patient groups had significantly greater mean percentage constriction in pupil size in response to dilute pilocarpine than controls. There was no significant difference between the mean percentage dilatation in response to cocaine 4% in diabetics and controls. A high proportion of patients had normal cardiovascular autonomic function particularly when this was assessed with the Valsalva ratio.Conclusions-Denervation hypersensitivity to dilute pilocarpine is a result of damage to the pupillary parasympathetic supply of diabetic patients. This occurs before the pupillary sympathetic pathway is affected, it can be detected early in the disease, and it may be a possible explanation for the small pupil size seen in diabetic patients. Pupillary autonomic dysfunction occurs before cardiovascular autonomic changes and detection of pupil denervation hypersensitivity to dilute pilocarpine is an inexpensive way to detect early DAN.

Background Almost all perforating eye injuries present to dedicated eye units. Data from eye units are therefore reliable indicators of the incidence of perforating injuries.Aims To establish the aetiology and visual outcome of perforating eye injuries presenting to one unit over a twelve-month period.Methods Patients with eye injury were identified from the operating room register. Case-notes were reviewed and eye examinations were performed to determine current level of vision.Results A total of 37 perforating eye injuries were operated on in the 12-month period from January to December 1995, Thirty one patients (83.8%) were male. The mean age was 33.9 years. The chief causes were work related or do-it-yourself (DIY) in 32.4%, miscellaneous accidents in 27.0%, assault in 16.2%, road traffic accidents in 10.8%, Twenty eyes (54.1%) were blind with acuity <6/60 at their most recent review,Conclusion Work-related and DIY injuries are the most common causes of eye perforation. Many of these injuries are easily preventable with appropriate eye protection. The proportion of injuries resulting from road traffic accidents was low. Injuries due to assault are becoming more prevalent and carry a poor visual prognosis.

AIM:To analyse the risk factors involved in the development of ocular complications after acoustic neuroma resection, in particular corneal complications and visual loss, and to identify measures that may reduce these.METHODS:62 patients who underwent surgery for acoustic neuroma had a standardised ophthalmic examination and retrospective case note review.RESULTS:At final review (mean 37.6 months), although 38 patients reported ocular symptoms, only 22% saw 6/12 or worse. Patients with hypoaesthetic corneas had a higher incidence of corneal pathology (79%) than those with normal sensation (39%). Lagophthalmos increased the incidence of corneal pathology (to 80%); in those with normal closure, the incidence was only 46%. 20 patients required at least one ophthalmic surgical procedure.CONCLUSIONS:After acoustic neuroma resection patients place a considerable burden on the ophthalmologist. Immediate referral postoperatively, and frequent review of those with abnormal sensation may reduce the severity of long term ocular complications.

Purpose To compare the safety and efficacy of polyacrylic acid 0.2% (PAA) gel and polyvinylalcohol 1.4% (PVA) in the treatment of patients with dry eyes. Methods Eighty-nine patients with dry eyes were randomly allocated to treatment with either PAA (48) or PVA (41) in a prospective, investigator-masked study in two centres. The parameters assessed were daily frequency of instillation of the study medications, ocular signs and symptoms, tear film break up time, Schirmer's test values, local tolerance and global assessment of the improvement following treatment. Results The two groups were similar in patient demographics and study parameters at baseline. The total score of symptoms (gritty or foreign body sensation, burning sensation, dry eye sensation, photophobia, others) and signs (conjunctival hyperaemia, ciliary injection, corneal and conjunctival epithelial staining) was reduced significantly more by treatment with PAA than with PVA at both three and six weeks (p<0.0001). The daily frequency of instillation of PAA was significantly less than that PVA on 38 of the 41 (93%) study days. Both PAA and PVA were safe and equally well-tolerated except for blurred vision, usually mild and transient, on PAA. On global assessment of the improvement in their dry eye condition, significantly more PAA patients felt better on treatment at six (p=0.02) weeks compared with those on PVA. Conclusions Polyacrylic acid gel was as safe as and more effective than polyvinylalcohol in the treatment of patients with dry eyes.

An autoimmune pathogeneses, at least in part, has been postulated for schizophrenia.Susceptibility to autoimmunity is strongly influenced by the genes clustered in the HLA region on chromosome 6, and linkage in a proportion of pedigrees has been reported in nearby markers.There is a negative association between schizophrenia and rheumatoid arthritis (RA), an autoimmune disease positively associated with HLA-DR4.Wright et al. (1996) postulated that there should therefore be a negative association between the DR4 allele and schizophrenia.In addition, a negative association between schizophrenia and DQB 1"0602 has been reported in American blacks (Nimgaonkar et al. 1993), and Chinese males (Zhang et al. 1994).We attempted to re-examine these findings in 229 familial schizophrenic probands and 248 unrelated controls at the DRB region, and 241 familial schizophrenic probands and 257 unrelated controls at the DQB region using the PCR-SSOP technique.The frequencies of DR4 in patients and controls was respectively 35.8 per cent vs. 35.8per cent, and the frequencies of DQBI*0602 in patients and controls was respectively 29.5 per cent vs. 27.6 per cent.These findings do not support the initial hypotheses.Some of the discrepancy may be due to study design in that the control frequencies in the Wright et al study were higher than in other samples from the region.It is also possible that the HLA association with schizophrenia is due to linkage disequilibrium with unidentified gene(s) within the HLA region which is less strong in the Irish population, particularly in the case of DQB 1"0602 as significant results were found.

Europe, in its true geographical sense of a continent extending from the Atlantic to the Urals, has such a variety of languages and cultures as to defy description and make one only marvel at the success of the USA in unifying a similarly vast continent. This article is confined to Europe of the European Union (EU) and the prospective members of the EU—that is, the northern European countries; Austria, Belgium, Denmark, Finland, France, Germany, the Netherlands, Ireland, Luxembourg, Sweden, and UK, and the southern European countries; Greece, Italy, Portugal, and Spain. Norway and Switzerland, although not members of the EU, have been recognised as members of the UEMS and send a delegate to many organisations. This large and disparate group will require major concessions among ourselves to produce a truly European state. Medicine is in many ways one of the simpler areas of activity to standardise, as there is a fairly broad consensus as to what a trained specialist should be. Up to now each country has controlled its specialist training in a completely individual way. The European Board of Ophthalmology (EBO) has been established with the aim of addressing this specific issue and developing a ‘standard’ examination for trainee ophthalmic specialists (see below). Basically there are three types of controlling authority. Some countries work through university departments controlled by a professor and Germany is at the forefront of this system. In addition, physician councils of the 16 federal states of Germany determine which non-university departments are allowed to train doctors. Other countries organise and control specialist training through elected colleges of ophthalmology of which the UK is the prime example. The third mechanism utilises an official state body and, perhaps, France would be the leader here. Each system has its own merits and disadvantages. Professorial control, to be satisfactory, …

An 85-year-old man with progressive external ophthalmoplegia and a history of COAD is reported. He presented with diplopia followed by a right partial and left complete ptosis. His impaired ocular motility mimicked 1V2 syndrome. Full blood count, ESR, urea, electrolytes, anti-acetyl-choline receptor antibodies, Tensilon test, thyroid function tests, CT brain and orbit and chest X-ray did not reveal the aetiology. Histological study of his sputum specimen showed oat cell carcinoma of the lung. Electromyography confirmed the diagnosis of Eaton Lambert syndrome (ELS). Involvement of extraocular muscles can be a presenting sign of ELS and is not as rare as previously speculated.

This paper reports two patients who had clinical disorders of eye movements which suggested discrete brainstem lesions. When magnetic resonance imaging (MRI) was performed, areas of demyelination Ear larger than expected were demonstrated and which had mass effect mimicking brainstem glioma. In both cases, there was clinical improvement with resolution of the MRI lesions without steroids or other treatment. The literature on MRI scanning in demyelinating disease is reviewed. MRI is an invaluable diagnostic tool in eye movement disorders related to demyelination, although the clinician must be aware of its limitations in tissue differentiation. We suspect that many ophthalmologists are unaware that the MRI appearances of demyelination may mimic tumour, particularly if it has mass effect.

We present two cases of ocular shotgun injury where pellets entered the cavernous sinus. Both injuries occurred accidently while shooting pheasants. The first patient developed a third nerve palsy, while the second developed a third and a sixth nerve palsy. In each case, CT scanning showed a pellet in the cavernous sinus. Both recovered completely within four months. In both cases, only one pellet had lodged in the orbital area and had entered medial to the globe causing only minor ocular contusions before entering the cavernous sinus. Shooting is well recognised as a dangerous pastime and reports of associated ocular injuries abound in the literature. In both our cases, the entry wound was in the medial canthal area; we postulate that pellets at this location are funnelled along the medial orbital wall, through the superior orbital fissure and into the cavernous sinus. We could find only one other reference describing a pellet in the cavernous sinus.

We compared the effects of the Brain laryngeal mask airway with a tracheal tube on intra-ocular pressure. Propofol was used as induction agent and atracurium as relaxant. Twenty-six patients with normal intra-ocular pressure undergoing cataract surgery were randomly allocated to two groups. Group A (n = 13) had a laryngeal mask airway inserted and Group B (n = 13) had a tracheal tube inserted. Intra-ocular pressure was measured just before insertion of the airway, 20 s after insertion and at 2 min. In the laryngeal mask airway group there were no significant changes in mean intra-ocular pressure. In the tracheal tube group there was a significant rise in mean intra-ocular pressure at 20 s (p = 0.0056) which returned to pre-insertion levels at 2 min. We conclude that the laryngeal mask airway continues to have advantages over the tracheal tube for ophthalmic surgery despite the use of propofol and atracurium as anaesthetic agents.

AIMS:An anatomical study was undertaken to determine the extraneural blood supply to the intracranial oculomotor nerve.METHODS:Human tissue blocks containing brainstem, cranial nerves II-VI, body of sphenoid, and associated cavernous sinuses were obtained, injected with contrast material, and dissected using a stereoscopic microscope.RESULTS:Eleven oculomotor nerves were dissected, the intracranial part being divided into proximal, middle, and distal (intracavernous) parts. The proximal part of the intracranial oculomotor nerve received extraneural nutrient arterioles from thalamoperforating arteries in all specimens and in six nerves this blood supply was supplemented by branches from other brainstem vessels. Four nerves were seen to be penetrated by branches of brainstem vessels and these penetrating arteries also supplied nutrient arterioles. The middle part of the intracranial oculomotor nerve did not receive nutrient arterioles from adjacent arteries. The distal part of the intracranial oculomotor nerve received nutrient arterioles from the inferior cavernous sinus artery in all 11 nerves and in seven nerves this was supplemented by a tentorial artery arising from the meningohypophyseal trunk. The inferior hypophyseal artery arose from the meningohypophyseal trunk in all 11 cavernous sinuses dissected.CONCLUSION:This study shows a constant pattern to the blood supply of the intracranial oculomotor nerve. It also highlights the close relation between the blood supplies to the intracavernous oculomotor nerve and the pituitary gland.

We investigated the early changes in the choroidal vasculature in rats following surgically induced renovascular hypertension. Renovascular hypertension was induced in a group of 12 male Wistar rats using a modified Goldblatt procedure. The rats were divided into four groups, each being sacrificed at weekly intervals, the first group being sacrificed 1 week following the procedure. Vascular casts were prepared of the choroidal circulation using acyl resin (mercox). These were then studied using the scanning electron microscope. No abnormality of the choroidal circulation was noted for the first 2 weeks. At 3 weeks, when a rise in the average mean arterial pressure was noted, nodular lesions were seen in the choroidal arteries and choriocapillaris. These lesions were present in far greater numbers by 4 weeks. It seems likely that the nodular lesions described are microaneurysms and may contribute to the pathogenesis of the clinically described Elschnig spot.

AIMS:The study was designed to investigate the bacterial flora of the operating field during routine cataract surgery and the source of intraocular lens contamination during the surgery.METHODS:The normal flora of the external eye and fornices of 17 patients undergoing selective cataract surgery was determined preoperatively. Swabs taken from the eyelid surface and lashes showed coagulase negative staphylococci (CNS) in 90%, Propionibacterium acnes in 62%, Corynebacterium sp in 18%, and Peptostreptococcus in 3% of the patients. The lower fornices of 70% had CNS, 47% P acnes, 6% Staphylococcus aureus, 6% Corynebacterium sp, and 6% Candida.RESULTS:A sterile PMMA intraocular lens was touched on the upper bulbar conjunctiva immediately before the surgery. Eighty two per cent of lenses grew CNS, 18% P acnes, 18% Bacillus sp, 12% S aureus, and 6% Corynebacterium sp. A second sterile PMMA intraocular lens was left on the drape and near the eye during surgery. Forty seven per cent of these cultured CNS, 12% Corynebacterium sp, and 6% Bacillus sp. A high count of bacteria in the operating field, especially CNS and P acnes can contribute to postoperative inflammation and endophthalmitis.CONCLUSION:Special measures are needed before and during the surgery to reduce the chance of intraocular inoculation of these bacteria. Use of proper culture media and techniques are necessary to identify these organisms, especially anaerobes, in postoperative inflammation.