'Can you touch your toes?' spondyloarthropathies and acute anterior uveitis for primary eyecare practitioners.

The rheumatological diseases known as spondyloarthropathies (SpAs) are reviewed with respect to the current classifications of SpAs and from the perspective of ophthalmic practitioners. The focus is on the most common spondyloarthropathy, ankylosing spondylitis (AS), and the key symptoms, such as inflammatory back pain. The association with HLA-B27 and acute anterior uveitis (AAU) and the major clinical considerations for primary eye care practitioners are reviewed. An atypical case study illustrates difficulties in the detection and diagnosis of ankylosing spondylitis.

'My pupil has gone black!' Subluxation of a total cataractous lens.

A patient with a history of longstanding opaque cataract and a white pupil reported a return to a black pupil, which was the result of lens subluxation. The case was complicated by optic nerve coloboma of the Morning Glory syndrome type and a total retinal detachment.

Acute anterior uveitis in primary care.

Acute anterior uveitis is an important ocular disease of considerable interest to therapeutically and non-therapeutically qualified optometrists. This review examines the role of optometrists in the primary care setting and gives guidelines for appropriate care of patients with anterior uveitis. Diagnosis and differentiation from other forms of anterior segment inflammation are the initial requirement. In parallel, possible medical conditions associated with acute anterior uveitis must be considered, with appropriate referral to medical practitioners. In uncomplicated cases of recurrent acute anterior uveitis, optometrists can initiate topical treatment and monitor resolution of inflammation, while being aware of possible complications of both the disease and its treatment. It is especially important in new attacks of anterior uveitis to liaise with the patient's general practitioner about medical investigation for underlying disease. Atypical, complicated or severe anterior uveitis should be promptly referred for specialist care.

Branch retinal artery occlusion during a migraine attack.

A 60-year-old male with a history of migraine presented with evidence of branch retinal arterial occlusion that developed at the time of an attack of retinal migraine. The diagnosis of branch arterial occlusion secondary to migraine was made after exclusion of numerous possible medical conditions. The possible role of vasospasm in this condition is discussed.

Dual macroaneurysms on the same retinal arteriole.

A case of two macroaneurysms on the same retinal arteriole is presented. After observation of these lesions for some weeks, an increased threat to the macula from oedema led to laser photocoagulation. Although treatment did not hasten resolution, the patient has remained asymptomatic. The aetiology and natural history of macroaneurysms are discussed.

Curious cilia cases.

Eyelashes can be observed in unusual anatomical locations after falling out of their hair follicles. Loose lashes can inadvertently enter a lacrimal punctum or with more difficulty, a Meibomian gland orifice They may even penetrate through anterior surface layers such as the conjunctiva or skin of the lid. There may be some diagnostic problems, occasionally questions of management and in rare instances, some risk of morbidity. Four cases are illustrated.

Hemianopic visual field loss as the first clinical evidence of occipital arteriovenous malformation.

A 43-year-old patient presenting with a highly congruous homonymous hemianopia was shown by neuro-imaging to have a very large arteriovenous malformation of the brain. The significance of finding this visual field defect, its unusual cause and the absence of symptoms other than longstanding migraine with aura are discussed.

Normal tension glaucoma: diagnostic features and comparisons with primary open angle glaucoma.

BACKGROUND: A significant proportion of patients diagnosed under the broad classification of open angle glaucoma actually has normal tension glaucoma (NTG). It has many clinical features that overlap with primary open angle glaucoma (POAG), yet there is a question of whether it has a different aetiology in which intraocular pressure plays less of a role. METHODS: The epidemiology and clinical features of normal tension glaucoma are reviewed with particular reference to possible differences from primary open angle glaucoma, which might permit differentiation. The pathophysiology is discussed, outlining recent research in cell death (apoptosis), axonal damage and neuroprotection. DISCUSSION AND CONCLUSION: There is considerable evidence that NTG develops with little contribution from the effect of intraocular pressure. However, the clinical diagnosis of NTG is often one of exclusion and the differentiation of NTG from POAG remains difficult because many clinical signs are suggestive but not definitive of NTG. More accurate diagnosis may be possible when individual patients exhibit a greater number of signs. Some evidence suggests that NTG with relatively high pressures (greater than 15 mmHg) is more likely to progress than NTG with relatively low pressures. Clinicians must be particularly alert to the possibility of NTG because IOP, a clinical marker for some glaucomas, is absent.

Diabetes mellitus: a brief history, epidemiology, definition and classification.

Diabetes mellitus is a systemic disease of great significance to optometrists. This review includes a brief history of the key discoveries in the understanding of diabetes from ancient times and a summary of the present knowledge of diabetes with respect to prevalence, epidemiology and major complications. The currently accepted classification of diabetes mellitus includes the major categories of type 1 and type 2 diabetes, specific diabetes types and gestational diabetes. The definition of diabetes has also been revised recently. The new diagnostic criterion for diabetes mellitus is a confirmed fasting plasma glucose equal to or greater than 7.0 mmol/L, with a reduced reliance on the role of oral glucose tolerance testing.

Perspectives on migraine: prevalence and visual symptoms.

About 20 per cent of women and 10 per cent of men experience migraine at some time in their lives, of whom about one half to two thirds will have had a migraine attack in the previous 12 months. Prevalences of this order have been found in a survey of patients in an Australian optometric practice. Between one third and one half of migraineurs experience sensory or motor aura. Visual aura are by far the most common of the aura. A high proportion (more than 40 per cent) of migraineurs presenting for routine optometric examination will not have had their headache or aura formally diagnosed. Optometrists can give reassurance by providing a formal diagnosis and, when appropriate, they can refer their migraine patients to sources of advice on how the frequency and severity of their attacks might be ameliorated. The diagnosis of migraine is straightforward when the migrainous episode and any associated aura follow a classical pattern. However, diagnosis is often challenging, especially for aura occurring without headache, when the aura are atypical, when the first attack of migraine occurs after the age of 50 years, when there are persistent visual field losses or when there are pupillary anomalies or extra-ocular muscle palsy and diplopia associated with the migraine. Unusual presentations must be approached with care, using a good knowledge of the diversity of migraine, careful history taking and a thorough ocular and visual examination. As visual field losses can be associated with migraine and migraine may be a risk factor for low-tension glaucoma, visual field examination is often indicated for patients with a history of migraine. In some cases of migraine, referral for neurological work-up will be necessary before concluding that the headache and visual symptoms can be attributed to migraine.