Coats' disease and Fuchs' heterochromic cyclitis.

The authors present an interesting case of a young boy with unilateral Coats' disease who after ten years of follow-up developed Fuchs' heterochromic cyclitis in the same eye.

Congenital oculomotor palsy: associated neurological and ophthalmological findings.

Congenital fourth and sixth nerve palsies are rarely associated with other evidence of neurological abnormality, but there have been conflicting reports in the literature on the associations of congenital third nerve palsy. In order to clarify the situation we report a series of 14 consecutive cases presenting to a paediatric tertiary referral service over the last 12 years. In this series of children, 5 had associated neurological abnormalities, lending support to the view that congenital third nerve palsy is commonly a manifestation of widespread neurological damage. We also describe for the first time a phenomenon of digital lid elevation to allow fixation with the affected eye. Two children demonstrated this phenomenon and in each case the accompanying neurological defect was profound. The frequency and severity of associated deficits is analysed, and the mechanism of fixation with the affected eye is discussed.

Latent proliferative sickle cell retinopathy in sickle cell trait.

PURPOSE: To describe a patient with sickle cell trait who developed latent proliferative sickle cell retinopathy after mild blunt trauma. METHOD: Case Report. A 20-year-old man with unilateral Stage 3 sickle retinopathy associated with an ischaemic ridge presenting three years after the initial mild blunt ocular trauma. RESULTS: Fundus examination of the left eye showed an ischaemic ridge delineating avascular from vascular retina. Fluorescein angiography of the left eye showed an avascular peripheral retina and multiple sea fan neovascularization. Blood studies showed him to be Hb AS. CONCLUSIONS: In our patient the proliferative changes were the result of his initial mild trauma associated with an increase in the intraocular pressure. The latent development of the sea-fan neovascularization associated with an ischaemic ridge is unusual. Advice about potential complications to patients with Hb AS after ocular trauma is advocated.

Are patient information leaflets contributing to informed consent for cataract surgery?

AIM: To assess, against a checklist of specific areas of required information and using standard published criteria, to what extent leaflets given before cataract surgery provided patients with enough information to give adequately informed consent. METHOD: Twelve ophthalmology departments in the West Midlands region were asked to submit the cataract information leaflets given to their patients at the preoperative assessment for analysis. Using criteria published by the General Medical Council, British Medical Association, and Medical Defence Union the leaflets were assessed for their contribution to informed consent for patients considering cataract surgery. Leaflets were scored according to the information they provided on: diagnosis, prognosis, treatment options, costs to the patient, details about the procedure, its purpose, likely benefits, how to prepare for it, what to expect during and after the operation, and the common as well as serious complications that may occur. The readability of the information was also assessed. RESULTS: All the units' leaflets provided information on diagnosis, the lifestyle changes required postoperatively, and cost involved to the patient. Only five units had leaflets that mentioned the risks involved in cataract surgery. The other areas of information were covered by 50-75% of the leaflets. Fifty per cent of the leaflets included a diagram. The average SMOG readability score was high. CONCLUSION: Although present cataract information leaflets make some contribution to the process of informed consent, most do not address important areas outlined by the General Medical Council. Many of the areas of information that are required for informed consent could easily be covered, and should be borne in mind when designing patient information leaflets. Resources are available on the internet including toolkits, guides, and means of assessment for the production of patient information leaflets.

Use of oral fluorescein angiography in the diagnosis of macular oedema within a diabetic retinopathy screening programme.

AIMS: To assess if oral fluorescein angiography (OFA) is a suitable screening method to detect macular oedema in diabetic retinopathy. METHODS: Eighty-four diabetic patients were included in the study. They were from a consecutive series of patients attending the diabetic eye-screening clinic, with retinopathy at the macula requiring ophthalmology assessment. All patients were subsequently examined in the eye hospital, by ophthalmologist slit lamp biomicroscopy assessment as the gold standard, followed by oral fluorescein angiography. RESULTS: This study indicates a sensitivity of 92% and specificity of 81%. Only 4.8% of patients developed a minor reaction to oral fluorescein; 84.5% of images were of good quality. CONCLUSIONS: Oral fluorescein angiography is an efficient and highly sensitive tool for the detection of macular oedema. It can be used as an adjunct in the diabetic screening service to identify patients with oedema within a disc diameter of the macula. Ultimately it will ensure that only necessary and smaller numbers of patients are referred to ophthalmologists.

From minimal background diabetic retinopathy to profuse sight threatening vitreoretinal haemorrhage: management issues in a case of pregestational diabetes and pregnancy.

Deterioration of retinopathy is a recognized complication of pregnancy in Type 1 diabetes. We discuss management issues relating to a case of rapid sight-threatening progression of retinopathy in pregnancy complicated by pregestational diabetes.

Flash and pattern visual evoked potentials in the diagnosis and monitoring of dysthyroid optic neuropathy.

Flash and pattern visual evoked potentials were recorded in 8 patients (13 eyes) with dysthyroid optic neuropathy (DON), diagnosed using the American Thyroid Association classification. All were treated with systemic steroids, but 4 patients (6 eyes) also required orbital decompression. Flash VEP (P2) and pattern VEP (P100) were recorded prior to and 2 weeks after commencing steroid treatment or decompression. Fifteen patients with Graves orbitopathy but without DON, and 20 healthy subjects, acted as controls. Before treatment visual acuity was reduced in 10 eyes and visual fields were abnormal in 5, but the VEP was abnormal in all 13, with the group mean amplitude of P2 and P100 significantly less than controls, and the group mean P100 latency significantly greater than controls. After treatment with high-dose steroids or surgical decompression there were significant improvements in the group mean amplitude of P2 and P100, and significant reductions in P2 and P100 latency; however, individually, improvements in amplitude were more significant than improvements in latency. We conclude that the VEP to flash and pattern stimuli provides a useful diagnostic and monitoring tool in patients with DON, combining objectivity with quantitative analysis.

Sex hormone preparations and retinal vein occlusion.

Retinal vein occlusion (RVO) is most commonly seen in middle-aged or older patients and is associated with underlying cardiovascular risk factors. It is much less common in younger patients. Use of the oral contraceptive pill (OCP) is known to be a risk factor for cardiovascular and cerebrovascular disease. There have previously been a few isolated case reports of patients sustaining an RVO whilst taking the OCP. The aim of this study was to investigate patients sustaining an RVO whilst taking the OCP or hormone replacement therapy (HRT). From a large series of 588 patients, we found 11 with an RVO associated with sex hormone preparations. Of these, 6 had taken the OCP and 5 were HRT users. From this large group there were only 9 female patients aged under 35 years who sustained an RVO. Of these, 6 were associated with use of the OCP. All patients were investigated for recognised medical risk factors for RVO. None of these factors were identified in the patients who had used the OCP. Of the patients taking HRT, 4 of the 5 had other potential risk factors. From our large series, the prevalence of RVO in female patients under 35 years taking the OCP was 66%. There is a 30% uptake of the OCP in the general population. These data support the view that RVO is a contraindication to the use of the OCP. Additionally, it would appear (albeit from limited data) that patients who sustain RVO may continue with their HRT, as HRT is not a major single risk factor for RVO.

Nine year follow-up study of morbidity and mortality in retinal vein occlusion.

PURPOSE: The aim of this study was to conduct a detailed retrospective follow-up of a large cohort of patients with retinal vein occlusion (RVO), examining morbidity and mortality, to investigate a possible relationship between RVO, large vessel disease and stroke, and to determine whether recurrence of RVO was influenced by treatment of associated medical conditions. METHODS: A follow-up study was undertaken in 1994 of all patients (n = 588) who presented to the medical ophthalmology clinics of the Birmingham and Midland Eye Hospital between 1982 and 1989 with a definitive diagnosis of RVO. RESULTS: Follow-up data were obtained on 549 patients (93%). Results showed that recurrence of RVO in the same or fellow eye was decreased by more than half in the follow-up group (3.3%) when compared with the known recurrence rate at initial presentation (8.8%). Comparison of the deceased with the survivors showed that the deceased patients were significantly older (mean age 70.2 vs 63.4 years). The prevalence of rubeosis iridis and smoking were statistically significantly increased when comparing the deceased with the survivors (p < 0.016 and p < 0.008 respectively). The deceased had a higher prevalence of diabetes (15.8% vs 10.1%), and there was a trend towards increased clinically evident macrovascular disease in those patients who had died (23.2% vs 19.5%). Neither hypertension nor hyperlipidaemia predicted death, as the prevalence rates of the two conditions were similar in survivors and those who had died (60.0% vs 60.6% and 48.4% vs 53.3%). The percentage of patients taking antiplatelet drug therapy was not different in the two groups (36.8% vs 38.3%). Analysis of the causes of death of the RVO population (n = 95) compared with the causes of death in the West Midlands population as a whole, showed that the percentage of deaths from myocardial infarction in the RVO population was significantly higher (23.1% vs 14.4%, p < 0.05). There was no statistical difference between the populations for ischaemic heart disease and stroke, although there was a trend for increased mortality from stroke (19% vs 13.5%). CONCLUSION: These data suggest a relationship between RVO, mortality and increased cardiovascular risk factors (smoking, diabetes and macrovascular disease), and support the possibility of an association between RVO and stroke. They also support the potential value of medical treatment of underlying medical conditions in preventing recurrence of RVO.