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Purpose: To compare the proportion and the agreement rate in the diagnosis of chronic ocular graft-versus-host disease (GVHD) among three criteria applied with and without ophthalmological examination before hematopoietic stem cell transplantation (HSCT). Methods: National Institutes of Health (NIH), International Consensus Criteria on ocular GVHD (ICCGVHD) and TFOS Dry Eye Workshop (DEWS) II criteria were used for the diagnosis of ocular GVHD according to two protocols: ophthalmological examination after HSCT (Protocol A), or before and after HSCT (Protocol B). Proportion of GVHD diagnosis and inter-rate agreement coefficient Kappa (K) among the criteria were calculated. Results: One hundred nine patients undergone HSCT were included. NIH, ICCGVHD and DEWS II criteria diagnosed ocular GVHD in 14.7%, 17.4% and 59.6% of the patients (Protocol A), whereas in 11.9%, 15.6% and 33.0% of the HSCT patients (Protocol B). The coefficient K for the proportion of patients diagnosed with ocular GVHD by NIH and ICCGVHD criteria was K = 0.626 (Protocol A) and K = 0.615 (Protocol B). The K coefficient by NIH and DEWS II criteria was K = 0.144 (Protocol A), and K = 0.233 (Protocol B). The K coefficient by ICCGVHD and DEWS II criteria was K = 0.250 (Protocol A) and K = 0.499 (Protocol B). The K coefficient for ocular GVHD diagnosis applying Protocol A and B was K = 0.881 if NIH criteria were used, K = 0.933 if ICCGVHD criteria were used and K = 0.501 if DEWS II criteria were used. Conclusions: The diagnosis of ocular GVHD varied significantly in our cohort of hematological patients according to both the diagnostic criteria used and the visit protocols applied.

This current review highlights some of the literature published in the past year from April 2013 to May 2014.

Purpose To evaluate Artelac Rebalance®eyedrops’ efficacy in symptoms reduction, ocular surface parameters recovery, and tolerability in the treatment of mild to moderate dry eye.Methods Fifteen patients were enrolled. Inclusion criteria were Ocular Surface Disease Index (OSDI) score >16, tear film break-up time (TFBUT) <10 seconds, Schirmer test I >10 mm/5 min, and mild ocular surface damage (Oxford grading) ≤3. Artelac Rebalance®eyedrops were administered 3 times daily for 2 months. Patients were evaluated at enrollment, after 2 days of washout (baseline), and after 1 and 2 months of treatment. Parameters for ocular discomfort (OSDI score), tear film quality (Schirmer test I, TFBUT, tear osmolarity), ocular surface damage (fluorescein staining, conjunctival imprint cytology), and inflammation (scraping cytology and exuded serum albumin) were measured. Tolerability and satisfaction were assessed by validated questionnaires.Results At endpoint versus baseline, all variables showed a statistically significant improvement (paired Student t test, p<0.01 for all parameters) as follows: OSDI score (21.9 ± 10.6 vs 35.8 ± 12.2), TFBUT (6.5 ± 1.1 s vs 5.2 ± 2.3 s), Oxford grading of corneal and conjunctival damage (0.56 ± 0.50 vs 1.16 ± 0.37), tear osmolarity (294.6 ± 2.1 mOsm/L vs 303.1 ± 4.6 mOsm/L), conjunctival goblet cell density/mm2(140.8 ± 43.3 cells/mm2vs 115.1 ± 15.8 cells/mm2), scraping cytology score (2.9 ± 1.0 vs 4.2 ± 1.3), and percentage of serum albumin in tears (9.2% ± 4.8% vs 24.1% ± 10.8%). Tolerability and satisfaction were scored high, with no adverse events reported.Conclusions Application of Artelac Rebalance®eyedrops for 2 months in mild to moderate dry eye resulted in a reduction of ocular inflammation parameters, ocular surface damage, and subjective discomfort symptoms, with a parallel improvement in tear film quality (measured by TFBUT and osmolarity).

The measurement of blood flow in the ocular fundus is of scientific and clinical interest. Investigating ocular blood flow in the choroid may be important to understand the pathogenesis of numerous ocular diseases, such as glaucoma or agerelated macular degeneration (AMD). Laser Doppler flowmetry (LDF) was applied to measure relative velocity, volume and flux of red blood cells in the tissues of human eye. Its main application lies in the possibility of assessing alterations in blood flow early in the course of diseases. The purpose of the present study was to investigate the effect of pupil dilatation with one drop of 1% tropicamide on blood flow in the foveal region of the choroid of the human fundus. The blood flow parameters were measured in 24 eyes during 30 minutes (one measurement in every 3 minutes) after the application of the drop. Since the Doppler parameters depend on the scattering geometry, which may change as the pupil dilates; an artificial pupil of 4mm in diameter was placed directly in front the eye. Following the administration of tropicamide the mean pupil diameter was increased from 3.29 mm to 8.25 mm (P<0.0001, Paired student t-test). In comparison to the baseline values, the data shows no significant increases were observed in velocity, volume, and flow with 4 mm artificial pupil (0.2%, 1.3%, 0.8% respectively) and a statistically significant increases were observed without artificial pupil (10.7%, 13.9%, 12.8% respectively) following the application of tropicamide.

The purpose of the present review is to describe recent insights into the pathomechanism of ocular surface impairment in the course of thyroid dysfunctions. The review focuses in particular on Graves' ophthalmopathy as the majority of the literature is published on this topic.

This study assessed whether dissociated vertical deviation, corresponding to an occasional elevation of the deviated eye, is accompanied by a binocular vertical perceptual adaptation. Dissociated vertical deviation was elicited by means of neutral filters in 16 patients, 8 who had undergone operations for the disorder of essential infantile esotropia and 8 who had not. Neutral filters elicited dissociation vertical deviation, which was accompanied by binocular vertical perceptual adaptation. This effect was significantly greater for patients who had operations and was enhanced by the filter density. Surgical elimination of inhibitory mechanisms for dissociated vertical deviation in patients with essential infantile esotropia appears to facilitate a loose sensory adaptation, which permits a binocular vertical perceptual adaptation.

It has been demonstrated that, besides sensory adaptation phenomena, sensorimotor phenoma may also develop in concomitant esotropia. The existence of the latter entity can be shown particularly by means of prisms and is interpreted as fusional in origin. It is therefore defined as ‘anomalous fusional movements.’

In this paper two relatively early cases of senile macular degeneration are compared by making use of a number of tests of visual function, some relatively new, coupled with observation of the fundus and analysis by fluorescein angiography. The functional tests include visual acuity, the sustainedlike and transientlike functions which are believed to test inner retinal receptive field properties and to have origin in the inner and outer plexiform layers, the Stiles-Crawford function which reflects the directional sensitivity and orientation of photoreceptors, and increment threshold curves.

PURPOSE. Cytidine-5'-diphosphocholine (CDP-choline) therapy is currently used to improve the consciousness level in patients with brain lesions and as a complement to levodopa therapy in Parkinson's disease. Recently, the substance has been shown to improve the visual acuity (VA) of both eyes of adults with amblyopia. This study aims at establishing whether Contrast Sensitivity (CS) and visually-evoked potentials (VEPs) also change after CDP-choline treatment. METHODS. VA, CS, and VEPs were measured in a group of amblyopic volunteers (n = 10, mean age 24.8 years) before treatment with Neuroton ® (CDP-choline, 1 g/day intramuscularly [IM] for 15 days) and the day after termination of the same. CS was evaluated, using a forced-choice, automatic procedure (QUEST: Watson and Pelli, 1983). Steady-state VEPs were recorded in response to counterphased (8 Hz) sinusoidal gratings (2 c/deg) of different contrasts. RESULTS. On average, after treatment, VA improved 1.4–1.5 lines in the amblyopic eyes and 0.4 lines in the normal eyes. CSs improved in both dominant and amblyopic eyes by about 3 dB. VEPs increased in amplitude (about 30%) and advanced in phase (about 0.2 p rad). Amplitude and phase changes were not correlated. CONCLUSIONS. Treating adult amblyopes with CDP-choline has the effect of improving their VA, CS and VEPs. Changes occur in both eyes, although to different extents, and resemble those previously reported for levodopa treatment.

• An objective method of registering the pupillomotor threshold was utilized to demonstrate pupillary hemiakinesia (Wernicke hemianopic phenomenon) in five patients with homonymous hemianopsia due to lesions above the lateral geniculate body. The results show that Wernicke hemianopic pupillary response is of no diagnostic value in differentiating between proximal lesions and those distal to the lateral geniculate body.

A new provocative test for early diagnosis of Multiple Sclerosis (MS) is presented. It is based on the recording of pattern visual evoked responses (VER) before and after exposing patients to a high luminance background. All 13 patients tested showed a biphasic enlargement of the P100 wave after bleaching even in the absence of an increased P100 latency. This biphasic enlargement can be interpreted as a fatigue or a saturation-like phenomenon as can be seen psychophysically. The saturation-like effect involves probably only affected fibers. No change in the VER was observed in 20 Normal observers examined in the same way. This test can be usefully employed in dubious cases of MS where routine VER do not provide reliable results.

Patients with optic neuritis describe image fading which is particularly evident at bright light levels. The effect is dependent on adaptation level, and high adaptation levels serve as a provocative test. Kinetic and static perimetry and interferometric acuity tests repeated in time reveal this loss in sensitivity. The latter test, using a large field and a high luminance level, is particularly sensitive to both the residua of pathology and very early phases of disease, often before subjective manifestations of anomalies are present. These effects are large in patients with demyelinating diseases. Here, we show that such changes may be revealed in optic neuritis due to other causes as well. Note, the same form of response may be detected in more central lesions, but usually in more circumscribed areas of field.

In this paper results are presented of errors in spatial localization found after encircling procedures for retinal detachment both in the operated and in the normal eye. Also changes in spatial localization were found in strabismus patients in which a stretch on the operated muscle was exerted after an adjustable recession. In both groups of patients a manipulation of the eye muscle was performed without inducing an eye muscle imbalance in the retinal detachment patients and without modifying the eye position in the strabismus patients in which a stretch was exerted. These data provide further evidence in favour of the role of proprioceptive information in space perception.

Vergence movements induced by base-out prisms were recorded, with an infrared eye movement recording system, in 5 patients with comitant esotropia and anomalous retinal correspondence and in 5 normal volunteers. The findings support the hypothesis that vergence movements in strabismus are induced by disparity, since accomodative as well as proximal vergence had been ruled out. Vergence movements are much slower and with different characteristics in strabismic patients with respect to normals. It may be argued that vergence movements represent the motor fusion component left over in strabismus. They may be considered the objective representation of the well-known phenomenon of prism compensation or adaptation, found in many strabismic patients.

Judgement of distances was evaluated in 19 patients with comitant esotropia and without appreciable stereopsis. In nine patients anomalous retinal correspondence (ARC) was present at Bagolini's striated glasses. In the remaining patients there was suppression with the same test. Distance judgement of strabismics with ARC does not differ statistically from that one of normals. Significantly different results were found in strabismics with suppression. It is concluded that ARC is not only an anti-diplopic mechanism, but provides the patients with useful clues in their daily life.

The visual evoked response transfer function of amblyopic subjects was studied. Strabismic amblyopes showed abnormalities only in the high spatial frequency range. Anisometropic amblyopes on the contrary, showed an abnormal function both in the low and high spatial frequency range. This is an objective correlate of functional differences between strabismic and anisometropic amblyopes.

In a series of 562 patients who underwent surgery for retinal detachment, 17 (3.02%) had significant post-operative muscle imbalance.

• Unilateral coronal suture stenosis provokes a shortening of the orbital roof of one side. It is argued that the effectiveness of the superior oblique muscle is reduced because of reduced length of its unreflected part and because of the increased angle between the reflected part of the tendon and ocular axis. This condition causes a clinical picture of superior oblique palsy, with ocular torticollis. We report four cases of this newly described clinical entity with various degrees of involvement of ocular motility.

• Monocular and binocular flashed visual evoked responses (VERs) were recorded in two normal subjects, two patients with partially accommodative refractive small-angle esotropia, and two patients with residual small-angle esotropia. Without optical correction the binocular VER of the patients with partially accommodative esotropia was equal to the monocular one, thus confirming suppression of the deviated eye as found with the striated glasses test. In the two patients with residual small-angle deviation and in the two with partially accommodative strabismus wearing an optical correction to reduce the angle of deviation, the binocular VER was larger than the monocular one. These patients showed anomalous retinal correspondence (ARC). Although the binocular recording of strabismic patients was smaller than the one obtained in normal subjects, still a cortical binocular interaction was found. In the subjects tested, ARC is objectively demonstrated to sustain an anomalous type of binocular vision.

Ten patients are presented with clinically relevant age-related maculopathy (AMD) in one eye. Five of them had severe amblyopia with eccentric fixation in the non-affected eye. The remaining five had equal visual acuity in the two eyes before the onset of AMD. All patients have been followed over a six year period, in order to detect the time-course of involvement of the second eye. Visual acuity measurements and fluorescein angiography were repeated annually. AMD in the affected eye evolved towards a cicatricial neovascular pattern. Initial fluoroangiographic lesions developed after the first year of observation in the non-amblyopic patients., These alterations evolved gradually and affected more or less severely visual function over the six year period. In comparison, no significant lesions developed in the second eye of patients with amblyopia.To our knowledge, this is the first report of a “protective” effect for AMD of severe amblyopia. It can be speculated that the non-use of the central retina delays the evolution of AMD. The same amount of light enters both eyes: light cannot be therefore considered as a causative or favoring element. Presumably, the inner retinal metabolism involved in image formation, has a contributing effect in establishing initial AMD lesions.

• With this technique simultaneous recording of EMG is shown from various extra-ocular muscles. Electrodes are applied in the muscles during surgical procedures and recordings are performed without discomfort in the following days. The electrical signals are acquired at large bandwidth, and various off-line elaborations are possible. Preliminary results as well as technical details are presented.

The relationship between photophobia and binocular function in intermittent exotropia was examined in 42 subjects (21 patients and 21 controls). In all subjects fusional amplitude and strength of binocular sensory status were tested before and during exposure to bright light. An explanation of photophobia in intermittent exotropia was suggested as impairment in binocular cooperation, since the indicators of binocular function were significantly altered in the patients, particularly during light exposure.

• A rapid visual resolution test conducted on available equipment reveals the presence of rapid falloff in acuity in a case of probable multiple sclerosis. Intense large field illumination was used, and grating acuity was tested using laser red light. The effect is so large that minor anomalies (not subjectively appreciated) or the residuum of earlier minor attacks of retrobulbar optic neuritis can be readily detected. A related "visual fatigue or saturation-like syndrome" was described earlier.In bright environments these patients' vision fades. Briefly closing the eyes restores visual sensitivity. Providing filters or lowering the light level tends to maintain vision.This test must be studied intensively. It offers a noninvasive simple means of showing underlying anomalies in neural conduction of the visual signal. Such anomalies can be prognostic and previously have been revealed only with sophisticated electrophysiological techniques.

Of a series of 57 formerly amblyopic patients who attained equal visual acuities (20/20 or better in each eye), only 29 were able to alternate after treatment. The oldest patient was 5 years old. The pattern visual-evoked response of the previously amblyopic eye in nonalternators showed a reduced amplitude as compared with that of the sound eye. This probably occurred because of a reduced number of cortical cells subserving the formerly amblyopic eye. Lack of alternation may be the result of cortical competition. More cortical cells are connected to the originally normal eye even after successful treatment of the amblyopic eye in the nonalterating patient.

• Patients with herpes zoster of the ophthalmic branch of the trigeminal nerve and normal ocular motility were examined. They were asked to point to targets without the sight of their own hand. Significant errors were found on the affected side. Proprioceptive information of the extraocular muscles is assumed to travel in the trigeminal nerve, and these results thus suggest the existence of peripheral afferent signals influencing eye-hand coordination.

• A Castroviejo caliper was modified, adding another caliper to one arm to be able to measure contemporaneously the amount of muscle recession and transposition.

TO THE EDITOR. —I read with great interest the article by Pratt-Johnson et al in the February Archives (1983;101:218-224) entitled "Suppression in Strabismus and the Hemiretinal Trigger Mechanism."The authors state that eight patients with monofixation syndrome and two patients with esotropia with abnormal retinal correspondence were tested. It was not stated in the article how retinal correspondence behaves in the monofixation syndrome under a causal seeing condition. In our experience this type of patient shows anomalous retinal correspondence (ARC) with the striated glasses and normal correspondence with suppression rarely. Moreover, we showed1-3 that in these patients there is an anomalous overlapping of the visual fields of the two eyes, sustained by ARC and with little or no suppression, if fusable stimuli are used as test targets. The authors state that, in monofixators, normal retinal correspondence may be found in the periphery of the visual field. The binocular single

TO THE EDITOR. —I read with great interest the article by Robert S. Hammond, OD, and Paulette P. Schmidt, OD, MS, entitled "A Random Dot E Stereogram for the Vision Screening of Children," that appeared in the Archives.1 I would like to point out that random dot stereopsis may coexist with a large amount of aniseikonia2 as well as with amblyopia.3 The validity of random dot stereograms for screening of amblyopia seems, therefore, questionable.