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In reply Since the publication of "Sudden Visual Loss Associated With Sexual Activity," 1 I have been deluged with requests for more detailed information about the risks for "blindness" occurring during sexual activity. Although our series was too small to provide meaningful incidence data, the risk for visual loss must be extremely small. Furthermore, none of the patients reported permanent damage. Your article was unfortunately not referenced because of its unique but rather obscure title. In it you outlined the development of ocular pain precipitated by sexual intercourse in a patient with gonioscopically narrow angles and suggested that such activity may even serve as a provocative test. Ocular mydriasis itself is part of the normal sexual response. Levi 2 has shown that there is an increase in the excretion of catecholamines during emotional and sexual excitement. Furthermore, pupillographic studies have been conducted and in some cases have been used as

• Dense inflammatory fibrocellular membranes may develop over the iris in an eye with endophthalmitis, completely obliterating any view of the posterior segment and hindering vitrectomy. To remove this debris, the edge of the membrane is first lifted from the surface of the iris with a small microvitreoretinal blade inserted through a limbal wound. The membrane is then engaged with an iris hook that is rotated until the debris is tightly wound on the shaft of the instrument. The iris hook is then removed from the anterior segment, delivering the inflammatory debris en bloc. This technique limits possible surgical trauma to the anterior segment and provides an excellent specimen for culture.

• Ocular rigidity is the change in intraocular pressure produced by an incremental change in intraocular volume. Ocular rigidity was determined in 14 donor eyes by injecting small increments of a balanced salt solution through the limbus, while continually monitoring the intraocular pressure with a transducer. A buckling procedure was then performed in these eyes with the use of various solid silicone or stainless steel encircling elements, and the experiments were repeated. Buckled eyes were significantly less rigid than unbuckled eyes, and eyes with higher buckles were significantly less rigid than those with shallower buckles. The observed changes in rigidity are likely secondary to changes in the shape and stress distribution of the scleral shell and are only to a small degree related to the elasticity of the encircling element. Greater volumes of vitreous substitutes, gases, or antibiotics may be injected into buckled eyes compared with unbuckled eyes before excessive intraocular pressures are reached.

• Visual loss is uncommon in thrombosis of the cavernous sinus. A patient observed closely in the acute stages developed high intraocular and intraorbital pressures. Although the retinal vasculature remained patent, total unilateral blindness occurred within 48 hours. To our knowledge this is the first documented case in which ischemic optic neuropathy caused blindness in a patient suffering from cavernous sinus thrombosis.

The penetration of indomethacin labeled with radioactive carbon (14C) into all ocular tissues and fluids was determined at various intervals in both phakic and aphakic rabbit eyes after either single or multiple (every 12 hours for three days) topical application (50 microL) regimens. More indomethacin was found in the vitreous of aphakic eyes compared with phakic eyes after single- or multiple-drop administration. Retinal and choroidal indomethacin concentrations were equal in both phakic and aphakic eyes after either drug regimen and are much greater than those of the vitreous. A pathway other than diffusion through the vitreous exists for the drug to reach these tissues. The concentration of indomethacin reaching the retina and choroid is not sufficient to inhibit prostaglandin formation locally. The concentrations of indomethacin are high enough to inhibit the biotransformation of prostaglandin precursor only in the anterior segment.

• We measured aqueous angiotensin-converting enzyme (ACE) activity in 37 patients. Patients with granulomatous uveitis and probable sarcoidosis (based on increased serum ACE activity or characteristic radiologic findings) had a significant increase in aqueous ACE activity compared with normal subjects. Aqueous ACE activity was also significantly elevated in patients with sarcoid who had normal serum ACE activity. We believe that measurement of aqueous ACE activity should be considered in patients with uveitis who have normal serum ACE activity and are suspected of having sarcoidosis.

• A patient with decreased visual acuity had small, glistening white particles that were scattered over both posterior poles. Monochromatic fundus photography revealed ghost vessels and intraluminal particulate matter in small retinal vessels. Fluorescein angiography demonstrated nonperfusion of small arterioles and macular capillaries. The patient admitted to multiple intravenous injections of crushed methylphenidate (Ritalin) hydrochloride tablets, which contain talc 18 months prior to examination. To our knowledge, visual loss and irreversible macular ischemia from talc emboli have not been previously documented.

To the Editor. —Serpiginous choroiditis is a recurrent, bilateral, multifocal inflammatory disease. Branch vein occlusion, retinal phlebitis, optic disc drusen, and elevated toxoplasmosis titers were unusual associated findings in the case described below. Report of a Case. —A healthy 42-year-old man noted blurring of the vision in his right eye. Visual acuity was 6/24 OD and 6/9 OS. Funduscopic examination disclosed multiple, oval, atrophic choroidal lesions and small optic disc drusen in both eyes. In the right eye, intraretinal hemorrhage characteristic of a branch vein occlusion was seen superotemporally along with focal areas of periphlebitis (Fig 1). In the left eye, an active gray-white lesion contiguous with a geographic zone of choroidal atrophy was present inferior to the macula along with periphlebitis (Fig 2). No cells were present in the vitreous cavity or in the anterior segment. The sedimentation rate, serum fluorescent treponomal antibody absorption, VDRL, and angiotensin-converting enzyme, complete

• Two eyes were enucleated for angle-closure associated with familial exudative vitreoretinopathy. Characteristic features included total retinal detachment, peripheral retinal vascular proliferation, and a fibrovascular preretinal membrane. Angle-closure glaucoma developed in one case when sudden massive subretinal hemorrhage, associated with abnormal intraretinal vessels, produced anterior displacement of the lens-iris diaphragm; in the second case, angle-closure was associated with the development of rubeosis iridis. Intraretinal inflammatory cells and exudates were also seen in the enucleated eyes.