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Monitoring optic nerve sheath meningiomas (ONSM) in Neurofibromatosis type 2 (NF2) patients remains difficult. Other ocular manifestations of NF2 may obscure ophthalmic assessment of optic nerve function in these patients. Serial magnetic resonance imaging (MRI) used to assess the optic nerve is not without limitations, being expensive and often requiring general anaesthetic in children, with associated risks. This study was undertaken to describe the use of multifocal visual evoked potentials (multifocal VEP, mfVEP) in the regular monitoring of NF2 patients with ONSM. This study involved three NF2 patients with ONSM who undertook mfVEP testing at an academic ophthalmic centre. Same day mfVEP and routine ophthalmic testing were undertaken. Topographical function of the optic nerve was assessed, utilising tools such as asymmetry deviation and accumap severity index. Results were assessed alongside MRI and visual acuity (VA). From the three patients, five eyes had ONSMs, of which two caused unilateral blindness. The remaining three affected eyes had initial VAs 6/6, 6/24, and 6/18. Over follow up, ranging from 5 to 12 years, all tumours progressed, and VA declined for all patients. Multifocal VEP detected optic nerve functional loss corresponding with visual decline. This case series suggests mfVEP is effective in the objective topographic monitoring of optic nerve function in NF2 patients with ONSM. Due also to its safety in a paediatric population, the test may be considered in the routine monitoring of these patients, to be used to assist regular ophthalmic review and MRI scans.

Aims: To elucidate if topically applied atorvastatin safely decreases corneal fluorescein staining in dry eyes associated with blepharitis. Methods: Ten dry eye and blepharitis (DEB) patients were enroled in a prospective pilot study. All patients were treated with topical atorvastatin (50 μM) 8 times a day for 4 weeks and allowed to continue with their existing dry eye treatment. The patients were examined weekly for 4 weeks. The primary outcome measure was corneal fluorescein staining. Secondary outcome measures were tear film break-up time (BUT), Schirmer I testing, blepharitis score and bulbar conjunctival injection. The subjective efficacy was evaluated with global symptom and facial analogue scores. Results: An improvement in corneal fluorescein staining in the treated eye by >1 point from baseline to completion of the trial at week 4 was found in 9 of 10 patients (p < 0.01). Topical atorvastatin significantly improved the tear film BUT (p < 0.01), blepharitis score (p < 0.05) and bulbar conjunctival injection (p < 0.05). The global symptom score and facial analogue score also improved (p < 0.05). There were no side effects. Conclusion: Topical atorvastatin is a potential therapy for DEB patients. Larger comparative clinical studies are required to establish the efficacy and safety of topical atorvastatin.

The Virtual Ophthalmology Clinic (VOC) is an interactive web-based teaching module, with special emphasis on history taking and clinical reasoning skills. The purpose of this study was to determine the impact of VOC on medical students’ learning. A randomised controlled trial (RCT) was conducted with medical students from the University of Sydney (n=188) who were randomly assigned into either an experimental (n=93) or a control group (n=95). A pre- and post-test and student satisfaction questionnaire were administered. Twelve months later a follow-up test was conducted to determine the long-term retention rate of graduates. There was a statistically significant (P

John Donald MacIntyre Gass, MD was one of the most significant figures to emerge in ophthalmology in the last 100 years. There could be few ophthalmologists who cannot attribute part of their increase in understanding of retinal disease to the influence of Don Gass. His insights opened up opportunities for many new effective therapies. He has influenced ophthalmic thought worldwide, if not by his presence as a visitor, then through his scientific publications, his outstanding books and the international fellows he trained. Like many distinguished physicians, Don Gass's clinical acumen was well grounded in his understanding of ocular pathology. This experience was gained under the mentorship of Lorenz E Zimmerman, MD, who trained a number of distinguished ophthalmologists, who subsequently became professors. Professor Gass passed away on February 26, 2005 at the age of 76 years from pancreatic carcinoma. With the demise of Don Gass, the world of ophthalmology has lost an extraordinary physician of great talent, commonsense and humility. On the other hand it has gained a generation of young ophthalmologists inspired by his example.

Although willingness, attitudes and beliefs surrounding solid-organ donation have been extensively investigated, much less is known about corneal donation. Despite evidence that a substantial number of families who agree to multiorgan donation also specifically refuse corneal donation, it is unclear why this occurs and what can be done to increase rates of corneal donation. We conducted a survey of 371 Australian adults regarding their views on corneal donation. Although willingness to donate corneas generally reflected a person's willingness to donate all of one's organs, unwillingness to donate corneas appeared to be due to other factors. Specifically, decisions not to donate appear to be driven by a range of concerns surrounding disfigurement. The survey also provides eye banks with reassurance about the acceptability of whole globe procurement, and recognition that research into blindness is a highly valued part of corneal donation. Finally, the survey identifies that many individuals see benefit in having their family engaged in the decision-making process, suggesting that decisions about donation are more complex than a simple appeal to the autonomy of the deceased.

Purpose To determine the ability of blue-on-yellow multifocal visual evoked potentials (BonY mfVEP) to identify functional loss in preperimetric glaucoma. Design Prospective case series. Participants Thirty patients with glaucomatous optic discs and normal standard visual fields. Methods All patients underwent BonY mfVEP, dilated optic disc stereophotography, and optical coherence tomography (Fast RNFL protocol). Optic disc photographs were assessed by 2 independent examiners in a masked fashion. Main Outcome Measures The mfVEP amplitude asymmetry and latency values were analyzed and compared topographically with findings of disc assessment. Average retinal nerve fiber layer (RNFL) thickness, RNFL asymmetry, and sectors with RNFL thinning were compared between patients with and without mfVEP defects. Results Fourteen (46.7%) patients demonstrated significant abnormality on amplitude asymmetry deviation plots of BonY mfVEP. In all 14 cases, the defect was monocular and corresponded to the eye with the worse disc. In 13 of 14 patients, the defect also corresponded to the location of the worst affected rim. Average RNFL thickness of eyes with mfVEP defects was 81.2±9.9 μm, significantly lower than that of patients without defects (90±10.5 μm; P = 0.035). Mean asymmetry of RNFL (better minus worse eye) also was significantly higher for patients with mfVEP defects compared with those without such defects (9.0±6.4 μm vs. 3.0±7 μm; P = 0.03). Average latency of both eyes of glaucomatous patients was delayed compared with that of controls, with no difference in latency between worse and better eyes of glaucoma patients. There was no association of latency delay with either the location of disc changes or mfVEP amplitude defects. Conclusions Amplitude asymmetry of the BonY mfVEP seems to be a promising tool to identify functional loss in preperimetric glaucoma. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

Aim: To study the maturation of multifocal visual evoked potentials (multifocal VEP) in normal children between the ages of 5 and 16 years and to apply the results clinically in selected cases to the diagnosis of optic pathway diseases. Method: 70 normal children were recruited from the community and multifocal VEP (Accumap ObjectiVision, Sydney, Australia) was recorded. The waveform of the evoked responses, the latency and amplitude were analysed. Using these data, an age matched comparison was made with three children with advanced optic nerve disease; two had optic nerve glioma and one had congenital glaucoma. Results: The full field amplitude did not correlate with age and varied greatly within each age group (coefficient of variability 28%). When scaled with respect to the background electroencephalogram the intra-age group variability decreased to 15% and a sigmoid relation was found between amplitude and age. The scaled amplitude remained largely unchanged till 11 years, between 11 and 13 years there was a rapid increase (40%), and remained stable thereafter. This relation was seen at all eccentricities tested. The latency decreased gradually with age and plateaued at 13 years. In the three children with vision abnormalities this test was able to detect scotomas consistent with their condition. Conclusion: Multifocal VEP perimetry shows an age related maturation in the visual pathway, characterised by distinctive timeframe of development for amplitude and latency. It can be performed by children as young as 5 years of age and holds promise as a diagnostic test capable of documenting children’s visual fields objectively, even before they are able to perform subjective field tests.

The purpose of this report is to describe a modified surgical iridocyclectomy technique and lensectomy for the removal of a recurrent iris cyst and a cataract in a child. A 3-year-old boy underwent uncomplicated standard iridocyclectomy for the removal of an enlarging congenital epidermal iris cyst. In the postoperative period, the cyst recurred. A second surgical intervention was performed using a modified iridocyclectomy technique. Sclerocorneal dissection of the involved quadrant was performed. After a lensectomy, an additional deep lamellar dissection of the peripheral cornea was undertaken prior to iris cyst removal and pupil reconstruction. This modified twolayered iridocyclectomy technique permits an elegant access to the iris lesion and allows the construction of a two-layered watertight wound, reducing the risk of hypotony and wound ectasia. We believe it also allows a better control of astigmatism and is a safe procedure in the pediatric population, particularly during the amblyogenic period. [Ophthalmic Surg Lasers 2002; 33:62-65]

Objective This study aimed to assess the effect of contact lens wear on the mucosal defenses of the outer eye against infection. Design A case-controlled study of daily contact lens wearers in their initial 6 months of contact lens wear. Participants Contact lens wearers (mean age, 23.1 years; 47 subjects) were compared with age-matched control subjects (mean age, 24.7 years; 44 subjects). Intervention Outer eye defenses were studied by assay of tear constituents and quantitative conjunctival microbiology. Main outcome measures Antimicrobial activity of tears was studied by assay of total immunoglobulin A (IgA), IgA isotype-specific antibodies reactive with Escherichia coli, Haemophilus influenzae, Staphylococcus epidermidis , albumin and lysozyme, and the ocular surface microbial load determined using quantitative microbiology of the conjunctival sac. Results The IgA isotype-specific antibodies reactive with E. coli ( P = 0.03) and S. epidermidis ( P = 0.068) were lower in contact lens wearers, but antibody:albumin ratios were not significantly different in the two groups. Contact lens wear also had no significant effect on tear IgA, albumin, or lysozyme or its ratios with albumin. Bacterial numbers and colonization rates for coagulase-negative staphylococci were greater in contact lens wearers than in age-matched control subjects. Corynebacterium sp. and non-Enterobacteriaceae ( P = 0.007) were isolated more frequently and in greater numbers from contact lens wearers. Colonization rates were increased for Corynebacterium sp., but non-Enterobacteriaceae were transient. In both daily contact lens wearers and age-matched control subjects, most conjunctival flora were transient rather than colonizing, and no subject developed an outer eye infection during the study. Conclusion These results suggest that daily contact lens wear does not significantly alter the mucosal defenses of the outer eye that function to eliminate organisms from the conjunctival sac and prevent outer eye infection.

To determine whether consent to corneal donation is related to which next of kin is asked to consent, the age of the potential donor and the indication about donation made by the deceased on their driving licence.The Lions New South Wales Eye Bank (Sydney, New South Wales, Australia) provides the corneal transplantation service for Australia's most populous state. Over the 18-month period from 1 July 2004 to 31 December 2005 for all requests for donation, records were kept of which next of kin was asked for consent, the age of the deceased and the indication about donation by the deceased on their driving licence.Over the 18-month study period, 841 people were approached about corneal donation. 63.2% of those people approached gave their consent to donation. Increasing age of the deceased was significantly positively associated with consent to donation (p = 0.006). Multivariable univariate analysis adjusting for age of deceased showed that relative type was strongly associated with consent (p0.001), with mothers and fathers more likely to donate than siblings, and siblings more likely to donate than children and spouses. An indication of willingness to donate on a driving licence was strongly associated with consent (p0.001).Higher consent rates from older donors have implications for policies to maximise corneal procurement. The decision to donate on behalf of a deceased family member is complex and influenced by social context. Research should investigate individualised strategies to be used when seeking consent from particular categories of next of kin.

We examined the records of 53 patients treated for choroidal melanoma between 1985 and 1989. The aim of this study was to assess the safety and short-term results of iodine-125 episcleral plaque therapy. There were 28 males and 25 females, aged 20 to 77 years (median 61 years), treated for single tumours with a median diameter of 9 mm (range 5 to 15 mm) and with a median thickness of 4 mm (range 2 to 10 mm). The plaques containing iodine-125 seeds were chosen according to tumour size: 10 mm (16 patients); 15 mm (36 patients); 20 mm (one patient). All patients are alive at last follow-up (median 1.3 years, range 4 months to 3.3 years). Four patients underwent enucleation for melanoma progression. Thirty patients have developed some type of complication (more than one complication occurred in the same eye in 12 patients): retinitis (19), optic neuropathy (7); cataract (4), rubeosis iridis (2). Overall, visual acuity deteriorated in 32 patients, remained stable in 12 patients and improved in 9 patients. Iodine-125 plaque therapy appears to offer patients good prospects of tumour control and preservation of useful vision.

To compare the long-term degradation of Novafil (polybutester, American Cyanamid Company) and nylon suture material, we examined corneoscleral sections of nine rabbits 23 months after the placement of sutures. Only two nylon sutures remained, one in each wound of two rabbits; all the Novafil sutures were still present. However, examination of the Novafil sutures with scanning electron microscopy revealed signs of disintegration.

PURPOSE: To examine the natural history of multifocal visual evoked potentials (mfVEPs) within 12 months of the first episode of optic neuritis (ON) in patients with possible multiple sclerosis (MS). METHODS: Twenty-seven patients with a first episode of ON, no previous demyelinating events, and MRI lesions consistent with demyelination were examined with mfVEP. Changes in amplitude and latency of mfVEP were analyzed at 1, 3, 6, and 12 months after an acute attack. RESULTS: Five of 27 patients had persistent loss of amplitude after 12 months of follow-up. This loss was most marked centrally. Amplitude recovered in the remaining 22 patients at 1 month, but delayed latency, which was also most marked centrally, persisted. Of these, two distinct subgroups were identified: six patients with no improvement in latency and 16 patients with significant latency recovery over the 12 months of follow-up, suggesting remyelination. Conversion to MS was highest in the group with severe amplitude loss, followed by the group with no latency recovery. The conversion rate was lowest in the group of patients with latency improvement. CONCLUSIONS: Distinct patterns of disease evolution were identified using mfVEP in patients with first episode of optic neuritis and at high risk for MS, supporting the concept of heterogeneity of early lesions in MS.

Purpose To describe a case of Euphorbia lactea sap keratouveitis and to review all reported cases of ocular toxicity caused by Euphorbia species. Methods Case report and review of literature. Results A 79-year-old woman presented 34 hours after she felt some sap of an E. lactea plant spray into her right eye. Visual acuity was counting fingers at 1 m. Examination revealed ciliary injection, 90% corneal epithelial defect, marked stromal edema with Descemet folds, and anterior-chamber flare with a 1-mm hypopyon. There was no vitreitis, and funduscopy was unremarkable. No foreign body was seen on B scan ultrasound or computed tomography scan of the orbits. Corneal scraping excluded bacterial and herpetic keratitis. Intensive topical antibiotic therapy was started with cephalothin 5% and gentamicin 0.9%, and the pupil was dilated with atropine. Topical steroids were started once the epithelial defect had healed. Examination 11 weeks after the injury revealed minimal subepithelial corneal haze and marked improvement in visual acuity. Conclusions To the best of our knowledge, this is only the third reported case of E. lactea sap keratouveitis. The clinical course of E. lactea sap keratouveitis is compared with that reported for other Euphorbia species.

To determine the prevalence and risk factors associated with secondary glaucoma postcongenital cataract surgery.All children diagnosed as having congenital cataracts in a major children's hospital between 1985 and 2005 were included in a retrospective case series. Medical records of 423 eyes among 283 patients who underwent cataract surgery with or without intraocular lens implantation at age/=16 for congenital cataract were reviewed. The main outcome measure was presence or absence of secondary glaucoma and time to glaucoma postsurgery. The following risk factors were evaluated: age at cataract surgery, presence of systemic anomalies, microcornea, persistent hyperplastic primary vitreous (PHPV), primary capsulotomy/anterior vitrectomy, primary intraocular lens implantation, secondary membrane surgery and duration of postoperative observation.The statistical methods were the use of Kaplan-Meier survival analysis and Multivariate Cox hazards regression analysis. The mean follow-up was 6.3 (SD 5.0) years (median 4.6 years; range 0.5 to 20.3 years). Glaucoma developed in 36 of 234 patients (15.4%). Multivariate Cox proportional hazards regression analysis identified age less than 9 months at time of surgery (RR 2.9, 95% CI 1.3 to 7.7; p = 0.03), microcornea (RR 3.7, 95% CI 2.0 to 7.0; p0.001), and follow-up time as important predictors of glaucoma. PHPV (RR 1.4, 95% CI 0.7 to 2.7; p = 0.41) and primary posterior capsulotomy/anterior vitrectomy (RR 2.2, 95% CI 0.9 to 5.5; p = 0.17) were not significantly associated with secondary glaucoma in the multivariate model. The mean time to glaucoma after congenital cataract surgery was 4.9 years (range 2 weeks to 16.8 years).Secondary glaucoma is an important sequela in patients who undergo surgery for congenital cataracts. It is imperative that these patients get lifelong surveillance, as glaucoma can occur years after the initial operation.

Background/aims: The literature on refractive change in thyroid eye disease (TED) is limited. This study documents the refractive change in patients with TED undergoing orbital decompression. The authors propose possible mechanisms for their acquired refractive error. Methods: This is a retrospective observational case study of five patients with progressive TED. Their detailed eye examinations including refractive state preoperatively and postoperatively are presented. Results: An acquired hypermetropic shift with active TED before orbital decompression of up to 3.75D spherical equivalent refraction (SER) is reported in one patient. Post-orbital decompression, an induced myopic shift of between 1.00–2.50D SER for all patients is observed, noted to range from 1 day following surgery to up to 9 months, dependent on the availability of data. Axial length increased in two cases corresponding to postoperative myopic shift. Magnetic resonance imaging findings of one patient demonstrate flattening of the posterior pole as a cause of the acquired preoperative hypermetropia. Conclusions: TED has a significant effect on the refractive state of patients. The proposed mechanism of acquired hypermetropia relates to increased volume of orbital contents with flattening of the posterior globe. This is reversed with successful orbital decompression. Documentation of refractive error in all cases of progressive TED is recommended. Progressive acquired hypermetropia may be suggestive of TED activity.

Naevus of Ota (naevus fusculocoeruleus ophthalmomaxillaris) was described by the Japanese dermatologist, Ota, in 1939 as a dermal melanocytic hamartoma that presents as bluish hyperpigmentation along the ophthalmic, maxillary, and mandibular branches of the trigeminal nerve. It is bilateral in less than 5% cases, occurring frequently in Orientals (0.2%–1%) and darker races and rarely in white people (0.04%). Open angle glaucomas and choroidal melanoma are the rare ocular involvements. Ota’s naevus is more common in Asians than white people but uveal melanoma occurs predominantly in white populations.1,2 Dark skinned patients represent only 1% of all cases of orbital melanomas.3 The risk of developing uveal melanoma in a patient with naevus of Ota is one in 400 patients in their lifetime.1,2 We report a rare case of bilateral naevus of Ota with a right (RE) …

Introduction Fresh frozen cadavers are effective training models for airway management. We hypothesised that residual carbon dioxide (CO 2 ) in cadaveric lung would be detectable using standard clinical monitoring systems, facilitating detection of tracheal tube placement and further enhancing the fidelity of clinical simulation using a cadaveric model. Methods The tracheas of two fresh frozen unembalmed cadavers were intubated via direct laryngoscopy. Each tracheal tube was connected to a self-inflating bag and a sidestream CO 2 detector. The capnograph display was observed and recorded in high-definition video. The cadavers were hand-ventilated with room air until the capnometer reached zero or the waveform approached baseline. Results A clear capnographic waveform was produced in both cadavers on the first postintubation expiration, simulating the appearances found in the clinical setting. In cadaver one, a consistent capnographic waveform was produced lasting over 100 s. Maximal end-tidal CO 2 was 8.5 kPa (65 mm Hg). In cadaver two, a consistent capnographic waveform was produced lasting over 50 s. Maximal end-tidal CO 2 was 5.9 kPa (45 mm Hg). Conclusions We believe this to be the first work to describe and quantify detectable end-tidal capnography in human cadavers. We have demonstrated that tracheal intubation of fresh frozen cadavers can be confirmed by life-like waveform capnography. This requires further validation in a larger sample size.

Background: To determine the effect of different stimulus frame rates and check sizes on blue−yellow multifocal visual evoked potentials (mVEP). Methods: Subjects were examined at the Save Sight Institute at the University Sydney. Experiment 1 involved five adult subjects who underwent binocular stimulation by the Accumap multifocal objective perimeter. The eyes were stimulated with a cortically scaled dartboard pattern consisting of isoluminant blue and yellow checks. These were arranged in three concentric rings extending to an eccentricity of 26° in the visual field. The stimulus pattern was driven by binary sequences resulting in pseudorandom binary exchange of two opposite checkerboard patterns at each of the 32 sites in the visual field. The mVEP were recorded at two different rates of display of the pattern stimulus. In experiment 2, mVEP were tested on 10 normal subjects. Each of the 36 stimulation sites contained a checkerboard pattern of 20, 30, 42 or 56 checks/site, the stimulation pattern was displayed at the optimum rate found in experiment 1. The size of the checks was inversely proportional to the number of checks per site. Results: In experiment 1, the slow frame rate significantly increased the average amplitude throughout the field tested by 50 ± 10.1% (P = 0.001). Latency was significantly shortened by 6.3% (P

Objective: To determine the safety of a single intravitreal injection of triamcinolone acetonide (4 mg) in patients with subfoveal choroidal neovascularization caused by age-related macular degeneration. Methods: A double-masked, placebo-controlled, randomized clinical trial was conducted at a public tertiary referral eye hospital. Patients participating had agerelated macular degeneration with evidence of choroidal neovascularization, any part of which was classic; age older than 59 years; and best-corrected visual acuity of 20/200 or better. Eyes were assigned to active study treatment or to placebo. Intraocular pressure and cataract grading were performed every 6 months for 3 years. Adverse events, from mild to vision-threatening or lifethreatening, were recorded as procedure-related or corticosteroid-related. Results: Seventy-five eyes were assigned to study treatment and 76 eyes to placebo. There were no moderate or severe adverse events related to the surgical procedure in either group. Triamcinolone-treated eyes had a significantly increased risk of developing mild or moderate elevation of the intraocular pressure. Topical glaucoma medication reduced intraocular pressure to acceptable levels in all patients. There was significant progression of cataract in the triamcinolone-treated eyes. Conclusion: Despite a significant adverse event profile, intravitreal triamcinolone is generally well tolerated by the human eye as long as patients are carefully followed up by their surgeon and treated appropriately, when necessary. Arch Ophthalmol. 2004;122:336-340

Clinical indocyanine green (ICG) angiography has gained an established role in the diagnosis of choroidal neovascularisation (CNV) in age related macular degeneration (AMD).1,2 It is potentially able to localise CNV with greater accuracy compared with fluorescein angiography because it fluoresces in the infrared range, allowing imaging of choroidal pathology through blood and pigment.3 Additionally ICG angiography may better define CNV because of its high protein binding affinity in serum,4 resulting in reduced leak from the CNV. This allows ICG angiography to clearly delineate the feeding vascular supply to the CNV allowing direct ablative thermal laser to precisely target this supply.5 Treatments for CNV, including thermal laser, photodynamic therapy, and macula translocation are all reliant on the ability of the clinician to diagnose accurately the location and nature of CNV. Few clinicopathological data exist to correlate the ICG angiographic appearance of CNV with its histology. The presence of CNV was shown pathologically in an eye with a plaque like hyperfluorescence on ICG angiography shown years previously.6 Lafaut reported the pathology of surgically removed recurrent CNV in two eyes that were preoperatively imaged with ICG angiography.7 The hyperfluorescence of drusen on ICG angiography in the monkey model has been correlated with ICG dye that has been found histologically on infrared fluorescence microscopy.8 In this case report we hope to correlate ICG angiographic findings in a patient with exudative AMD with the histological localisation of ICG to the surgically excised CNV. This will verify that ICG angiographic findings are an accurate representation of the location and nature of the CNV. A 71 year old patient with classic subfoveal CNV was …

This report describes different modes of management in 3 sisters with anterior megalophthalmos. We report our management of the anterior megalophthalmos and a new technique of anterior chamber intraocular lens implantation, which was used in 1 case.

Aims: To review factors affecting graft survival and determinants of visual acuity after penetrating keratoplasty in children. Methods: All cases of penetrating keratoplasty performed in an ophthalmic unit, in children aged less than 15 years at the time of operation, for the period 1984 to 2002 were included. Results: 19 penetrating keratoplasties were done in 18 eyes of 16 children, age range 2 weeks to 14 years 8 months (mean 9.24 years), with mean follow up 6.6 years. 73.7% of grafts have remained clear for up to 14 years. Postoperative visual acuity among congenital indications for graft was better than 6/60 in only 14.2% of cases, but was better than or equal to 6/12 in all cases of keratoconus. Conclusion: This series shows that prolonged corneal graft survival can be achieved in children, but successful restoration of visual acuity depends upon a period of normal visual development before the onset of corneal opacification.

Uveal melanoma, affecting iris, ciliary body, and choroid, is the most common primary ocular malignancy in adults, with an average incidence of 8 per 1 000 000. Smaller primary lesions may be controlled with local resection, laser photocoagulation, proton therapy, or plaque radiotherapy. However, these treatments are often associated with sight threatening complications including radiation retinopathy, macula oedema, scarring, and haemorrhaging.1 Recurrence of the primary tumour after local resection is also commonly observed, with recurrence rates for iris, ciliary body, and choroidal tumours between 11% and 32%.2–4 Treatment of recurrent disease usually involves enucleation of the eye. Even with effective early treatment of the primary tumour, uveal melanoma displays an unpredictable clinical course during which clinically evident metastases may occur after a prolonged disease free interval.1 Metastatic disease from primary uveal melanoma usually appears in 10–40% of patients within 10 years, mostly in the liver, and with an average survival of 5.4 months following diagnosis.5,6 Development of metastatic disease is currently untreatable. Chemotherapy is generally ineffective because of the restricted period of action during the therapeutic cycle. Immunotherapy is still in the experimental stage and its effects remain elusive. However, α radioimmunotherapy is worth consideration as a potential treatment of primary and metastatic ocular melanoma. For example, the radionucleotide bismuth-213 (213Bi) (t1/2 = 46 minutes), which has been chelated to some monoclonal antibodies, emits an α particle with short range (80 μm) and high linear energy transfer radiation which is about 100 times greater than for β particles.7 mAb 9.2.27 recognises a Mr 250 000 glycoprotein NG2, associated with a chondroitin sulphate proteoglycan8,9 and is expressed on most human cutaneous melanomas and some gliomas.10 The epitope for antibody binding has high in vivo expression and has been detected on >90% of melanoma cells in cutaneous lesions,11 with high cell surface specificity for human cutaneous melanoma cells. The expression of mAb 9.2.27 has not yet been investigated in human ocular melanoma. mAb 9.2.27 has also been used extensively in vitro and in vivo as a tumour marker for therapeutic purposes,12–15 and has also been tested in a limited phase I clinical trial.16 Our group has recently chelated the α emitting radioisotope 213Bi to mAb 9.2.27 to form an α immunoconjugate (AIC), which is highly specific and cytotoxic to cutaneous melanoma cells in vitro17 and can completely regress tumour growth in a xenograft mouse model after local injection.18 Preliminary results from our phase I clinical trial also demonstrate that AIC can target cutaneous melanoma cells after local injection (unpublished data). As a first step in the selection of a possible cell surface target antigen for AIC therapy of uveal melanoma, we examined 26 cases of pathologically confirmed uveal melanomas for NG2 immunoreactivity, using mAb 9.2.27 immunohistochemistry.

To assess whether an association exists between systemic use of anti-inflammatory medications at baseline and the prevalence or incidence of either late or early age-related maculopathy (ARM) in a population-based cohort.3654 participants of the Blue Mountains Eye Study baseline examination (1992-94) were followed during 1997-99. Use of anti-inflammatory medication was recorded during the baseline interview. After excluding 543 persons who died since baseline, 2334 (75% of the surviving participants) attended 5-year follow-up examinations. Retinal photographs taken during both examinations were graded using the Wisconsin Age-Related Maculopathy Grading System. Prevalence refers to the proportion of participants having ARM at baseline. Incidence refers to the proportion of participants without ARM at baseline who developed it over the 5-year period. Known ARM risk factors were adjusted for when assessing the relationship between use of anti-inflammatory medications and ARM.At baseline, 1010 (27.6%) of 3654 participants were current users of non-steroidal anti-inflammatory drugs (NSAIDs), 514 (14.1%) were past users and 1282 (35.1%) were ever users. The corresponding numbers of subjects reporting current, past or ever use of corticosteroids (including inhaled steroids) were 225 (6.2%), 519 (14.2) and 564 (15.4), respectively. Late ARM was present in 72 participants (2.0%) and early ARM was present in 171 participants (4.9%) at the baseline examination. During the follow-up period, 25 participants (1.1%) developed incident late ARM and 192 (8.7%) developed incident early ARM. After adjusting for age, sex, family history of ARM and smoking, no significant associations were evident for the use of NSAIDs or corticosteroids and the prevalence of either late or early ARM. There were also no associations found between use of these medications at baseline and the 5-year incidence of either late or early ARM.No association was found between use of systemic anti-inflammatory medications and either the cross-sectional prevalence or longitudinal incidence of ARM in this population.

To describe the natural history of optic pathway gliomas (OPGs) in patients with neurofibromatosis type 1 (NF1), and to evaluate the current recommended guidelines for monitoring and follow-up of OPGs in this population.Retrospective case series.Patients with OPGs and NF1 seen in the neurofibromatosis clinic at the Children's Hospital at Westmead in Sydney, Australia.Patients with definite NF1 and confirmed OPGs were identified and their medical records searched to obtain data on demographics, details of the OPG diagnosis, and serial ophthalmic examination findings. Patients were stratified into groups according to age and mode of presentation.Visual acuity was recorded for each eye and grouped into mild (Snellen equivalentor = 6/12), moderate (Snellen equivalent = 6/15-6/60), and severe (Snellen equivalent6/60) visual impairment at time of diagnosis, during follow-up, and at the most recent examination.Data were collected on 54 patients, the majority of whom (78%) were seen from 1990 to 2002, with an average follow-up of 8.6 years. The mean age at the time of OPG diagnosis was 5.2 years, with 32 patients having symptoms or signs at the time of diagnosis. Seventeen patients were diagnosed after the age of 6 years (range, 7-15). Twenty-two patients had tumor progression within 1 year of diagnosis, and a further 6 patients showed progression after 1 year. Most patients' conditions were managed conservatively (68.5%). At follow-up, 17 patients (31.5%) had severe visual impairment (6/60 Snellen equivalent) in their worse eye, and 16.7% had bilateral moderate/severe visual impairment.Contrary to some previous reports, our results show that OPGs in patients with NF1 often present in older children and may progress some time after diagnosis. Given the potential for serious visual consequences, these findings indicate a need for regular ophthalmological monitoring of this population for a long duration.

Aims: To assess the aetiological factors associated with the occurrence of perforating ocular injuries in children in an urban setting and to assess the visual outcomes of such injuries. Methods: All cases of perforating ocular injury presenting to a single paediatric hospital (age less than 16 years) over a 17 year period were identified by a medical record search. All new cases of perforating ocular injury identified were included. All information was obtained retrospectively from the medical records. Results: There were 72 cases identified. The commonest causes of perforating ocular injury were sharp tools (knives/scissors) poked by the child into his/her own eye (17%), or objects thrown at the child (17%). Injuries were most likely to have occurred at home (58%). The age range for injuries was 8 months to 14 years 8 months. Perforating ocular injury was most frequent in the 3–6 year group (32%) followed by the 6–9 year group (25%). Males were more frequently involved than females (48–24). There was no correlation between the laterality of the eye, the time of day of the occurrence, or the day of the week of the occurrence. The final acuity achieved was better or equal to 6/12 in 36% and less than 6/60 in 31%. Injuries occurred more frequently on weekends than on weekdays. There were six enucleations (8%). Follow up was for an average period of 25 months. Conclusions: Penetrating ocular injury occurs most frequently in the home setting and mostly as the result of the use of sharp tools or by thrown objects. Prevention of penetrating ocular injury requires greater education of children and their carers especially on the potential dangers within the home.

AIMS—To describe features influencing the management of primary iris melanoma and report the outcome of conservative surgical treatment of patients diagnosed with this condition in a tertiary referral academic setting over a 20 year period. METHODS—Retrospective non-comparative case series of consecutive patients diagnosed with iris melanoma from 1980-2000 using medical records from the University of Sydney Department of Ophthalmology and NSW Cancer Registry RESULTS—51 cases were identified. The most common presentation was growth of a previously noted pigmented lesion. Initial management was either observation or local resection (two had enucleations) with iris reconstruction where possible (23.8%). The mean follow up was 8.7 years (range 1-17 years). Vision of 6/12 or better was maintained in the majority (78.6%) treated by local resection. Pupil reconstruction significantly reduced reported postoperative glare symptoms. Four patients had features suggestive of local recurrence and there was no documented metastatic disease or death from iris melanoma in this series. Histologically, the majority were spindle B cell melanomas. Clinical features including prominent tumour vascularity, rapid growth, and heterogeneous pigmentation were each significantly associated with an epithelioid cell component. Involvement of the iridocorneal angle was frequently associated with ciliary body invasion. CONCLUSIONS—Management decisions for iris melanoma will depend on the clinical features. Mixed or epithelioid histology is more likely in the presence of two or more of the features of malignancy and may justify earlier intervention. When treatment is undertaken, local resection achieves long term tumour clearance with an acceptable morbidity. In resecting iris melanoma, careful assessment for iridocorneal angle involvement is important in treatment planning. Iris reconstruction has a useful role in reducing postoperative photophobia.

Maternal infection with rubella in the first trimester is an important cause of congenital cataract. Any injury affecting the foetus following maternal rubella infection in the phase of organogenesis results in congenital defects collectively termed as congenital rubella syndrome (CRS). Although rubella embryopathy is a less common cause for congenital cataract than in the past, it is still seen. The number of cases reduced to one in 1997 after which there were no new cases till 2002. However, there have been two new cases of CRS in 2003. Herein another one in early 2004 is reported. Outbreaks of CRS will continue until the percentage of susceptible individuals is reduced to a minimum through immunization. The majority of rubella cases in Australia are confined to young female immigrants, many coming for marriage. We must continue to immunize children, identify and immunize vaccine failures and susceptible women before they become pregnant, and to screen pregnant women so they can be vaccinated after delivery.

Purpose: The use of adjunctive antimitotics with conventional filtering surgery appears to have decreased the need for Molteno implants in glaucomas with a poor prognosis. We review the current status, results and complications of Molteno implants. Methods: Review of the literature and practical experience from two university departments of ophthalmology. Results: Improvements in the design and surgical techniques for Molteno implants have decreased the incidence of over filtration, but this and other complications continue to pose problems. Increased success rates may be possible if antimitotics are used with Molteno implants. Conclusion: Molteno implants continue to be an option when conventional filtration with or without antimitotics has failed: they continue to be regarded as a last resort for filtration. The use of antimitotics to increase the success rate of Molteno implants is not proven, but merits further investigation.

The authors present a case of optic neuritis in an adult patient who had been self-prescribing extraordinarily large dosages of chloramphenicol for chronic prostatitis over several years. The visual symptoms resolved upon cessation of the drug and prescription of B group vitamins. Chloramphenicol optic neuritis has not been described in the literature for over 20 years and previously predominantly in children with cystic fibrosis.

A number of reports have suggested that oxidative damage in the retina may contribute to the pathogenesis of Age-related macular degeneration (AMD). The present study was designed to investigate the hypothesis that serum levels of the antioxidants, Vitamin E and selenium are related to the pathogenesis of AMD. Fasting bloods were obtained from 80 patients with AMD and 86 controls. Assays for serum levels of Vitamin E, selenium, cholesterol and triglycerides were performed. Assessment of patients and controls was based upon eye examination, fundus photography and medical history. No significant difference was found in serum levels of Vitamin E between subjects and controls, however, there was a borderline association between AMD and both serum selenium levels and current smoking status. The results suggest that if oxidative damage is a factor in the pathogenesis of AMD, it is not reflected in serum levels of Vitamin E; further studies are required to clarify the possible relationship between serum selenium levels, smoking and AMD.

Parry Romberg syndrome is a rare disorder characterised by progressive hemifacial atrophy that is usually unilateral, involving the skin, subcutaneous tissue, and subsequently the muscle, cartilage and bone. Previous cases with various ocular manifestations have been reported. A case of Parry Romberg syndrome with retinal vasculitis is reported.

The results of 32 choroidal melanomas managed by observation, Iodine-125 scleral plaques and local surgical excision are presented. Initially, 12 patients were managed by observation, and of these three continued to be managed by observation alone. Fifteen patients were managed with Iodine-125 scleral plaques and followed for an average of 15 months. The tumour regressed in 11, remained the same in three, and recurred in one case. The final visual acuity remained within two Snellen lines of that recorded preoperatively in 10 patients. Fourteen patients underwent local excision with an average follow-up of 31 months. These cases, in general, had larger tumours. The final visual acuity was within two Snellen lines of the pre-operative vision in four patients. Five eyes required enucleation at a later date. Four of the five enucle-ations occurred earlier in the series. The management of choroidal melanoma remains controversial. Various methods of conservative treatment are described and the indications for conservative management by observation, scleral plaque and local excision are discussed.

PURPOSE. To determine whether simultaneous binocular (dichoptic) stimulation for multifocal visual evoked potentials (mfVEP) detects glaucomatous defects and decreases intereye variability. METHODS. Twenty-eight patients with glaucoma and 30 healthy subjects underwent mfVEP on monocular and dichoptic stimulation. Dichoptic stimulation was presented with the use of virtual reality goggles (recording time, 7 minutes). Monocular mfVEPs were recorded sequentially for each eye (recording time, 10 minutes). RESULTS. Comparison of mean relative asymmetry coefficient (RAC; calculated as difference in amplitudes between eyes/ sum of amplitudes of both eyes at each segment) on monocular and dichoptic mfVEP revealed significantly lower RAC on dichoptic (0.003 0.03) compared with monocular testing (0.02 0.04; P 0.002). In all 28 patients, dichoptic mfVEP identified defects with excellent topographic correspondence. Of 56 hemifields (28 eyes), 33 had Humphrey visual field (HFA) scotomas, all of which were detected by dichoptic mfVEP. Among 23 hemifields with normal HFA, two were abnormal on monocular and dichoptic mfVEP. Five hemifields (five patients) normal on HFA and monocular mfVEP were abnormal on dichoptic mfVEP. In all five patients, corresponding rim changes were observed on disc photographs. Mean RAC of glaucomatous eyes was significantly higher on dichoptic (0.283 0.18) compared with monocular (0.199 0.12) tests (P 0.0006). CONCLUSIONS. Dichoptic mfVEP not only detects HFA losses, it may identify early defects in areas unaffected on HFA and monocular mfVEP while reducing testing time by 30%. Asymmetry was tighter among healthy subjects but wider in patients with glaucoma on simultaneous binocular stimulation, which is potentially a new tool in the early detection of glaucoma. (Invest Ophthalmol Vis Sci. 2007;48:4590‐4596) DOI: 10.1167/iovs.07-0318

Aniridia and its variants may cause diagnostic difficulty especially when the iris is not wholly or partially absent.1,2 In congenital iris ectropion (also called ectropion uveae), the posterior pigment epithelium of the iris extends onto the anterior iris surface causing darkening around the pupil. We report a man and his infant son with variant aniridia and a mutation in the PAX6 gene, where the major anterior segment finding was iris ectropion. A 30 year old man with bilateral iris ectropion, vision impairment, and nystagmus attributed to optic nerve hypoplasia, and his infant son also with poor vision, were examined. A search of the man’s previous ophthalmic records indicated that at 6 weeks of age he had poor vision, nystagmus, myopia (−6.0 D), and small, anomalous optic discs. Ectropion uveae was noted in the records at age 9 years. A poorly developed foveal reflex was identified in his late teens. A magnetic resonance imaging (MRI) …

Objective To determine if a single intravitreal injection of 4 mg of triamcinolone acetonide in patients with classic choroidal neovascularization associated with age-related macular degeneration can safely reduce the risk of severe visual loss. Methods A double-masked, placebo-controlled, randomized clinical trial was performed in patients 60 years or older who had choroidal neovascularization with any classic component, a duration of symptoms of less than 1 year, and a visual acuity of 20/200 or better. Best-corrected visual acuity, intraocular pressure, and cataract grading were performed before the injection and then at 3, 6, and 12 months. Main Outcome Measure The development of severe loss of vision (30 letters) by survival analysis on an intention-to-treat basis. Results One hundred fifty-one eyes were randomized into the study, and follow-up data were obtained for 73 (97%) of the 75 eyes in the treated group and for 70 (92%) of the 76 eyes in the control group. There was no difference between the 2 groups for the development of severe visual loss during the first year of the study (log-rank χ21= 0.03,P= .90). In both groups, the 12-month risk of severe visual loss was 35%, with a hazard ratio of 1.05 (95% confidence interval, 0.59-1.86). The change in size of the neovascular membranes, however, wassignificantly less in eyes receiving triamcinolone thanin those receiving placebo 3 months after treatment (P= .01), although no difference was noted after 12 months. After 12 months, treated eyes had a significantly higher risk of an elevated intraocular pressure (31/75 [41%] vs 3/76 [4%];P Conclusions A single dose of intravitreal triamcinolone had no effect on the risk of loss of visual acuity during the first year of the study in eyes with age-related macular degeneration and classic choroidal neovascularization, despite a significant antiangiogenic effect found 3 months after treatment. This biological effect warrants further study.

Purpose: To evaluate the presence of central nervous system degeneration in patients with low-tension glaucoma using magnetic resonance imaging. Method: Ten patients with low-tension glaucoma and ten age-matched control subjects underwent magnetic resonance imaging. Cortical atrophy and cerebral infarcts were graded from "0" (normal) to "3," which was done subjectively by two neuroradiologists independently in a masked fashion. Midsagittal corpus callosum section was evaluated by measuring the thickness and cross-sectional area. Results: There was a significantly greater extent of cerebral infarcts in the patients with low-tension glaucoma ( P = 0.02). The thickness of the body ( P = 0.03) and genu ( P = 0.04) of the corpus callosum were thinner in the patients with low-tension glaucoma. The corpus callosum cross-sectional area was smaller in the low-tension glaucoma group ( P = 0.04). There were no significant differences in the other parameters in this study. Conclusion: This study suggests a greater extent of cerebral infarcts and corpus callosum atrophy in patients with low-tension glaucoma. This may imply a greater degree of neuronal degeneration, possibly on an ischemic basis in low-tension glaucoma.

Six cases of malignant choroidal melanoma were treated by microsurgical excision under hypotensive anaesthesia with follow-up periods varying from four months to four years. This paper presents the case for local excision of malignant choroidal melanoma in the light of the current controversy surrounding the management and natural history of choroidal melanoma. The indications for surgery, techniques, and results are described. Vision was preserved best in tumours with diameters of less than 10 mm. No deaths and no evidence of extraocular recurrence occurred.

We compared a newly available nonabsorbable monofilament ophthalmic suture, 9/0 Novafil (Davis & Geck), with 10/0 nylon (Alcon), currently the most popular suture for closure of corneoscleral sections. Surgery was performed on nine rats and ten rabbits. In each case a 120° corneoscleral section was made in each eye and closed with interrupted sutures of 9/0 Novafil in one eye and 10/0 nylon in the other. We compared their handling qualities during surgery, as well as their effect on postoperative wound inflammation. In addition we examined the suture material from each eye of the rats by scanning electron microscopy (SEM) after 3 months, and we compared the surgically induced astigmatism in the rabbits in the two suture groups. Both suture materials were easy to handle and well tolerated. Nylon sutures from six of the eight rat eyes studied showed SEM evidence of surface disintegration after 3 months, whereas all the Novafil sutures remained intact.

This paper reports all cases of retinoblastoma occurring in Victoria over a 20-year period between 1956 and 1976. It suggests that the natural history of treated retinoblastoma in an Australian community, is characterized by low mortality (8.3%), but significant morbidity. The most common problem in management of unilateral cases was one of diagnosis in contrast to bilateral cases, in which the problem was one of maintaining useful vision whilst at the same time eradicating a life-threatening tumour. Suggestions are made as to how management of retinoblastoma may be further improved, and the need for an active national register is discussed.

Over the past two years 15 dermis-fat grafts were performed Ten were primary grafts, two were implanted because of migrated implants, two for extruding implants and one to correct deep superior sulcus recession. Our experience showed dermis-tat grafts to be an effective method of correcting orbital volume deficit, of maintaining satisfactory prosthetic motility and of preventing the development of conjunctival deficiency. In primary dermis-tat grafts fat atrophy was less than 70%, whilst in secondary implants fat atrophy was less than 30% Complications were minimal in our small series

A case of optic nerve hypoplasia in the Conradi-Hunermann form of chondrodysplasia punctata is reported. This is the first published report of such a case. The authors suggest that optic nerve hypoplasia in chondrodysplasia punctata may be the significant lesion of the optic nerve rather than atrophy as has been previously reported.

In recent years, the ophthalmic examination of infants has been of increasing interest to both clinicians and vision researchers. Clinicians have documented a greater risk of retinopathy, strabismus and amblyopia in premature infants, especially those of low birthweight. In addition to the external and retinal examination of the infant eye, a number of clinical tests can help the ophthalmologist to detect visual dysfunction through the evaluation of pupillary responses and ocular motility. Recently, the development of objective techniques (optokinetic nystagmus, forced choice preferential looking, and visually evoked potentials) have not only aided in the detection of ophthalmic disorders in infants; they have contributed to useful definitions of "normal" vision at various ages and to the understanding of factors that influence the pre- and post-gestational development of visual function.