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A 75-year-old hypertensive female with stable idiopathic intermediate uveitis presented with bilateral sequential optic neuropathy with optic disc swelling. The optic neuropathy in the first affected eye (right) was thought to be due to non-arteritic anterior ischaemic optic neuropathy (NAION). Asymptomatic left optic disc swelling was found at routine review 2 months later, and a diagnosis of giant cell arteritis (GCA) was sought. Temporal artery duplex ultrasound showed the “halo sign,” but a subsequent temporal artery biopsy showed light-chain (AL) amyloidosis with no signs of giant cell arteritis. In this case, bilateral sequential ischaemic optic neuropathy mimicking non-arteritic anterior ischaemic optic neuropathy was the presenting sign of systemic amyloidosis involving the temporal arteries.

Purpose: In addition to measuring ocular blood flow, the ocular blood flow tonometer (OBF) can also be set to solely record intraocular pressure (IOP). In this mode it provides a quick means of tonometry which may allow nursing staff to be more easily trained in its use than conventional Goldmann tonometry. With a view to its eventual use in nurse-led clinics we undertook a study to compare both the OBF tonometer and our currently favoured nurse practitioners tonometer the tonopen XL with Goldmann tonometry. Method: IOP was measured in 99 eyes with all three tonometers in a random order. Results: There was not any statistically significant difference between the measurements of all three tonometers. Conclusions: It is concluded that OBF tonometer can provide clinically useful measurements of intraocular pressure which may in fact be more accurate than the tonopen, however, our opinion is that it possibly is not suitable for a universal glaucoma clinics application.

Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology and establishing the correct diagnosis can be challenging. Although dysfunction of the anterior visual pathways is uncommon, it is the most common neuro-ophthalmological manifestation of this condition and given the potential for irreversible, severe visual loss, prompt diagnosis and treatment are essential. We describe a patient with optic perineuritis as a rare initial presentation of sarcoidosis and discuss the underlying pathophysiology and management.

Acute angle closure glaucoma is a comparatively rare, acute form of glaucoma that may be associated with various systemic symptoms; these can overshadow the primary ocular problem. In some cases this delay in diagnosis may result in blindness. We report on three women who presented to our department with acute angle closure glaucoma during one fortnight. Their initial symptoms were attributed to surgical and psychiatric problems rather than to their ocular disease. Acute angle closure glaucoma can present with systemic symptoms such as headache or gastrointestinal disturbance A 63 year old hypermetropic (long sighted) woman presented to her general practitioner with a 24 hour history of right sided headache followed, several hours later, by vomiting, diarrhoea, and non-specific abdominal pain. Her symptoms failed to settle and she was referred to hospital and admitted under a surgical team. No cause could be found for her gastrointestinal disturbance, but the following day her right eye was noted to be red; on direct questioning she admitted to a reduction in visual acuity in that eye, which had coincided with the onset of her symptoms. She was referred to the eye accident and emergency department. The visual acuity in her right eye was reduced to hand movements and associated with a raised intraocular pressure of 44 mm Hg (normal range 10-21 mm Hg), a fixed, mid-dilated pupil, substantial corneal oedema, and a very shallow anterior chamber. Angle closure glaucoma was diagnosed and the intraocular pressure lowered medically. Her systemic symptoms resolved completely. Bilateral laser peripheral iridotomies were performed on the next day. Her visual acuity improved to 6/12 in the right eye compared with 6/6 in …

AIMS The effect of local anaesthetics on optic nerve function can be investigated by quantifying the relative afferent pupillary defect (RAPD). METHODS The study compared the depth of induced RAPD following posterior sub-Tenon9s, retrobulbar, and peribulbar local anaesthetics using crossed polarising filters before cataract surgery (time 1 = 5 minutes), immediately after surgery (time 2 = 42 minutes (av)), and once again on the ward (time 3 = 107 minutes (av)). RESULTS All patients developed a RAPD. There was no significant difference in the depth of RAPD between the groups at any one time period. The peribulbar group had a significantly steeper decay in RAPD from time 1 to time 2 (p = 0.014). This effect was reduced when the shorter operation time for this group was entered as a cofactor (p = 0.063). By time 3 the RAPDs for all groups had decayed similarly so that no differences could be detected. CONCLUSION All three anaesthetic methods caused a similar level of disruption to optic nerve conduction immediately following administration and at the time of day case discharge.

PURPOSE To report on a patient who developed retinal toxicity from an intraocular copper foreign body in the absence of any signs of chalcosis or inflammation. METHOD Case report. RESULT Removal of the copper foreign body resulted in electroretinographic improvement and the patient has retained good vision. CONCLUSION Retinal toxicity from intraocular copper can be subclinical and such foreign bodies should be removed. Removal of the foreign body can be associated with at least partial reversal of retinal toxicity.

Sharif A Issa, Omar H Hadid, Oliver Baylis, Margaret DayanDepartment of Ophthalmology, Royal Victoria Infirmary, Newcastle upon Tyne, UKBackground: To determine occurrence of features of intraoperative floppy iris syndrome (IFIS) during cataract surgery in patients taking systemic alpha-antagonists (AA).Methods: We prospectively studied patients on AA and who underwent phacoemulsification. The following were recorded: pupil diameter preoperatively, iris flaccidity, iris prolapse and peroperative miosis.Results: We studied 40 eyes of 31 subjects. Mean age was 78 years. Overall, 14 eyes (13 patients) showed signs of IFIS: 9/13 (69%) eyes of patients on tamsulosin, 1/18 (6%) eyes in the doxazosin group, 2/2 prazosin patients, 1/4 eyes in the indoramin group, and 1/2 eyes in two patients on a combination of doxazosin and tamsulosin. Most cases (92%) had only one or two signs of IFIS. Bilateral cataract surgery was undertaken in 9 patients but only one patient (on tamsulosin) had features of IFIS in both eyes, while 4 patients (2 on tamsulosin and 2 on other AA) showed signs of IFIS in one eye only, and 4 patients did not show IFIS in either eye.Conclusion: Most AA were associated with IFIS, but it tends to present as a spectrum of signs rather than full triad originally described. Tamsulosin was most likely to be associated with IFIS; however, its intake does not necessarily mean that IFIS will occur. For patients on AA, the behavior of the iris intraoperatively in one eye is a poor predictor of the other eye. Surgeons should anticipate the occurrence of IFIS in any patient on AA.Keywords: alpha blocker, alpha antagonist, cataract surgery, intraoperative floppy iris syndrome, tamsulosin.

Editor,—Aneurysms of the posterior communicating artery classically present with a painful progressive palsy of the third cranial nerve producing ptosis, ophthalmoparesis, and mydriasis. We present a case in which aneurysmal compression of the third nerve produced a variable ptosis and ophthalmoparesis without pupillary involvement in association with intermittent hyperfunction of the ipsilateral third nerve innervated muscles. ### CASE REPORT A 73 year old woman with a history of hypertension and ischaemic heart disease was referred to the eye department with a 3 week history of intermittent diplopia which she described as inconsistently horizontal, vertical, or oblique, and a 2 week history of right retro-orbital pain and difficulty in opening her right eye. The diplopia and ptosis were often worse in the mornings. On examination the corrected visual acuities were right 6/6 and left 6/9. There was a very variable and apparently fatiguable right ptosis which was occasionally replaced by right upper …

Editor,—The Royal College of Optometrists guidelines 19971 suggest routine eye tests include “visual field assessment on all relevant patients, especially those at risk of glaucoma (this includes all patients over age 40 years)”. It has been our clinical impression that many optometrists now routinely perform automated perimetry on all patients over the age of 40 years, identifying more false positives than treatable pathology. We prospectively studied all asymptomatic patients referred from an optometrist with abnormal …