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Objective To present a patient with systemic lupus erythematosus who developed infarction and melting of the orbit secondary to her systemic disease. Design A case report. Participant A 61-year-old white woman with a 5-year history of systemic lupus erythematosus. Methods The patient presented with left orbital pain, limitation of extraocular movements, and a fistula from the ethmoid sinus to the upper eyelid. A detailed examination with computerized tomography, ultrasound, and a comprehensive medical evaluation with laboratory testing was performed. Histopathologic analysis with special stains of the orbital tissues was also performed. Results Histopathologic examination of the biopsy specimens revealed the features of an inflammatory process involving the orbit, similar to a panniculitis. These include a lymphocytic reaction with a predominance of plasma cells, vasculitis with occlusion, and thickening of the vessel walls, necrosis, and hyalinization of fat. Conclusion This is a unique case in which infarction and melting of the entire orbital structures occurred in the presence of systemic lupus erythematosus. The underlying disease process is a lupus-related panniculitis. The authors stress that this is a very rare entity and that other diseases should be ruled out before entertaining this diagnosis.

Background: Cataract surgery in a population with mild levels of functional impairment was studied in the Regional Evaluation of Surgical Indications and Outcomes (RESIO) project.The RESIO investigators assessed the overall visual function assessment (VFA) score before and after surgery. In this study we reanalysed available RESIO data to better understand the findings for individual VFA items in this patient population. Methods: We calculated effect sizes for longitudinal changes in each VFA item and for changes in overall VFA scores using the Mann—Whitney statistic. We considered effect sizes less than 0.3 as small, between 0.3 and 0.8 as moderate, and more than 0.8 as large. We compared differences in the individual VFA item scores before and after cataract surgery using a paired t test and Wilcoxon's signed-rank test. Results: Of the 32 surgeons originally involved in the RESIO project, 18 (60%) agreed to have the data for their patients reanalysed. We found pre- and postoperative VFA data for 709 cataract operations (mean age of patients 73.4 years [standard deviation 9.4 years]; 60.7% women). Of the 47 people with a perfect preoperative VFA score, 28 (59.6%) had a perfect score postoperatively, 13 (27.6%) had a score of 90 or better, 5 (10.6%) had a score of 87 to 90, and 1 (2.1%) had a score of 67. Among the 200 people with a preoperative VFA score of 90 to 99, postoperatively the VFA score improved for 146 (73.0%), remained the same for 43 (21.5%) and worsened for 11 (5.5%). The mean scores for all individual VFA items improved postoperatively. The largest improvements were noted for "driving during the day" (effect size 1.1), "selfcare activities" (0.8), "driving during the night" (0.5), "doing fine handiwork" (0.5), "reading newspaper or book" (0.4) and "participating in religious activities" (0.4). Interpretation: The original conclusion from the RESIO project seems correct: based on VFA, the current threshold for cataract surgery in British Columbia is very low. Individual VFA items, particularly reading and night driving, are most strongly and consistently influenced by cataract surgery, regardless of overall VFA score. In the absence of visual acuity data, it is not possible to relate VFA to cataract surgical decisionmaking in British Columbia.

The diversity of pathogenetic mechanisms involved in posttraumatic visual impairment was reviewed in a study of the hospital records of 24 patients admitted with multiple injuries. Most major visual abnormalities occurred in young people (average age 33 years) who presented with a wide range of overall severity of injury (injury severity score 13-47) and involvement of the central nervous system (Glasgow coma scale 5-15). Bilateral or monocular blindness developed in 63% of patients. Seventy percent of the injuries involved the anterior visual pathways with damage to the optic nerve alone accounting for 35%. Fractures of the sphenoid bone, particularly of the body, accompanied optic nerve and chiasmal injuries and some cases of traumatic carotid-cavernous fistulas. Pathogenetic mechanisms varied according to the site of injury and included vitreous hemorrhage and optic atrophy secondary to raised intracranial pressure, retinal hypoxia from carotid-cavernous fistulas, shearing and compression injuries of the optic nerve, traumatic chiasmal syndrome, temporoparietal and occipital contusions, and transtentorial herniation with occipital infarction. Visual abnormalities varied in severity from moderately reduced visual acuity and diverse hemianopias and scotomas to blindness. The incidence of posttraumatic residual visual abnormalities is likely to increase in the wake of improved acute care of the traumatized victim.

The authors examined 200 consecutive patients with pituitary adenomas admitted to the neuroendocrine service at the Montreal General Hospital between 1976 and 1981. The main presenting signs and symptoms were amenorrhea/impotence (70%), headache (46%), and typical acromegalic or cushingoid features (28%). Only 9% had visual field defects, 2% had optic atrophy, and 1% had ocular motility problems. A comparison of our findings with four previous studies has demonstrated an increasing incidence of reproductive system abnormalities and a decreasing incidence of visual abnormalities in patients with pituitary tumor. The reasons for this changing pattern are discussed and the role of the ophthalmologist in the care of these patients is redefined.

A bilateral sixth nerve palsy portends serious disease of the central nervous system and precipitates extensive patient studies. Spasm of the near reflex, characterized by intermittent convergence, accommodation, and miosis, is a functional disturbance. Five patients with hysterical spasm of the near reflex erroneously diagnosed as a bilateral sixth nerve palsy are reported. The pupillary sign, intense miosis on attempted lateral gaze, is emphasized as an important clue to the correct diagnosis. Despite extensive investigation, no disease of the central nervous system was found. Neurotic or hysterical features were evident in every patient.