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Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

An 82-year-old woman who had a history of essential thrombocythemia presented with ocular pain, bleeding, and decreased visual acuity of the left eye. Orbital computed tomography revealed a relatively well-defined homogenous mass-like lesion in the left subconjunctival and intraconal space. Conjunctival biopsy showed acute inflammation with necrosis, vascular ectasia with thrombosis and hemorrhage. After the treatment with hydroxyurea and anagrelide, her symptom and lesion were markedly improved. Hematologic disorders like essential thrombocythemia should be considered in patients with severe spontaneous bleeding around the eye.

Purpose: To report the incidence and management of haemorrhagic Descemet membrane detachment (HDMD) in canaloplasty and phacocanaloplasty., Methods: This study included 105 eyes of 92 patients with uncontrolled open angle glaucoma who underwent canaloplasty and phacocanaloplasty between 2010 and 2014. Eyes that developed either HDMD or non-HDMD were identified. The main outcome measures were the development of HDMD and non-HDMD, best corrected visual acuity, recovery time after Descemet membrane detachment (DMD), intra-ocular pressure (IOP) and number of antiglaucoma medications. Each eye was managed according to the time of development, type and extent of DMD., Results: Ten eyes (9.5%) developed DMD- four eyes underwent canaloplasty (3.8%) and six eyes underwent phacocanaloplasty (5.7%). Three of 10 eyes developed non-HDMD while seven of 10 developed HDMD, the majority of HDMD cases occurred in combination with phacocanaloplasty (five of seven). The non-HDMD eyes resolved completely within 2 weeks without intervention. One eye with HDMD was observed for 2 weeks, before a 15% sulphur hexafluoride (SF6) intracameral injection was given. The patient developed a dense corneal stain that was resolving slowly over 30 months. One eye with HDMD underwent YAG laser membranotomy 2 weeks after being identified, which regained corneal transparency 1 month after treatment, while the remaining five eyes underwent immediate surgical drainage and regained corneal transparency 1 day post-procedure., Conclusion: HDMD occurred in up to 6.7% in canaloplasty and phacocanaloplasty procedures, mostly during catheter withdrawal and the viscodilation step. Early recognition and management prevented further manipulation., (© 2015 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Importance: In noninferiority trials, novel oral anticoagulants (NOACs), also known as non-vitamin K oral anticoagulants, were at least noninferior to standard care in the prevention of most prothrombotic conditions. However, differences exist in the safety profile of antithrombotic drugs, and little is known about their intraocular bleeding risk., Objective: To evaluate the risk of substantial intraocular bleeding associated with NOACs., Data Sources: MEDLINE, Cochrane Library, SciELO collection, and Web of Science databases were searched from inception to November 2014, as well as other systematic reviews and regulatory agencies documentation., Study Selection: All phase 3 randomized clinical trials (RCTs) comparing NOACs with any other control that reported intraocular bleeding events., Data Extraction and Synthesis: Data were extracted independently by 2 of the authors and pooled using random-effects meta-analysis. Heterogeneity was assessed with the I2 test., Main Outcomes and Measures: Substantial intraocular bleeding was evaluated with pooled risk ratios (RRs) and 95% CIs., Results: Seventeen RCTs were included. In patients with atrial fibrillation, no difference was identified between NOACs and vitamin K antagonists (RR, 0.84; 95% CI, 0.59-1.19; I2 = 35%; 5 RCTs), and no increased risk was identified compared with acetylsalicylic acid (RR, 14.96; 95% CI, 0.85-262.00; 1 RCT). In patients with venous thromboembolism, no increased risk of substantial intraocular bleeding compared with sequential treatment with low-molecular-weight heparin and a vitamin K antagonist (RR, 0.67; 95% CI, 0.37-1.20; I2 = 0%; 5 RCTs) was identified. Regarding patients who underwent orthopedic surgery, the risk was not different between NOACs and low-molecular-weight heparin (RR, 2.13; 95% CI, 0.22-20.50; I2 = 0%; 5 RCTs)., Conclusions and Relevance: Randomized data suggest that no differences exist in the risk of substantial intraocular bleeding between NOACs and other antithrombotic drugs. However, the number of events was scarce so that additional studies from larger databases that monitor patients under conditions of ophthalmologic routine clinical practice should be performed to better characterize the safety profile of NOACs.

We present an unusual case of congestion bleeding of the head and neck following myocardial infarction. A 51-year-old man presented with widespread facial petechiae and subconjunctival haemorrhages following a collapse associated with evolving electrocardiographic changes. Emergency coronary artery stent placement was undertaken. No cardiopulmonary resuscitation (CPR) was performed. We hypothesise that the presence of facial petechiae in our case following transient loss of consciousness due to a presumed ventricular arrhythmia in the setting of acute myocardial ischaemia, may have been precipitated by a Valsalva manoeuvre on regaining consciousness with sudden acute increase in venous pressure and consequent venous congestion of the head and neck, and that congestion bleeding of the face may occur in acute cardiac events without a history of CPR.

Introduction: Red Bull Stratos was a commercial program that brought a test parachutist protected by a full pressure suit to 127,852 ft (38,964 m), via a stratospheric balloon with a pressurized capsule, from which he free fell and subsequently parachuted to the ground. In light of the uniqueness of the operation and the medical threats faced, medical protocols specific to distinctive injury patterns were developed. One unique threat was that of a flat spin during free fall with resultant exposure to -Gz (toe-to-head) acceleration. In preparation for stratospheric free fall, the medical team conducted a review of the literature on the spectrum of human and animal injury patterns attributable to -Gz exposures. Based on the findings, an emergency medical field response protocol was developed for the rapid assessment, diagnosis, and treatment of individuals suspected of -Gz injury., Methods: A systematic review was conducted on available literature on human and animal studies involving significant -Gz exposure, with subsequent development of an applicable field treatment protocol., Results: The literature review identified pathophysiologic processes and mitigation strategies that were used to develop a prevention and treatment protocol, outlining appropriate interventions using current best medical practices. A medical field treatment protocol was successfully established for the high-altitude balloon program., Discussion: Available literature provided insight into best medical practices for the prevention and treatment of significant -Gz exposures during high-altitude parachute activity. Using the protocol developed for the field medical response, injuries from sustained -Gz exposure can be effectively managed in similar high-altitude and space operations.

Purpose of Review: To review the most recent literature on the management of the orbit under high pressure (the tight orbit) with threatened visual loss., Recent Findings: Definitive management of traumatic optic neuropathy remains unclear, lacking randomized head-to-head treatment option trials. Instead, numerous case series and anecdotal reports show benefit in each of the four treatment modalities currently in use, but a multitude of variables confound cross-study comparison. In contrast, the management of orbital hemorrhage and orbital emphysema is well known. A number of immunomodulatory protocols have recently arisen for the medical suppression of Graves' ophthalmopathy, but when surgical decompression is required, most authors currently favor a combined transconjunctival and endoscopic endonasal approach., Summary: This article reviews the anatomy, pathophysiology, diagnosis, and intervention of the 'tight orbit' with associated visual loss. Guidelines for the intervention are given.

Purpose: To the best of our knowledge, no large population-based studies on the relationship between conjunctival haemorrhage and stroke have been conducted to date. Using a nationwide population-based data set, this study investigated the relationship between conjunctival haemorrhage and the subsequent risk of stroke within a 3-year period following diagnosis., Methods: We analysed data sourced from the Taiwan Longitudinal Health Insurance Database 2000. The study cohort consisted of 17 349 patients with conjunctival haemorrhage and 86 745 comparison subjects. Each patient was individually tracked for a 3-year period from their index date to identify all those who had subsequently received a diagnosis of stroke., Results:   The incidence rate of stroke was 2.44 (95% CI = 2.31-2.55) per 100 person-years in patients with conjunctival haemorrhage and 1.63 (95% CI = 1.59-1.68) per 100 person-years in comparison patients. After adjusting for patients' monthly income and geographic location, as well as for hypertension, atrial fibrillation, diabetes, hyperlipidaemia and coronary heart disease, stratified Cox proportional hazards regressions revealed a statistically significant hazard ratio for stroke in patients with conjunctival haemorrhage (HR = 1.33; 95% CI = 1.24-1.42, p < 0.001)., Conclusions: In this study, patients with conjunctival haemorrhage were found to be at a significant risk of stroke during a 3-year follow-up period after diagnosis., (© 2012 The Authors. Acta Ophthalmologica © 2012 Acta Ophthalmologica Scandinavica Foundation.)

Purpose: To evaluate the tear film characteristics of spontaneous subconjunctival hemorrhage patients by Schirmer test I and tear interferometry., Methods: Forty-six spontaneous subconjunctival hemorrhage patients and 46 controls were enrolled in the study. Schirmer test I and tear interferometry were performed in all 92 subjects. The results obtained were compared between the two groups., Results: The Schirmer test I value of the spontaneous subconjunctival hemorrhage patients was 6.93 (4.72) mm, and that of the controls was 14.70 (3.70) mm. A statistical difference was found between the two groups (independent samples t test, t=-8.79, p<0.001). The mean rank of the tear interferometry patterns of the spontaneous subconjunctival hemorrhage patients was 50.07, and that of the controls was 42.93. No statistical difference was found between the two groups (Mann-Whitney U test, Z=-1.85, p=0.064)., Conclusions: For the spontaneous subconjunctival hemorrhage patients, the Schirmer test I value was lower than that of the controls, whereas the tear interferometry patterns were comparable to that of the controls.

Objective: Subconjunctival hemorrhage (SCH) is a relatively common disease, but there have been no reports concerning the relationship between SCH and conjunctivochalasis (CCh). We compared the grade of CCh between patients with SCH and control patients., Design: Prospective, nonrandomized study., Participants: A total of 104 patients with SCH aged 41 to 94 years and 120 age- and gender-matched controls aged 41 to 94 years were enrolled., Methods: The conjunctiva was divided into the following 8 equal areas: superior, superior/nasal, nasal, inferior/nasal, inferior, inferior/temporal, temporal, and superior/temporal. The age, gender, medical history, ocular history, site of hemorrhage, grade of CCh at 3 locations (nasal, middle, and temporal), and other parameters of CCh were determined in all subjects., Main Outcome Measures: Grade of each CCh parameter and location of SCH., Results: The mean grade of CCh was higher in patients with SCH than in control patients at the nasal (P<0.00001), middle (P<0.00001), and temporal areas (P<0.00001). The downward gaze- or digital pressure-dependent changes of CCh and the frequency of superficial punctate keratitis were all increased in SCH patients compared with control patients (P<0.00001, P<0.00001, and P = 0.00106, respectively). The number of areas involved by SCH and the presence of SCH in each area were positively correlated with the grade of each CCh-related parameter (P<0.05)., Conclusions: This was the first assessment of the grade of CCh in a large series of consecutive patients with SCH. Our results strongly suggest that CCh may have an important role in the pathogenesis of SCH.

Purpose: To document the clinical features of disc hemorrhage in patients with branch retinal vein occlusion (BRVO) and normal tension glaucoma (NTG), and to evaluate the relationship between BRVO and NTG with disc hemorrhages., Methods: From July 2001 to May 2006, sixteen patients with both NTG and BRVO in different eyes were successively collected from outpatient population of Seoul National University Hospital in this observational case series. The frequency and location of disc hemorrhages, history of associated systemic diseases, and the order of the time of diagnosis between NTG and BRVO were studied., Results: All patients had unilateral BRVO, and their mean age was 63.3+/-10.6 years. Disc hemorrhages were detected in eight patients (50%) during the mean follow-up of 26.8 months (range, 3-96 months). Six patients (75%) had disc hemorrhages in the non-BRVO eyes and two patients (25%) in BRVO eyes. Five hemorrhages (62.5%) were located at inferior-temporal quadrant of the optic disc. History of systemic hypertension was identified in 12 patients (75.0%). In 11 patients (68.8%), NTG was diagnosed at the same time as BRVO., Conclusions: A higher frequency of disc hemorrhages was identified in patients with both BRVO and NTG. Therefore, some cases of NTG, especially with disc hemorrhages, may share a common vascular pathophysiology with BRVO.

Purpose: To determine progression factors at the end of the Early Manifest Glaucoma Trial (EMGT) based on all EMGT patients and evaluate separately patients with higher and lower baseline intraocular pressure (IOP; median split)., Design: Cohort of clinical trial participants., Participants: Patients with early open-angle glaucoma randomized to argon laser trabeculoplasty plus betaxolol (n = 129) or no immediate treatment (n = 126), examined every 3 months for up to 11 years., Methods: Cox proportional hazard analyses, expressed by hazard ratios (HRs) and 95% confidence intervals (CIs)., Main Outcome Measure: Time to progression, defined by perimetric and photographic disc criteria., Results: Overall progression was 67% when follow-up ended (median, 8 years). Treatment approximately halved progression risk (HR, 0.53; 95% CI, 0.39-0.72); results were similar for patients with higher and lower baseline IOP (HRs, 0.41 and 0.55). Baseline progression factors (HRs, 1.51-2.12; P<0.01) were higher IOP, exfoliation, bilateral disease, and older age, as previously reported. New baseline predictors were lower ocular systolic perfusion pressure in all patients (< or =160 mmHg; HR, 1.42; 95% CI, 1.04-1.94), cardiovascular disease history (HR, 2.75; 95% CI, 1.44-5.26) in patients with higher baseline IOP, and lower systolic blood pressure (BP) (< or =125 mmHg; HR, 0.46; 95% CI, 0.21-1.02) in patients with lower baseline IOP. Postbaseline progression factors were IOP levels at follow-up, with 12% to 13% average increase per millimeter of mercury in all patients (HRs, 1.12-1.13 per mmHg higher) and similar results in patients with higher and lower baseline IOP (HRs, 1.15 and 1.13 per mmHg higher). Disc hemorrhages (HR, 1.02; 95% CI, 1.01-1.03 per percent higher frequency) also predicted progression. Thinner central corneal thickness (CCT) (HR, 1.25; 95% CI, 1.01-1.55 per 40 microm lower) was a new significant factor, a result observed in patients with higher baseline IOP (HR, 1.42; 95% CI, 1.05-1.92 per 40 microm lower) but not lower baseline IOP, with significant IOP-CCT interaction., Conclusions: Treatment and follow-up IOP continued to have a marked influence on progression, regardless of baseline IOP. Other significant factors were age, bilaterality, exfoliation, and disc hemorrhages, as previously determined. Lower systolic perfusion pressure, lower systolic BP, and cardiovascular disease history emerged as new predictors, suggesting a vascular role in glaucoma progression. Another new factor was thinner CCT, with results possibly indicating a preferential CCT effect with higher IOP.

Purpose: To investigate the effect of subconjunctival injection of liposome-bound, low-molecular-weight heparin (LMWH) on the absorption rate of subconjunctival hemorrhages., Methods: Subconjunctival hemorrhages were induced in both eyes of 30 rabbits by the subconjunctival injection of 0.1 mL of autologous blood from auricular marginal veins. After 8 hours, randomized subconjunctival injections of one of three materials were made: 5 IU/mL liposome-bound LMWH (0.1 mL) in 18 eyes (group A), only liposomes (0.1 mL) in 14 eyes (group B), the free form of LMWH (5 IU/mL, 0.1 mL) in 14 eyes (group C), or no injection in 14 eyes (group D). Subconjunctival hemorrhages were photographed with a digital camera at 8, 24, 48, 72, 96, and 120 hours after induction of subconjunctival hemorrhages, sized with an image analyzer, and compared between groups., Results: Subconjunctival hemorrhages were absorbed faster in group A (liposome-bound LMWH injected) than in with group B (liposome injected). Comparison of groups A and C (free LMWH injected) showed statistical differences in the absorption rates at 96 and 120 hours except at 24, 48, and 72 hours. The mean elapsed time for the complete resorption of subconjunctival hemorrhages was shortest in group A among four groups, whereas group B and the control showed no significant differences. The ocular and systemic absorption of LMWH were significantly lower after injection of the liposome-bound than the free form., Conclusions: The subconjunctival injection of liposome-bound LMWH appears to enhance subconjunctival hemorrhage absorption in rabbits.

Purpose: To investigate the prevalence and characteristics of optic disc hemorrhages., Materials and Methods: We took IMAGEnet fundus photographs of 14,779 participants, aged 40 years or older in a large-scale eye disease screening project conducted in Tajimi, Japan. A single researcher reviewed all of the photographs for the presence of ocular abnormality in the optic nerve head and retina, paying special attention to the presence or absence of optic disc hemorrhages. Glaucomatous optic neuropathy was diagnosed based on the presence of nerve fiber layer defects and/or the appearance of the optic disc., Results: Fundus photographs of 13,965 cases (27,930 eyes) were successfully reviewed bilaterally. We found disc hemorrhages at 92 locations of 92 (0.3%) eyes of 88 (0.6%) cases. Twenty-four hemorrhages of 23 (26%) cases were found in bilateral non-glaucoma cases and the remaining 68 hemorrhages of 65 (74%) cases were found in glaucoma cases. The prevalence of disc hemorrhages was 8.2% in 793 glaucoma cases and 0.2% in non-glaucoma cases. Hemorrhages developed significantly more frequently in females and in the elderly. The hemorrhages were predominantly found in the inferotemporal and superotemporal regions. The intraocular pressure was less than 20 mm Hg in all cases. The mean intraocular pressure was 15.0 mm Hg for glaucoma cases with hemorrhages and 13.9 mm Hg for non-glaucoma cases with hemorrhages., Conclusion: Disc hemorrhages occur more frequently in females, in elderly persons, and in glaucoma cases in Japanese aged 40 or older. The intraocular pressure of the eyes with disc hemorrhages is close to that of the normal population.

Purpose: To describe the clinical features and to present results of new diagnostic methods to help define the cause of the clinical syndrome of intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage (IHAPSH)., Design: Retrospective review of patients with IHAPSH at presentation seen in 3 centers in Hawaii and Japan., Methods: We analyzed data including patient demographics, presenting symptoms, initial and final visual acuities, biomicroscopic findings, fundus photographs, and results of available ancillary testing, including fluorescein angiography, B-scan ultrasonography, and optical coherence tomography., Results: There were 10 eyes of 9 patients (7 female and 2 male, 8 Asian and 1 white) aged 14 to 79 years. All patients experienced an acute onset of visual symptoms. Eight eyes had mild to severe myopia (-2.50 diopters [D] to -9.50 D), and 8 eyes had a tilted disc. Hemorrhage within the disc and adjacent subretinal hemorrhage were located nasally in 6 eyes, superiorly in 2 eyes, and temporally in 2 eyes. Vitreous hemorrhage was noted in 6 of 10 eyes. Posterior vitreous evaluation by biomicroscopy (10 eyes), by B-scan ultrasonography (4 eyes), and by optical coherence tomography (2 eyes) revealed no evidence of vitreopapillary traction, except for a follow-up optical coherence tomography in 1 eye showing localized vitreoretinal separation with residual attachment to the optic disc 10 months after presentation. Fluorescein angiography showed mild disc staining in 4 of 8 eyes. Hemorrhage spontaneously resolved within 1 to 7 months, and there were no recurrent hemorrhages with an average follow-up of 13.5 months (range, 2-31 months). Visual acuities maintained or improved to 20/25 or better in 8 eyes. The other 2 eyes had unrelated poor vision., Conclusions: Intrapapillary hemorrhage with adjacent peripapillary subretinal hemorrhage is more common in myopic eyes and spontaneously resolves without treatment. The unique structural architecture of the elevated nasal edge of the myopic tilted disc and the choroidal blood supply of the prelaminar optic nerve may predispose patients to bleeding from the optic discs, which may be spontaneous or may be precipitated by acute disc edema, Valsalva maneuver, or vitreopapillary traction.

Aim: To study the visual performance in eyes with interface haemorrhage during laser assisted in situ keratomileusis (LASIK)., Methods: Case records of 20 patients, who had bleeding from the limbal vessels in one eye during LASIK (group 1) and uncomplicated surgery in the fellow eye (group 2) were studied. The parameters evaluated were uncorrected visual acuity (UCVA) best corrected visual acuity (BCVA), spherical equivalent of refraction (SEQ), contrast sensitivity, and glare acuity preoperatively and at 1, 3, and 6 months postoperatively., Results: The mean preoperative SEQ in group 1 and 2 eyes was -5.79 (2.3) D and -5.27 (1.68) D, respectively. The mean decimal UCVA at 6 months after LASIK in group 1 and 2 eyes were 0.6 (0.2) and 1.0 respectively (p<0.001). The mean decimal BCVA at 1 week after LASIK in group 1 and 2 eyes were 0.89 (0.04) and 1.0 respectively (p<0.05). However, all eyes had a BCVA of 6/6 at 1, 3, and 6 months after LASIK. The mean contrast sensitivity values preoperatively in group 1 and 2 eyes were 161.3 (8.7) and 172 (68.2) respectively. There was a significant decrease in group 1 at 6 months (102 (60.5) (p<0.01)) compared to group 2. The decimal glare acuity preoperatively in group 1 and 2 eyes was 0.95 (0.11) and 0.89 (0.12), respectively. It decreased significantly in group 1 (0.7) (0.1 (p<0.01)) compared to group 2 at the 6 month follow up., Conclusion: Occurrence of intraoperative interface haemorrhage may affect the visual performance following LASIK surgery.

Therapy of intraocular traumatic hemorrhage with the new drug hemaz is an important problem of ophthalmic traumatology. Seventy patients (76 eyes) with intraocular hemorrhages of traumatic origin were treated. Forty four patients (44 eyes) presented with hyphemas and 32 (32 eyes) with hemophthalmia. The results of hemaz therapy were compared with those of traditional treatment. The results confirm the high efficacy of hemaz which was well tolerated with sub-conjunctival and parabulbar injection. Indications for the use of this drug in clinical practice were formulated: it is recommended for the treatment of posttraumatic and postoperative hyphemas of any volume, including pupil hyphema, and for partial posttraumatic hemophthalmia.

Purpose: To report a case of intracorneal hematoma occurring in association with Mooren ulceration., Method: Case report., Results: In an 81-year-old man with bilateral Mooren ulceration, a dense intracorneal hemorrhage occurred in the right eye secondary to peripheral corneal neovascularization and was followed by slow resolution over a 3-year period. Following subsequent lamellar and penetrating keratoplasty, histopathologic examination demonstrated the association between the stromal neovascularization and the residual interlamellar hemorrhage, as well as phagocytosis of residual hemosiderin by macrophages., Conclusion: Intracorneal hematoma with spontaneous resolution has been documented clinically and histopathologically in an eye with Mooren ulceration.

Recent publications have suggested that intra-ocular pressure (IOP) may be an indirect assessment of intra-cranial pressure (ICP). Both IOP and ICP have similar physiologic pressure ranges and similar responses to changes in intra-abdominal, intra-thoracic and aortic pressure. Previous studies have demonstrated the relationships between retinal arterial pressure and aortic pressure, intra-ocular pressure and retinal venous pressure, intra-cranial pressure and retinal venous pressure. Power athletes routinely utilize the Valsalva maneuver during weightlifting. In fact there are reports of stroke, cerebral hemorrhage, subarachnoid hemorrhage, conjunctival, foveal and retinal hemorrhage, retinal detachment, hiatal hernia and pneumothorax associated with weightlifting. These events are thought to occur secondary to the extreme pressure elevations that occur in the intra-abdominal, intra-thoracic, intra-cranial, intra-ocular and vascular compartments. To date no human studies have examined the IOP changes that may occur with heavy resistance exercise. Therefore, we recruited power athletes (n = 11), who had participated in prior studies, from the local metropolitan area. The athletes had blood pressure status, drug screening and medical histories performed during previous investigations. Intra-ocular pressure was measured by noncontact tonometry at rest and during maximal isometric contraction. All subjects resting IOP were within normal ranges (mean 13 +/- 2.8 mmHg). Intra-ocular pressures were significantly (p < 0.0001) elevated in each subject during maximal contraction (mean 28 +/- 9.3 mmHg). One subject's IOP reached 46 mmHg during maximal contraction. Linear regression analysis demonstrated a significant linear relationship (r = 0.62, p < 0.0001) in the net change of IOP from rest to maximal contraction for each subject. This study demonstrates that IOP elevates to pathophysiologic levels during resistance exercise. The findings of conjunctival hemorrhages in two subjects further supports IOP being reflective of retinal venous pressure. The enormous pressures generated by power athletes during weightlifting leads to elevations in ICP which obstruct venous outflow leading to hemorrhage and elevations in IOP. The question remains as to whether these intermittent bursts of elevated IOP can lead to long-term pathological sequelae.

The article presents a clinical case of functional recuperation after perforated corneo-scleral wound with partial evisceration of the eye and lens. The authors describe the possibilities of evolution and the surgical modalities for correction of aphakia.

Object: The syndrome of retinal or vitreous hemorrhage in association with subarachnoid hemorrhage (SAH) is known as Terson's syndrome. The authors' purpose was to determine whether intraocular hemorrhage occurs with similar incidence when caused by severe brain injury accompanied by acutely raised intracranial pressure (ICP)., Methods: Prospective ophthalmological examination was performed in 22 consecutive patients with SAH or severe brain injury and elevated ICP. Thirteen patients were admitted for SAH (World Federation of Neurological Surgeons Grades II-IV) and nine for severe brain injury (Glasgow Coma Scale scores 3-10). Monitoring of ICP was performed at the time of admission via a ventricular catheter. Initial ICP exceeded 20 mm Hg in all patients. Indirect ophthalmoscopy without induced mydriasis was performed within the 1st week after the acute event. Retinal or vitreous hemorrhage was seen in six (46%) of 13 patients with SAH and in four (44%) of nine patients with severe brain injury. Ocular bleeding was found bilaterally in three patients with SAH and in one patient with severe brain injury (18%). Six of the 10 patients with Terson's syndrome died as a result of their acute event., Conclusions: The present results indicate that Terson's syndrome may be related to acute elevation of ICP, independent of its causes, and may occur with similar incidence in patients with severe brain injury and those with SAH. Because recognition and treatment of Terson's syndrome may prevent visual impairment and associated secondary damage to the eye, increased awareness of this entity in all patients with acute raised intracranial hypertension is recommended.

Intraorbital hemorrhage may arise spontaneously or following orbital or periorbital surgery or trauma and may be associated with visual loss or impairment. This project was designed to evaluate the ophthalmic effects and underlying mechanism(s) associated with visual impairment secondary to intraorbital hemorrhage. An experimental surgical procedure was developed to simulate intraorbital hemorrhage. A reversible state of unilateral visual loss secondary to acutely increased intraorbital volume was induced and maintained under general anesthesia for either 90, 120, or 180 min duration in nine adult nonhuman primates (NHPs) (Macaca arctoides). Color funduscopic photography, i.v. fluorescein angiography, electrophysiological testing, and tonometry were obtained during baseline, experimental, and follow-up procedures. The globes and optic nerves were obtained for histopathologic evaluation. One of three animals in the 180 min experimental group exhibited clinical and histopathological changes of optic neuropathy 6 weeks after the experimental procedure. Optic neuropathy is one of several proposed etiologies for producing visual loss secondary to intraorbital hemorrhage. This study offers a reliable, safe, and reversible technique to study the effects of acutely increased intraorbital volume in nonhuman primates. The animal model described may be useful for evaluating mechanism(s) involved with visual impairment in other acquired optic neuropathies.

The relationship between the condition of spontaneous subconjunctival haemorrhage (SCH) and hypertension was investigated. Seventy eight patients with SCH and 78 controls with unrelated ophthalmic conditions were compared. Blood pressure (BP) was significantly higher at presentation in the group with SCH at 149 (SD 27)/89 (SD 15) versus 142 (SD 25)/81 (SD 12). The proportion of hypertensives by WHO criteria (systolic blood pressure > 160 and/or diastolic blood pressure >95) was 46% on presentation compared with 23% of the control group. The morphology of the lesion did not influence the association with hypertension although there was a suggestion that the group with raised haemorrhages had a tendency to higher systolic blood pressure. It is recommended that all patients with SCH have their BP checked; this will result in the diagnosis of a significant number of new hypertensives.

Of 111 newborns examined, 33 had subconjunctival hemorrhage (SCHN). Three of 19 patients delivered by cesarean section and 30 of 92 newborns delivered by the vaginal route had SCHN. Perinatal factors including duration of membrane rupture, length of second stage of labor, maternal weight and weight/length ratio, maternal ingestion of anti-inflammatory drugs, gravidity, birth weight, and Apgar score did not differ significantly in the groups with and without SCHN. It is proposed that in the majority of cases SCHN is a consequence of elevated venous pressure in the head and neck produced by compression of the fetal thorax and/or abdomen by uterine contractions. Tight umbilical cord around the neck probably represents an additional mechanism for SCHN.

Three cases of spontaneous expulsive haemorrhage during the year 1990 are presented in this publication. They represent the dramatic outcome of an ulcero-necrotic syndrome of the cornea with disorganization of the anterior segment, which is frequent of tropical areas. Only a few cases have been reported in the literature. The factors related to their development, could contribute to the knowledge of the pathophysiology of expulsive haemorrhages in general. A spontaneous haemorrhage is always a very distressing complication. The treatment consisted in completing the spontaneous evisceration. The means of prevention are tricky. Faced with such a predisposition, an evisceration can be proposed. But, it is not well accepted by the patients.