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There is increasing evidence and appreciation of idiopathic intracranial hypertension (IIH) in medicine. The pathological processes underlying raised intracranial pressure are being studied, with new insights found in both hormonal dysregulation and the metabolic neuroendocrine axis. These will potentially lead to novel therapeutic targets for IIH. The first consensus guidelines have been published on the investigation and management of adult IIH, and the International Headache Society criteria for headache attributable to IIH have been modified to reflect our evolving understanding of IIH. Randomized clinical trials have been published, and a number of studies in this disease area are ongoing.

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.

Changes in the UK undergraduate medical curriculum mean that a clinical placement in ophthalmology is no longer a requirement. An ophthalmic assessment is necessary for a full physical examination and failure to elicit and interpret signs could mean missing sight and life-threatening pathology. This study was to investigate current undergraduate ophthalmology teaching. An email questionnaire, about the content and delivery of the ophthalmology teaching, was sent to each UK medical school in 2007/2008. The response rate was 83%. Nineteen (79%) medical schools had a compulsory attachment to the ophthalmology department with an average length of 7.6 days (range 3.5-15 days). There was variation as to how ophthalmology was included in the curriculum. Teaching methods and standards also varied. Finally, assessments ranged from formal written and practical exams in some medical schools to informal or non-existent ones in others. The most striking finding was the variation in ophthalmology education a student may receive, with some students receiving none. It is necessary to improve the profile of ophthalmology and ensure that all students achieve a minimum basic standard.

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.

Previous studies have demonstrated an increased incidence of delayed-type hypersensitivity to staphylococcal antigens in patients with blepharitis, but this does not predict subsequent development of marginal keratitis (MK). Superantigens are potent immune-modifying molecules produced by pathogenic organisms including Staphylococcus aureus. To study whether staphylococcal superantigens play a role in the development of MK, conjunctival and lid margin cultures were taken from 26 subjects with MK and 24 controls. Four of 8 eyes with their first episode of MK grew strains of S. aureus, of which only one was superantigen-producing. None of the subjects with recurrent MK and only one control grew S. aureus. We conclude that staphylococcal superantigens are unlikely to play a central role in the development of MK. The absence of S. aureus on the lids of subjects with recurrent MK may reflect an alteration in lid flora due to previous topical antibiotic and steroid treatment.

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 …

Purpose. The aim of the study was to determine whether patients presenting with an isolated posterior vitreous detachment require follow-up to identify retinal breaks not apparent at presentation and whether some histories are more predictive of associated serious posterior segment pathology. Methods. The notes of 295 patients presenting to eye casualty with flashes and/or floaters were reviewed. Results. One hundred and eighty-nine patients (64%) had isolated posterior vitreous detachments, 49 (16.6%) had retinal detachments and 31 (10.5%) had flat retinal tears. Three new breaks (3.3% of all tears found, 1.9% of review appointments) were identified only at follow-up. Although a subjective reduction in vision and a history of less than 6 weeks' duration were strongly predictive of retinal breaks, the large group of patients presenting with floaters alone (124/295, 42%) still harboured a significant proportion (26.7%) of the retinal breaks. Conclusions. A follow-up visit for patients with an isolated posterior vitreous detachment can be justified to detect the small percentage of asymptomatic retinal breaks. Although a subjective reduction of vision is the symptom most predictive of serious posterior segment pathology, it would be unsafe to identify particular subgroups of patients alone for careful examination.

Giant cell arteritis is a common condition that can result in permanent visual loss. It has traditionally been diagnosed by invasive temporal artery biopsy in cases of clinical suspicion. The findings of colour duplex ultrasound have recently been described. We report the use of duplex ultrasound to diagnose temporal arteritis, with clinicopathological correlation, and discuss the possible application of this non-invasive technique to the management of giant cell arteritis.

Aim: To examine the effect of up to 6 weeks of corticosteroid treatment on the positive temporal artery biopsy rate in giant cell arteritis (GCA). Methods: Prospective comparative clinical study of 11 patients meeting the American College of Rheumatology criteria for diagnosis of GCA. Patients underwent temporal artery biopsy within 1 week, at 2–3 weeks, or after 4 weeks of corticosteroid treatment. Results: Overall, nine of 11 (82%) patients had positive temporal artery biopsies. Six of seven (86%) biopsies performed after 4 or more weeks of steroid treatment were positive. Conclusion: Temporal artery biopsy is useful several weeks after institution of steroids.

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.

At some point in their career most ophthalmologists will face the problem of a patient with unexplained visual loss and an empty sella turcica on neuro-imaging. Should the visual loss be ascribed to empty sella syndrome, or should the empty sella be considered a coincidental finding and other pathology sought? There have been many case reports and a few reviews 1-26 discussing empty sella and its possible role in the pathogenesis of visual loss. However, most of these date from the era of pneumoen cephalography or CT scanning and the spectrum of patients is probably different from that seen today with the advent of magnetic resonance imaging (MRI) of the anterior visual pathway. The appearance of empty sella on neuro­ imaging is due to partial or total loss of pituitary tissue, enlargement of the sella turcica or both. A primary or idiopathic empty sella (PES) is thought to be due to an incompetent diaphragm sellae, which has been shown to be present in 10% of an autopsy series.2 The defect in the diaphragm allows arachnoid to herniate through the opening compressing the pituitary gland and eroding the floor of the sella. This is consistent with the reported association between PES and pseudotumour cerebri?,17 The defect in the diaphragm may allow the increased intracranial pressure to force an arachnoid diverticulum through the pre­ existing defect compressing the pituitary and eroding the sella floor. In this setting PES may be reversible if intracranial pressure

The diagnosis of DON should be made correctly; those affected should be treated promptly and those unaffected spared the risks associated with treatment.

Perioptic neuritis caused by secondary syphilis is a rare ophthalmic manifestation in the HIV-infected host. Early diagnosis and treatment of this condition is required to prevent further visual damage. We report a case of unilateral syphilitic perioptic neuritis in a patient coinfected with HIV-1.

Diclofenac is a non-steroidal anti-inflammatory drug available in an ophthalmic preparation. We present a prospective randomised double-masked placebo-controlled trial involving 40 patients that assessed the effectiveness of topical diclofenac in relieving pain from traumatic corneal abrasions. Statistical analysis of visual analogue and categorical pain scores revealed a significant reduction in pain experienced by subjects in the diclofenac group (p < 0.02).

Approximately 6% of general practitioners have worked in ophthalmology but to our knowledge the relevance of this training has not previously been evaluated.We sent an anonymous questionnaire to all doctors who had held general practitioner registrar (vocational training) posts in ophthalmology in the Northern Region during a 5-year period (1989-1994).Twenty-six of 48 (54%) questionnaires were returned. Twenty-five of 26 respondents (96%) thought the training was useful, with 22 (91.7%) continuing to use some ophthalmic practical skills and 17 (65.4%) said they had received adequate and relevant clinical exposure. Twenty-one (87.5%) of those in general practice felt that they were more confident with eye problems than their peers and 12 (50%) said their referral patterns differed. Eleven (46%) had provided advice for colleagues. However, 9 (34.6%) commented on the large service commitment and 5 (19%) felt that supervision had been inadequate. Only 9 (34.6%) had received relevant teaching and 18 (69%) thought more was necessary.We conclude that general practitioner registrar posts in ophthalmology are useful and rewarding but that there is scope for improvement.

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.

Editor, G iant cell arteritis (GCA) is a neuro-ophthalmological emergency given the risk of permanent, severe visual loss if left untreated (Hayreh et al. 1998a). We present a rare case of biopsy-proven GCA with normal inflammatory markers at first presentation. A 74-year-old woman was referred to us with a 2 month history of rightsided temporal headaches. She had no relevant past medical history but her sister suffered from polymyalgia rheumatica. The headaches occurred almost daily and often lasted several hours. She reported no visual symptoms, jaw claudication or other classical symptoms of polymyalgia rheumatica or GCA. Her Snellen visual acuity was 6 ⁄ 6 in both eyes and ocular examination was entirely normal. Her temporal arteries on both sides were pulsatile, non-tender and normal in appearance. Inflammatory markers were requested to rule out GCA; these were normal, with an erythrocyte sedimentation rate (ESR) of 30 mm ⁄hr and a C-reactive protein (CRP)

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 …