Margaret Dayan

Effect of prior steroid treatment on temporal artery biopsy findings in 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.

Undergraduate ophthalmology education – A survey of UK medical schools

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.

THE EFFECTIVENESS OF TOPICAL DICLOFENAC IN RELIEVING DISCOMFORT FOLLOWING TRAUMATIC CORNEAL ABRASIONS

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 dicIofenac 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).

Alpha antagonists and intraoperative floppy iris syndrome: A spectrum.

Background 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.

Dysthyroid optic neuropathy: a clinical diagnosis or a definable entity?

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

Quantification of relative afferent pupillary defects induced by posterior sub-Tenon's, peribulbar, and retrobulbar anaesthetics.

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-Tenons, 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.

The role of staphylococcal superantigens in the pathogenesis of marginal keratitis

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.

Fluctuating oculomotor hyperfunction and hypofunction caused by aneurysmal compression of the third cranial nerve.

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 …

Bilateral Non-arteritic Anterior Ischaemic Optic Neuropathy as the Presentation of Systemic Amyloidosis

ABSTRACT 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.

Response to Dr. Pellegrini Regarding Comments on “Bilateral Non-arteritic Anterior Ischaemic Optic Neuropathy as the Presentation of Systemic Amyloidosis”

We thank Dr. Pellegrini and his colleagues for their thoughts and thorough comments and review of the previous literature with regard to the relation of intermediate uveitis with the diagnosis of amyloidosis. We have considered his opinion regarding the possible relation between the initial presentation of “intermediate uveitis” and the later on diagnosis of systemic amyloidosis, hence we reply to the comments. In our case, the patient had previous intermediate uveitis defined as active vitritis and haze and she required systemic immunosuppression for about 6 years. The vitritis had been inactive following the cessation of the systemic therapy for 2 years at the time of presentation with ischaemic optic neuropathy. Indeed, at the time of the optic disc swelling, we examined the vitreous thoroughly to exclude the possibility of the optic disc swelling secondary to inflammation. The vitreous was clear with no haze, opacities or structural changes. The picture was definitely of inactive vitritis, and there were no signs of vitreous involvement with amyloidosis. We believe that these are two separate entities causing initially the intermediate uveitis, followed by the ischaemic optic neuropathy many years thereafter.