Unifocal, unisystem LCH often presents to the ophthalmologist and can usually be diagnosed on clinical and imaging grounds. Computed tomography and magnetic resonance imaging are complementary imaging studies. Biopsy is essential to confirm diagnosis. Unifocal, unisystem disease can be treated with local excision and curettage. Incomplete excision, recurrent disease or multifocal disease may require systemic chemotherapy.

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The features and management of two adult patients with ophthalmoplegic migraine and longlasting sixth nerve palsies are described. Both had had previous shorter episodes of diplopia following migraine-like headaches. One recovered following an injection of botulinum toxin to the medial rectus of her affected eye 11 months after the onset of diplopia. The other patient had previously had surgery for a consecutive divergent squint and required further squint surgery to realign his eyes 1 year after the onset of his sixth nerve palsy. Both botulinum toxin and squint surgery may be useful in the management of longstanding sixth nerve palsy in patients with ophthalmoplegic migraine. The aetiology of ophthalmoplegic migraine is discussed.

Botulinum toxin appears to have a role in the treatment of secondary strabismus, since only 3% (14) failed to obtain any reduction in their angle. It was well tolerated, with no permanent side effects. Only 22 (4%) patients developed ptosis.

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