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Leber's hereditary optic neuropathy (LHON) is an inherited condition leading to bilateral centrocaecal scotoma. Phosphodiesterase type-5 (PDE5) inhibitors such as tadalafil are widely used for male erectile dysfunction. We present a case of a middle-aged male whose LHON presented acutely following tadalafil use. It is postulated that this is due to alteration in the optic nerve head perfusion.

Sir, Intravascular papillary endothelial hyperplasia (IPEH) mimicking a lacrimal sac massA patient with epiphora and a medial canthus mass below the medial canthal tendon most often has a lacrimal sac mucocoele. We present the case of a woman with epiphora and a painless medial canthal swelling who had an exogenous benign vascular tumour anterior to the lacrimal sac. We discuss the differential diagnosis of medial canthal masses. Case reportA 59-year-old woman presented with a 16-month history of right epiphora, more marked than on the left. She had a non-reducible mass below the right medial canthal tendon. This was non-tender, firm and rounded and it seemed to arise from the lacrimal fossa. The overlying soft tissue was normal, with no signs of inflammation.

To date, there have been only six cases of eyelid EPC reported in the literature. EPC has significant risk of recurrence and metastases after local excision. It is therefore important to consider it in the differential diagnosis of malignant eyelid tumour. A histological diagnosis should prompt wide margin excision, assessment of the patient for regional lymph node involvement, and imaging for metastatic disease.