No abstract

SUMMARY We present a case of rapid progressive unilateral visual loss in a 69-year-old woman who presented with facial pain, ipsilateral proptosis and restriction of eye movements, and nasal symptoms suggestive of sinusitis. A diagnosis of allergic aspergillus sinusitis was made on the basis of local histopathology and systemic features. Over a three-week period vision deteriorated to bare perception of light but showed a dramatic improvement to a level of 6/9 central vision on systemic steroid therapy. The mechanism of visual failure in the context of allergic aspergillus sinusitis and the therapeutic implications are discussed.

Two cases are presented in which multiple episodic retrobulbar botulinum toxin injections have diminished incapacitating acquired oscillopsia and nystagmus and improved visual acuity. One transient ptosis occurred in six procedures. Improvement duration averaged approximately three months. This is a simple, safe and effective therapy where alternative treatments are typically unsatisfactory.Key words: Botulinum toxin, oscillopsia, retrobulbar injection.Since Scott introduced the use of botulinum toxin A (BTA) in ocular motility disorders,' the toxin has proved effective for a wide variety of neuromuscular conditions in both ophthalmology and neuro10gy.~~~ In particular, many, such as blepharospasm, torticollis, spastic dysphonia and detrusor spasticity, lack acceptable and reliable alternatives for effective treatment. Similarly, incapacitating oscillopsia and nystagmus do not respond well to traditional ocular muscle surgery nor to central nervous system neuromuscular depressants.Helveston has described the use of retrobulbar BTA with encouraging results in the management of acquired nystagmus in two patient^.^ We report its use in a further two patients in the management of oscillopsia, which had significantly reduced their visual acuity. Case ReportsCase 1 A 63-year-old man suffered a pontine haemorrhage which left him with a right gaze palsy and left internuclear ophthalmoplegia (one-and-a-half syndrome), together with downbeat nystagmus more pronounced on the left. This restricted his visual acuity to 6/36 on the right and 6/24 left (there was a degree of cataract more right than left). His best visual acuity was attained with the right eye occluded.Twenty units of BTA in a volume of 0.1 mL of saline was given into the left retrobulbar space using a standard 37 mm, 25 gauge retrobulbar needle. This produced total ophthalmoplegia including complete ptosis within 48 hours of injection. The ptosis resolved completely within a month with good control of the nystagmus. The visual acuity improved to 6/12 + 1 with good subjective improvement. The injections have been repeated five times over a 24-month period. By using a slightly smaller dose (15 units) and aiming to site the injection inferiorly the problem of ptosis has been avoided since the first injection. Although the injections were given inferiorly they did not result in a predominant inferior rectus palsy, the eye tending to lie in approximately the primary position. The right gaze palsy and internuclear ophthalmoplegia persisted. As the effect diminishes visual acuity drops so that with moderate nystagmus the acuity drops to 6/18 and back to 6/24 with severe nystagmus. The patient was thus able to subjectively report when the benefit of the injection had ~~~~~~ ~ ~~ ~~~ ~~~ ~~~ ~

SUMMARYWe report a meta-analysis of randomised, controlled, clinical trials of systemic anti-fibrinolytics in traumatic hyphaema . Outcome measures were rate of secondary haemorrhage and final visual acuity. An estimate of the overall odds ratio for each outcome measure was calcu lated both by combining the logarithms of the odds ratios, and by the Mantel-Haenszel method. The results confirm a beneficial effect of systemic antifibrinolytics on the rate of secondary haemorrhage, but not on final visual acuity.Traumatic hyphaema is a relatively common problem in Meta-analysis is a method of formal statistical analysis of data from several published trials, and may be con sidered to be a more rigorous alternative to narrative liter ature review. It has been widely applied in the social sciences, psychology and medicine, for example to resolve doubts about the role of intravenous streptokinase METHODSPublished trials of anti-fibrinolytic agents in the treatment of traumatic hyphaema were located by searching bio medical computer databases, recent review articles and reference lists of relevant reports. Only those trials which used a prospective, randomised, controlled study design were included in the analysis. Six such publications were found, in four of which the anti-fibrinolytic agent was aminocaproic acid9-1 2 and in two of which it was tranex amic acid. 1 3 , 1 4The following data were extracted from each trial report: The number of patients in both treatment and con trol groups with (1) secondary haemorrhage, (2) final visual acuity of 6/18 or worse, and (3) final visual acuity of 6/60 or worse. Figures for secondary haemorrhage were available in all six reports, but data on visual acuity were not given in one report. 1 3We carried out meta-analysis for the three separate sets of data described by constructing standard 2 x 2 tables, with columns for treated patients and controls, and rows for presence or absence of the outcome. Where zero entries were present for both treated and control groups Tables I to III give the raw data used in the 2 x 2 tables for the three outcome measures: rate of secondary haemor rhage, final visual acuity 6/18 or worse, and final visual acuity 6/60 or worse. RESULTSThe studies used in each meta-analysis and the results

Purpose: To present a case of improvement of ocular motility in a patient with chronic progressive external ophthalmoplegia (CPEO) with Coenzyme Qio Methods: Coenzyme QIO 300 mg daily was given for three years with a three-day trial period of 200 mg daily after one year. Ocular ductions were measured by synoptophore. Results: Ocular ductions improved with treatment with Coenzyme QiaConclusion: Coenzyme Qw, is effective in limiting the severity of ophthalmoplegia in this case.