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A 50-year-old Caucasian woman presented with an acute decrease in vision in her right eye that deteriorated over approximately 48 h. Visual acuity was counting fingers from 1 foot on the right and 20/80 on the left. There were nuclear cataracts in both eyes. The right fundus demonstrated retinal oedema, cherry-red spot and 'kickboxing' of the retinal arterial flow. The left fundus appeared normal. Since the symptoms had been present for a little less than 48 h the patient was treated with ocular massage, sub-lingual isosorbide dinitrate, intravenous acetazolamide 500 mg, parenteral glycerol 50% 1 mg/kg, anterior chamber paracentesis, retrobulbar tolazoline and intravenous methylprednisolone 500 mg followed by streptokinase 750 000 units, but vision remained unchanged. Concomitantly, she was treated with coumadin 2.5 mg/ day. Two years earlier the patient had been diagnosed as having primary antiphospholipid syndrome. She suffered from systemic hypertension, chronic renal failure, deep vein thrombosis, ulcus cruris, thrombocytopenia, seizure disorder and had a history of

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Aims-To determine the relation between pH of anaesthetic solutions and patient perception of pain with peribulbar injection of local anaesthesia. Methods-This prospective randomised controlled double blind pilot study involved 60 consecutive patients who received a peribulbar block with either a standard acidic local anaesthetic of 5 ml 2% lignocaine and 5 ml of 0.5% bupivacaine (solution A), or an alkalinised solution composed of the same anaesthetic agents but with a pH of 7.44 (solution B). Before surgery patients were asked to grade the pain of both the preoperative dilating drops and the peribulbar injection using a visual analogue scale. Results-The mean pain scores were similar in the two treatment groupsslightly higher (4.97) in group B who received the buVered solution, compared with group A (4.84) who received the plain solution. The small diVerence (−0.13, 95% confidence limits −1.6 and +1.3) was not significant. There was, however, a highly significant association between pain threshold ("drop pain") and injection pain levels (p<0.0001). Conclusion-This study showed no diVerence in the reduction in the pain experienced by patients undergoing peribulbar anaesthesia with pH buVered local anaesthetic. The study suggests the importance of "pain threshold" as a confounder and also showed the considerable pain felt by some patients on instillation of the preoperative dilating drops. (Br J Ophthalmol