This technique is recommended as a safe and effective method of treating bleb encapsulation.

Botulinum toxin inhibits acetylcholine release and therefore could cause mydriasis. We report a case of acute angle-closure glaucoma which occurred shortly after a series of injections of botulinum toxin round the eyelids for blepharospasm. 16 November 1989 TECHNIQUE 0 05 mg of freeze-dried botulinum toxinhaemagglutin complex (0-008 mg neurotoxin) was reconstituted with 1 ml of sterile saline and then diluted in a further 9 ml of saline.3 A 0 5 ml syringe with a 0-36 mmx 12-7 mm needle was used. Four injections of 0-1 ml or 0-15 ml were given subcutaneously round each eye, two immediately above each eyebrow and two a similar distance below the eye.Initially she received two 0'15 ml injections above each eye and two 0 -ml injections below each eye, with good relief from blepharospasm and no side effects. Thirteen weeks later blepharospasm had recurred on the right but not on the left. She received two injections of 0-1 ml of toxin above each eye.Three hours later she developed an ache about her left eye, and within six hours this had become severe and was associated with blurred vision in the left eye, nausea, and vomiting. Despite her severe symptoms she did not seek medical help for her eye condition for a further three days. On examination at the eye casualty department the visual acuity was 6/36 in her right eye and perception of light in her left eye. The conjunctiva and episclera of her left eye were inflamed and the cornea was oedematous.

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Cogan's syndrome is characterized by a non-luetic interstitial keratitis associated with vertigo, tinnitus and profound deafness. Evidence of a systemic vasculitis is found in up to 50% of patients. Atypical forms of Cogan's syndrome have been described in which the ocular inflammatory disease may be more severe. We describe a case of atypical Cogan's syndrome in association with bilateral posterior scleritis. Serial B-scan ultrasound measurements of posterior scleral thickness were found to be useful in assessing disease activity, in combination with clinical findings. Combination therapy with prednisolone and cyclosporin controlled the ocular disease but the deafness was irreversible. The length of follow-up of this case highlights the frequent relapses and difficult management problems which may be faced. This multisystem disease requires the close co-operation of ophthalmologist, physician and otorhinolaryngologist. Aggressive therapeutic intervention with high-dose combined immunosuppressive agents may be necessary to control severe ocular inflammatory disease.

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