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Objective: To describe plateau iris syndrome associated with multiple neuroepithelial cysts of the pars plicata. Methods: Case reports of 3 patients with plateau iris syndrome who were found to have multiple bilateral ciliary body cysts on ultrasound biomicroscopic examination. Results: Ultrasound biomicroscopy revealed classic features of plateau iris syndrome in each patient but also showed multiple neuroepithelial cysts of the ciliary body in each eye. Conclusion: Plateau iris syndrome may be associated with multiple ciliary body cysts.

We describe our experience with intrableb autologous blood injection to manage over-filtering and leaking blebs. Autologous blood was injected into 12 thin cystic filtration blebs of 12 eyes. Indications for blood injection included symptomatic hypotony in five eyes, hypotony associated with bleb leakage in five eyes, and bleb leakage without hypotony in two eyes. Seven eyes (58.3%) were classified as successes and five eyes (41.7%) were classified as failures. The mean (+/- SD) follow-up was 6.8 +/- 2.6 months. Among the eyes classified as successes, a significant increase was noted in intraocular pressure and visual acuity by a mean (+/- SD) of 5.1 +/- 2.9 mm Hg and 5.3 +/- 2.1 lines, respectively. Bleb leakage resolved in four of seven eyes. The most common complication was hyphema formation. Injection of autologous blood into a filtration bleb is an alternative procedure for management of excessive filtration or bleb leakage in selected patients.

Objective: To determine race-, age-, gender-, and refractive error—related differences in the size and topography of the optic disc in healthy Americans. Design: Population-based study. Setting: Eastern and southeastern health districts of Baltimore, Md. Participants: A population-based sample of 4877 noninstitutionalized black and white individuals aged 40 years or older without evidence of optic nerve disease. Main Outcome Measure: Race-, age-, gender-, and refractive error—related differences in optic disc measurements: disc area, neural rim area, cup area, cup-to-disc ratio, and neural rim area—to—disc area ratio. Results: We analyzed simultaneous stereoscopic optic disc photographs from 3387 (1534 black and 1853 white) of the 4877 healthy individuals using an image analyzer (Topcon Image Analyzer, Topcon Instrument Corporation, Paramus, NJ). A total of 1490 individuals were excluded owing to the absence of good-quality images from either eye. The image analyzer defined the cup margin 150 μm below the surface of the disc margin. On average, blacks had significantly larger disc areas (blacks, 2.94 mm2; whites, 2.63 mm2), larger cup areas (blacks, 1.04 mm2; whites, 0.71 mm2), larger cup-to-disc ratios (blacks, 0.56; whites, 0.49), similar neural rim areas (blacks, 1.90 mm2; whites, 1.92 mm2), and smaller neural rim area-to—disc area ratios (blacks, 0.66; whites, 0.74) compared with whites. There were no age-related differences in any of the disc measurements. Male subjects had 2% to 3% larger optic discs compared with female subjects. No association between refractive error and any of the optic disc mesurements studied was detected. Conclusions: Racial differences in the normal optic disc are present among urban Americans, and these differences must be considered in evaluation of the optic disc for glaucoma and other optic neuropathies. Among the individuals in our study, all of whom were 40 years of age or older, no progressive age-related decline in neural rim area was detectable. Neither gender nor refractive error were associated with any significant differences in the size and topography of the normal optic disc.

• To our knowledge, this is the first histopathologic report of skin eruptions due to oral methazolamide. From the four cases studied, we conclude that there are at least two histopathologic types: one is characterized by perivascular lymphocytic infiltrate with a vacuolar alteration at the dermoepidermal junction, the other by perivascular eosinophils, lymphocytes, and scattered mast cells. There also seem to be at least two patterns of skin eruptions: one maculopapular and the other urticarial. The type of skin eruption and the histopathologic type appear to be related.

To the Editor. —We read the timely article by Sharma and coworkers 1 of nine cases of Acanthamoeba keratitis in non-contact lens wearers in India during a 2-year period. We fully agree with the authors that the diagnosis of Acanthamoeba keratitis may be unduly delayed if the clinician fails to consider risk factors other than contact lens wear, ie, foreign-body injuries to the cornea and contact with contaminated water. 2 There is very little reason to believe Acanthamoeba keratitis in non-contact lens wearers is a new phenomenon; it is more likely that many of these cases were missed in the past. Only now are we able to appreciate the true incidence of Acanthamoeba keratitis in non-contact lens wearers, owing to a combination of heightened awareness, better clinical diagnostic criteria, and improved laboratory studies. See also p 471. In our own 2-year experience, three of 12 cases of culture-proven Acanthamoeba ulcerative

To the Editor. —I found especially interesting Flynn and Brod's 1 letter in theArchiveson protection from operating microscope-induced retinal phototoxicity during pars plana vitrectomy. Retinal phototoxicity is of special importance in patients with glaucoma. It matters relatively little, and probably not at all from a functional point of view, when an individual with a normal complement of retinal receptors and appropriate connections to the geniculate body has a small percentage of neuronal elements temporarily or even permanently damaged. However, in the patients with far-advanced glaucoma, who may have only a tiny percent of their neurons remaining, often concentrated in the macular area, damage or death of five to ten thousand neurons may represent a devastating loss. My colleagues and I have had one patient with far-advanced glaucoma experience a diminution of visual acuity from 6/9 to 6/15, following photography of his optic discs. Some of the loss of

• Scanning and transmission electron microscopy were performed on peripheral iridectomy specimens from seven patients with failed pulsed argon laser iridotomies. Four to seven hours after the laser, severe edema, coagulation necrosis, focal vascular occlusion, and hemorrhage were present. Five days after the laser, cell detritus and collapsed cell processes were noted. Forty-two days after the laser, the anterior iris surface appeared considerably thinned and irregular. Eight and one-half months after the laser, the burn site displayed a dense matted appearance. Two years after the laser, the anterior iris showed a depression with pigment dispersion, irregular stroma, and disruption of the dilator muscle. The lack of inflammation could be due to the use of pulsed argon laser heat delivered at very short intervals, with deep penetration and minimal heat dispersion, since the beam is highly collimated.

The optic nerves of 34 eyes of 34 patients with low-tension glaucoma were compared with those of 41 eyes of 41 patients with high-tension glaucoma. Mean intraocular pressure in the low-tension group was 16.9 +/- 0.7 mm Hg (mean +/- SEM) compared with 31.7 +/- 0.8 mm Hg in the high-tension group. Mean total visual field loss was not significantly different in the two groups, as determined by computerized threshold perimetry (OCTOPUS). The optic disc rim in low-tension eyes was significantly thinner than in high-tension eyes (P = .018); the largest difference occurred inferiorly and inferotemporally (P less than .001). The appearance of the optic nerve is useful to distinguish between these two subtypes of glaucoma and may be a more meaningful indicator than intraocular pressure. Our findings support the hypothesis that there are at least two different mechanisms for optic nerve damage in glaucoma.

A discussion of malignancy of the lacrimal sac is disregarded almost entirely in textbooks on pathology, regardless of whether these be on general pathology or related wholly to ophthalmic pathology. One such textbook states: "Carcinoma of the tear sac is rarely primary, usually secondary, infiltrative from the paranasal sinus, and may also appear as adenocarcinoma." In contradistinction, I have never found a certain secondary carcinoma; all were primary, and none arose from the nasal accessory sinuses. Extension from the lacrimal sac to the sinuses is the common sequence, never the opposite. One can hardly consider a case to be malignancy of the lacrimal sac when this is a part of tremendous orbital and periorbital extension, originating elsewhere. If it were not for Duke-Elder's 1 consideration of this subject, one might think the condition rare. I have had, up to this present moment, seven cases of malignancy of the lacrimal sac.

Unilateral exophthalmos is not of necessity similar etiologically to the bilateral condition. There is no doubt that many unilateral exophthalmic conditions may be simply incomplete, in terms of bilateral involvement seen in cases of exophthalmic goiter. It is just as true, however, that in many cases the primary characteristic is unilateral displacement of the eyeball. Involvement of the opposite side would be in such cases secondary and not consequent. Perhaps the best example of such instances is a case of neurofibromatosis. It seems as though unilateral exophthalmos is properly considered a definite clinical entity in a large number of instances. Even in cases of unilateral exophthalmos associated with exophthalmic goiter this condition, in my experience, presents various signs less commonly seen in cases of the bilateral variety. There is no certain reason why exophthalmos should at times be almost purely unilateral, but the fact stands that

In this review regarding the surgical correction of retinal separation certain factors are considered which must be of etiologic importance, judging from the successes and failures resulting from present day operations. They are presented without any attempt at correlation save their apparent pertinence. It is even impossible to estimate the relative importance of some of these various factors, one as compared with the other. The only certainty is that all are relevant. HISTORY The modern treatment of separation of the retina is perhaps the outstanding single advance in ophthalmology within the present generation. Even this period, relatively short as it is, is definitely narrowed, in that the earliest article which initiated the recent research (and the tremendous strides which have been achieved) is that by Verhoeff 1 in 1917. From this time until Larsson's 2 work in 1928 and in 1930, Vogt's 3 in 1929, Sourdille's 4

I have had under observation an interesting case of swelling of the nerve heads associated with arachnoiditis and with unusual changes in the visual fields. REPORT OF A CASE A man, aged 41, was referred to me for refraction a little more than twentyfour months ago. At that time he gave a history of migraine which had been present for nineteen years, the attacks averaging two a month and always being accompanied by intense pain in the head, by nausea and by prostration. The pain was so severe that repeated doses of morphine were necessary. He had acquired considerable tolerance for this drug, and large doses were necessary for relief ; he did not, however, use morphine except during the attacks. Corrected vision was 6/5 in the right eye and 6/15 in the left. The left eye showed an old paralysis of the inferior rectus muscle, for which he had

Recession of the anterior chamber angle was present in 60% of 43 patients who had traumatic hyphema three or four years previously. Average intraocular pressure of traumatized eyes did not differ significantly from that of nontraumatized eyes. On the other hand, pressure in eyes with angle recession was significantly higher than in those without recession (16.4 mm Hg vs 13.6). Moreover, intraocular pressure in nontraumatized eyes of patients with angle recession in their traumatized eyes was higher than in nontraumatized eyes of patients without recession in their traumatized eyes. Topical dexamethasone caused an increase in pressure as follows: (1) greatest in eyes with angle recession (8.8 mm Hg), (2) next largest in nontraumatized eyes of patients with recession in their traumatized eyes (7.6 mm Hg), (3) smaller in traumatized eyes without recession (5.6 mm Hg), and (4) smallest in nontraumatized eyes of patients without angle recession in their traumatized eye (4.1 mm Hg). Responsiveness of eyes to the hypertensive effect of topical corticosteroids may not be determined solely by genetic factors.

DEFECTIVE abduction is the result of various conditions having little in common other than a limitation in abduction. For this reason, it is evident that these various conditions are nonconcomitant. They have therefore few, if any, of the various causes of concomitant strabismus. In all cases the defective abduction is the result of a peripheral orbital defect, i. e., neuromuscular, of the muscle alone, or of the muscle and the fascia, or is due to a pathological condition of the central nervous system, i. e., congenital (perhaps developmental), disease of the central nervous system, trauma, or neoplasm. Three of the defects to be considered are usually spoken of as congenital. These are the Duane retraction syndrome, strabismus fixus, and so-called congenital sixth nerve paralysis. A fourth, to be discussed, is an acquired, or permanent, form of sixth nerve paralysis. THE RETRACTION SYNDROME The retraction syndrome is an interesting syndrome, or

Four Negro patients who have Oguchi's disease are presented. All patients are members of the same family. The family history and the clinical and fluorescein angiographic findings are described. Mizuo's phenomenon is demonstrated and a possible defect in pigment epithelium is described. To the best of our knowledge, this is the first reported occurrence of Oguchi's Disease in Negroes.

In discussing the function of visual acuity one is inclined to speak at times too casually of perception of light, of color vision and of perception and identification of form. One may fail, however, except when under the necessity of considering details of retinal physiology, to differentiate retinal function into that which is purely ocular and that which is neurocentral, even of a subcortical nature. Thus, one is vague and indecisive in separating retinal sensitivity and response into certain stages : the first, that of primitive perception ; the second, that wherein there is an integration of recepts of a more highly discriminative pattern in which qualitative as well as quantitative details of the constituent sensations carry into consciousness factors such as attention and awareness, the third, a "learning by experience" stage. The first stage can be called a dyscritic stage; it is a purely primitive one wherein no discrimination or

The differential diagnosis of these two allied conditions, the ocular manifestations of hysteria and of ocular malingering, cannot be covered in a comparative review by a mere cataloging of facts, of more or less authoritative statements and of clinical observations, not to mention various theories and deductions. Even a bibliography must be given with an apology; it cannot be outlined with meticulous detail. The literature is voluminous, and the ramifications of allied interests are extensive. Also, this review is not a dissertation on the ocular manifestations of hysteria, save for its application to the second condition. De Schweinitz has long since covered hysteria in a complete manner, but little else can be said on the subject. An attempt will be made first to differentiate one from the other by an understanding of each, and then to compare the conditions as two definite pathologic entities. The various tests for the