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I read with interest the article by Drs Olson and Putterman. 1 In the discussion of their article they stated, "Unlike other investigators, we believe that frontalis muscle use is enlisted in downgaze... " in reference to my article. 2 They seem to imply that I do not believe that the frontalis muscle is used in patients with ptosis or in downgaze. I am puzzled as to why they state this, since I certainly did not make this statement anywhere in the article to which they refer. The concept of patients with ptosis using the frontalis muscle to elevate the eyelids is well documented and indeed the basis for ptosis repair with a sling. In my article, which is the first description of ptosis appearing in downgaze only, all measurements were made without the use of the frontalis muscle so as to study the effect of the only levator muscle on

Objective. —To assess the safety and efficacy of optic nerve decompression surgery compared with careful follow-up alone in patients with nonarteritic anterior ischemic optic neuropathy (NAION). Design. —The Ischemic Optic Neuropathy Decompression Trial (IONDT) is a randomized, single-masked, multicenter trial. Setting. —Twenty-five US clinical centers. Participants. —The IONDT ceased recruitment on October 20, 1994, on the recommendation of its Data and Safety Monitoring Committee. The preliminary results presented herein are based on data as of September 8,1994, from 244 patients with NAION and visual acuity of 20/64 or worse. One hundred twenty-five patients had been randomized to careful follow-up, and 119 had been randomized to surgery, with 91 and 95, respectively, having completed 6 months of follow-up. Intervention. —Patients in the surgery group received optic nerve decompression surgery and follow-up ophthalmologic examinations; those in the careful follow-up group received ophthalmologic examinations at the same times as the surgery group. Main Outcome Measures. —Gain or loss of three or more lines of visual acuity on the New York Lighthouse chart at 6 months after randomization, as measured by a technician masked to treatment assignment. Results. —Patients assigned to surgery did no better when compared with patients assigned to careful follow-up regarding improved visual acuity of three or more lines at 6 months: 32.6% of the surgery group improved compared with 42.7% of the careful follow-up group. The odds ratio (OR) for three or more lines better, adjusted for baseline visual acuity and diabetes, was 0.74 (95% confidence interval [CI], 0.39 to 1.38). Patients receiving surgery had a significantly greater risk of losing three or more lines of vision at 6 months: 23.9% in the surgery group worsened compared with 12.4% in the careful follow-up group. The 6-month adjusted OR for three or more lines worse was 1.96 (95% CI, 0.87 to 4.41). No difference in treatment effect was observed between patients with progressive NAION and all others. Conclusion. —Results from the IONDT indicate that optic nerve decompression surgery for NAION is not effective, may be harmful, and should be abandoned. The spontaneous improvement rate is better than previously reported. ( JAMA . 1995;273:625-632)

When considering a diagnosis of periorbital cellulitis, findings of a systemic evaluation of the patient must be taken into account. Although leukemia is characterized by infiltration of bone marrow and blood with immature leukocytes, other organs may be involved, including the skin. We describe a patient with acute myeloblastic leukemia who clinically appeared to have periorbital cellulitis. Report of a Case. —An 85-year-old man was evaluated for bilateral periorbital edema and erythema that had been present for 2 weeks. His past history included multiple myeloma diagnosed 3 years earlier. Three months prior to evaluation, he developed myelodysplastic syndrome, which was treated with chemotherapeutic agents and corticosteroids. The patient had refractory anemia and within 2 weeks prior to evaluation was found to have excess blasts in his peripheral blood consistent with acute myeloblastic leukemia. The patient was initially treated with systemic ciprofloxacin hydrochloride for presumed infectious periorbital cellulitis and failed to