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Purpose: To investigate visual function in adults post hemispherectomy in childhood., Design: Noncomparative case series., Methods: All participants underwent visual acuity, binocular function, visual field, optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL), and monocular pattern reversal visually evoked potentials (prVEP)., Participants: Six adults who had a hemispherectomy in childhood (median 21.5 years postoperative)., Main Outcome Measures: Comparison was made of visual acuity, visual field height, global RNFL thickness, and prVEP amplitude evoked by full- and half-field stimulation. Comparison of the eye ipsilateral to the side of surgery to the contralateral eye was achieved employing paired t tests to the visual function measures., Results: All participants had homonymous hemianopia. The residual seeing visual field was constricted in all cases when compared with normative data despite crossing the midline into the blind hemifield in 11 of 12 eyes. This observation was supported by prVEP to stimuli presented in the blind half field. The height of the visual field was smaller in the eye contralateral to the side of surgery compared with the ipsilateral side (P = .047). Visual acuity and RNFL thickness also showed greater diminution in the contralateral eye (P = .040 and P = .0004). Divergent strabismus was found in 4 participants with greater field loss., Conclusions: Adults post hemispherectomy in childhood may have better visual function in the eye ipsilateral to the side of the hemispherectomy compared with the contralateral eye. Possible mechanisms of the interocular difference are discussed. Though visual fields and prVEP responses demonstrate evidence of reorganization into the blind half field, they also reveal significant unexpected constriction of the functional field., (Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.)

Purpose: To measure visual acuity (VA) outcomes, complication rates, and the social impact of cataract surgery in a cohort who underwent surgery as children in Bangladesh., Design: Case series., Participants: A total of 471 of 850 children from 6 Bangladeshi districts who had been identified as cataract blind using key informants (KIs) between 2004 and 2009 during the Bangladesh Childhood Cataract Campaign (BCCC) together with all those children not included in the BCCC database but in the Child Sight Foundation (CSF) database who had been identified as cataract blind., Methods: The subjects and families were contacted again by KIs and transported to local examination centers, where parents and subjects were administered a questionnaire and subjects underwent full ocular examination. Where operative data were available (15%), they were analyzed in conjunction with questionnaire and examination findings. Statistical analysis was performed using SPSS Statistics (IBM, Armonk, NY)., Main Outcome Measures: Presenting and best-corrected visual acuities (BCVAs), cause(s) of poor outcome, postoperative refraction, and school attendance., Results: A total of 407 of the participants had undergone bilateral surgery as children, with a mean follow-up of 8.8 years. The mean age at examination was 16 years (range, 5-28 years; standard deviation [SD], 4.6 years); 63% of those examined were male; 22% had a binocular presenting VA of >20/60; and 53% were severely visually impaired or blind (VA <20/200). After refraction, 33% had VA >20/60 in their better eye and 33% had VA <20/200. Factors that predicted poor VA in multivariate logistic regression analysis were nystagmus (P < 0.001), longer delay in presentation (P < 0.001), and magnitude of absolute spherical equivalent refractive error (P<0.001). Some 50% had nystagmus, and 69% of those currently aged ≤16 years were attending school. Better acuity was associated with school attendance (P < 0.001), whereas gender was not., Conclusions: Approximately one third of all participants had a BCVA of ≥20/60 in their better eye. Amblyopia and nystagmus limited visual outcome, indicating the need for earlier detection and treatment. This is the first study to show the link between pediatric cataract outcome and access to education, a millennium development goal., (Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Therapeutic plasma exchange (TPE) without plasma replacement results in coagulation factor removal. Warfarin decreases the activity of vitamin K dependent coagulation factors. The combined effect of TPE and warfarin on the coagulation system has not been studied. A prospective, observational study was conducted in patients undergoing TPE while on warfarin. One plasma volume TPEs were performed on the COBE Spectra Apheresis System (Terumo BCT, Lakewood, CO) with 5% albumin. International normalized ratio (INR), fibrinogen, and factor II activity were obtained pre and post procedure. Eight patients underwent 121 TPEs that met study criteria with pre and post data. The average pre values were INR 2.09 ± 0.58, fibrinogen 263 ± 76 mg/dl, and factor II 29 ± 16% and the average post values were INR 4.12 ± 1.44, fibrinogen 105 ± 31 mg/dl, and factor II 13 ± 7%. The pre-INR was ≥2.00 for 55% of TPEs. The pre value (Y0 ) predicts the post value (Y) by the following equations Y = -0.54 + 2.21Y0 , Y =12.10 + 0.35Y0, and Y =1.83 + 0.39Y0 for INR, fibrinogen, and factor II respectively. In conclusion, pre procedure laboratory values can predict the post laboratory values for patients on warfarin receiving single plasma volume TPE with albumin replacement. The post-INR is approximately twice the pre-INR. At normal and mildly elevated pre-INR, the effect of TPE on the INR is less marked. A single plasma volume TPE decreases the plasma level by ∼65% for fibrinogen and 60% for factor II., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: For patients with thrombocytopenia without bleeding risk factors, a platelet transfusion trigger of 10 × 10(9) /L is recommended. No studies have evaluated the clinicians' decision-making process leading to trigger changes., Study Design and Methods: We report on the evaluation of trigger changes and the relation with bleeding. Eighty patients previously enrolled in the SPRINT trial represent the patient population for the current analysis., Results: Seventy-four patients had a starting trigger of 10 × 10(9) /L. Only a minority of patients treated with chemotherapy alone (3/12, 25%) and autologous transplant (6/15, 40%) had a change in their trigger in contrast to the majority of allogeneic transplant (37/47, 79%; p = 0.001 and p = 0.009, respectively, when compared to allogeneic transplant group). Bleeding was the main reason reported by clinicians for a trigger change, but the occurrence of significant bleeding (Grade 2-4) was similar in patients with or without a trigger change (51 and 54%, p = 1.00). Clinicians were influenced by the bleeding system: grade 1 mucocutaneous bleeding leading to a trigger change was overrepresented (71% of cases), as was grade 2 genitourinary bleeding not leading to a trigger change (57% of cases)., Conclusion: A universal trigger of 10 × 10(9) /L may not be maintained in a diverse population of patients with their respective bleeding risk factors. Because the trigger is changed often, it may not be as effective as previously believed., (© 2012 American Association of Blood Banks.)

Purpose: To examine the profile of retinoblastoma in a national tertiary referral center in Tanzania and to report first-year outcomes of its treatment using chemotherapy., Methods: All patients with retinoblastoma referred in 2008 were included. Disease was classified on clinical grounds as ocular, orbital, or metastatic. Those with ocular and orbital disease received chemotherapy. Remission was the main outcome measure and defined as absence of disease at the end of treatment., Results: In 2008, 37 patients (20 males and 17 females) with retinoblastoma were referred to Ocean Road Cancer Institute. The mean delay from the first sign of disease to presentation at hospital was 10.4 ± 8.7 months. Disease was ocular in 32% (12 of 37), orbital in 57% (21 of 37), and metastatic in 11% (4 of 37). Of those with ocular disease, 67% (8 of 12) completed chemotherapy and all (8 of 8) achieved remission. In contrast, 48% (10 of 21) with orbital disease completed chemotherapy and only 50% (5 of 10) achieved remission. The difference in outcome between the groups was statistically significant (P = .001, Fisher exact test)., Conclusion: The profile of retinoblastoma in Tanzania is skewed toward severe invasive disease. Despite the introduction of chemotherapy, further improvements in mortality and morbidity can only be achieved through emphasis on early detection., (Copyright 2012, SLACK Incorporated.)

Aims: Bilateral optic neuropathy in Dar-es-Salaam, Tanzania was first reported as an epidemic in 1988. Now argued to be endemic in 2010, the aetiology remains unclear. The authors investigated the hypothesis that low folate and vitamin B₁₂ status are associated with optic neuropathy, and also sought to investigate whether mercury, commonly used drugs, dietary factors and indoor pollution may also be risk factors., Methods: 57 cases and 102 controls were recruited from two tertiary referral centres in Dar-es-Salaam. Data were collected on demographic characteristics, diet, medication history and HIV status. Folate and vitamin B₁₂ (holo-transcobalamin) were measured in stored serum samples. Exposure to mercury was assessed from concentrations in random urine samples., Results: Cooking indoors more than twice per week (OR 54.48 (95% CI 9.30 to 319.10)) and indoor use of charcoal or firewood (OR 21.20 (95% CI 2.51 to 179.36)) increased the risk of optic neuropathy. Risk was reduced in those with a higher folate status (highest versus lowest quartile OR=0.11 (95% CI 0.02 to 0.51)) and higher protein intakes (OR=0.84 (95% CI 0.72 to 0.96). No association was found with mercury exposure or any common drug or food commodity., Conclusion: This study presents the first direct evidence of low folate status and indoor pollution in the aetiology of endemic bilateral optic neuropathy in Tanzania.

Purpose: To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) in patients with previous renal transplantation., Patients and Methods: We retrospectively identified all patients who had undergone RARP for localized prostate cancer between 2005 and 2008 at a single institution (N=228). Of these, three patients were renal transplant recipients. A four-arm robotic configuration was used in all patients. Port placement was modified in two of the three renal transplant recipients to avoid trauma to the renal allograft. Preoperative demographics, perioperative parameters, and postoperative outcomes were reviewed., Results: RARP was completed successfully in all three renal transplant recipients. As expected, the American Society of Anesthesiologists score (3.3 vs 2.4) and Charlson weighted index of comorbidity (4.7 vs 2.4) were greater in previous transplant patients. There were no major differences in mean age, Gleason score, body mass index, estimated blood loss, operative time, complications, or oncologic outcomes between the two groups. Each of the patients with renal allografts had an undetectable prostate-specific antigen level and was continent (needing no pads) at 13 months of follow-up., Conclusions: RARP is feasible in patients with a previous renal transplant. Although technically more challenging, RARP can be performed in previous transplant patients with acceptable morbidity and oncologic outcomes similar to those of other prostate cancer patients.

Objectives: Although the long-term effects of radiation exposure are not completely predictable, the principle of keeping radiation exposure "as low as reasonably achievable" should be used. The purpose of this study was to compare fluoroscopy times before and after the implementation of a protocol designed to reduce fluoroscopy usage during ureteroscopy., Methods: A retrospective review was conducted of 300 consecutive ureteroscopy patients at a single institution. Patients undergoing simple ureteroscopy without ancillary procedures or balloon dilation were further evaluated to determine the effect of a reduced fluoroscopy protocol. The protocol included several measures, including use of a laser-guided C-arm, use of a designated fluoroscopy technician and substitution of visual for fluoroscopic cues during ureteroscopy. Fluoroscopy times were compared between groups using a paired t test with P < .05 considered significant., Results: Ureteroscopy cases before protocol implementation (n = 30) were compared with procedures after implementation (n = 30). Stone size and location were similar between groups. Protocol implementation significantly reduced the mean fluoroscopy exposure from 86.1 seconds (range 30-300) to 15.5 seconds (range 0-54; P < .001). There was no difference in mean operative time (74.2 vs 65.1 minutes; P = .14), or complications (2 patients vs 2 patients; P = 1) between groups. No complication in either group could be ascribed to the fluoroscopic technique., Conclusions: The reduced fluoroscopy protocol resulted in an 82% reduction in fluoroscopy time without altering patient outcomes. These simple radiation-reducing techniques add no technical difficulty and improve safety for the patient, surgeon, and operating room staff by lowering radiation exposure., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background and Purpose: Laparoendoscopic single-site (LESS) surgery produces virtually no scar but is technically challenging because of the loss of triangulation. The objective of this study is to compare classic transumbilical LESS nephrectomy with needlescopic-assisted laparoscopy (NAL) surgery. In doing so, we evaluated whether the addition of a single 2-mm subcostal port could restore triangulation while not jeopardizing recovery or cosmetic outcome in the porcine model., Materials and Methods: Ten female farm pigs were randomized to laparoscopic nephrectomy with either LESS or NAL. In LESS, a TriPort was placed through a single 2.5-cm umbilical incision. In NAL, 5- and 10-mm ports were placed in the umbilicus and a 2-mm port was placed in the midclavicular line. Preoperative, perioperative, and postoperative parameters were compared. Variables were analyzed with the Wilcoxon signed-rank test and two-tailed Fisher exact test. Cosmesis was evaluated objectively using the Vancouver Scar Scale and subjectively by a blinded dermatologist. A cost analysis was performed., Results: Estimated blood loss was minimal in both groups (28.8 mL in LESS and 9.4 mL in NAL). Operative time was significantly shorter in NAL (103 vs 150 min; P<0.001). There was no difference in complications (2 vs 1; P=0.500), objective cosmesis (3.9 vs 3.8; P>0.2), or subjective cosmesis (2 vs 3; P=0.500). The NAL protocol had significantly lower disposable equipment costs ($363 vs $1696)., Conclusions: The addition of a 2-mm subcostal port and the restoration of triangulation in the NAL protocol enable shorter operative times, increased surgeon comfort, improved technical ease, and lower costs while maintaining the scarless cosmesis of the traditional LESS protocol.

Objective: To evaluate the effectiveness of goniotomy to treat primary congenital glaucoma in an east African population., Design: A retrospective series using case records. For patients who underwent goniotomies in both eyes, only the first was analyzed., Participants: Forty-seven children undergoing goniotomy (47/80 operated eyes analyzed). Thirty-six children (77%) were male. Mean age was 19 months (range 1-204 months, standard deviation [SD] = 35)., Intervention: First goniotomy was performed from the temporal side. Repeat surgery, if necessary, was performed via nasal side approach and 100% ethanol-soaked cotton-tipped swabs were used to clear the corneal epithelium when necessary for angle visualization., Main Outcome Measures: Postoperative intraocular pressure (IOP) <21 mmHg was considered success. Potential risk factors for failure were analyzed. Quantitative visual acuities were measured with Cardiff acuity cards and Lea tests in older children., Results: A total of 36 of 47 children (77%) returned for follow-up. Mean follow-up interval was 12 months (range, 1-62 months; SD = 15). A total of 28 of 47 children (60%) had >3 months of follow-up, and 11 children had >1 year of follow-up. A total of 12 of 47 eyes (26%) required repeat goniotomy. Three of these required further trabeculectomy with mitomycin C, 1 of which required eventual enucleation after failure to control IOP, enlargement, and pain. A total of 11 of 28 children (39%) with >3 months follow-up required repeat surgery. A total of 24 of 28 children (86%) with follow-up intervals of at least 3 months achieved postoperative IOPs of <21 mmHg. Mean IOPs decreased (t = 6.1, P < 0.0005) from 23.4 mmHg (SD = 5.3 mmHg) to 14.4 mmHg (SD = 7.6 mmHg). Only 1 predictor of failure to achieve successful control of IOP was identified: female gender (relative risk = 5.3, 95% confidence interval, 1.1-26.3). Corneas were clear in 4 of 47 eyes (8.5%) preoperatively and 32 of 41 eyes (78%) postoperatively. Of 25 children with preoperative and postoperative acuities measured, 22 (88%) recorded improvement., Conclusions: Preliminary results of goniotomy in an African population with advanced disease and late presentation are reasonably encouraging. Overall results are comparable with historical drainage procedures, with the advantage of preserving conjunctiva. Further studies are justified., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Leukocoria, a presenting sign in several significant pediatric ocular conditions, can be artefactually produced by off-axis flash photography in healthy eyes. The authors demonstrate the conditions needed to produce this phenomenon, which is more commonly seen in children due to their larger-sized pupils, photogenicity, and frequent off-axis shots., (Copyright 2009, SLACK Incorporated.)

Aim: To investigate visual and intra-ocular pressure (IOP) outcomes of combined cataract and glaucoma surgery at a high-volume centre in East Africa carried out over a 1-year period (2006)., Methods: A retrospective analysis of patient records., Results: A total of 163 patients were identified. Mean age was 67 years (SD 11, range 21-86 years) and 113 (69%) were men. Presenting visual acuity in the operated eye was 6/60 or worse in 135/163 (93%) and was <3/60 in 76 of 163 (47%) patients. Mean presenting IOP was 28 mm Hg (SD 9, range 12-60). Pre-operative cup disc ratios were 0.8 or worse in 131 of 163 (85%) patients. Phacotrabeculectomy (PT) was carried out in 130 (80%) cases, small incision cataract surgery trabeculectomy (SICST) in 10 (6.1%) cases, and extra-capsular cataract extraction trabeculectomy (ECCET) in 23 (14.1%) cases. In all, 107 (66%) attended for follow-up (mean interval 104 days, range: 6-390 years, SD 88) and at follow-up 75 (70%) patients had improved visual acuity pre-operatively. Pre-operative cup disc ratio of 0.9 or greater predicted failure to improve VA at follow-up (OR 4.0 95% confidence interval (CI) 1.30-12.1). Fifty-nine (62% (95%CI 52-71%)) patients had follow-up IOPs of 6-15 mm Hg and 82 (85% (95% CI 78-92%)) had follow-up IOPs of 6-20 mm Hg., Conclusion: Combined surgery produces visual benefit for most patients with similar pressure control to pure trabeculectomy and is therefore a useful option in practises where follow-up may be doubtful.

Aim: To investigate the prevalence and causes of optic neuropathy, reported as epidemic in 1997, among secondary school students in Dar es Salaam, Tanzania., Patients and Methods: First year students (n = 10,892) from 63 secondary schools located within 30 km from the base hospital were interviewed and had a visual acuity (VA) screening test. Students failing the 6/12-line in either eye were defined as having "poor eyesight" and referred to the base hospital where an optometrist re-tested VA and refracted them. An ophthalmologist examined students with VA of 6/12 or worse in either eye and visual impairment was defined as VA of worse than 6/12 with best correction. Associations between optic neuropathy, socioeconomic status and educational results were investigated., Results: Students' ages ranged from 12 to 22 (mean 15.2) years; 50.6% were male. The prevalence of optic neuropathy was 0.3 (SD 0.051)%. The condition affected older students and was associated with the family having fewer economic possessions (car, computer, television). Optic neuropathy accounted for 19/33 (58%) of bilateral visual impairment cases. No effect of the disease on educational performance was identified., Conclusion: Optic neuropathy remains a significant problem in this population and can now be termed endemic rather than epidemic. Further research into its causes is required.

Purpose: To establish the proportion of patients who are blind or have low vision prior to undergoing cataract surgery at tertiary referral centers in Tanzania. To assess which patient groups presenting for cataract surgery are more likely to be blind or visually impaired., Methods: Using pre-existing computerized audit systems we gathered data on pre-operative visual status, age, gender and presentation mode (walk-in or outreach) for 3765 patients undergoing 4258 cataract operations at 2 hospitals in Tanzania. Visual status was defined based on vision in the better eye., Results: 32% of operations were performed on blind patients, 37% on patients with low vision and 31% on normally sighted patients. Predictors of blindness at presentation were: female sex (OR 1.15; 95% CI 1.00-1.32); referral from a rural outreach program (OR 1.75; 95% CI 1.51-2.02) and older age (OR 1.02; 95% CI 1.01-1.02)., Conclusions: It is not only the blind who present to cataract services in Tanzania. The demand for surgery amongst patients who or are normally sighted represents a positive move towards prevention, and not only cure of cataract blindness in Tanzania. However, it also highlights the need to target those left blind from cataract in order to deliver services to those most in need. Cataract programs targeting patients in rural areas and older patients are likely to increase the number of blind patients benefiting from cataract services.

We estimated the proportion of patients reaching a pediatric ophthalmology unit (Comprehensive Community Based Rehabilitation for Tanzania Disability Hospital, CCBRT) or an oncology unit (ORCI) in east Africa and investigated presentation, histology, and treatment outcomes of patients with retinoblastoma. A 5-year retrospective study identified 91 patients, representing approximately 18% of the nationwide total. Mean lag time was 10 months (standard deviation (SD) = 17) and mean follow-up was 8 months (SD = 11, range 0-40, n = 91). Thirty months disease-free survival probability was 0.23 (standard error = 0.07). Outcomes for retinoblastoma in Africa remain poor. The data presented here suggest strategies for improving the outcomes, including encouraging earlier presentation and establishment of multi-disciplinary treatment centers., ((c) 2007 Wiley-Liss, Inc.)

Objective: To investigate outcomes of bilateral pediatric cataract surgery in east Africa., Design: Retrospective interventional case series., Participants: Two hundred forty-three children who underwent bilateral cataract surgery at the Comprehensive Community-Based Rehabilitation for Tanzania Disability Hospital between 2001 and 2004., Methods: Demographic, surgical, preoperative, and postoperative clinical characteristics obtained from patient records were entered into a database (Microsoft Excel; Microsoft, Redmond, WA), and statistical analysis was conducted using SPSS software for Windows (SPSS, Inc., Chicago, IL)., Main Outcome Measures: Postoperative visual acuities and factors affecting them and postoperative refraction results., Results: Intraocular lenses were inserted in the first eyes of 232 children (149 Alcon AcrySof [Alcon Laboratories, Fort Worth, TX], 83 polymethyl methacrylate [PMMA]). Fifty-eight (62%) of 94 patients with final follow-up acuities recorded in both eyes achieved 20/60 or better in their better eye and 13 (13%) of 94 patients were blind. Of the various predictors of good visual outcome identified for children or eyes, only absence of preoperative blindness (odds ratio [OR], 7.3; 95% confidence interval [CI], 3.0-18.0; P<0.0005) remained significant in a multivariate logistic regression model. One hundred nine (51%) of 212 refracted first eyes had early postoperative refractive error spherical equivalent magnitudes of 2 diopters (D) or more. Ninety-nine (47%) of 212 eyes had initial postoperative cylinders of 3 D or more, dropping to 30 (18%) of 164 of those who had later follow-up refraction. Presence of biometric data was not associated with smaller postoperative refractive errors. Eyes with AcrySof lenses were less likely (OR, 2.5; 95% CI, 1.04-6.06) to have more than 3 D of astigmatism at latest follow-up. AcrySof lenses also were more likely (OR, 2.1; 95% CI, 1.2-3.7) to be fixated in the bag than PMMA lenses. Acute fibrinous uveitis occurred in 30 cases (12%), and transient corneal haze occurred in 20 cases (8%). Twenty-seven (11%) had chronic complications, 69 (28%) underwent a further general anesthetic procedure, and 9 (4%) underwent yytrium-aluminum-garnet capsulotomy., Conclusions: Preoperative blindness was the strongest predictor of poor postoperative visual outcome; the use of AcrySof lenses as opposed to PMMA lenses made in-the-bag fixation more likely and also reduced postoperative astigmatism.

Purpose: Trachoma is the leading infectious cause of blindness. However, there are few data on the natural history of trachomatous trichiasis to guide program planning or that investigate its pathogenesis., Methods: A cohort of Gambians with trichiasis in one or both eyes who had declined surgery was observed. Clinical examinations were performed at baseline and 4 years later. Conjunctival swab samples were collected for Chlamydia trachomatis PCR and bacteriology., Results: One hundred fifty-four people were examined at baseline and 4 years later (241 nonsurgical eyes). At baseline 124 (52%) eyes had major trichiasis (5+ lashes), 75 (31%) minor trichiasis (1-4 lashes), and 42 (17%) no trichiasis. By 4 years, trichiasis had developed in 12 (29%) of 42 previously unaffected eyes. Minor trichiasis progressed to major in 28 (37%) of 75 eyes. New corneal opacification more commonly developed in eyes that had major (10%) compared to minor (5%) trichiasis at baseline. Bacterial infection was common (23%), becoming more frequent with increasing trichiasis. C. trachomatis infection was rare (1%). Conjunctival inflammation was common (29%) and was associated with progressive trichiasis and corneal opacification., Conclusions: Trichiasis progressed in the long-term in this environment, despite a low prevalence of C. trachomatis. Blinding corneal opacification develops infrequently, unless major trichiasis is present. Epilation and early surgery need to be formally compared for the management of minor trichiasis. The pathologic correlates and promoters of conjunctival inflammation need to be investigated.

We evaluated the reliability of photographs to verify field diagnoses of active trachoma. We examined 956 residents of a trachoma-endemic village for signs of trachoma using the World Health Organization simplified grading system. Two photographs of the right eye of 948 persons were independently graded (masked to field assessment) by the field examiner and two other experienced graders. There was only moderate agreement between field assessment and the subsequent photographic evaluations by the three graders. When we counted ungradable photographs as disagreements, mean kappa scores for the signs trachomatous inflammation (follicular [TF]) and trachomatous inflammation (intense [TI]) were 0.44 and 0.51, respectively. There was also only fair-to-moderate agreement between the three assessments (by different examiners) of the photographs. Either the signs TF and TI themselves are not as reliable as previously believed, or photographs should be used for their diagnosis only when reliability testing demonstrates better agreement than found here.

Background: In all, 1.4 million children are estimated to be blind worldwide and only 6.5% of these are thought to come from the more affluent countries. The focus of this paper is therefore the developing world and Africa in particular, where evidence suggests that congenital cataract is becoming the leading cause of childhood blindness., Methods: A review of the literature on management of congenital cataract was combined with original data from the author's experience in east Africa., Conclusions: Health service structure, surgical technique, health education, and community screening to promote early referral, good surgical follow-up, and training of multidisciplinary teams based at specialist children's eye centres are all essential components for effective strategies to control childhood blindness due to congenital cataract.

Aim: To investigate the presentation of POAG at a tertiary referral hospital in East Africa, including intraocular pressures, visual status and management decisions., Methods: Retrospective review of first-time presenters with POAG over a 6-month period., Results: Of the 298 patients identified, mean age 57 years (n = 296, range = 14-88, SD = 14), 213 (72%) male, 122 (41%) had normal vision (using WHO better eye acuity criteria: visual impairment < 6/18, blind < 3/60) at presentation, 87 (30%) had visual impairment and 86 (29%) were blind. The mean presenting IOP was 32 mmHg (SD = 11) and 70% of the patients had a cup:disc ratio of 0.8 or worse in the better eye. Longer disease duration (OR = 1.20, 95% CI 1.04-1.39) and higher mean IOP (OR = 1.06, 95% CI 1.02-1.10) were associated with visual impairment or blindness. Intraocular pressure showed a negative linear correlation with presenting logMAR acuity (R(2) = 0.115, SE = 1.30, p < 0.0005). The mean IOP in eyes that had undergone trabeculectomy (19 mmHg, SD = 8, n = 17) was significantly (p < 0.0005) lower than that in eyes that had not (34 mmHg, SD = 12, n = 274). The referral rate for trabeculectomy was 158/275 (57%). Male sex (OR = 2.17, 95% CI 1.0-4.72), higher mean IOP (OR = 1.09, 95% CI 1.05-1.14) and not being blind (OR = 26.47, 95% CI 9.90-70.78) were associated with surgical referral. Of the 158 patients, 76 (48%) accepted surgery., Conclusions: A high proportion of patients presenting to our unit with POAG are visually impaired or blind and the higher their presenting IOP the poorer their visual acuity. Previous trabeculectomy was associated with lower IOPs and protection from visual impairment and blindness. Further training of clinic staff towards early surgical referral and investigation of gender barriers is required.

Background: Trichiasis surgery is believed to reduce the risk of losing vision from trachoma. There are limited data on the long term outcome of surgery and its effect on vision and corneal opacification. Similarly, the determinants of failure are not well understood., Methods: A cohort of people in the Gambia who had undergone surgery for trachomatous trichiasis 3-4 years earlier was re-assessed. They were examined clinically and the conjunctiva was sampled for Chlamydia trachomatis polymerase chain reaction (PCR) and general bacterial culture., Results: In total, 141/162 people were re-examined. Recurrent trichiasis was found in 89/214 (41.6%) operated eyes and 52 (24.3%) eyes had five or more lashes touching the globe. Corneal opacification improved in 36 of 78 previously affected eyes. There was a general deterioration in visual acuity between surgery and follow up, which was greater if new corneal opacification developed or trichiasis returned. Recurrent trichiasis was associated with severe conjunctival inflammation and bacterial infection. C trachomatis was detected in only one individual., Conclusions: Recurrent trichiasis following surgery is a common potentially sight threatening problem. Some improvement in the cornea can occur following surgery and the rate of visual loss tended to be less in those without recurrent trichiasis. The role of conjunctival inflammation and bacterial infection needs to be investigated further. Follow up of patients is advised to identify individuals needing additional surgical treatment.

Aims: To propose a classification system for periocular haemangiomas based on ultrasound evaluation., Methods: Retrospective review of ultrasound images from children seen in the authors' unit with periocular haemangiomas. Static ultrasound images from 50 patients with periocular haemangiomas were reviewed as identified from a computerised database. Each haemangioma ultrasound image was classified into three categories: (1) preseptal only; (2) preseptal + extraconal; (3) preseptal + extraconal + intraconal. These were compared with the categories given to each patient at first presentation after dynamic scanning., Results: Classification was possible from the static images in 44 (88%) cases. Of those classified 20 (45%) were preseptal only; 17 (39%) were preseptal + extraconal, and seven (16%) had an additional intraconal component. The classification in all 44 cases was the same as that given at the time of presentation. In the small number of cases which went to surgery or had neuroimaging, the ultrasound classification was confirmed., Conclusions: Ultrasound classification was not difficult to perform and no child needed sedation or general anaesthesia for this exam. Ultrasound anatomical classification is an important first step in determining appropriate treatment of periocular haemangiomas. The authors present what they believe to be the first such classification.

Introduction: Brimonidine 0.2% (Alphagan) is a topical alpha-2 agonist widely used as an antihypertensive. There have been occasional reports of systemic adverse effects in children including apparent central nervous system depression. There are few data available on the overall safety of brimonidine 0.2% in children., Methods: Computerised pharmacy records were used to identify all children who had been prescribed brimonidine 0.2% in our eye department between August 1999 and June 2001, and their notes were reviewed., Results: In all, 23 patients were identified from pharmacy records and 22 sets of notes were recovered and reviewed. The mean age at commencement of treatment was 8 years (range 0-14 years). In all, 10 (46%) were treated in one eye and 12 (54%) in both. Brimonidine 0.2% was taken for a mean 14 months (range 1 day-75 months). A total of 14 (64%) patients were already taking a topical beta-blocker when brimonidine 0.2% was commenced and a further four (18%) were being treated with another topical hypotensive agent. Of the 22 patients, six (27%) had to stop brimonidine 0.2% because of adverse side effects (two because of local irritation/allergy, two because of tiredness, and two because of fainting attacks)., Discussion: Many topical hypotensive agents are not licensed for use in children and few safety data are available. In this study, 18% of children had systemic adverse effects sufficient to necessitate stopping the drug. It is possible that educational impairment may have passed unnoticed in others. Larger studies are required to investigate this further.

Objectives: To assess the accuracy and efficiency of telemedicine in diagnosing and managing eye problems presenting to accident and emergency departments., Design: A controlled trial with a face-to-face and telemedicine phases, each involving 40 patients undergoing two consecutive consultations. In the face-to-face phase, both consultations were in person; in the telemedicine phase, observer 1 used videoconferencing technology at 384 kbit/s (separate nonslit lamp-torchlight and slit lamp examinations) and observer 2 saw the patient face to face. Setting The accident and emergency department at Moorfields Eye Hospital.Participants In total, 80 consenting new patients presenting to the department., Main Outcome Measures: (1) Agreement levels between the two observers for each phase (judged by an independent masked investigator), (2) length of consultation, and (3) number of unnecessary recalls., Results: Agreement rates were as follows. Face-to-face phase: total agreement (30/40=75%), trivial disagreement (8/40=20%), clinically important disagreement (2/40=5%). Telemedicine phase (torchlight): complete agreement (16/40=40%), trivial disagreement (20/40=50%), clinically important disagreement (4/40=10%). Telemedicine phase (slit lamp): total agreement (23/40=58%), trivial disagreement (15/40=37%), clinically important disagreement (2/40=5%). Agreement levels in the telemedicine phase with torchlight examination were significantly lower (chi(2)=10.07, P=0.007) for any disagreement. Telemedicine consultations erred on the side of clinical caution and were no slower than face-to-face consultations (mean 6 min for observer 1 in both phases). Recalls were more likely (chi(2)=5.16, P=0.02) after telemedicine consultations with torchlight only (9/40) compared with face-to-face consultations (2/40). Although there were more significant disagreements using the telemedicine, in each case the telemedicine diagnosis and management erred on the side of safety; hence, no patient would have suffered by wrong management because of the consultation using telemedicine., Conclusions: Telemedicine was found to be an accurate, safe, and efficient method of diagnosing and managing these patients, especially if slit lamp images were used. Advice using telemedicine erred on the side of caution, which resulted in more recalls.

Purpose: Investigation of compliance with surgery for trachomatous trichiasis has become a priority of the World Health Organization. This study was conducted to investigate attitudes toward trichiasis and its treatment and to determine the rate of surgical uptake in The Gambia., Methods: A 1-year longitudinal study was performed in 190 subjects with trichiasis. Persons with major trichiasis (involving five lashes or more) were referred for surgery, and those with minor trichiasis were advised to epilate. Outcome measures included attitudes toward trichiasis and its treatment, reported barriers to surgical uptake, acceptance rates for surgery, and factors affecting acceptance., Results: Twenty-three percent (95% confidence interval [CI] 16.5%-30.6%) of subjects with major trichiasis attended for surgery during the year. Degree of ignorance about surgery, symptoms impeding work, and a multiple income source for the head of household predicted attendance. Reported lack of time predicted nonattendance. Sixty-eight percent of patients who had undergone surgery were trichiasis free at last follow-up., Conclusions: Poor attendance for surgery remains a problem in The Gambia. Barriers include ignorance and lack of time and money. Health education and surgical delivery strategies are needed to overcome these barriers. Regular audit of surgical results is necessary, with retraining where indicated.

Aim: Investigation of the natural history of trachomatous trichiasis in the Gambia and of the outcome of self epilation and surgery for the condition., Methods: A 1 year longitudinal study of 190 subjects with trichiasis was performed. Major trichiasis cases (five lashes or more) were referred for surgery and minor trichiasis cases were advised to epilate. Outcome measures included progression of trichiasis and corneal scarring; attendance for and results of surgery., Results: 34 of 148 (23%, 95% CI 16 to 31) subjects with major trichiasis attended for surgery over the year. Progression from minor to major trichiasis occurred in 18 of 55 subjects (33%, 95% CI 21 to 47). Progression of corneal scarring occurred in 60 of 167 patients (36%, 95% CI 29 to 44). Clinically active trachoma and conjunctival bacterial isolation predicted progression of corneal opacity. Surgery was successful in 39 of 54 (72%) eyes., Conclusions: Despite the overall decline in trachoma in the Gambia, patients with both minor and major trichiasis remain at risk of developing corneal opacity. Active trachomatous inflammation and additional infection with bacteria may accelerate this process. Antibiotic treatment for trichiasis patients (in addition to surgery) should be investigated. Surgery for minor trichiasis may be indicated. Regular audit of surgical results is necessary with retraining where needed.

Trachoma, a recurrent follicular conjunctivitis caused by Chlamydia trachomatis, is the leading cause of preventable blindness worldwide. Efforts to control this disease have met with limited success. This failure is due in part to the limitations of conventional antibiotic treatment, a prolonged course of topical tetracycline. Azithromycin, an azalide antibiotic, is effective against chlamydial infections when given as a single oral dose. Recent research from Africa has shown azithromycin to be as effective as tetracycline in the treatment of trachoma. Under operational conditions azithromycin proved to be more effective. This success is attributed to a much-improved compliance with treatment. Community-wide mass treatment with azithromycin is advocated as a means of controlling trachoma in endemic countries. Questions still remain over the use of azithromycin for this purpose. The frequency and target population of mass distribution campaigns need to be defined. A few countries are beneficiaries of a philanthropic donation by the manufacturer of azithromycin, Pfizer Inc. However, in the absence of a drug donation programme the cost-effectiveness of this measure is unclear.

Aims: National blindness surveys conducted in the Gambia in 1986 and 1996 showed an increase in blindness and visual impairment from non-trachomatous opacity. This study aimed to investigate the aetiology of these opacities and to assess the resulting visual burden., Methods: A population-based, randomised blindness survey was conducted in the Gambia in 1996. Patients with visual impairment or blindness were examined by an ophthalmologist with a slit lamp. Causes of corneal opacity were determined as accurately as possible by clinical history and examination., Results: A total of 154 patients with non trachomatous corneal opacity were examined of whom 39 had bilateral opacities and 115, unilateral. Causes included corneal infection, measles/vitamin A deficiency, harmful traditional practices and trauma (unilateral scarring). Overall, corneal pathology alone was responsible for bilateral visual impairment or blindness in 19 (12%) patients and unilateral visual impairment or blindness in 88 (57%) patients. Those patients with bilateral visual impairment or blindness (mean age 59, SD) were older (P= 0.003) than others (mean age 44, SD = 20). The use of harmful traditional eye practices was associated with bilateral corneal blindness or visual impairment (RR = 2.63, 95% CI 1.11-6.21, P = 0.04). Although none of the corneal scars reported here were attributed to trachoma, in patients over the age of 45, the prevalence of trachomatous conjunctival scarring in this group was 38.8% compared to 19.4% of the whole nationwide sample., Discussion: Strategies for the prevention (including the quest for cheaper anti-microbial drugs and co-operation with traditional healers) and surgical treatment of these corneal opacities are discussed.

Purpose: The sight-threatening complications of trachoma are trichiasis and corneal opacity, and these remain the world's most common cause of preventable blindness. The aim of the study was to investigate the rate of progression of trachomatous conjunctival scarring to trichiasis and corneal opacity and to investigate risk factors for such progression., Design: A 12-year, longitudinal study of the incidence and risk factors for the development of trichiasis and corneal opacity in a cohort of patients initially identified with trachomatous scarring in The Gambia., Participants: Six hundred thirty-nine subjects with some degree of trachomatous scarring were identified from the 1986 survey, and attempts were made to trace all these subjects., Methods: Successfully traced subjects were interviewed, examined, and graded for trachoma., Main Outcome Measures: (1) Twelve-year rates of progression. (2) Risk factors for progression of disease., Results: Three hundred twenty-six of six hundred thirty-nine (51%) subjects were traced and examined, 108 (17%) had died, and 205 (32%) were lost to follow-up. After 12 years, 6.4% (95% confidence interval [CI], 4.0-9.97) of scarred subjects had trichiasis develop, 5.96% (95% CI, 3.67-9.42) had corneal opacity develop, 16.51% (95% CI, 12.71-21.13) had visual impairment/blindness develop, and 2.5% (95% CI, 1.2-5.0) had corneal visual impairment/blindness develop. Mandinka ethnicity was a risk factor for trichiasis (odds ratio [OR], 4.3; 95% CI, 1.3-14.4), and trichiasis at baseline was a risk factor for corneal opacity (OR, 8.4; 95% CI, 1.8-39.2). History of lid surgery for trichiasis was associated with corneal opacity at follow-up (OR, 4.4; 95%CI, 1.4-14.0). Older age was a significant risk factor for development of trichiasis, corneal opacity, and visual loss (OR, 1.07; 95% CI, 1.01-1.12). Bilateral cataract was present in 40% of traced subjects and was associated with the incidence of visual impairment/blindness (OR, 9.4; 95%CI, 4.5-19.6), Conclusions: This is the first study to demonstrate the link between trichiasis and future corneal opacity, and it provides the rationale for performing lid rotation surgery on patients with trichiasis who do not yet have corneal opacity. The association between corneal opacity at follow-up and previous surgery among trichiasis patients suggests late presentation as a problem. The planning of surgical services will be aided by the incidence figures generated by this study.

Aim: Untreated trichiasis can lead to corneal opacity. Surgery to prevent the eyelashes from rubbing against the cornea is available, but many individuals with trichiasis never undergo the operation. This study estimates the cost of illness of untreated trichiasis and the willingness to pay for surgery and compares them with the actual cost of providing surgery., Materials and Methods: The cost of illness estimate is based on trichiasis patient demographics. Data on the implicit price of obtaining surgery and surgical utilization in a matched pair randomized trial are used to infer individual willingness to pay for trichiasis surgery. Patients in the study paid nothing out-of-pocket for surgery; the price of obtaining surgery is the value of the individual's time needed for travel and surgery plus the price of public transportation. The cost of producing surgery was calculated from project records., Results: All monetary figures are reported in 1998 US dollars. The average cost of untreated trichiasis, or the net present value of life-time lost economic productivity, was $89. Individuals facing a lower cost were more likely to undergo an operation; the inferred average willingness to pay was $1.43 (SD 0.244). Surgery cost $6.13 to provide, including $0.86 for transportation to the village., Discussion: Whether the value of trichiasis surgery exceeds the cost in The Gambia depends on how the value is measured. Individuals are willing to use only limited resources to obtain surgery even though lifetime economic productivity may increase substantially. All three economic measures can be used to inform policy.

We determined the size of genets of late-stage ectomycorrhizal fungi in field sites in coastal Northern California. Basidiocarps were collected, mapped and subjected to genetic fingerprinting using amplified fragment length polymorphisms (AFLPs). The minimum size estimates for the largest genets of Amanita francheti, Lactarius xanthogalactus and Russula cremoricolor were 1.5, 9.3 and 1.1 m2, respectively. The molecular markers also showed that R. cremoricolor is dimorphic, with red- and white-capped morphotypes of this species forming a continuous population. Our results suggest that spore propagation plays a much more important role in the life history of the Russulaceae in undisturbed forest settings than previously recognized. Fungi appearing late in the succession sequence and systems without obvious disturbance therefore do not necessarily colonize primarily by mycelium.

Purpose: World Health Organization guidelines for antibiotic treatment of trachoma currently include a 6-week course of tetracycline eye ointment twice daily or a single dose of oral azithromycin. Previous trials have shown similar efficacy of these two alternatives when administration of the ointment was carefully supervised. It is believed, however, that azithromycin may be a more effective treatment in practice, and the purpose of this study was to test that hypothesis., Methods: A masked randomized controlled trial was conducted to compare azithromycin and tetracycline under practical operational conditions-i.e., without supervision of the administration of the ointment. Three hundred fourteen children aged 6 months to 10 years with clinically active trachoma were recruited and individually randomized to receive one of the two treatments. Follow-up visits were conducted at 10 weeks and 6 months. The outcome was resolution of disease (clinical "cure")., Results: Children allocated to azithromycin were significantly more likely to have resolved disease than those allocated to tetracycline, both at 10 weeks (68% versus 51%; cure rate ratio, 1.31; 95% confidence interval [CI], 1.08-1.59; P = 0.007) and at 6 months (88% versus 73%; cure rate ratio, 1.19; 95% CI, 1.06-1.34; P = 0.004). Azithromycin was particularly effective for intense inflammation (P = 0.023, Fisher's exact test)., Conclusions: Single-dose oral azithromycin was a more effective treatment for active trachoma than tetracycline ointment as applied by caregivers. The high cure rate achieved with tetracycline in this study in the absence of supervision and the significantly higher costs of azithromycin, suggest that in the absence of donation programs, switching routine treatment from tetracycline to azithromycin would not be a good use of resources.

Background: Surgery is an important component of the SAFE strategy which has been shown to improve visual acuity. There are limited data on long-term surgical success and patient perceptions and satisfaction. A sample of patients from the Gambia who had undergone previous lid surgery for trichiasis were therefore examined for recurrence of trichiasis and interviewed for patient satisfaction., Methods: Health centre surgical records and community screening were used to identify patients who had undergone previous lid surgery. Consenting patients were examined and a questionnaire administered. Kaplan-Meier survival plots were constructed for recurrence of trichiasis., Results: Sixty-five subjects were recruited. Median age at surgery was 50 years. Median time since surgery was 7 years. Fifty-two of 115 (45%) operated eyes were free of trichiasis at follow-up and 23 of 65 (35%) patients had not suffered recurrent trichiasis in an operated eye. Median time from surgery to recurrence of trichiasis was estimated as 10.0 years (95% CI 3.7-16.3). Recurrent trichiasis was not significantly associated with visual impairment or blindness at follow-up. The following patient perceptions were reported: satisfaction with surgery (88%), less discomfort than before surgery (93%), improved vision (83%), work easier (38%), worth the expenditure (94%), would recommend it to others (93%), had recommended it to others (38%), experienced intra-operative pain (26%) and experienced post-operative pain (26%)., Conclusion: Factors affecting surgical success, including surgical technique and re-exposure to infection, are discussed. This study provides important preliminary data for programme planners but larger prospective studies are required.

Introduction: Surgery for trachomatous trichiasis prevents blindness and is advocated by the WHO as part of the SAFE strategy for the global elimination of trachoma. We conducted a randomised community trial to investigate the effect of providing surgery in villages on surgical uptake in The Gambia., Methods: 56 villages from two divisions were assigned to eight pairs of clusters matched by geographical division and proximity. One cluster from each pair was randomly assigned to receive village-based surgery and the other cluster health centre-based surgery. Outcome measures were uptake rates and surgical results after 1 week and 3 months. The paired t-test was used to analyse the results., Results: Overall uptake was 66% in the village-based clusters and 44% in the health centre-based clusters. Subjects in the village-based surgery arm had significantly shorter journey times (P = 0.01) and lower costs (P = 0.002). The mean difference in absolute acceptance rates of surgery was 20% better in village-based clusters (95% CI -9 to + 49%, P = 0.15), which would equate to an improvement of 45% (95% CI -20% to 120%) on the average acceptance rates of 44% in the health centre-based group., Conclusion: These results strongly suggest better surgical uptake when surgery is provided in patients' villages due to lower cost to the patient, time saved and less fear of the operation.

Aim: To investigate risk factors, visual outcome, and graft survival for traumatic wound rupture after penetrating keratoplasty., Methods: A retrospective analysis of 336 patients who underwent penetrating keratoplasty from 1988 to 1995., Results: 19 patients (5.7%) suffered traumatic postoperative wound rupture requiring surgical repair. They were younger (mean age 16.6 years, 95% CI 13.2-20.6) and more frequently keratoconic (p = 0.01) than other patients (mean age 28.9 years, 95% CI 26.-31.0). Mean postoperative follow up was 37.7 (SD 22.9) months and 24.5 (18.9) months for the rupture and non-rupture patients. Mean interval between keratoplasty and rupture was 18 (21) weeks. The lens was damaged and removed in 37% of ruptured eyes. For keratoconics, the probability of graft survival at 5 years was lower (p = 0.03) in the ruptured eyes (75%) than in the non-ruptured eyes (90%). Endothelial failure was a more common (p <0.05) cause of graft opacification in ruptured grafts than in intact grafts. Of the ruptured eyes, 53% achieved a final corrected acuity of at least 6/18 and 63% achieved at least 6/60 compared with 48% and 71% of the intact eyes respectively (both p >0.1). The proportion of keratoconic eyes which achieved at least 6/60 was lower (p = 0.02) in the ruptured eyes (67%) than the non-ruptured eyes (87%). Eyes with wound ruptures of 5 clock hours or greater were less likely (p <0.05) to achieve an acuity of 6/18 and were more likely (p <0.05) to have an associated lens injury., Conclusions: Graft rupture is relatively common in African practice, particularly in young keratoconics. Visual outcome and graft survival are not significantly worse than for other grafted eyes, but are significantly worse than for other grafted keratoconic eyes.

Objective: This study aimed to audit the surgical strategy of primary posterior chamber intraocular lens implantation for cases of recent penetrating trauma involving the lens in an African population., Design: Retrospective, noncomparative case series., Participants: Seventy-two cases are reported, including all patients who underwent primary intraocular lens implantation for traumatic cataract extraction performed within 1 month of injury between 1988 and 1996., Main Outcome Measures: Demographic characteristics and follow-up attendance rates are analyzed. Surgical technique and the occurrence of intraoperative and postoperative complications are reported. Visual outcomes are reported with detailed analysis for cases of poor visual outcome., Results: Mean age was 14.3 years (standard deviation = 11.1), 57 (79%) were male and 15 (21%) were female (chi-square = 23.66, P < 0.01). Fifty-eight patients (80%) attended for follow-up with a mean follow-up duration of 14.3 months (standard deviation = 17.3). No demographic or surgical differences were identified between attendees and nonattendees. The posterior capsule had been breached by the trauma in 27 (38%) cases, and 15 of these required anterior vitrectomy. Capsular fixation of the implant was achieved in 49% of patients, the remainder having sulcus fixation. Intraoperative rupture of the posterior capsule occurred in four cases. The only common postoperative complication was acute fibrinous anterior uveitis, which occurred in 29 (40%) patients, and 32% of patients followed up for at least 6 months required secondary posterior capsulotomy. This was more common in younger patients (chi-square = 4.2, P < 0.05). Corrected postoperative visual acuities were available for 51 patients, of which 71% achieved 20/60 or better visual acuity. Patients 6 years of age or younger were less likely to achieve 20/60 (chi-square = 6.61, P = 0.01)., Conclusions: This surgical strategy has proved successful, producing good visual results and causing no sight-threatening complications. Primary posterior capsulotomy may be appropriate for younger patients.

Aims: The aim of this study was to investigate the long-term outcome of the treatment of amblyopia as a sequel to preschool screening, which has not hither-to been described., Methods: All patients originally referred from a preschool screening programme were recalled for examination by letter. 255 patients were reviewed at least 4 years after discharge of which 88 were definitely amblyopic at presentation and 107 were not amblyopic at presentation and were used as controls., Results: 79% of the amblyopes improved or maintained visual acuity after discharge but this was reduced to 42% after an age induced increase (estimated from the controls) was compensated for. The mean drop in visual acuity in the amblyopic eyes which deteriorated was 0.23 (SD 0.15) logMAR units. Stepwise multiple linear regression showed that the best single predictor of post-discharge deterioration in visual acuity was the improvement in visual acuity seen during treatment (R2 = 19%). Eccentric fixation at time of follow up (increasing R2 to 47%) and good presenting acuity (further raising R2 to 57%) contributed additional information, and were both associated with greater post-discharge deterioration in visual acuity., Conclusions: The majority of amblyopes who attended for follow up maintained or improved their visual acuities after discharge. Those patients who demonstrated deterioration of their amblyopia had usually improved well during the programme and were often fixating eccentrically at follow up.

A prospective, randomised controlled study was performed to investigate whether hyaluronidase improved the efficacy of peribulbar anaesthesia. Ninety-two patients undergoing peribulbar anaesthesia for intraocular surgery all received 10 ml of an anaesthetic solution consisting of a 50:50 mixture of 2% lignocaine with 1 in 200,000 adrenaline and 0.5% bupivacaine. Patients were randomised to a hyaluronidase group which received 150 IU/ml hyaluronidase in this anaesthetic solution (a higher concentration than previous studies) or a control group which received no hyaluronidase. There were 44 patients in the hyaluronidase group and 48 patients in the control group. All anaesthetic injections were administered by an experienced ophthalmologist and no supplementary injections were required in any case. The mean time interval between administration of the block and commencement of surgery was 22 minutes. No statistically significant difference was found between the two groups for pre-operative akinesia (p = 0.16), intraoperative akinesia (p = 0.25), eyelid paralysis (p = 0.72), objective analgesia (p = 0.23) or subjective analgesia (p = 0.60). The majority of patients in both groups achieved excellent akinesia, eyelid paralysis and analgesia. The reasons for these findings in the light of previously conflicting reports on the value of hyaluronidase in peribulbar anaesthesia are discussed.