SUMMARY Histological examination of 99 human lacrimal glands showed a relationship between atrophy of the secretory acini and secretory duct obstruction, ascending periductal fibrosis, and obliteration of the adjacent blood vessels caused by lymphocytic and polymorphonuclear inflammation. Investigation of the subgroups of the B lymphocytic series by immunohistochemistry did not show any statistical change with age, sex, fibrosis, or lymphocytic inflammation. The concept of senile atrophy occurring as a result of senescent involution of the lacrimal gland is challenged on the basis of the histological findings.Keratoconjunctivitis sicca in the elderly population is widely considered to be due to senescent involution of the lacrimal gland. '`This degeneration has been termed 'senile atrophy" to distinguish the condition from atrophy secondary to Sjogren's syndrome, infection, and malignancy. Although arteriosclerosis45 and inflammation"7 were formerly considered to be important causative factors, various clinical reports8" have recently stressed the need for further contemporary histological studies of age related changes in the lacrimal gland.This study of the human lacrimal gland was carried out in order to define the nature and prevalence of fibrosis, acinar atrophy, and duct pathology. The original hypothesis was that, if a low intensity inflammatory process had caused these changes, there might be alterations in the relative frequency and distribution of the subgroups ofthe B lymphocytic series.Accordingly this component of the immune system was investigated by means of immunohistochemistry. Materials and methodsLacrimal gland tissue was obtained from two exenteration specimens and 97 post-mortem examinations of patients in a general hospital. Two-thirds of these specimens were used in a previous study.3 The patients were randomly selected, and cases were excluded from the study only if the quality or quantity of the material did not permit histological grading of the degree of fibrosis.The lacrimal gland was removed from one or both sides within 24 hours post mortem either via the orbit or by the conjunctival route. The tissue was fixed in cacodylate gluteraldehyde 2-5% or buffered formalin and embedded in paraffin. Sections were stained with haematoxylin and eosin, and Unna-Pappenheim technique, and the immunoperoxidase technique for immunoglobulins and macrophages "' (Dakopatts A/S). Without prior knowledge of the age, sex, and cause of death the pathological material was categorised according to the degree of fibrosis, duct pathology, and acinar atrophy. When both glands had been removed, quantitative assessment was carried out on only one specimen, which was chosen at random. This was because prior examination had revealed no significant differences between the two sides.The

Purpose To review recent advances in the diagnosis and treatment of congenital vascular malformations of the retina and choroid. Methods Review of the current literature on retinal haemangioblastoma, racemose haemangiomatosis, retinal cavernous haemangioblastoma, circumscribed choroidal haemangioma, and diffuse choroidal haemangioma. Conclusion The management of patients with congenital vascular lesions of the retina and choroid is advancing rapidly through recent developments in genetic testing, ocular imaging, and treatment. Most are associated with systemic disease, which may be lifethreatening. New therapeutic methods such as Verteporfin photodynamic therapy and antiangiogenic therapy have significantly improved the treatment of retinal and choroidal angiomas and vascular malformations. Ophthalmologists have a major role in detecting and diagnosing these tumours and in providing long-term care in collaboration with a specialist in the field.

SUMMARY S-100 protein is a 21 000 dalton acidic calcium-binding protein present in ocular melanomas and some normal ocular tissues. Ocular fluids and extracts of ocular tumours were examined by a sensitive radioimmunoassay that could detect less than 5 ng of S-100 protein in minute volumes of fluid. Three ocular melanoma biopsy specimens had S-100 protein at levels between 25 and 1300 ng/ml, comparable to that found in a cutaneous melanoma biopsy specimen (1000 ng/ml). (SI conversion: ng/ml= [tg/l.) Six melanoma culture lines had 1000 to 125 000 ng/ml.Four lymphoblastoid cultures had less than 2 ng/ml, and three colon carcinoma cultures had 180 ng/ml. Subretinal fluid from 23 melanoma-containing eyes had 10 to 76 800 ng/ml. Lesser amounts were found in eyes with small, anteriorly located, lightly pigmented tumours. Vitreous from 3 melanoma-containing eyes had 10 000 to 11 000 ng/ml. Vitreous obtained from three eyes during tractional retinal detachment repair had 500 to 1600 ng/ml, and vitreous obtained at necropsy from six normal eyes had 2 to 120 ng/ml. Aqueous from six melanoma-containing eyes had 10 to 30 ng/ml, levels not significantly different from those observed in three normal eyes (80-120 ng/ml

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This case illustrates that deferring the treatment of a choroidal melanoma presenting during pregnancy can be a reasonable treatment plan, if the patient is highly motivated to keep the eye.

and the Departments of2Ophthalmology and 3Pathology, Western Infirmary, Glasgow SUMMARY Tests of cell mediated immunity (one and two stage leucocyte migration inhibition assays) and humoural immunity (membrane immunofluorescence and serum effects on leucocyte migration) were done with leucocytes and sera from 36 patients with uveal melanoma, five with conjunctival melanoma, 21 with non-malignant ocular disease, and 189 with cutaneous melanoma. Cell mediated reactivity with melanoma extracts and serum reactivity with cultured melanoma cells were significantly more frequent in the melanoma patients, but control donor reactivity was also relatively high. Maximum reactivity was found with cells or serum from those patients in whom, on pathological examination, the intraocujar melanoma had penetrated the sclera and in patients with conjunctival melanoma. Maximum separation of melanoma patients from control donors was achieved by consideration of the results of several tests done simultaneously. These immunopathological studies were made during the period from 1972 to 1978. At follow-up in 1983 four of the five patients suffering from conjunctival melanoma had died from metastases, and 10 of the 36 with uveal melanoma had died from metastatic disease. The immunological reactions, while of some value in separating melanoma patients from those without melanoma, did not predict whether a particular patient with uveal melanoma would die of metastatic disease or would survive.In eyes with clear media malignant melanoma of the uveal tract seldom presents a significant diagnostic problem. This is because of the application of supplementary techniques such as 32P uptake, fluorescein angiography, and ultrasonography.'2 However, with opaque media, and occasionally even with clear media, assessment of a possible tumour may remain difficult. Current and fundamental problems include a basic lack of understanding of the factors that govern the biological behaviour of ocular melanoma. In particular there is no possibility of our being able to assess the chances of long-term survival for the individual patient, though statistical analysis of large numbers of enucleated eyes has emphasised the importance in prognosis of factors such as tumour size, cell type, and the presence or absence of extraocular spread at enucleation.3 A factor to be taken into account when the nature and mechanisms of metastatic disease are under consideration is the host-tumour relationship. This is also relevant to the Correspondence to Alistair J Cochran, MD.

Using a preincisional retrobulbar injection of bupivacaine with adrenaline, BS-11 pain scores remained low with no or minimal additional analgesia for up to 4 hours post surgery. In combination with oral analgesia, effective pain control was provided in most cases for up to 8 hours post block.

Purpose Uveal melanoma threatens the patient with metastatic death, visual handicap, loss of independence, financial hardship, and facial disfigurement. Ocular treatment is aimed not only at preventing metastatic death but also enhancing the patient's quality of life by conserving the eye and useful vision. The aim of this study was to measure quality of life after treatment of uveal melanoma and to correlate psychological well‐being with age, sex, prognosis, ocular outcomes, family support and other factors. Methods We measured functional well‐being, anxiety and depression in 511 patients treated for uveal melanoma in the previous five years and, using hierarchical linear regression analysis, we correlated the results with sociodemographic characteristics, baseline ocular features, tumour stage, ocular treatment, and post‐treatment ocular symptoms. Results Levels of function, depression and anxiety were similar to normative values. All outcomes were unrelated to visual acuity, tumour characteristics, whether or not the eye was preserved and the time since being treated. Women were more anxious than men, and older patients were more depressed than younger ones. Patients with good social support had consistently better outcomes than those with poor support.Patients with local recurrence at the time of completing questionnaires tended to be more anxious than others, but were not more impaired in depression or function. All PROMS were associated with ophthalmological symptoms. Patients with worse symptoms had poorer function and worse depression and anxiety. Conclusion Patients can be reassured that good psychological outcomes are normal, especially if there is good social support.