SUMMARY A patient with temporal arteritis developed a variety of ischaemic lesions in the eyes. Infarction of the inner retina and optic nerve head was delineated on presentation by white swelling in the retinal nerve fibre layer. The role of interrupted axoplasmic transport in the production of this sign is discussed. Outer retinal infarction was also noted on presentation and subsequently gave rise to striking pigmented scars.Temporal arteritis often presents with visual loss, and necropsy examination in such cases shows widespread disease of the ophthalmic artery and the extraocular course of its ciliary and retinal branches (Henkind et al., 1970). The medial and lateral posterior ciliary arteries supply the optic nerve head, the outer retina, and, in 20 to 50% of individuals, a variable area of inner retina contiguous with the optic disc (Hayreh, 1969); the central retinal artery supplies the remainder of the inner retina.We present a patient with a unique combination of fundus signs resulting from arteritic obstruction of the blood supply to each of the above arterial territories. The clinical findings are correlated with recent experimental work on the pathophysiology of ischaemic fundus lesions. Case reportA 75-year-old woman presented with a 2-week history of 'misty' vision in each eye. She had suffered weight loss, bitemporal headaches, jaw claudication, and aching limbs during the previous 3 months.On examination vision in each eye was found to be reduced to perception of hand movements only. Pupil reactions were sluggish, and there was a left relative afferent pupillary defect. Examination of the right fundus revealed pallor and swelling of the optic disc and mild translucent swelling of the temporal parapapillary retina (Fig. 1) At first sight the left eye showed a similar ophthalmoscopic picture, with pale swelling of the nasal part of the optic disc and a row of fluffy white cotton-wool spots crossing the papillomacular bundle (Fig. 2). However, there was no cilioretinal arteriolar supply to this eye, and the temporal parapapillary retina was normal in appearance. The remainder of the fundus showed diffuse translucent swelling of the inner retina sparing the fovea, and a band of opacity of the outer retina was noted in the macula (Fig. 2). The central arterioles were attenuated, and the venous blood was markedly deoxygenated.Fluorescein fundus angiography on the right showed satisfactory filling of the central retinal artery but slow filling of the choroid, optic nerve head, and cilioretinal arterioles. In the left eye markedly impaired perfusion was evident in the territories of supply of both the posterior ciliary arteries and the central retinal artery. Both optic discs showed excessive dye leakage in the late pictures. The right eye had a normal electroretinogram (ERG) and electro-oculogram (EOG), but there were minimal electroretinal responses from the left eye.The patient appeared to be indifferent to her loss of sight. No other abnormality was found on general examination. The erythrocyte se...

SUMMARY Bupivacaine 0°5% when used as a local anaesthetic for ocular cataract surgery does not give absolute ocular akinesia but provides adequate and prolonged pain relief. In comparison lignocaine provides good ocular akinesia at operation but pain relief is short lived. In the present study the adequacy of analgesia, operating conditions, and complications were compared for three drug regimens under standard operating conditions. The retrobulbar block was performed with either lignocaine or bupivacaine or a mixture of lignocaine and bupivacaine according to a predetermined protocol.The success of any nerve block depends on the operator, who requires a thorough knowledge of the anatomy. Diffusion of drugs is restricted by anatomical boundaries, and correct placement of drugs leads to a smaller dose being necessary. The study was therefore designed for blocks to be performed solely by the operator, so as to use the minimal doses of the various local anaesthetics to give acceptable ocular anaesthesia and akinesia. Material and methodsNinety adult consenting patients were allocated randomly to one of three groups (A, B, and C), 30 patients in each group. Group A had their cataract surgery performed under bupivacaine as the local Correspondence to Rcvd Professor E 0 Oji, FRCS, University of Jos Medical School, Jos, Plateau State, Nigeria.anaesthetic. Group B had their cataract surgery under lignocaine, and in group C a mixture of lignocaine and bupivacaine was administered.Each patient received 75 mg of pethidine intramuscularly one hour preoperatively to provide minimal sedation and analgesia. Thirty minutes before surgery each patient also received topical drops of 0*4% oxybuprocaine to the eye for surgery every 5 to 10 minutes till the operation began.Group A patients received 1-5 ml of 0-5% bupivacaine through a retrobulbar needle, 4-0 ml of 0-5% bupivacaine at the stylomastoid foramen and around the parotid distribution of the facial nerve for the seventh cranial nerve block, band 0-5 ml of 0-5% bupivacaine each to the upper and lower lids for paralysis immediately before surgery.Similarly, group B patients received 1-5 ml of 2% lignocaine retrobulbarly, 4-0 ml of 2% lignocaine for the facial nerve block and 0-5 ml of 2% lignocaine each to the upper and lower lids.For the group C patients a mixture of 0-5% bupivacaine 3-5 ml and 2% lignocaine 3 5 ml was used. The two were thoroughly mixed before the C~H3 -m >~~~NH C t CH3N bupivacaine C H9 ACH3~1

Etomidate (R-( +)-ethyl-1-(pentylethyl) IHimidazole-5-carboxylate sulphate) is a recently introduced intravenous anaesthetic induction agent. It is rapidly broken down in the liver and plasma, and unlike other intravenous hynotics, does not produce a rise in plasma histamine.' Clinical and laboratory ~t u d i e s~-~ have shown that minimal cardiovascular or respiratory depression occurs with etomidate. The drug is available for general anaesthesia in this country, and in selected patients it has definite advantages over other anaesthetic drugs with regard to rapidity of recovery, the absence of histamine release and cardiovascular stability.The two most common side-effects are involuntary muscle movements, which occur in up to 20% of patients, and pain on injection into small peripheral veins. A significant reduction in intraocular pressure (IOP) has recently been reported in patients induced with e t~m i d a t e .~ However, IOP was measured after the time of maximal involuntary muscle activity, with a Schiotz tonometer.In this study the effect of etomidate on IOP was observed with special reference to the duration of any change in the pressure of the eye and its relationship to involuntary muscle movement and dosage. MethodInformed consent was obtained from seventy patients whose ages ranged from 16 to 85 years.They presented for general surgical, gynaecological and orthopaedic operations. Preoperative medication was administered according to the physical status and age of the patient. Anaesthesia was induced by an intravenous injection of etomidate, the first fifty patients receiving 0.3 mglkg body weight and the remainder 0.25 mg/kg.The calculated dose of etomidate was injected over 10-15 s and observations about the following were made, Involuntary muscle movements were classified as mild (slight twitching), moderate (where there was contraction of a large group of muscles) or severe (resembling a generalised convulsion).Eye movements: nystagmus or Bell's phenomenon.Pupillary size: simple estimation with a ruler. Site of injection (whenever possible etomidate was injected into a large vein).Pain on injection. Pulse rate at 1-min intervals. Arterial blood pressure ; pre-induction and at 1 and 5 min following induction. Respiratory disturbancesAnaesthesia was maintained after the first minute with the patient breathing spontaneously, with 60% nitrous oxide and 40% oxygen using a Magill system. Halothane was gradually added to the inspired gas during the next minute in order to avoid return of consciousness.

Summary Oculomycosis may be divided into the orbital infections of phycomycosis of Aspergillus and other species and the infections of the globe. The latter comprise endogenous, post-surgical or traumatic intra-ocular infections and direct infections of the cornea: these are the commonest form of oculomycosis. They are not easy to differentiate from other, more common causes of septic infection of the eye. The early recognition of fungal infections of the eye thus rests on maintaining an efficient service for all septic infections of the eye. Candida albicans and other dimorphic fungal infections are best treated with flucytosine combined with either polyenes such as amphotericin B and natamycin or combined with imidazoles such as clotrimazole or miconazole. Aspergillus spp. account for about 50% of the cases of filamentous fungal infection of the cornea but more than 100 species of varying pathogenicity and drug sensitivity have been implicated. Econazole, clotrimazole or miconazole combined with thiabendazole are recommended for Aspergillus spp. Econazole, thiabendazole or miconazole combined with flucytosine for Cladosporium sp. For Fusarium solani and other species econazole is the best drug but some isolates are sensitive to thiabendazole or other imidazoles. Alternatively, filamentous fungal infections may be treated with natamycin which has a broad spectrum of activity; but does not penetrate well and, like other polyenes, should not be combined with imidazole antifungal chemotherapy because of antagonistic drug interaction. Overall, econazole emerges as the most widely acting drug; but successful results are dependent on rather complex investigation with intensive and protracted care that can best be provided in a few centres of referral.