Background/aims-Tuberous sclerosis complex (TSC) has retinal and nonretinal ophthalmic manifestations. This study was designed to determine the prevalence of the ophthalmic manifestations and of refractive errors in a population of patients with TSC. Methods-179 patients identified were in a prevalence study of TSC in the south of England and 107 of these agreed to full ophthalmic examination which was successful in 100. Ophthalmic examination included examination of the eyelids, cover test, examination of the irides, dilation funduscopy using both direct and indirect ophthalmoscopy, and refraction using retinoscopy. Myopia was defined as a spherical equivalent <−0.5D and hyperopia as a spherical equivalent >+0.5D. Results-Retinal hamartomas were seen in 44 of the 100 patients. The commonest morphological type of hamartoma seen was the flat, translucent lesion in 31 of the 44 patients (70%). The multinodular "mulberry" lesion was seen in 24 of the 44 patients (55%) and the transitional type lesion was seen in four of the 44 patients (9%). Punched out areas of retinal depigmentation were seen in 39 of the 100 patients but only six of 100 controls. 27% of eyes were myopic, 22% were hyperopic, and 27% had astigmatism >0.75D. Of the non-retinal findings, 39 patients had angiofibromas of the eyelids, five had nonparalytic strabismus, and three had colobomas. Conclusion-Apart from the higher prevalence of flat retinal hamartomas, the findings of this study compare closely with previous large clinic based series of TSC patients. Refractive findings were similar to previous studies of a similarly aged non-TSC population. This is the first series to document the statistically significant association of punched out chorioretinal depigmentation with TSC and the authors believe that it should be looked for as an aid to diagnosis. (Br J Ophthalmol 2001;85:420-423) Tuberous sclerosis complex (TSC) is a multisystem disorder characterised by hamartomatous growths that can occur in almost any organ or tissue. The first description of TSC is usually attributed to Bourneville in 1880 1 and in 1908, Vogt described the classic triad of epilepsy, mental retardation, and adenoma sebaceum (now called angiofibromatosis).2 The clinical manifestations of TSC are now known to be far more diverse and a more inclusive system of primary and secondary diagnostic criteria have been introduced.3 These include cortical tubers, retinal astrocytomas, facial angiofibromas, ungual fibromas, hypomelanotic skin lesions, shagreen patch, and renal angiomyolipomas.Ophthalmic features associated with TSC can be divided into retinal and non-retinal. The retinal associations of TSC were first noted by Van der Hoeve in 1921. 4 He termed these lesions phakomas (derived from the greek phakos, meaning spot) and introduced the concept of phakomatosis. These retinal lesions are now known to be astrocytic hamartomas.5

Aim: To investigate the retinal toxicity of intravitreal injection of a novel fibrinolytic tenecteplase in rabbit eyes. Methods: Tenecteplase (25-350 mg in 0.1 ml BSS) was injected into the vitreous cavity of normal rabbit eyes. Control (fellow) eyes received 0.1 ml of BSS. One day, 1 week, and 2 months post-injection, the eyes were examined by slit lamp biomicroscopy, indirect ophthalmoscopy, and electroretinography, and then harvested for histopathological examination. Results: No evidence of retinal toxicity was seen with tenecteplase doses up to and including 50 mg. At a dose of 150 mg ophthalmoscopy was normal, but histology showed mild retinal damage in the inner nuclear layer and electroretinography showed a temporary reduction in B-wave amplitude. At doses of 200 mg and above, there was evidence of retinal toxicity on electroretinography, ophthalmoscopy, and histology. Ophthalmoscopic findings included vitreal fibrosis, retinal necrosis and tractional retinal detachment and light microscopy revealed necrosis of retinal pigment epithelium and other retinal layers. Damage was centred around the injection site but was more widespread with the higher doses. Conclusion: A dose of 50 mg tenecteplase appears safe for intravitreal injection in the rabbit. Tenecteplase could have potential applications in the treatment of submacular haemorrhage and retinal vein occlusion.T issue plasminogen activator (tPA) is a recombinant plasminogen activator which binds to the fibrin component of thrombus and converts thrombus bound plasminogen to plasmin which initiates local fibrinolysis. Although primarily used in the management of acute myocardial infarction, it has also been used for various indications in the field of ophthalmology. These include dissolution of fibrin from the surface of intraocular lenses, 1 accelerating the resolution of post-vitrectomy fibrin, 2 treatment of central retinal vein occlusion with local 3 and systemic treatment, 4 and facilitating clearance of submacular haemorrhage. 5Shortcomings of tPA in the management of acute myocardial infarction include short half life necessitating infusion rather than a bolus injection 6 and this has led to the development of modified tPA compounds such as tenecteplase. Compared to tPA, tenecteplase has a longer half life and greater fibrin specificity, and so has potentially greater efficacy in thrombus dissolution.7 This could provide significant advantages in ophthalmic applications.The results in animal studies of intravitreal injection of tPA in concentrations greater than 25 mg/0.1 ml have implied that use of this dose of tPA in humans would be unsafe. 8 9 As tenecteplase may have a better outcome in ophthalmic use, we therefore investigated the retinal toxicity of intravitreal injections of various doses of tenecteplase using slit lamp examination, indirect ophthalmoscopy, electroretinography (ERG), and light microscopy. MATERIALS AND METHODSThe tenecteplase used in this study was the commercially available preparation and was donated by the manufacturer (...

Aims-A prospective, randomised, double blind study was used to investigate the eVect of hyaluronidase on the quality of block achieved with sub-Tenon's local anaesthesia. Methods-150 patients scheduled for elective cataract surgery were randomly allocated to either sub-Tenon's block with 3 ml lignocaine 2%/adrenaline 1:200 000 alone or with the addition of 30 IU/ml of hyaluronidase. The blocks were assessed for degree of akinesia and reduction of eyelid movement, and also post-injection and postoperative pain scores. Results-Akinesia and reduction of eyelid movement measured 10 minutes after injection were significantly better in the group with hyaluronidase added to the anaesthetic solution. Postoperative pain scores were not significantly diVerent between the two groups but the postinjection pain score was greater (marginally significant) in the group with hyaluronidase added. Conclusion-The addition of hyaluronidase significantly improves the quality of the motor blockade achieved with subTenon's local anaesthesia, but has no eVect on the sensory blockade. (Br J Ophthalmol 2000;84:435-436) The single quadrant technique for sub-Tenon's local anaesthesia was popularised by Stevens 1 in 1992 as a safe and eVective method for ophthalmic anaesthesia, avoiding the risks of sharp needle techniques. Delivery of the local anaesthetic solution to the posterior sub-Tenon's space is followed by diVusion of the solution through Tenon's capsule and into the retrobulbar compartment where the anaesthetic exerts its eVect.

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tests so that those in whom 5 consecutive measurements showed a difference of more than 3 mmHg were excluded. Measurements in 62 of 94 eyes showed a variation of 3 mmHg or less, and these were considered suitable for the definitive studies. All preparations were administered by a third party to ensure double-blindedness on the part of subject and investigator, and were instilled into the left eye. Intraocular pressure' 3 and radial pulse rate over 1 minute after 5 minutes at rest (sitting) were measured before and at 30, 60, and 90 minutes after drug instillation. Three recordings of intraocular pressure in each eye were taken on each occasion and the means recorded.Two studies were carried out, the first comparing timolol 0 25 and 0 5% with normal saline, and the second pindolol 1%, timolol 0-25%, and normal saline. In each study 12 subjects were studied, no subjects taking part in more than 1 study. They attended on 3 occasions at least 1 week apart for instillation of 1 drop into the conjunctival sac (a) timolol 0.25%, 0.5%, or saline 0. 9%, or (b) pindolol 1 %, timolol 0-25 %, or saline 09 %, given in a balanced design based on 4 Latin squares.

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Most ophthalmologists are aware of the risk of elevated intraocular pressure developing 1 or 2 months after an intravitreal injection of triamcinolone. However, the two cases reported here demonstrate that such a rise can occur significantly later than this. All patients who have had intravitreal steroid injection should therefore have prolonged intraocular pressure monitoring.