36 The eye and orbit BRUCE R. MATHALONE Periorbital and orbital swellings Swellings related to the su raorbital !

argin "er!oid #$sts "er!oid #$sts are usuall$ e%ternal angular #$sts although the$ !a$ o##ur !ediall$ &'ig. ().*+. The$ o,ten #ause a bon$ de ression b$ their ressure- and !a$ ha.e a du!b/bell e%tension into the orbit. The$ #an also erode the orbital late o, the ,rontal bone- to be#o!e atta#hed to dura- and ,or this reason it is i! ortant to do #o! uterised to!ogra h$ &CT+ o, the area be,ore e%#ision. Neuro,ibro!atosis Neuro,ibro!atosis !a$ also rodu#e swellings abo.e the e$e. The diagnosis #an usuall$ be #on,ir!ed b$ an e%a!ination o, the whole bod$- as there are o,ten !ulti le lesions. Pro tosis #an also result &'ig. ().0+. Swellings o, the lids Meibo!ian #$sts &#hala1ion+ These are the !ost #o!!on lid swellings &'ig. ().(+. A !eibo!ian #$st is a #hroni# granulo!atous in,la!!ation o, a !eibo!ian gland. 2t !a$ o##ur on either u er or lower lids and resents as a s!ooth ainless swelling. 2t #an be ,elt b$ rolling the #$st on the tarsal late. 2t is distinguished ,ro! a st$e &hordeolu!+ whi#h is an in,e#tion o, a hair ,olli#le- usuall$ ain,ul. Meibo!ian #$sts are treated b$ in#ision and #urettage ,ro! the #on3un#ti.al sur,a#e. St$es are treated b$ antibioti#s and lo#al heat. Basal #ell #ar#ino!as &rodent ul#ers+ This is the !ost #o!!on !alignant tu!our o, the e$elids &'ig. ().4+. 2t is lo#all$ !alignant- is !ore #o!!on on the lower lids- and usuall$ starts as a s!all i! le whi#h ul#erates and has raised edges. 2t is easil$ e%#ised in the earl$ stages- and #an be treated with lo#al radiothera $ i, too big to be e%#ised. Other lid swellings These #an o##ur- but are less #o!!on. These in#lude seba#eous #$sts- a illo!as5eratoa#anthosis- #$sts o, Moll &'ig. ().6+&sweat glands+ or 7eiss &seba#eous glands+ and !ollus#u! #ontagiosu!. 8hen !ollus#u! #ontagiosu! o##urs on the lid !argin- the$ #an gi.e rise to a !ild 5erato#on3un#ti.itis and should be #uretted. Car#ino!a o, the !eibo!ian glands and rhabdo!$osar#o!as are rare lesions9 the$ need to be treated radi#all$. Meibo!ian #$sts that re#ur ,re:uentl$ should be sub!itted to bio s$. Swellings o, the La#ri!al s$ste! La#ri!al sa# !u#o#ele This o##urs ,ro! obstru#tion o, the la#ri!al du#t be$ond the sa#- and results in a ,lu#tuant swelling- whi#h bulges out 3ust below the !edial #anthus. 2t #an be#o!e in,e#ted to gi.e rise to a ain,ul tense swelling &a#ute da#r$o#$stitis+. 2, untreated it !a$ gi.e rise to a ,istula. Treat!ent is b$ er,or!ing a b$ ass o eration between the la#ri!al sa# and the nose ;a da#r$o#$storrhinosto!$ &"CR+<. 8atering o, the e$e #an o##ur due to e.ersion o, the lower lid &e#tro ion+- whi#h #auses loss o, #onta#t between the lower un#tu! and the tear ,il!- and this !ust be distinguished ,ro! a !u#o#ele.

La#ri!al gland tu!ours Pathologi#all$ these rese!ble arotid turnouts &Cha ter 40+. These are swellings o, the gland whi#h lie in the u er lateral as e#t o, the orbit- and e.entuall$ the$ lead to i! air!ent o, o#ular !o.e!ents and dis la#e!ent o, the globe ,orwards- downwards and inwards. The$ #an be leo!or hi# adeno!as with or without #ar#ino!atous #hange- #ar#ino!as or !u#oe ider!oid tu!ours. Orbital swellings 2, these rea#h an$ si1e the$ result in dis la#e!ent o, the globe and li!itation o, !o.e!ent. A ,ull des#ri tion o, these is outside the real! o, the te%t- but so!e o, the !ost #o!!on #auses in#lude the ,ollowing. = Pseudo ro tosis. This results ,ro! a large e$eball- as seen in #ongenital glau#o!a or high !$o ia. = Orbital in,la!!ator$ #onditions result in orbital #ellulitis &'ig. ().)+. = Hae!orrhagi# lesions o##ur in the orbit- a,ter trau!a or retrobulbar in3e#tions. = Neo lasia a,,e#ts the la#ri!al gland- the o ti# ner.e- the nasal sinuses and glio!a &neuro,ibro!atosis+ &'ig. ().)+- !eningio!a and osteo!a &'ig. ().>+. = "$sth$roid e%o hthal!os &'ig ().?- 'ig. ().@ and ().*A+. O,ten unrelated to a#ti.e th$roid disease .but #an start a,ter th$roide#to!$ and !a$ need urgent tarsorrha h$large doses o, steroids or e.en orbital de#o! ression- i, the e$eball is threatened b$ e% osure. This is !ost easil$ done into the nasal sinuses &Cha ter 44+. CT and !agneti# resonan#e i!aging &MR2+ s#ans are use,ul in diagnosis. = Pseudotu!our- or !alignant l$! ho!a. = Hae!angio!as o, the orbit &'ig. ().**+. = Tu!our se#ondaries or !etastases. These are rare. 2n #hildren the$ usuall$ #o!e ,ro! neuroblasto!a o, the adrenal gland- whereas in adults- the oeso hagus- sto!a#hbreast and rostate #an be sites o, ri!ar$ lesions. "iagnosti# aids "iagnosti# aids in#ludeB radiogra h$- to!ogra h$- orbital .enogra h$ultrasonogra h$- CT and MR2. Treat!ent Treat!entis dire#ted to the #ause o, the lesion i, at all ossible- ta5ing #are to re.ent e% osure o, the e$e and dis#o!,ort ,ro! di lo ia. 2ntrao#ular tu!ours Children Retinoblasto!a is a !ulti#entri# !alignant tu!our o, the retina- whi#h #an be bilateral. So!e are s oradi#- but !an$ are hereditar$. Children with a ,a!il$ histor$ should be #are,ull$ !onitored ,ro! birth. 2t is o,ten not s otted until the tu!our ,ills the globe and resents as a white re,le% in the u il &'ig. ().*0+. "i,,erential diagnosis is ,ro! retino ath$ o, re!aturit$- ri!ar$ h$ er lasi# .itreous and intrao#ular in,e#tions. 2, the tu!our is large- enu#leation !a$ be re:uired- but radiothera $- #r$othera $ or laser treat!ent #an #ure s!all lesions. Adults Malignant !elano!a is the !ost #o!!on tu!our- and it originates in the ig!ent #ells o, the #horoid #iliar$ bod$ &'ig ().*( and 'ig. ().*4+ or iris. 2t #an resent a redu#tion in .ision- a .itreous hae!orrhage or b$ the #han#e ,inding o, an ele.ated ig!ented lesion in the e$e. Crowth #an be ra id or ,airl$ slow9 as a general rule- the !ore osterior the lesion the !ore !alignant it is li5el$ to be. Malignan#$ is ulti!atel$ related to the #ell t$ e. S read is o,ten dela$ed ,or !an$ $ears- and o,ten goes to the li.er- hen#e the ad.i#e Dbeware o, the atient with a glass e$e- and an enlarged li.erE. Treat!ent is b$ light or laser #oagulation- radioa#ti.e la:ues- radio/

thera $- enu#leation and in sele#ted #ases it is b$ lo#al e%#ision using h$ otensi.e anaesthesia. NoteB a blind ain,ul e$e !a$ hide a !alignant !elano!a. "iagnosis is !ade either b$ dire#t obser.ation or b$ ultrasound whi#h shows a solid tu!our &'ig. ().*6+. 2n3uries in.ol.ing the e$e and ad3a#ent stru#tures Corneal abrasions and ul#eration The #ornea is ,re:uentl$ da!aged b$ trau!a and ,oreign bodies &'ig. ().*)+. Ul#eration #an o##ur with in,e#tion or a,ter da!age to the ,a#ial ner.e &Cha ter (4+. Post her eti# ul#eration is #o!!on and serious i, not treated. 'luores#ein instillation #an show u #ornea+ ul#eration at an earl$ stage. Treat!ent is b$ rote#tion &e$e adstarsorrha h$ or a bandage #onta#t lens+- and antibioti#s to i#all$ and s$ste!i#all$B A.6 er #ent #hlora! heni#ol or o,lo%a#in e$e dro s are #o!!onl$ used. The e$e is !ade !ore #o!,ortable b$ the use o, !$driati#s su#h as ho!atro ine or #$#lo entolate. Her es si! le% ul#ers are treated with a#$#lo.ir oint!ent. 2n #ountries in the 'ar and Middle East #hroni# in,e#tion with tra#ho!a #an #ause #orneal o a#i,i#ation and blindness. Cornea+ gra,ting is the onl$ #ure ,or an o a:ue #ornea. OsteoFodonto 5erato rosthesis #an be done in .er$ se.ere #ases o, o a:ue #orneas whi#h are not suitable ,or gra,ting. A#anthoe!eba is a serious #ause o, #ornea+ in,e#tion. This ,ungal #orneal in,e#tion usuall$ ,ollows the use o, #onta#t lenses. These rare #ases need s e#ialist treat!ent. Blunt in3uries to the e$e and orbit The ,loor o, the orbit is its wea5est wall- and in blunt trau!a- su#h as ,ist in3uries- it is o,ten ,ra#tured without ,ra#tures o, the other walls. This is #alled a blow/out ,ra#ture. Clini#al signs are eno hthal!os- bruising around the orbit and li!itation o, u ward ga1e and di lo ia. This o##urs when the e%trao#ular !us#les be#o!e tra ed in the ,ra#ture- and #an be identi,ied as a so,t tissue !ass in the antru! on a radiogra h &'ig. ().*>+- although to!ogra!s or CT s#ans !a$ be ne#essar$. Surgi#al re air o, the orbital ,loor with ,reeing o, the tra ed #ontents !a$ be ne#essar$ i, troubleso!e di lo ia ersists. Large doses o, steroids so!eti!es relie.e s$! to!s in a#ute #ases. 2, an orbital hae!orrhage is too e%tensi.e to e%a!ine the e$e- it !a$ be ne#essar$ to e%a!ine the e$e under anaesthesia be#ause there !a$ be a hidden er,oration o, the globe. 2n3uries to the lids and lid !argins !ust be re aired- and i, the la#ri!al #anali#uli are da!aged the$ should be re aired i, ossible- es e#iall$ the lower #anali#ulus- be#ause @6 er #ent o, tear drainage goes through it. Blunt in3uries #an also #ause da!age to the o ti# ner.e whi#h #an result in blindness and a total a,,erent ner.e de,e#t &'ig ().*? and 'ig ().*@+. Con#ussional in3uries Con#ussional in3uries o, the e$e #an gi.e rise to se.eral roble!s- whi#h in#lude the ,ollowing. = H$ hae!a &blood in the anterior #ha!ber+ &'ig. ().0A+. Bed rest and sedation are ad.ised be#ause the !ain danger in this #ondition is se#ondar$ bleeding- resulting in an a#ute rise in intrao#ular ressure and blood staining o, the #ornea. The use o, anti,ibrinol$ti# agents &e/a!ino#a roi# a#id+ has been ad.o#ated and- i, the ressure rises- surger$ to wash out the blood !a$ be ne#essar$. = Sublu%ation o, the lens #an be sus e#ted i, the iris- or art o, the iris- DwobblesE on !o.e!ent . = Se#ondar$ glau#o!a o,ten asso#iated with re#ession o, the angle. = Retinal and !a#ular hae!orrhages and #horoidal tears &'ig. ().0*+. = Retinal dial$sis- whi#h !a$ lead to a retinal deta#h!ent and er!anent da!age to .ision &'ig. ().00+.

Penetrating e$e in3uries These o##ur when the globe is enetrated- o,ten in road tra,,i# and other !a3or a##idents &'ig. ().0(+- and also in in3uries ,ro! shar instru!ents. 2n the UG- the seat belt law has redu#ed this t$ e o, e$e in3ur$ b$ u to >( er #ent in so!e series. The resen#e o, an irregular u il suggests rola se o, the iris- and should arouse the sus i#ion o, a enetrating in3ur$. Treat!ent is i!!ediate surger$ to restore the integrit$ o, the globe. 2, a er,oration is sus e#ted- e%tensi.e e$e e%a!ination should not be atte! ted be,ore anaesthesia be#ause this !a$ lead to ,urther e%trusion o, the intrao#ular #ontents. 2n se.ere #orneal and intrao#ular in3uries- ri!ar$ #ornea+ gra,ting- lense#to!$ and .itre#to!$ ha.e #onsiderabl$ i! ro.ed the .isual rognosis9 these !ust be done b$ an e% erien#ed e$e surgeon. 2n3uries to the o ti# ner.es !ust also be e%#luded in se.ere a##idents. 2ntrao#ular ,oreign bodies 2ntrao#ular ,oreign bodies !ust alwa$s be e%#luded when atients attend the a##ident and e!ergen#$ de art!ent with a histor$ o, wor5ing with a ha!!er and #hisel. Radiogra h$ o, the orbits should alwa$s be er,or!ed- and ,errous and #o er ,oreign bodies should alwa$s be re!o.ed. Beta/s#an ultrasonogra h$ #an also assist in lo#alising ,oreign bodies when a .itreous hae!orrhage is resent. CT #an be usedbut MR2 is #ontraindi#ated ,or orbital lesions. Burns Radiation burns These o##ur a,ter e% osure to ultra.iolet radiation a,ter ar# welding or e%#essi.e sunlight &snow blindness+ and sun la! s. Su#h burns #ause intense ain and hoto hobia due to a 5eratitis- whi#h !a$ start so!e hours a,ter e% osure. M$driati# and lo#al steroid dro s ease the #ondition- and healing usuall$ o##urs a,ter 04 hours. Ther!al burns 2, these in.ol.e the ,ull thi#5ness o, the lids- #orneal s#arring !a$ o##ur- and i!!ediate s5in gra,ting to the lids is ne#essar$. A s lash o, !olten !etal !a$ #ause !ar5ed lo#al ne#rosis- and !a$ lead to er!anent #orneal s#arring. Treat!ent is to re!o.e an$ debris b$ irrigation- and to instil lo#al atro ine- antibioti#s and steroids to re.ent su eradded in,e#tion and s#arring. Che!i#al burns Che!i#al burns- and es e#iall$ al5ali burns- #an be serious be#ause o#ular enetration o##urs :ui#5l$ and is#hae!i# ne#rosis #an result. 2!!ediate irrigation will ensure that the #he!i#al is diluted as !u#h as ossible- and all arti#les should be re!o.ed ,ro! the ,orni#es. Treat!ent #an then be #ontinued as with ther!al burns. 8ell/,itting goggles should re.ent su#h in3uries &'ig. ().04+. "i,,erential diagnosis o, the a#ute red e$e The i! ortan#e o, this is in the !anage!ent o, !inor o#ular #o! laints- and the re#ognition o, #onditions re:uiring e% ert attention. Possible #auses o, the a#ute red e$e #an be di.ided intoB =#on3un#ti.itis9 =5eratitis9 =u.eitis9 =e is#leritis and s#leritis9 =a#ute glau#o!a. Con3un#ti.itis

S$! to!s are grittiness- redness and dis#harge. Causes are in,e#ti.e- .iral- trau!ati# or allergi#. 2n the newborn it #an be serious- and gono#o##al and #hla!$dial in,e#tion !ust be e%#luded. Hernal #on3un#ti.itis &'ig. ().06+ is a ,or! o, allergi# #on3un#ti.itis- usuall$ worse in the s ring and earl$ su!!er- and o,ten asso#iated with other allergi# roble!s su#h as ha$ ,e.er. Clini#all$- !ost signs are under the u er lid whi#h !a$ ha.e a #obblestone a earan#e instead o, a s!ooth sur,a#e. Ciant u illar$ #on3un#ti.itis with large a illi under the u er lid !a$ be seen in so,t #onta#t lens wearers. This is usuall$ due to an allerg$ to the sterilising solutions and !a$ be hel ed b$ either using a reser.ati.e/,ree solution or using dail$ wear dis osable lenses where these are a li#able. Hiral #on3un#ti.itis has be#o!e !u#h !ore #o!!on. Chla!$dial and adeno.irus in,e#tions !ust be #onsidered. Adeno.iral in,e#tions usuall$ a,,e#t one e$e !u#h !ore than the other and are o,ten asso#iated with a al able reauri#ular gland. Ga osiEs sar#o!a #an resent li5e a sub#on3un#ti.al hae!orrhage &'ig. ().0)+. Considerable #on3un#ti.al irritation #an be #aused b$ the lids turning in &entro ion+ &'ig. ().0>+ or turning out &e#tro ion+ &'ig ().0? and 'ig ().0@+ and b$ ingrowing lashes. The lids should be re aired surgi#all$ to their nor!al osition. Hision is not a,,e#ted in #on3un#ti.itis- but with so!e .irus in,e#tions a 5eratitis !a$ be resent- and result in .isual loss and ain. All o, the other #onditions are ain,uland usuall$ a,,e#t .ision.Her es si! le% in,e#tion is the !ost serious- and resents itsel, as a dendriti# &bran#hing+ ul#er- shown easil$ b$ staining with ,luores#ein or Bengal rose. 2t is treated with a#$#lo.ir oint!ent ,i.e ti!es a da$. The use o, steroid dro s !ust be a.oided as this #an !a5e the #ondition !u#h worse &'ig. (4.(A+. Cornea+ ul#eration !a$ o##ur due to ingrowing lashes or #orneal ,oreign bodies!arginal ul#eration and in,e#ted ul#ers. 2n,e#ted ul#ers #an o##ur in atients wearing so,t #onta#t lenses. Her es 1oster &shingles+ a,,e#ts the o hthal!i# di.ision o, the ,i,th ner.e- and #an gi.e rise to a 5eratitis and u.eitis. 2t is i! ortant to e%#lude the use o, steroid dro s until a diagnosis has been !ade. Lo#al anaestheti# dro s should also not be gi.en on a regular basis. U.eitis This #an be anterior &inns+ or osterior. 2n anterior u.eitis the u il will be s!allso!eti!es irregular- there is #sr#u!#ornea+ in3e#tion and there !a$ be 5erati# re#i itates &GPs+ resent on the osterior sur,a#e o, the #ornea. Pain- hoto hobia and so!e .isual loss are usuall$ resent. Posterior u.eitis #an resent with a white e$e and blurred .ision. 2t usuall$ ta5es a #hroni# #ourse. Cranulo!atous diseasesBehIetEs disease- to%o las!osis and #$to!egalo.irus in,e#tion should be e%#luded. S$ste!i# steroids and #$toto%i# drugs are so!eti!es use,ul in treating these #onditions. E is#leritis and s#leritis E is#leritis or in,la!!ation o, the e is#leral tissue o,ten o##urs as an allergi# rea#tion ,ollowing an e$e in,e#tion &'ig. ().(*+. S#leritis is a !ore serious #ondition in whi#h the dee er s#lera is in.ol.ed. There is o,ten an asso#iated u.eitis and thinning o, the s#lera. 2t !a$ re:uire the use o, s$ste!i# steroids in order to treat ade:uatel$ S#leritis is o,ten asso#iated with se.ere rheu!atoid #onditions. A#ute glau#o!a This usuall$ o##urs in older- o,ten h$ er!etro i# atients. The #ornea be#o!es ha1$the u il o.al and dilated- the .ision .er$ oor and the e$e ,eels ro#5 hard. 2n se.ere #ases the ain !a$ be a##o! anied b$ .o!iting- and the ain #an be !ista5en ,or one o, an a#ute abdo!en. 2n doubt,ul #ases the use o, the tono!eter to !easure the

intrao#ular ressure is a use,ul diagnosti# ro#edure. Urgent treat!ent to redu#e the ressure b$ ilo#ar ine- a#eta1ola!ide and !annitol should be started ,ollowed b$ a surgi#al iride#to!$ or laser iridoto!$. The #ondition is usuall$ bilateral- and the se#ond e$e usuall$ needs treat!ent at the sa!e ti!e. E%#e t ,or a si! le #on3un#ti.itis- whi#h is sel,/li!iting- these #onditions re:uire e% ert treat!ent and a s e#ialist o inion should be sought. A ain,ul e$e with a third ner.e als$ o,ten signi,ies an intra#ranial aneur$s! and should be in.estigated i!!ediatel$. Painless loss o, .ision This !a$ o##ur in one or both e$es- and the .isual loss !a$ be transient or er!anent. Possible #auses areB =obstru#tion o, the #entral retinal arter$ &'ig. ().(0+9 =obstru#tion o, the #entral retinal .ein &'ig. ().((+9 =#ranial arteritis9 =is#hae!i# o ti# neuro ath$9 =!igraine and other .as#ular #auses9 =retrobulbar neuritis and a illitis9 =.itreous and retinal hae!orrhages9 =retinal deta#h!ent &'ig. ().(4+9 =!a#ular hole- #$st or hae!orrhage9 =#$stoid !a#ular oede!a o,ten a,ter surger$9 =h$steri#al blindness. S e#ialist hel should be sought in an$ #ase o, loss o, .ision. The er$thro#$te sedi!entation rate and C/rea#ti.e rotein should be !easured i!!ediatel$ i, #ranial arteritis is sus e#ted- and the #arotid s$ste! should be e%a!ined ,or bruits and other signs o, arterios#lerosis in #ases o, is#hae!i# o ti# neuro ath$ and #entral retinal arter$ o##lusion. Clau#o!a- h$ ertension- !$elo!a and diabetes should be loo5ed ,or in #ases o, #entral .ein thro!bosis. Recent developments in eye surgery 2n the last two de#ades- e$e surger$ has be#o!e a !i#ro/surgi#al s e#ialit$. Catara#t surger$ has been trans,or!ed b$ #hanges in lo#al anaesthesia- i! lantsha5oe!ulsi,i#ation and s!all in#ision surger$ whi#h allows #o! ressible sili#one or a#r$li# i! lants to be inserted through a (/!! in#ision. The i! lant ower #an be !ore a##uratel$ !easured b$ new ,or!ulae and the use o, A/S#an ultrasonogra h$. The de.elo !ents in .itreous surger$ ha.e enabled !e!branes to be eeled o,, the retina and !a#ular holes to be re aired and ha.e also in#reased the su##ess rate in retinal deta#h!ent surger$ with the additional use o, gases and sili#one oil inserted into the .itreous #a.it$. So!e aral$ti# s:uints #an be hel ed b$ the use o, ad3ustable sutures or in3e#tions o, botulinu! to%in into the o.era#ting !us#les. Re,ra#ti.e error #an be treated either b$ surger$ &radial 5erato!etr$+ or b$ the e%#i!er laser. This #an be #o!bined with LAS2G surger$ &laser in situ 5erato!eilusis+ whi#h in.ol.es re!o.ing a #ornea+ ,la and doing the laser surger$ at a dee er le.el. There ha.e been so!e #on#erns about de,e#ti.e #ontrast sensiti.it$ and roble!s with night .ision a,ter laser #orre#tion o, !$o ia. Pha5i# i! lants ha.e also been used to #orre#t high re,ra#ti.e errors.

Corneal to ogra h$ #an hel in !a5ing #orneal and re,ra#ti.e surger$ !ore a##urateand the in#reased use o, CT and MR2 s#ans hel s to diagnose orbital and intra#ranial lesions in.ol.ing the o ti# athwa$s &'ig ().(6F'ig ().(>+. 'luores#ein angiogra h$ and indo#$anine green angiogra h$ hel in the diagnosis and o##asional treat!ent o, !a#ular lesions. The onl$ ad.antage o, indo#$anine green is that the .as#ularisation o, the #horoid is !u#h easier to see. Lasers in o hthal!olog$ These were originall$ used as #oagulators. The rub$ laser was su erseded b$ the argon blueFgreen laser and then the argon green/onl$ laser- as the blue light was dangerous both to the o erator and to the atientEs !a#ula. Jellow and red wa.e lengths are also used and the doubled ,re:uen#$ JAC &$ttriu!Falu!iniu!Fgarnet+ laser #an be used as a #oagulator with a ,re:uen#$ o, 6((. The JAC laser was de.elo ed together with e%tra#a sular surger$ and is used ,or #a suloto!iesiridoto!ies and #utting anterior .itreous bands. 2n its #ontinuous !ode it #an be used to treat se.ere glau#o!as. Hol!iu! and erbiu! lasers ha.e been used to #reate sub#on3un#ti.al drainage in glau#o!a and the hol!iu! laser #an also be used in la#ri!al obstru#tion during a "CR &da#r$o#$storhinosto!$+ o eration. CO0 lasers are used to re!o.e e%ternal lesion o, the e$elids and e%#i!er lasers are used ,or re,ra#ti.e surger$. The diode laser #an be used both as a hoto#oagulator and ,or treating the #iliar$ bod$ in ad.an#ed #ases o, glau#o!a. Lasers #o!bined with ha5oe!ulsi,i#ation to li:ue,$ the hu!an lens are being de.elo ed. Laser surger$ is !a5ing ra id ad.an#es and no doubt !an$ new ,or!s o, lasers will be de.elo ed ,or use in o hthal!olog$ in the ne%t ,ew $ears. Surgi#al ro#edures E%#isiono, an e$eball 2ndi#ations in#lude a blind- ain,ul e$e- a blind- #os!eti#all$ oor e$e- intrao#ular neo las! and in #ada.ers ,or use in #orneal gra,ting.The o eration. The s e#ulu! is introdu#ed between the lids and o ened. The #on3u#ti.a is i#5ed u with toothed ,or#e s and di.ided #o! letel$ all round as near as ossible to the #ornea- TenonEs #a sule is entered- and ea#h o, the re#tus tendons hoo5ed u on a stabis!us hoo5 and di.ided #lose to the s#lera. The s e#ulu! is now ressed ba#5wards and the e$eball ro3e#ts ,orwards- blunt s#issors- #ur.ed on the ,lat- are insinuated on the inner side o, the globe- and these are used to se.er the o ti# ner.e. The e$eball #an now be drawn ,orwards with the ,or#e s- and the obli:ue !us#les- together with an$ other strands o, tissue whi#h are still atta#hing the globe to the orbit- are di.ided. A swab !oistened with hot water and ressed into the orbit will #ontrol the hae!orrhage. 2, an oribital i! lant is inserted to gi.e better e$e !o.e!ent- the !us#les are sutured to the i! lant at the a ro riate sites. E.is#eration o, an e$eball As a result o, the danger o, o ening u l$! hati# s a#es at the ba#5 o, the globe- and thus ,a.ouring !eningitis- e.is#eration is to be re,erred to e%#ision in ano hthal!itis. The s#lera is trans,i%ed with a ointed 5ni,e a little behind the #orneos#leroti# 3un#tion- and the #ornea is re!o.ed entirel$ b$ #o! leting the en#ir#ling in#ision in the s#lera. The #ontents o, the globe are then re!o.ed with a #urette- #are being e%er#ised to re!o.e all o, the u.eal tra#t. At the end o, the o eration the interior !ust a ear er,e#tl$ white. 2n#ision and #urettage o, #hala1ion &!eibo!ian #$st+

The lid !argin is e.erted to allow the a li#ation o, a !eibo!ian #la! . The ring o, the #la! is la#ed on the al ebral #on3un#ti.a with the granulo!a in the #entre. An in#ision is !ade with a sterile blade in the a%is o, the gland. The herniating granulo!atous tissue is /re!o.ed with a #urette and the gland is s#ra ed #lear. Re#urrent#$sts !a$ ha.e to ha.e the #$st wall disse#ted awa$ with s#issors. A bio s$ !a$ be ne#essar$ in re#urrent #$sts to e%#lude !alignant #hange. A#:uired i!!unode,i#ien#$ s$ndro!e &A2"S+ and the e$e &See Cha ter @+. Ga osiEs sar#o!as- ur lish or brown non ruriti# nodules or !a#ules- are a ,re:uent earl$ !ani,estation o, A2"S. Co!!onl$ a,,e#ting the ,a#e- es e#iall$ the ti o, the nose- the lesions !a$ in.ol.e the e$elids and the #on3un#ti.a. 'undus lesions are di.ided into Dnonin,e#ti.eE and Din,e#ti.eE #ategories. Nonin,e#ti.e #hanges #onsist o, #otton/wool s ots- hae!orrhages and .as#ular sheathing. These o##ur in u to 4A er #ent o, atients with the disease. 2n,e#ti.e lesions are usuall$ #aused b$ a #$to!egalo.irus in,e#tion. These lesions !a$ ha.e been des#ribed as to!ato 5et#hu and salad #rea! retino ath$E- but the attern is now #hanging and not so ,lorid. Her es 1oster- to%o las!osis- neu!o#$stis and #andidiasis lesions #an also o##ur in the retinae. C$to!egalo.irus retinitis #an be re.ented ,ro! s reading b$ treat!ent with gan#i#lo.ir or ,os#arnet or a #o!bination o, the two. These arehowe.er- to%i# in the doses re:uiredB gan#i#lo.ir to the leu#o#$tes- ,os#arnet to the 5idne$s. 2ntra.itreal in3e#tions o, gan#i#lo.ir twi#e a wee5 until the #ondition regresses is an alternati.e i, s$ste!i# treat!ent is not tolerated. 2ntra.itreal i! lants o, gan#i#lo.ir or ,os#arnet are now being used. Neuro/o hthal!ologi#al #o! li#ations in A2"S ha.e been re orted- !ost ,re:uentl$ as ner.e alsies asso#iated with intra#ranial in,e#tions with #r$ oto#o##i and to%o las!osis- or as a !ani,estation o, an intra#ranial l$! ho!a. 'urther reading Blaustein- B.H. &*@@4+ O#ular Mani,estation o, S$ste!i# "isease- Butterworth/ Heine!ann- O%,ord. Collin- K.R.O. &*@?@+ A Manual o, S$ste!ati# E$elid Surger$- 0nd edn- Chur#hill Li.ingstone- Edinburgh. 'indla$- R.". and Pa$ne- P.A.C. &*@@>+ The E$e in Ceneral Pra#ti#e- Butterworth/ Heine!ann- O%,ord. Gans5i- K. &*@@6+ Clini#al O hthal!olog$- (rd edn- Butterworth/Heine!ann- O%,ord. Ro er/Hall- M.K. &ed.+ &*@?@+ StallardEs E$e Surger$- 8right- Bristol.