Editorial stance on duplicate and salami publication

In this edition of the British Orthoptic Journal the notice to contributors has been amended. The sentence ‘Papers are considered for publication on the understanding that they are not being submitted elsewhere at the same time’ has been extended to address the problem of duplicate publication and now appears under ‘Terms of submission’

Ocular sequelae from the illicit use of class A drugs

Aim: To highlight the changes that may take place in the visual system of the class A drug abuser. Methods: A literature review was carried out of ocular/visual sequelae of the more common class A drugs. These include stimulants (cocaine and crack cocaine), narcotics (heroin, morphine, methadone) and hallucinogenics (ecstasy, lysergic acid diethylamide, magic mushrooms, mescaline, phencyclidine). Results: Ocular sequelae affecting visual acuity, the eye and its adnexa, ocular posture and ocular motility can result from recreational use of these drug(s). Conclusions: Awareness of the consequences of illicit drug use should lead to more pertinent questioning during history-taking

Heroin and diplopia

Aims: To describe the eye misalignments that occur during heroin use and heroin detoxification and to give an overview of the management of persisting diplopia (double vision) which results from eye misalignment. Methods: A literature review using Medline and the search terms strabismus, heroin and substance withdrawal syndrome is presented. General management of cases presenting to the ophthalmologist and orthoptist with acute acquired concomitant esotropia is described. Findings: A tendency towards a divergence of the visual axes appears to be present in heroin users, although when present it may not always lead to diplopia. Following detoxification intermittent esotropia or constant esotropia (convergence of the visual axes) can occur; if intermittent the angle tends to be small and diplopia present when viewing distance objects. Occlusion of one eye to eliminate the second image could encourage the development of a constant deviation. The deviation is not caused by a cranial nerve palsy. Constant deviations of this type are classified as 'acute acquired concomitant esotropia'. Relief from the diplopia may be gained by prismatic correction, and the deviation may then resolve spontaneously. Botulinum toxin or surgical intervention may be necessary in cases that do not resolve. Conclusions: Heroin use may lead to intermittent or constant exotropia and withdrawal may result in intermittent or constant esotropia. Awareness of the mechanism causing this may avoid referral to other specialties (e.g. neurology) and awareness of treatment modalities could encourage patients to seek appropriate help for relief of symptoms

Sixty yet still active!

The British Orthoptic Society published the first British Orthoptic Journal in 1939, the second appeared in 1944 then, with the exception of 1946, annually. In the first copy of the British Orthoptic Journal the editorial outlines the events leading up to the formation of the British Orthoptic Society, and this and the subsequent history of the Society is described in the 1987 editorial, the year of the Society’s Golden Jubilee. In the president’s letter published in that first edition, Mary Maddox wrote: ‘This journal will afford a method of recording the progress of orthoptics.

Heroin withdrawal as a possible cause of acute concomitant esotropia in adults

Aim: To report the possible effects of heroin withdrawal on binocular vision. Methods: To present a case series of patients in whom esotropia developed on cessation of heroin use. Results: In each case the esotropia was concomitant and prismatic correction restored binocular single vision. Intermittent spontaneous control occurred in one patient, the deviation resolved in one and one patient was lost to follow-up. Conclusions: Heroin withdrawal should be considered as a cause of acute concomitant esotropia. However, accurate history of other medication is needed to ensure that this is not the cause of decompensation

Class A drug abuse: an ophthalmologist's problem?

[First Paragraph] The 2002/3 British Crime Survey reported that 3% of all 16 to 59 year olds (equating to around one million people) had used a class A drug in the last year. Use of a class A drug in the 16-24 year old age group (8%) has remained similar since 1996. Use of cocaine and crack cocaine are on the increase. For the first time since 1996 the use of ecstasy has decreased. Poly drug use is not uncommon. During the year 2000/1, 118,500 patients were in treatment with drug misuse agencies and general practitioners. Ocular sequelae from illicit drug use are varied, affecting visual acuity, visual perception, ocular posture or motility, the globe itself or its adnexa. Large studies are not available to allow us to quantify the problem, and many of the reports are of single cases or small case series. However, an awareness of possible problems which may arise from the use of class A drugs may alert the clinician to this as the aetiology of a condition presenting to them

Is there a relationship between prism fusion range and vergence facility?

Aim: To investigate the relationship between prism fusion range (PFR) and vergence facility (VF) measurements in subjects with normal binocular vision. Methods: Twenty-eight subjects (mean age 19 ± 1 years) with normal binocular single vision (BSV) underwent measurement of the PFR and VF in a varied order, at a test distance of 1/3 m. The PFR measurements recorded were the base out (BO) range to blur and break point and base in (BI) range to break point. The total PFR was calculated. The VF was assessed over a 1 min time period using a 12(Δ)BO/ 3(Δ)BI flip prism and recorded in cycles per minute (cpm). Results: No correlation was demonstrable between any of the single measures of the PFR and the VF results. The BO PFR to break point and the BI PFR results obtained (means 46(Δ) BO and 14(Δ) BI) were not significantly different from quoted ‘normal’ values. The VF results obtained (mean 12 ± 4.2 cpm) were found to be significantly different from the reported mean value. Conclusion: In a group of young adults with normal BSV, no correlation between PFR and VF was found. The two tests may quantify different aspects of vergence or, alternatively, results of one or both tests in this study may be unreliable

Blur point versus indistinguishable point in assessment of accommodation: objective and subjective findings in early presbyopes

Aim: To measure the distance from the eye and the refraction of the eye at the point at which print blurs and the point at which it becomes unreadable. Methods: Subjective accommodation in 7 early presbyopic subjects (mean age 45 years), with no additional near correction, was tested using 6/12 reduced Snellen and 6/12 Lea symbols. The point at which blur was first noticed and the point at which the print became indistinguishable were noted in centimetres. Objective measures of refraction were taken at each of these points. Results: Subjective and objective results for reduced Snellen and Lea symbols were similar ( p = 0.91; p = 0.81) as were the points where the print was no longer distinguishable ( p = 0.23; p = 0.72). The difference between the blur point and the indistinguishable point measured in centimetres for both the reduced Snellen text and Lea symbols were statistically significant ( p = 0.005; p = 0.0001). The objective measures for these points, however, were not statistically different ( p = 0.32 and p = 0.63, respectively). Conclusion: A clinically significant difference exists in the distance from the eyes between the point at which text blurs and the point at which it becomes indistinguishable. No significant change occurs in accommodation when measured objectively after the blur point. It is recommended that the end point of this test is the point at which print starts to blur

Orthoptic status before and immediately after heroin detoxification

Aim: To determine whether changes in orthoptic status take place during withdrawal from heroin and/or methadone. Method: A prospective study of patients, using a repeated measures design, attending a 5 day naltrexone compressed opiate detoxification programme. Results: 83 patients were seen before detoxification (mean age 27.1 (SD 4.6) years) and 69 after detoxification. The horizontal angle of deviation became less exo/more eso at distance (p<0.001) but no significant change was found at near (p = 0.069). Stereoacuity, visual acuity, and convergence were found to be reduced in the immediate post-detoxification period. Prism fusion range, refractive error, subjective accommodation, and objective accommodation at 33 cm did not reduce but a small decrease was found in objective accommodation at 20 cm. Conclusions: The eso trend found in these patients may be responsible for the development of acute concomitant esotropia in some patients undergoing heroin detoxification. However, the mechanism for this trend does not appear to be caused by divergence insufficiency or sixth nerve palsy

Quantifying the vertical fusion range at four distances of fixation in a normal population.

Aim: To compare the vertical fusional amplitudes in isometropic participants with normal binocular single vision at four distances of fixation: 33 cm, 1 m, 4 m, 6 m. Methods: Vertical fusion ranges (break point and recovery point) were measured with a Gulden vertical prism bar with the participant fixing a 6/12 Snellen equivalent letter, twice at each distance. Order effects were controlled with randomisation of both fixation distance and prism direction. Results: Twenty-seven participants were examined (aged 20.4 ± 1.05 years). Base up and base down measurements were similar, therefore measurements were combined to give a total vertical range. Median values for the break points were: 33 cm, 6(Δ) ; 1 m, 6(Δ); 4 m, 5.5(Δ); 6 m, 5.5(Δ); and for the recovery points were: 33 cm, 4(Δ); 1 m, 4(Δ); 4 m, 3.5(Δ); 6 m, 3.5(Δ). The difference was significant between either of the near measures (i.e. 33 cm and 1 m) and either of the far measures (i.e. 4 m and 6 m). Conclusions: The vertical fusion range appears to be slightly greater at near than distance. However, the difference is not clinically significant. Measurements for distance, in a normal population, appear to be the same whether a fixation distance of 4 m or 6 m is used