- Email: [email protected]
American Board of Ophthalmology*
AMERICAN BOARD OF OPHTHALMOLOGY
690
est and, if necessary, because of a round pupil, to tumble the lens and deliver it without changing the hold on the capsule; ( 2 ) for grasping the upper part of the anterior capsule between the equator and
below. It is preferable to dislocate the lens below first and then shift the hold of the forceps to the upper part of the capsule and deliver the lens by traction and counter-pressure. T h e shafts of the forceps are 90 mm. in length, the neck is 6.5 mm. in length, and the grasping semilunar tip 2 mm. in length by 2 mm. in breadth. T h e tip of the capsule is a small replica of the W a l ker tip. 1 T w o models are available, one a crossed-action forceps which permits re laxation of pressure on the shafts after the capsule is grasped, and the other a direct-action forceps (fig. 1 ) . 35 East Seventieth Street.
Fig. 1 (Berens). A new capsule forceps. the anterior pole where it is thickest and either by traction or counter-pressure re moving the lens without dislocating it
REFERENCE
' Walker, C. E., Jr. 1936, v. 19, p. 794.
A modified capsule forceps for cataract extraction. Amer. Jour. Ophth.,
AMERICAN BOARD O F
OPHTHALMOLOGY*
C A S E REPORT C. H .
ALBAUGH,
New FINAL
M.D.
York
DIAGNOSIS : BILATERAL GONORRHEAL
SUMMARY
This is the case report of a 10-year-old boy with bilateral gonorrheal ophthalmia, who was treated with sulfanilamide. At * The case report herewith published was submitted by the American Board of Ophthal mology as representative of the type of report desired by the Board. In publishing these case histories the Journal departs from its usual method of avoiding spe cial headings and presenting a narrative de scription in order to conform with the style approved by the American Board of Ophthal mology. The Journal will from time to time present such case histories submitted by the Board in order to encourage a high type of case reporting and to recognize meritorious re ports.
OPHTHALMIA
first the improvement was satisfactory, but a drop in the blood level of the drug allowed an exacerbation of the disease to occur. Reestablishment of the blood level of sulfanilamide was followed by improvement and cure of the disease, but not without the appearance of general complications which required transfusion. T h e final result of the treatment was ex cellent. F . B., a 10-year-old white boy, was ad mitted to the Massachusetts Eye and E a r Infirmary (unit No. 188261) on April 19, 1939, and was discharged on May 24, 1939.
CASE HISTORY
691
Because the parents were not present when the patient was admitted, no previ ous history was obtained for the record. The mother was questioned at a subse quent time and stated that the child had always been healthy.
chusetts General Hospital was called in consultation in order to ascertain whether the child had any signs of gonorrhea in the urethra. It was reported that there was no evidence of gonorrheal urethritis and that it was believed that the source of infection was undoubtedly some mem ber of the family.
Present History
Eye Examination
The patient had had no eye complaints until four days before admission. He awakened that morning to find the right eye sealed shut with crusts. The eyes generally became red and sore, and a yellow creamy pus appeared in the conjunctival sac. For two days the patient's mother treated the eye with boric-acid irrigations, but because no remission of symptoms followed, she called the family physician who in turn called in an oculist. The latter referred the patient to the In firmary. Until shortly after the patient had been discharged, no reliable present history could be obtained from the family. Fin ally, after confidence had been established between the mother and the examiner, the following history was obtained: The probable source for the infection was the patient's father. He had had an acute urethritis, which the local physician diagnosed as gonorrheal. This urethritis had been present for several weeks before the patient was affected.
O.D. Examination with the focusedbeam flashlight and a loupe was produc tive of the following observations: The lids were very swollen, red, and indu rated. The palpebral conjunctiva was chemotic, fiery red, and velvety in tex ture. The cornea was clear and took no fluorescein stain. A thick, creamy dis charge welled up from the conjunctival sac. O.S. There was only slight conjunc tival injection. The cornea was clear and did not stain with fluorescein.
Previous History
Physical Examination As is customary at the Massachusetts Eye and Ear Infirmary, this examina tion was made by the Pediatric Service of the Massachusetts General Hospital. The results of the physical examination were entirely negative except for the ob servation that the child had no uvula, and that the eyes were involved in a local process. The Urological Service of the Massa
Laboratory Reports Smears and cultures (blood-agar medi um) were taken from each eye at the time of admission. The smears were stained by the Gram method and were examined at once. Study of the cultures 48 hours later confirmed the smear find ings: Smear O.D.: Loaded with pus cells, many of which contained as many as 50 gram-negative intracellular diplococci. Smear O.S.: No organisms were seen, only occasional pus cells were evident. The patient was sent to the ward and was put on a regime that is routine for this type of case: (1) Buller's shield O.S. (2) Two-percent boric-acid-solution irrigations O.D. as often as necessary to keep the eye free of exudate. (3) One-half-percent zinc-sulphate so lution every two hours in both eyes. (4) One-percent atropine-sulphate so-
692
AMERICAN BOARD OF OPHTHALMOLOGY
lution in the right eye three times daily. (5) Ten-percent protargol in both eyes three times daily. Because the use of sulfanilamide was planned, the blood-cell counts and urine were checked at once. Blood—WBC, 11,900; RBC, 4,800,000. Urine—entirely normal. Clinical Progress The administration of sulfanilamide was begun on the evening of the day of entry. Since the patient weighed about 80 pounds, the dose was set at 100 grains by mouth daily. The following morning the cornea of the right eye stained with fluorescein over about three quarters of its area. The bulbar conjunctiva had become quite chemotic and a "gutter" had formed at the limbus. Furthermore, smears were now positive for gonococci in the left eye. Treatment was ordered for both eyes and the dose of sulfanilamide was increased to 120 grains daily. On April 22, 1939, the fourth day of ■hospitalization, the blood level of sulfa nilamide was 15.6 mg. percent, and the right eye showed staining only in the lower half of the cornea. The involve ment was quite superficial. Smears from both eyes had become negative for gono cocci, although they still showed many pus cells. The discharge had become less abundant in the right eye and was mini mal in the left. On April 25, 1939, the seventh hospital day, the blood level of sulfanilamide was 13.1 mg. percent, and the right eye seemed worse in that, although the stain ing was less in extent, the appearance of a dark-green color suggested that the lesion was becoming deeper. The lesion was almost limited to an area below the pupillary border, about 2 mm. in di ameter. Smears were again negative for gonococci.
By April 27, 1939, the ninth hospital day, the contral portion of the ulcer in the right eye had begun to bulge as does a descemetocele, and the discharge from the left eye had increased in amount. Smears were still negative. Study of the situation revealed that the blood level of sulfanilamide had fallen to 10.6 mg. per cent because the child had been drinking large amounts of fluid. The drug had thus been washed out of the body through the kidneys. In view of the grave condition of the eyes, in consideration of the youth and excellent physical condition of the pa tient, and after consultation with Dr. Champ Lyons, surgeon-bacteriologist from the Massachusetts General Hos pital, drastic measures were taken. The dose of sulfanilamide was increased to 180 grains a day and the fluid intake was carefully limited to 1,500 c.c. a day. The rise in sulfanilamide level from 10.6 mg. percent on April 27th, to 19.6 mg. percent on April 28th, and to 24.4 mg. percent on May 1st, was accompanied by, at first, a gradual, then a rapid improvement in the condition of the eyes. By May 5th, there was almost no discharge from either eye, smears were negative, and the ulcer in the right eye had begun to heal, as was evidenced by the reduction in the bulging and the penetration of vessels inward toward the ulcer from the limbus below. The irrigations were stopped. Meanwhile, however, difficulties had been encountered. The patient had gradu ally become dehydrated and nauseated, and developed a distinctly dulled sensorium. The temperature gradually rose to fluctuate near 104°F. and the red-bloodcell and white-blood-cell count dropped from values of 4,800,000 and 13,000 on entry to 2,500,000 and 5,300, respectively, on May 3d. Therefore, on May 3, 1939, the fif teenth hospital day, the administration of
CASE HISTORY sulfanilamide was stopped. After proper blood typing and cross matching had been checked, the patient was given 400 c.c. of whole blood intravenously. This was followed with 1,000 c.c. of 5-percent glucose in saline intravenously. The general physical response was ex cellent, for by May 5, 1939, the patient was definitely better in all respects. The eyes had improved markedly. There was no discharge from the right eye, the con junctiva was only slightly red, and there was only a slight ptosis of the right up per lid. The patient was discharged on May 24, 1939, and given 0.25-percent zincsulphate-solution drops for instillation in both eyes three times a day. Out-Patient Visits June 6, 1939: vision (uncorrected) was: O.D., 2 0 / 3 0 - 3 ; O.S., 20/30. Examination was made with the aid of the bright flashlight, the slitlamp, and corneal microscope, and with the oph thalmoscope. The left eye was completely white and quiet. The right eye showed a vessel-infiltrated scar below in the posi tion which the ulcer had occupied. The scar involved approximately two thirds the depth of the cornea. The fundus of both eyes was perfectly normal. There was also a slight residual ptosis of the right upper lid. August 16, 1939: Examination was carried out as before. The patient had used 0.5-percent atropine sulphate in the eyes three times a day for the preceding three days. Refraction revealed the fol lowing : O.D., - 0 . 2 5 D.sph. = o - 0 . 7 5 D.cyl.
693
ax. 90° = 2 0 / 1 5 - 6 ; O.S., - 0 . 2 5 D.sph. =C= - 0 . 2 5 D.cyl. ax. 60° = 20/15. This was given as the prescription. The patient was advised to return to the hospital for a check-up examination in one year. DISCUSSION
This case has demonstrated: (1) That there is a minimum blood level of sulfanilamide for maximum therapeutic efficiency. In this case it would seem to be about 15 mg. percent. (2) That the methods of elimination of the drug must be taken into consideration in order that the blood level may be maintained without the use of unduly large doses. (3) That the use of sulfanilamide in adequate doses is not without danger. The blood picture must be watched care fully (in this case counts were made daily during administration of the drug), and in each case preparations should be made for transfusion at the time the medication is started. (4) That smears may be negative for gonococci very soon after the drug is in use, but that the organisms are not neces sarily killed, for they continue their de structive effects. Much has been learned about the use of sulfanilamide in the last year, hence these points are recapitulatory. However, at the time the case was seen, the lessons it taught were most valuable in the sub sequent treatment of patients by this method. 630 West Street.
One hundred
sixty-eighth
690
est and, if necessary, because of a round pupil, to tumble the lens and deliver it without changing the hold on the capsule; ( 2 ) for grasping the upper part of the anterior capsule between the equator and
below. It is preferable to dislocate the lens below first and then shift the hold of the forceps to the upper part of the capsule and deliver the lens by traction and counter-pressure. T h e shafts of the forceps are 90 mm. in length, the neck is 6.5 mm. in length, and the grasping semilunar tip 2 mm. in length by 2 mm. in breadth. T h e tip of the capsule is a small replica of the W a l ker tip. 1 T w o models are available, one a crossed-action forceps which permits re laxation of pressure on the shafts after the capsule is grasped, and the other a direct-action forceps (fig. 1 ) . 35 East Seventieth Street.
Fig. 1 (Berens). A new capsule forceps. the anterior pole where it is thickest and either by traction or counter-pressure re moving the lens without dislocating it
REFERENCE
' Walker, C. E., Jr. 1936, v. 19, p. 794.
A modified capsule forceps for cataract extraction. Amer. Jour. Ophth.,
AMERICAN BOARD O F
OPHTHALMOLOGY*
C A S E REPORT C. H .
ALBAUGH,
New FINAL
M.D.
York
DIAGNOSIS : BILATERAL GONORRHEAL
SUMMARY
This is the case report of a 10-year-old boy with bilateral gonorrheal ophthalmia, who was treated with sulfanilamide. At * The case report herewith published was submitted by the American Board of Ophthal mology as representative of the type of report desired by the Board. In publishing these case histories the Journal departs from its usual method of avoiding spe cial headings and presenting a narrative de scription in order to conform with the style approved by the American Board of Ophthal mology. The Journal will from time to time present such case histories submitted by the Board in order to encourage a high type of case reporting and to recognize meritorious re ports.
OPHTHALMIA
first the improvement was satisfactory, but a drop in the blood level of the drug allowed an exacerbation of the disease to occur. Reestablishment of the blood level of sulfanilamide was followed by improvement and cure of the disease, but not without the appearance of general complications which required transfusion. T h e final result of the treatment was ex cellent. F . B., a 10-year-old white boy, was ad mitted to the Massachusetts Eye and E a r Infirmary (unit No. 188261) on April 19, 1939, and was discharged on May 24, 1939.
CASE HISTORY
691
Because the parents were not present when the patient was admitted, no previ ous history was obtained for the record. The mother was questioned at a subse quent time and stated that the child had always been healthy.
chusetts General Hospital was called in consultation in order to ascertain whether the child had any signs of gonorrhea in the urethra. It was reported that there was no evidence of gonorrheal urethritis and that it was believed that the source of infection was undoubtedly some mem ber of the family.
Present History
Eye Examination
The patient had had no eye complaints until four days before admission. He awakened that morning to find the right eye sealed shut with crusts. The eyes generally became red and sore, and a yellow creamy pus appeared in the conjunctival sac. For two days the patient's mother treated the eye with boric-acid irrigations, but because no remission of symptoms followed, she called the family physician who in turn called in an oculist. The latter referred the patient to the In firmary. Until shortly after the patient had been discharged, no reliable present history could be obtained from the family. Fin ally, after confidence had been established between the mother and the examiner, the following history was obtained: The probable source for the infection was the patient's father. He had had an acute urethritis, which the local physician diagnosed as gonorrheal. This urethritis had been present for several weeks before the patient was affected.
O.D. Examination with the focusedbeam flashlight and a loupe was produc tive of the following observations: The lids were very swollen, red, and indu rated. The palpebral conjunctiva was chemotic, fiery red, and velvety in tex ture. The cornea was clear and took no fluorescein stain. A thick, creamy dis charge welled up from the conjunctival sac. O.S. There was only slight conjunc tival injection. The cornea was clear and did not stain with fluorescein.
Previous History
Physical Examination As is customary at the Massachusetts Eye and Ear Infirmary, this examina tion was made by the Pediatric Service of the Massachusetts General Hospital. The results of the physical examination were entirely negative except for the ob servation that the child had no uvula, and that the eyes were involved in a local process. The Urological Service of the Massa
Laboratory Reports Smears and cultures (blood-agar medi um) were taken from each eye at the time of admission. The smears were stained by the Gram method and were examined at once. Study of the cultures 48 hours later confirmed the smear find ings: Smear O.D.: Loaded with pus cells, many of which contained as many as 50 gram-negative intracellular diplococci. Smear O.S.: No organisms were seen, only occasional pus cells were evident. The patient was sent to the ward and was put on a regime that is routine for this type of case: (1) Buller's shield O.S. (2) Two-percent boric-acid-solution irrigations O.D. as often as necessary to keep the eye free of exudate. (3) One-half-percent zinc-sulphate so lution every two hours in both eyes. (4) One-percent atropine-sulphate so-
692
AMERICAN BOARD OF OPHTHALMOLOGY
lution in the right eye three times daily. (5) Ten-percent protargol in both eyes three times daily. Because the use of sulfanilamide was planned, the blood-cell counts and urine were checked at once. Blood—WBC, 11,900; RBC, 4,800,000. Urine—entirely normal. Clinical Progress The administration of sulfanilamide was begun on the evening of the day of entry. Since the patient weighed about 80 pounds, the dose was set at 100 grains by mouth daily. The following morning the cornea of the right eye stained with fluorescein over about three quarters of its area. The bulbar conjunctiva had become quite chemotic and a "gutter" had formed at the limbus. Furthermore, smears were now positive for gonococci in the left eye. Treatment was ordered for both eyes and the dose of sulfanilamide was increased to 120 grains daily. On April 22, 1939, the fourth day of ■hospitalization, the blood level of sulfa nilamide was 15.6 mg. percent, and the right eye showed staining only in the lower half of the cornea. The involve ment was quite superficial. Smears from both eyes had become negative for gono cocci, although they still showed many pus cells. The discharge had become less abundant in the right eye and was mini mal in the left. On April 25, 1939, the seventh hospital day, the blood level of sulfanilamide was 13.1 mg. percent, and the right eye seemed worse in that, although the stain ing was less in extent, the appearance of a dark-green color suggested that the lesion was becoming deeper. The lesion was almost limited to an area below the pupillary border, about 2 mm. in di ameter. Smears were again negative for gonococci.
By April 27, 1939, the ninth hospital day, the contral portion of the ulcer in the right eye had begun to bulge as does a descemetocele, and the discharge from the left eye had increased in amount. Smears were still negative. Study of the situation revealed that the blood level of sulfanilamide had fallen to 10.6 mg. per cent because the child had been drinking large amounts of fluid. The drug had thus been washed out of the body through the kidneys. In view of the grave condition of the eyes, in consideration of the youth and excellent physical condition of the pa tient, and after consultation with Dr. Champ Lyons, surgeon-bacteriologist from the Massachusetts General Hos pital, drastic measures were taken. The dose of sulfanilamide was increased to 180 grains a day and the fluid intake was carefully limited to 1,500 c.c. a day. The rise in sulfanilamide level from 10.6 mg. percent on April 27th, to 19.6 mg. percent on April 28th, and to 24.4 mg. percent on May 1st, was accompanied by, at first, a gradual, then a rapid improvement in the condition of the eyes. By May 5th, there was almost no discharge from either eye, smears were negative, and the ulcer in the right eye had begun to heal, as was evidenced by the reduction in the bulging and the penetration of vessels inward toward the ulcer from the limbus below. The irrigations were stopped. Meanwhile, however, difficulties had been encountered. The patient had gradu ally become dehydrated and nauseated, and developed a distinctly dulled sensorium. The temperature gradually rose to fluctuate near 104°F. and the red-bloodcell and white-blood-cell count dropped from values of 4,800,000 and 13,000 on entry to 2,500,000 and 5,300, respectively, on May 3d. Therefore, on May 3, 1939, the fif teenth hospital day, the administration of
CASE HISTORY sulfanilamide was stopped. After proper blood typing and cross matching had been checked, the patient was given 400 c.c. of whole blood intravenously. This was followed with 1,000 c.c. of 5-percent glucose in saline intravenously. The general physical response was ex cellent, for by May 5, 1939, the patient was definitely better in all respects. The eyes had improved markedly. There was no discharge from the right eye, the con junctiva was only slightly red, and there was only a slight ptosis of the right up per lid. The patient was discharged on May 24, 1939, and given 0.25-percent zincsulphate-solution drops for instillation in both eyes three times a day. Out-Patient Visits June 6, 1939: vision (uncorrected) was: O.D., 2 0 / 3 0 - 3 ; O.S., 20/30. Examination was made with the aid of the bright flashlight, the slitlamp, and corneal microscope, and with the oph thalmoscope. The left eye was completely white and quiet. The right eye showed a vessel-infiltrated scar below in the posi tion which the ulcer had occupied. The scar involved approximately two thirds the depth of the cornea. The fundus of both eyes was perfectly normal. There was also a slight residual ptosis of the right upper lid. August 16, 1939: Examination was carried out as before. The patient had used 0.5-percent atropine sulphate in the eyes three times a day for the preceding three days. Refraction revealed the fol lowing : O.D., - 0 . 2 5 D.sph. = o - 0 . 7 5 D.cyl.
693
ax. 90° = 2 0 / 1 5 - 6 ; O.S., - 0 . 2 5 D.sph. =C= - 0 . 2 5 D.cyl. ax. 60° = 20/15. This was given as the prescription. The patient was advised to return to the hospital for a check-up examination in one year. DISCUSSION
This case has demonstrated: (1) That there is a minimum blood level of sulfanilamide for maximum therapeutic efficiency. In this case it would seem to be about 15 mg. percent. (2) That the methods of elimination of the drug must be taken into consideration in order that the blood level may be maintained without the use of unduly large doses. (3) That the use of sulfanilamide in adequate doses is not without danger. The blood picture must be watched care fully (in this case counts were made daily during administration of the drug), and in each case preparations should be made for transfusion at the time the medication is started. (4) That smears may be negative for gonococci very soon after the drug is in use, but that the organisms are not neces sarily killed, for they continue their de structive effects. Much has been learned about the use of sulfanilamide in the last year, hence these points are recapitulatory. However, at the time the case was seen, the lessons it taught were most valuable in the sub sequent treatment of patients by this method. 630 West Street.
One hundred
sixty-eighth