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Minnesota Academy of Ophthalmology and Otolaryngology
SOCIETY PROCEEDINGS Discussion. DR. W M . F. HARDY asked if students had difficulty with their work due to monocular cycloplegia; also what percentage of eyes showed stopping or recession of myopia; and how long the cycloplegia was main tained. He also inquired as to the effect on esophoria. DR. J. ELLIS JENNINGS mentioned the
difficulty of knowing which cases re quired such treatment as described. Watchmakers were not considered good examples as their work was begun after the eyeball was hard enough to resist the effect of convergence. Myopia usually ceased to increase by the end of school age. A case was cited with myopia of —6.0 D.S. at the age of four years which through college had shown no increased myopia though no treat ment had been given except proper lenses. DR. TOOKER suggested that the increase noted in Dr. Luedde's cases might have been due to ciliary spasm. DR. LUEDDE, closing, said that confu sion caused by eliminating binocular fixation in students varied but usually did not interfere more than a day or two. Recessions in myopia were noted in six or eight cases. The period of treatment varied from weeks to months, first one eye and then the other being treated. No marked increase in exophoria for distance was noted but that should be watched, though muscle bal ance for distance might not be dis turbed. Using a magnifying loupe over one eye might retard development of myopia but benefit of rest for the eye by atropin was lost. There seemed to be a difference between mere conver gence and convergence with binocular fixation as in the latter there was prob ably pressure at the equator with tend ency to produce axial elongation. Con vergence took place but binocular fixa tion for near was broken up by monocu lar cycloplegia. It was in those cases that this treatment seemed beneficial. Ciliary spasm was eliminated as a fac tor, in results quoted, by alternating cyclopegia from eye to eye. The binocu lar recession or control of the manifest myopia also argued against ciliary spasm. A case of myopia had been seen
823
in a watchmaker but statistics showed a lowered incidence in watchmakers as a class. B. Y. ALVIS,
Editor.
MINNESOTA ACADEMY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY Section of Ophthalmology February 13,1931 DR. JOHN BROWN presiding
Ocular pemphigus DR. ERLING W. HANSEN presented a
patient aged sixty-six years with ocular pemphigus that began thirty years pre viously. Symblepharon of both eyes was present. There was some question of the diagnosis between old trachoma and pemphigus. There was no history of skin nor mucous membrane involve ment. Dr. Hansen said that this disease was variable in its clinical manifestations as to the site of the lesions and the mortality. Ocular pemphigus usually began in the conjunctiva, starting as greyish patches and not true bleb formation. The surface of the patches soon became shredded and was cast off. The condition might last for years and usually ended by shrinking of the con junctiva. The pathology was a fluid infiltra tion, not cellular, and shredding of the surface. The disease occurred at all ages. Discussion. DR. W. W. LEWIS had seen the case before and did not believe it to be pemphigus because of the lack of other mucous membrane or skin in volvement and lack of bleb formation. He said that trachoma led to sym blepharon. A recent case was first diagnosed by the dermatologists as erythema multiforme. Pemphigus blebs developed and included the conjunctiva. T h e patient died in about four weeks. Another case had died within three weeks. DR. HANSEN said that the diagnosis in this case was probably pemphigus but he knew of no proof. There were many cases reported by students of this dis-
824
SOCIETY PROCEEDINGS
ease, without mucous membrane in volvement. The patchy condition found in the lower lid which looked much as though there had been discrete plaques and because both outer canthi were thinned and adherent led him to sus pect pemphigus. Congenital cataract DR. HANSEN also presented a case of bilateral congenital cataracts in a man forty years old and said he thought it would be interesting to take a vote of the members on whether or not it would be wise to operate on this man. He had 20/100 vision in each eye with out any glasses. Sight could be im proved slightly with a rather high cor rection for compound myopic astigma tism. (The members present voted un animously against operation in this case.)
Paul) stated that the fundus camera and the work which Dr. Fellows was doing with it at the Eye Clinic of the University was especially valuable in providing permanent record of fundus pathology. In cases like one of those shown, which was presumably a be ginning sarcoma and, if so, probably as small a sarcoma as one ever saw, it was impossible to make positive diag nosis without further observation. The patient was returning for another photograph, about sixty days after this photograph was made. By taking later photographs and enlarging them as this one was, exact measurements of growth could be made from time to time until the diagnosis was certain. The record was of value from that standpoint alone.
Tuberculous choroiditis DR. F. FELLOWS presented the case of Sarcoma of the choroid a white male, twenty-four years of age, whose left eye was removed in Febru DR. F. FELLOWS (Minneapolis) (by invitation) reported the case of a ary, 1929, a few days following injury. woman forty-five years of age, who first In July he was seen by an oculist to noticed a dull aching pain in the occiput whom he was sent with a presumptive about February, 1930. This was worse diagnosis of sympathetic ophthalmia in the morning or during the day when of the right eye. However, the oculist she would get up after lying down for found considerable ciliary injection, a a time. This pain was associated with cloudy vitreous, and loss of pigmenta an occasional throbbing pain in the tion throughout the retina with numer temporal region on the right side and ous choroidal spots on the nasal retina. sometimes an aching sensation in the Reaction to tuberculin was strongly whole eyeball following reading or sew positive. X-rays of the chest were ing. About April first she noticed that negative. newspaper lines appeared to slant Upon his admission to the University downward from left to right. About the Hospital, December 31, 1930, the vi middle of April she noticed, when look sion was 20/20. The fundus showed ing straight ahead, that objects below many fine vitreous opacities. There was the horizontal disappeared. Her vision a fine membrane present in the vitreous had gradually become worse and since to the temporal side of the disc and ap August she had been unable to read. parently fixed in position, the free Vision in that eye now was limited to edge floating about with movement of light perception and peripheral move the eye. The retina showed a moderate ments. Fundus examination showed a amount of edema and on the nasal side round elevated mass, bluish-gray in there were about six spots of choroiditis color, in the macular region, about one- with one large and a smaller white third disc diameter in size and sur raised area giving the appearance of rounded, when first seen, by a slight tubercles. A diagnosis of solitary tuber halo of hyperemia. There was no exu- cles with tuberculous choroiditis was date present and no signs of other pa made. thology. The diagnosis lay between a Discussion. DR. F. E. BURCH called at tubercle and a sarcoma. tention to the striking contrast between Discussion. DR. F, E. BURCH (St. the picture of the beginning sarcoma
SOCIETY PROCEEDINGS
825
degree of exophoria for near, and so rarely was it accompanied by symp toms, that it might be considered to be within physiological limits. High de grees of exophoria, paradoxical though it might at first seem, seldom gave rise to symptoms. This was due, he felt, to the fact that, no sooner was near work begun than the exophoria became an exotropia. This was made evident by the fact that a symptom-producing ex ophoria would be relieved from dis comfort if one eye was bandaged. Heterophoria was an over or under action of certain muscle coordinates. Such a deranged action of the extraocular musculature could only be meas ured in dynamic units. Therefore a Jawblinking phenomenon heterophoria must logically be meas DR. H. W. GRANT (St. Paul) showed ured with the eyes in action. moving pictures of a case of this con When one eye was bandaged for a dition. prolonged period as in the occlusion Discussion. DR. E. S. STROUT (Minne test, the heterophoria that existed in apolis) stated he was very much inter that patient under ordinary circum ested in Dr. Grant's paper and case stances was disturbed and an artificial report, as he had had a similar case five condition produced. T h e coordination years ago. This was in a girl ten years that existed between accommodation of age, with a congenital ptosis involv and convergence was largely ignored. ing the left eye. She was able to raise That the prolonged covering of the lid only by opening her mouth one eye would in time fully uncover widely and protruding the tongue to the the "latent" heterophoria was untrue. left side. While accommodation was permitted to A Reese operation for the correction exist the adjustment between accom of the ptosis was performed and quite modation and convergence would exert a satisfactory result obtained. The pa its influence on the covered eye. Only tient had not been seen for several years through the prolonged covering of both so her present status was unknown. eyes might the "latent" heterophoria WALTER CAMP, become fully manifest. Recorder. In conclusion he said the occlusion test for estimating heterophoria was illogical for it was an attempt to esti MINNESOTA ACADEMY OF mate the dynamic power of the extraOPHTHALMOLOGY A N D ocular musculature by static standards. OTOLARYNGOLOGY DR. W. E. CAMP (Minneapolis) felt Section of Ophthalmology that the occlusion test might be of value in certain unusual cases of unex January 9, 1931 plained asthenopia, and believed that it DR. JOHN BROWN presiding would be of more value in the cases of Test for latent muscular imbalance vertical deviation than those of lateral DR. WALTER H. F I N K (Minneapolis) deviation. Appleman, in his paper in read a paper on this subject. the January, 1931, number of the Discussion. DR. PAUL BERRISFORD (St. American Journal of Ophthalmology Paul) said that no phase of his practice gave an analysis of 500 cases tested by gave him more trouble therapeutically his method which practically amounted than moderate degrees of exophoria. So to fogging the patient with prisms. Dr. common was the existence of a small Camp did not believe that this method and the other one which was undoubt edly a tubercle. In looking at the two pictures one could see some haziness in the vitreous anterior to the tubercle but none anterior to the sarcoma. The pigment change and the outlying pa thology with the tubercle were lacking in the sarcoma case. The latter seemed to have a halo around the growth as if retinal detachment were imminent. These two cases could almost be diag nosed clinically from the fundus photo graphs alone. T h e stereo-photographs would be even more helpful. Dr. Burch felt that the camera was a very promis ing addition to our armamentarium, both for diagnosis and for case records.
difficulty of knowing which cases re quired such treatment as described. Watchmakers were not considered good examples as their work was begun after the eyeball was hard enough to resist the effect of convergence. Myopia usually ceased to increase by the end of school age. A case was cited with myopia of —6.0 D.S. at the age of four years which through college had shown no increased myopia though no treat ment had been given except proper lenses. DR. TOOKER suggested that the increase noted in Dr. Luedde's cases might have been due to ciliary spasm. DR. LUEDDE, closing, said that confu sion caused by eliminating binocular fixation in students varied but usually did not interfere more than a day or two. Recessions in myopia were noted in six or eight cases. The period of treatment varied from weeks to months, first one eye and then the other being treated. No marked increase in exophoria for distance was noted but that should be watched, though muscle bal ance for distance might not be dis turbed. Using a magnifying loupe over one eye might retard development of myopia but benefit of rest for the eye by atropin was lost. There seemed to be a difference between mere conver gence and convergence with binocular fixation as in the latter there was prob ably pressure at the equator with tend ency to produce axial elongation. Con vergence took place but binocular fixa tion for near was broken up by monocu lar cycloplegia. It was in those cases that this treatment seemed beneficial. Ciliary spasm was eliminated as a fac tor, in results quoted, by alternating cyclopegia from eye to eye. The binocu lar recession or control of the manifest myopia also argued against ciliary spasm. A case of myopia had been seen
823
in a watchmaker but statistics showed a lowered incidence in watchmakers as a class. B. Y. ALVIS,
Editor.
MINNESOTA ACADEMY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY Section of Ophthalmology February 13,1931 DR. JOHN BROWN presiding
Ocular pemphigus DR. ERLING W. HANSEN presented a
patient aged sixty-six years with ocular pemphigus that began thirty years pre viously. Symblepharon of both eyes was present. There was some question of the diagnosis between old trachoma and pemphigus. There was no history of skin nor mucous membrane involve ment. Dr. Hansen said that this disease was variable in its clinical manifestations as to the site of the lesions and the mortality. Ocular pemphigus usually began in the conjunctiva, starting as greyish patches and not true bleb formation. The surface of the patches soon became shredded and was cast off. The condition might last for years and usually ended by shrinking of the con junctiva. The pathology was a fluid infiltra tion, not cellular, and shredding of the surface. The disease occurred at all ages. Discussion. DR. W. W. LEWIS had seen the case before and did not believe it to be pemphigus because of the lack of other mucous membrane or skin in volvement and lack of bleb formation. He said that trachoma led to sym blepharon. A recent case was first diagnosed by the dermatologists as erythema multiforme. Pemphigus blebs developed and included the conjunctiva. T h e patient died in about four weeks. Another case had died within three weeks. DR. HANSEN said that the diagnosis in this case was probably pemphigus but he knew of no proof. There were many cases reported by students of this dis-
824
SOCIETY PROCEEDINGS
ease, without mucous membrane in volvement. The patchy condition found in the lower lid which looked much as though there had been discrete plaques and because both outer canthi were thinned and adherent led him to sus pect pemphigus. Congenital cataract DR. HANSEN also presented a case of bilateral congenital cataracts in a man forty years old and said he thought it would be interesting to take a vote of the members on whether or not it would be wise to operate on this man. He had 20/100 vision in each eye with out any glasses. Sight could be im proved slightly with a rather high cor rection for compound myopic astigma tism. (The members present voted un animously against operation in this case.)
Paul) stated that the fundus camera and the work which Dr. Fellows was doing with it at the Eye Clinic of the University was especially valuable in providing permanent record of fundus pathology. In cases like one of those shown, which was presumably a be ginning sarcoma and, if so, probably as small a sarcoma as one ever saw, it was impossible to make positive diag nosis without further observation. The patient was returning for another photograph, about sixty days after this photograph was made. By taking later photographs and enlarging them as this one was, exact measurements of growth could be made from time to time until the diagnosis was certain. The record was of value from that standpoint alone.
Tuberculous choroiditis DR. F. FELLOWS presented the case of Sarcoma of the choroid a white male, twenty-four years of age, whose left eye was removed in Febru DR. F. FELLOWS (Minneapolis) (by invitation) reported the case of a ary, 1929, a few days following injury. woman forty-five years of age, who first In July he was seen by an oculist to noticed a dull aching pain in the occiput whom he was sent with a presumptive about February, 1930. This was worse diagnosis of sympathetic ophthalmia in the morning or during the day when of the right eye. However, the oculist she would get up after lying down for found considerable ciliary injection, a a time. This pain was associated with cloudy vitreous, and loss of pigmenta an occasional throbbing pain in the tion throughout the retina with numer temporal region on the right side and ous choroidal spots on the nasal retina. sometimes an aching sensation in the Reaction to tuberculin was strongly whole eyeball following reading or sew positive. X-rays of the chest were ing. About April first she noticed that negative. newspaper lines appeared to slant Upon his admission to the University downward from left to right. About the Hospital, December 31, 1930, the vi middle of April she noticed, when look sion was 20/20. The fundus showed ing straight ahead, that objects below many fine vitreous opacities. There was the horizontal disappeared. Her vision a fine membrane present in the vitreous had gradually become worse and since to the temporal side of the disc and ap August she had been unable to read. parently fixed in position, the free Vision in that eye now was limited to edge floating about with movement of light perception and peripheral move the eye. The retina showed a moderate ments. Fundus examination showed a amount of edema and on the nasal side round elevated mass, bluish-gray in there were about six spots of choroiditis color, in the macular region, about one- with one large and a smaller white third disc diameter in size and sur raised area giving the appearance of rounded, when first seen, by a slight tubercles. A diagnosis of solitary tuber halo of hyperemia. There was no exu- cles with tuberculous choroiditis was date present and no signs of other pa made. thology. The diagnosis lay between a Discussion. DR. F. E. BURCH called at tubercle and a sarcoma. tention to the striking contrast between Discussion. DR. F, E. BURCH (St. the picture of the beginning sarcoma
SOCIETY PROCEEDINGS
825
degree of exophoria for near, and so rarely was it accompanied by symp toms, that it might be considered to be within physiological limits. High de grees of exophoria, paradoxical though it might at first seem, seldom gave rise to symptoms. This was due, he felt, to the fact that, no sooner was near work begun than the exophoria became an exotropia. This was made evident by the fact that a symptom-producing ex ophoria would be relieved from dis comfort if one eye was bandaged. Heterophoria was an over or under action of certain muscle coordinates. Such a deranged action of the extraocular musculature could only be meas ured in dynamic units. Therefore a Jawblinking phenomenon heterophoria must logically be meas DR. H. W. GRANT (St. Paul) showed ured with the eyes in action. moving pictures of a case of this con When one eye was bandaged for a dition. prolonged period as in the occlusion Discussion. DR. E. S. STROUT (Minne test, the heterophoria that existed in apolis) stated he was very much inter that patient under ordinary circum ested in Dr. Grant's paper and case stances was disturbed and an artificial report, as he had had a similar case five condition produced. T h e coordination years ago. This was in a girl ten years that existed between accommodation of age, with a congenital ptosis involv and convergence was largely ignored. ing the left eye. She was able to raise That the prolonged covering of the lid only by opening her mouth one eye would in time fully uncover widely and protruding the tongue to the the "latent" heterophoria was untrue. left side. While accommodation was permitted to A Reese operation for the correction exist the adjustment between accom of the ptosis was performed and quite modation and convergence would exert a satisfactory result obtained. The pa its influence on the covered eye. Only tient had not been seen for several years through the prolonged covering of both so her present status was unknown. eyes might the "latent" heterophoria WALTER CAMP, become fully manifest. Recorder. In conclusion he said the occlusion test for estimating heterophoria was illogical for it was an attempt to esti MINNESOTA ACADEMY OF mate the dynamic power of the extraOPHTHALMOLOGY A N D ocular musculature by static standards. OTOLARYNGOLOGY DR. W. E. CAMP (Minneapolis) felt Section of Ophthalmology that the occlusion test might be of value in certain unusual cases of unex January 9, 1931 plained asthenopia, and believed that it DR. JOHN BROWN presiding would be of more value in the cases of Test for latent muscular imbalance vertical deviation than those of lateral DR. WALTER H. F I N K (Minneapolis) deviation. Appleman, in his paper in read a paper on this subject. the January, 1931, number of the Discussion. DR. PAUL BERRISFORD (St. American Journal of Ophthalmology Paul) said that no phase of his practice gave an analysis of 500 cases tested by gave him more trouble therapeutically his method which practically amounted than moderate degrees of exophoria. So to fogging the patient with prisms. Dr. common was the existence of a small Camp did not believe that this method and the other one which was undoubt edly a tubercle. In looking at the two pictures one could see some haziness in the vitreous anterior to the tubercle but none anterior to the sarcoma. The pigment change and the outlying pa thology with the tubercle were lacking in the sarcoma case. The latter seemed to have a halo around the growth as if retinal detachment were imminent. These two cases could almost be diag nosed clinically from the fundus photo graphs alone. T h e stereo-photographs would be even more helpful. Dr. Burch felt that the camera was a very promis ing addition to our armamentarium, both for diagnosis and for case records.