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Reversal of Lens Changes in Early Diabetes
219
NOTES, CASES, INSTRUMENTS VISUAL ACUITY AND COLOR RECOGNITION TEST FOR CHILDREN* CONRAD B E R E N S ,
M.D.
New York Although it is exceedingly important to determine the visual acuity of small children under four years of age, to obtain even an approximation of visual acuity is often prac tically impossible. After having used the test to be described for several years, it seems to be about as practical as any method I have used for obtaining approximation of visual acuity in young children. The apparatus consists of an open box, neutral gray in color, which contains 20 red, green, blue, and white enameled spheres of various sizes. t These test objects are 15 mm., 10 mm., 5.0 mm., and 3.0 mm. in diameter which, at the distance that the test normally is used (conveniently 25 c m . ) , subtends an approximate visual angle of 3° 14' for the 15mm. ball; 2° 6 ' for the 10-mm. ball; 1° 5' for the 5.0-mm. ball and 0° 3 9 ' for the 3.0mm. ball. T h e colored spheres have the following specifications* according to H a r d y ' s mea surements on the brightness of the four 10mm. objects indicated their reflection factors as: White 0.877, or 87.7% Green 0.388, or 38.8% Red 0.345, or 34.5% Blue 0.065 to 0.07, or 6.5% to 7% The results of measurements on fresh Heidelberg papers 5 showed the following: Red 0.09, or 9%
Blue Green
0.04 to 0.09, or 4% to 9% 0.38, or 38%
T h e high reflection factor for the red test object is due to a disproportionate mixture of white enamel and can be adjusted down ward by decreasing this ingredient, if de sired. T h e color extends entirely through the spheres so that if they should be chipped this would make no serious difference. Washing the test objects does not change their quality, nor is this affected by exposure to ultraviolet rays for 30 minutes. Used as a visual acuity test, one or more of the spheres is left in the box which is brought to within 25 cm. of the child's eyes to be tested. T h e box is moved, activating the ball to attract the child's attention and to stimulate him to reach for the object and attempt to remove it. T h e smallest ball which the child apparently sees or preferably can pick up, indicates the visual acuity for both eyes at 25 cm. A n attempt may then be made to test each eye separately. I n testing the color identifying ability of slightly older children who will have at least some knowledge of red and green, they may be asked to pick out a red or green ball from the other balls which are left in the box. This test has been found practical in my hands and I hope others also may find it useful. 708 Park Avenue.
REVERSAL OF LENS CHANGES IN EARLY DIABETES C H A R L E S A.
TURTZ,
M.D.
AND
* From the Department of Research, New York Association for the Blind, and the Department of Ophthalmology, New York University Post-Graduate School of Medicine. Aided by a grant from The Ophthalmological Foundation, Inc. t Distributed by R. O. Gulden, Philadelphia 20, Pennsylvania. * Manufactured by J. A. Deknatel and Son, Long Island, New York. § Hardy, L. H.: Scotometry: History and tech nique with a scotometric tangent screen and scales. Tr. Am. Ophth. Soc, 29:486, 1931.
A R N O L D I. T U R T Z ,
M.D.
New York E a r l y diabetes mellitus may be associated with changes in refraction or by a physical change in the appearance of the lens. A shift toward myopia and weakness of accommoda tion are often seen. Less common are opaci ties in the posterior subcapsular region of the lens. All of these changes are reversible
NOTES, CASES, INSTRUMENTS
220
with prompt institution of antidiabetic ther apy.
normal for his age (near-point of accommodation, 12 cm.). Slitlamp examination revealed a complete absorption of the lens opacities.
C A S E REPORT
Mr. A. L., aged 22 years, an assistant purser on a ship, consulted us on February 1, 19SS, and gave a history of blurred vision for several weeks. He first noticed this when he went to the movies and was obliged to sit unusually far forward in order to see the screen clearly. Examination revealed a tall, apparently healthy young male. His past medical history was irelevant except for an eye injury many years ago. Family history was negative. Ocular examination in our office one year before revealed a visual acuity of 20/25 in each eye. Retinoscopy revealed a low de gree of hyperopic astigmatism for which corrective lenses did not seem necessary. At the present examination visual acuity was 20/100, O.D., and 20/70, O.S. (with some squint ing). Vision was correctible to 20/25 in eacli eve by -2.75D. sph., O.D., and -2.25D. sph., O.S. He exhibited obvious weakness of accommodation (near-point of accommodation, 25 cm.). The lids were inflamed and scaly because of chronic seborrheic blepharitis. The corneas were clear, pupillary reactions active, tension and motility normal. Slitlamp examination revealed discrete, pinpoint, scat tered subcapsular and cortical opacities in each lens with some tendency for coalescence. Fundus examination revealed ovoid, well-defined discs of good color. In the left temporal periphery was an area of healed chorioretinitis, possibly trau matic in origin. The vessels were normal. There were no hemorrhages nor exudates. The patient was referred for a diabetic workup and the studies revealed: Urine, specific gravity was 1.026 and a trace of sugar was present. Blood sugar was 220 mg. He was placed on a diabetic regime and when he returned six weeks later his visual acuity was 20/25, O.U. Accommodation was
COMMENT
W i t h elevation of blood sugar there is a decrease in aqueous osmotic pressure. The fluid content of the lens cortex is increased, with a corresponding increase in curvature leading to myopia. In addition, the decrease in optical density of the cortex relative to the nucleus results in greater refractive power and further myopia. 1 Accommodative weak ness was found in 21 percent of diabetics by Waite and Beetham. 2 Duke-Elder states that the onset is typically sudden and bilateral in young persons, and tends to disappear with institution of therapy. The mechanism is ob scure ; it may be neural or lenticular in ori gin. Evanescent lens opacities are difficult to explain except as a further effect of lens cortical hydration, before actual protein denaturation occurs. SUMMARY
A young man with blurred vision was found to have developed myopia, accommo dative weakness, and lens opacities. T h e etio logy was found to be diabetes mellitus. All changes were reversed by prompt antidiabetic therapy. 525 Park Avenue.
REFERENCES
1. Duke-Elder, W. S.: Textbook of Ophthalmology. St. Louis, Mosby, 1949, v. 3 and 4. 2. Waite, J. H., and Beetham, W. P.: The visual mechanism in diabetes. New England J. Med., 212:367, 1935; 212:429, 1935.
Quezon City, Philippine Islands
cosmetic appearance. Although I have used this procedure in some cases with complete paralysis of the levator palpebrae superioris, the indications for its use and the advantages and disadvantages of the technique are out side the scope of this paper.
In this paper is presented a modification of the Friedenwald-Guyton technique 1 ; it offers a simpler procedure to restore func tion and at the same time to enhance the
* From the Eye, Ear, Nose, and Throat Service, V. Luna General Hospital, Armed Forces of the Philippines. t Chief, EENT Service.
CORRECTION OF BLEPHAROPTOSIS* WITH
A S I M P L E SURGICAL
BURGOS T.
TECHNIQUE
SAYOC, + L I E U T . COL.
(MC)
NOTES, CASES, INSTRUMENTS VISUAL ACUITY AND COLOR RECOGNITION TEST FOR CHILDREN* CONRAD B E R E N S ,
M.D.
New York Although it is exceedingly important to determine the visual acuity of small children under four years of age, to obtain even an approximation of visual acuity is often prac tically impossible. After having used the test to be described for several years, it seems to be about as practical as any method I have used for obtaining approximation of visual acuity in young children. The apparatus consists of an open box, neutral gray in color, which contains 20 red, green, blue, and white enameled spheres of various sizes. t These test objects are 15 mm., 10 mm., 5.0 mm., and 3.0 mm. in diameter which, at the distance that the test normally is used (conveniently 25 c m . ) , subtends an approximate visual angle of 3° 14' for the 15mm. ball; 2° 6 ' for the 10-mm. ball; 1° 5' for the 5.0-mm. ball and 0° 3 9 ' for the 3.0mm. ball. T h e colored spheres have the following specifications* according to H a r d y ' s mea surements on the brightness of the four 10mm. objects indicated their reflection factors as: White 0.877, or 87.7% Green 0.388, or 38.8% Red 0.345, or 34.5% Blue 0.065 to 0.07, or 6.5% to 7% The results of measurements on fresh Heidelberg papers 5 showed the following: Red 0.09, or 9%
Blue Green
0.04 to 0.09, or 4% to 9% 0.38, or 38%
T h e high reflection factor for the red test object is due to a disproportionate mixture of white enamel and can be adjusted down ward by decreasing this ingredient, if de sired. T h e color extends entirely through the spheres so that if they should be chipped this would make no serious difference. Washing the test objects does not change their quality, nor is this affected by exposure to ultraviolet rays for 30 minutes. Used as a visual acuity test, one or more of the spheres is left in the box which is brought to within 25 cm. of the child's eyes to be tested. T h e box is moved, activating the ball to attract the child's attention and to stimulate him to reach for the object and attempt to remove it. T h e smallest ball which the child apparently sees or preferably can pick up, indicates the visual acuity for both eyes at 25 cm. A n attempt may then be made to test each eye separately. I n testing the color identifying ability of slightly older children who will have at least some knowledge of red and green, they may be asked to pick out a red or green ball from the other balls which are left in the box. This test has been found practical in my hands and I hope others also may find it useful. 708 Park Avenue.
REVERSAL OF LENS CHANGES IN EARLY DIABETES C H A R L E S A.
TURTZ,
M.D.
AND
* From the Department of Research, New York Association for the Blind, and the Department of Ophthalmology, New York University Post-Graduate School of Medicine. Aided by a grant from The Ophthalmological Foundation, Inc. t Distributed by R. O. Gulden, Philadelphia 20, Pennsylvania. * Manufactured by J. A. Deknatel and Son, Long Island, New York. § Hardy, L. H.: Scotometry: History and tech nique with a scotometric tangent screen and scales. Tr. Am. Ophth. Soc, 29:486, 1931.
A R N O L D I. T U R T Z ,
M.D.
New York E a r l y diabetes mellitus may be associated with changes in refraction or by a physical change in the appearance of the lens. A shift toward myopia and weakness of accommoda tion are often seen. Less common are opaci ties in the posterior subcapsular region of the lens. All of these changes are reversible
NOTES, CASES, INSTRUMENTS
220
with prompt institution of antidiabetic ther apy.
normal for his age (near-point of accommodation, 12 cm.). Slitlamp examination revealed a complete absorption of the lens opacities.
C A S E REPORT
Mr. A. L., aged 22 years, an assistant purser on a ship, consulted us on February 1, 19SS, and gave a history of blurred vision for several weeks. He first noticed this when he went to the movies and was obliged to sit unusually far forward in order to see the screen clearly. Examination revealed a tall, apparently healthy young male. His past medical history was irelevant except for an eye injury many years ago. Family history was negative. Ocular examination in our office one year before revealed a visual acuity of 20/25 in each eye. Retinoscopy revealed a low de gree of hyperopic astigmatism for which corrective lenses did not seem necessary. At the present examination visual acuity was 20/100, O.D., and 20/70, O.S. (with some squint ing). Vision was correctible to 20/25 in eacli eve by -2.75D. sph., O.D., and -2.25D. sph., O.S. He exhibited obvious weakness of accommodation (near-point of accommodation, 25 cm.). The lids were inflamed and scaly because of chronic seborrheic blepharitis. The corneas were clear, pupillary reactions active, tension and motility normal. Slitlamp examination revealed discrete, pinpoint, scat tered subcapsular and cortical opacities in each lens with some tendency for coalescence. Fundus examination revealed ovoid, well-defined discs of good color. In the left temporal periphery was an area of healed chorioretinitis, possibly trau matic in origin. The vessels were normal. There were no hemorrhages nor exudates. The patient was referred for a diabetic workup and the studies revealed: Urine, specific gravity was 1.026 and a trace of sugar was present. Blood sugar was 220 mg. He was placed on a diabetic regime and when he returned six weeks later his visual acuity was 20/25, O.U. Accommodation was
COMMENT
W i t h elevation of blood sugar there is a decrease in aqueous osmotic pressure. The fluid content of the lens cortex is increased, with a corresponding increase in curvature leading to myopia. In addition, the decrease in optical density of the cortex relative to the nucleus results in greater refractive power and further myopia. 1 Accommodative weak ness was found in 21 percent of diabetics by Waite and Beetham. 2 Duke-Elder states that the onset is typically sudden and bilateral in young persons, and tends to disappear with institution of therapy. The mechanism is ob scure ; it may be neural or lenticular in ori gin. Evanescent lens opacities are difficult to explain except as a further effect of lens cortical hydration, before actual protein denaturation occurs. SUMMARY
A young man with blurred vision was found to have developed myopia, accommo dative weakness, and lens opacities. T h e etio logy was found to be diabetes mellitus. All changes were reversed by prompt antidiabetic therapy. 525 Park Avenue.
REFERENCES
1. Duke-Elder, W. S.: Textbook of Ophthalmology. St. Louis, Mosby, 1949, v. 3 and 4. 2. Waite, J. H., and Beetham, W. P.: The visual mechanism in diabetes. New England J. Med., 212:367, 1935; 212:429, 1935.
Quezon City, Philippine Islands
cosmetic appearance. Although I have used this procedure in some cases with complete paralysis of the levator palpebrae superioris, the indications for its use and the advantages and disadvantages of the technique are out side the scope of this paper.
In this paper is presented a modification of the Friedenwald-Guyton technique 1 ; it offers a simpler procedure to restore func tion and at the same time to enhance the
* From the Eye, Ear, Nose, and Throat Service, V. Luna General Hospital, Armed Forces of the Philippines. t Chief, EENT Service.
CORRECTION OF BLEPHAROPTOSIS* WITH
A S I M P L E SURGICAL
BURGOS T.
TECHNIQUE
SAYOC, + L I E U T . COL.
(MC)