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The Israel Ophthalmological Society
MEETINGS, CONFERENCES, SYMPOSIA EDITED BY THOMAS CHALKLEY,
T H E N E W ENGLAND OPHTHALMOLOGICAL SOCIETY The 511th meeting of the NEOS was opened by Dr. G. Sullivan, January 21, 1970, in Boston. Dr. C. K. Beyer presented help ful hints on the appropriate plastic surgical procedures to be employed in the common ophthalmic eyelid procedures. He empha sized the utility and safety of using scierai shells while working on the eyelids. As can cer cases were presented, Dr. M. Schulz advocated a trial of radiation whenever the biopsy warranted radiation. Radiation should precede rather than follow surgery. Dr. C. E. Iliff believes forehead flaps to orbital defects should be avoided where possible. The afternoon session at the Museum of Science was chaired by Dr. G. Sullivan. Dr. S. D. Hecht presented an upper to lower eyelid, full-thickness sharing technique. He creates a bridge of the upper tarsus by bringing a full-thickness flap of skin, orbicularis, levator and conjunctiva down to fill the lower eyelid defect. After a suitable healing time, he separates the flap. The remarkable features include no ptosis or lagophthalmos and no vertical tropia. He was unable to ex plain why the complications did not occcur, a pleasant position to be in. Dr. M. Schulz, Chief of Radiotherapy at Massachusetts General Hospital, favors radiotherapy over surgery for skin cancer about the eyelids, claiming less cosmetic de ficiency. He reported a 90% success rate when radiotherapy is used on small carci nomas. If the tumor is large, inavding the orbit or fixed, then only a 33% success rate was present. Throughout the day, there re mained unchanged those surgeons who fa vored surgery in difficult cases, and those radiologists and some ophthalmologists who favored radiotherapy. Both agreed that bi opsy was a prerequisite to all treatment. Dr. Schulz reported the succcessful use of a lead scierai shell which permits the specific appli
M.D. 32
cation of a P impregnated template to treat tumors of either the tarsal or bulbar conjunctiva. Blepharoptosis treatment was reviewed by Dr. C. C. Johnson who emphasized the im portance of a suitably placed eyelid fold. Dr. C. K. Beyer reviewed the approaches to treat exposed and extruded orbital implants. Although most methods are successful in the orginators hands, he feels the small glass beads offer flexibility in application, both as to site and amount. Drs. Reinecke and Carroll reviewed the complications and care of silicone lacrimal tubes. The sniffing patient (while occluding his naris) keeps the silicone tube patent and clean, preventing several complications. The complications were numerous, but all of a trival nature. Persistence of the doctor and patient yield a high success rate. A kaleidoscope of plastic surgical proce dures of the eye was presented by Dr. Charles E. Iliff of Baltimore. His lucid teaching, ac cented with appropriate examples of photos and movies, delighted and taught the audi ence new skills in eye plastic care. Following dinner, Dr. Raymond Robillard, President, Federation of Medical Spe cialists of Quebec, reviewed the effectiveness of the bargaining power of physicians' unions in Canada. He predicted national health insurance for all in the United States within the next five years. Robert D. Reinecke T H E ISRAEL OPHTHALMOLOGICAL SOCIETY The 7th symposial meeting of the Israel Ophthalmological Society was held in Jeru salem March, 12 to 14, 1970, under the chair manship of Prof. Otto Kurz. The main topic of discussion was the prevention of retinal detachment. Dr. G. Meyer-Schwickerath, West Ger many, in discussing the closure of retinal 877
878
AMERICAN JOURNAL OF OPHTHALMOLOGY
holes, emphasized that the most satisfactory method is by means of photocoagulation which has all the advantages of diathermy and cryocoagulation without having their disadvantages. Dr. J. François, Belgium, in a general re view, emphasized that the benefit of prophy lactic treatment of retinal detachment is no longer in doubt. He indicated the conditions requiring treatment and those, including nonprogressive dischisis and degeneration without hole formation, in which treatment is not indicated. In 3653 cases prophylactically treated, only 140 cases of subsequent detachment occurred (3.8%), and less than 1% were the result of the treatment. Drs. B. R. Straatsma, J. T. Pearlman and R. Y. Foos, California, gave a general re view of the circumstances of peripheral ret inal degenerations and presented a classifi cation of these changes. The general ana tomical features of the retinal periphery were described, emphasis being placed on the retinal thickness in this area being but 0.1 mm. The classification is based on pathogenetic consideration, depending on whether the process is trophic, tractional, or a com bination of both ; partly anatomical, depend ing on whether the inner, middle or outer retinal layers are involved ; and partly patho logic. Precise information regarding these degeneration can make possible the assess ment of the pathophysiologic implications of retinal abnormalities. In a comprehensive description, Dr. Har vey Lincoff, United States, surveyed the en circling operation for retinal detachment with particular regard to his modifications of the Custodis procedure, and indicated their mutual dependence in certain cases. The necessity, in these cases, of an encircling procedure, was indicated and description given of innovations designed to obviate the complications of constriction of the globe. Lincoff described the methods employed in his procedure. He reported that 23% of cases had encircular constriction, and that in half of these cases drainage was not neces
MAY, 1970
sary, a normal aqueous outflow being pres ent. Drainage was indicated when there was old fluid with inferior holes, and where, because of giant tears or massive preretinal retraction, it is intended to use intravitreal injection. The technique used was described in detail. Dr. L. G. Fison, England, reviewed the main theories of the formation of the subretinal fluid, and in their light discussed the treatment of the subretinal fluid in opera tions for retinal detachment. Dr. R. Klöti, Switzerland, exhibited a film demonstrating the preventive closure of retinal holes, using photocoagulation and cryopexy ; as draining methods, if needed for retinal detachment, he uses katholysis punc ture, incision in a scierai bed, or full-thick ness incision on the central side of a scierai buckle. The main steps of his surgical meth ods were shown, with special emphasis on the fascia lata technique in a case of a cen tral retinal detachment, caused by a macular hole. Dr. R. K. Abraham, Los Angeles, de scribed the results of cryoretinopexy on 632 eyes with retinal holes and degeneration. In all instances the adhesive isolation of the treated lesions was excellent. There were two ensuing detachments (an incidence of 0.32%). In all cases the macula and vitreous body were unaffected. Dr. A. I. Friedman, of England, discussed pathogenesis and symptomatology of 33 cases of chiasmal compression. In all cases, including those with normal neurosurgical findings, the diagnosis had been confirmed by means of repeated central visual fields, using the visual field analyzer. In a description of fluorescein studies in retinal detachment, Dr. E. Rosen, England, showed in simple retinal detachment neovascularization, microaneurysm formation, and saccular capillary dilatation close to the edge of retinal holes. The later phase showed gross tissue staining with fluorescein. With a detachment preceded by venous occlusion, the main feature was avascularity of the
VOL. 69, NO. S
MEETINGS, CONFERENCES, SYMPOSIA
retina in the region of the retinal holes. No late phase staining of the retina or subretinal fluid was noted. In contrast, the fluorescein photography features of retinal detachment due to malignant melanoma were demon strated. The anatomical evolution of scierai pock ets was discussed by Dr. Philippe Sourdille of France. The advantages of this method were described, particular emphasis being laid on the extensiveness of the area that can be indented, the evenness of the indentations and its slow decrease following the period of choroidoretinal scarring. Drs. I. C. Michaelson and R. Stein gave a report on the Israel cooperative study in the prevention of retinal detachment, being carried out with the cooperation of all heads of eye departments in Israel. This study has continued since 1960 and has as its primary purposes: first, the assessment of the inci dence of retinal detachment in defined popu lation group during a number of years, and the effect on this incidence of a known num ber of prophylactic measures ; second, a study of the natural history of detachment retinopathy. Monthly lists consisting of nominal roles of all cases of preventive treat ment and of all cases of idiopathic detach ment are centralized for recording from each of the 12 departments. These lists give some general information on the patient, informa tion regarding the situation, shape, and num ber of the retinal holes, and afford data re garding:
879
6. The number of aphakic myopic eyes treated preventively. The average incidence of idiopathic retinal detachment between 1962 and 1968 was 8.9 per 100,000 of the population. The percent age of "second" to "first" eyes dropped dur ing the years of observation from about 10 to 4.2%. The formula for estimating retinal detachment/retinal hole ratio was discussed, and described. It was emphasized that basic to an understanding of retinal hole/retinal detachment relationship is information re garding the prevalence of retinal holes with out detachment in defined eye populations such as myopic, "second," and aphakic eyes. Such prevalence studies were reported on. A series of tables showing detachment/hole probability ratios wre demonstrated, having reference to the shape, position and size of the holes, and to the general parameter of refraction and of occurrence of retinal de tachment in the other eye.
Dr. S. Merin gave a report from the na tional cooperative study in the prevention of retinal detachment, covering a period of seven years with respect to the fate of the fellow eye. In 1962, before prevention mea sures on a national scale were introduced, 10.9% of fellow eyes developed retinal de tachment. Because of preventive measures, the percentage of second eye detachments fell in Israel in 1968 to 4.2%, probably the lowest reported figure. This figure includes 1.3% of detached second eyes where the first eye detachment occurred before 1960, in the 1. The total number of eyes operated on period when relatively little preventive treat ment was carried out. There must, however, for retinal detachment. 2. The number of second eyes in the total always remain a hard core of unpreventable number of eyes operated on for retinal de detachments in which the time period be tween hole formation and retinal detachment tachment. 3. The number of aphakic myopic eyes in • is too short for the hole to be detected by the total number of eyes operated on for any routine method. retinal detachment. Dr. H. Savir described a posterior sub4. The number of preventively treated capsular cupuliform cataract, characteristi eyes. cally found in 20% of eyes operated on for 5. The number of "second" eyes treated retinal detachment. preventively. Drs. E. Berman, H. Zauberman and G.
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AMERICAN JOURNAL OF OPHTHALMOLOGY
Bach described a sensitive method for mea suring, in the cat, the strength of the adhesion between the sensory retina and the pigment epithelial cell layer. The energy required to separate the two layers, using strips of 3 mm width, was calculated from recording made on a tensiometer. These values were found to be 8.2 ± 1.3 ergs/cm a in the tapetum lucidum region, and 18.8 ± 1 . 8 ergs/cm 2 in the pigmented region. These experiments suggest that the adhesive forces may be mediated either by the delicate processes of the pigment epithelium, or by the extracellu lar acid mucopolysaccharides present in the matrix in which the photoreceptor cells are embedded. Drs. M. Feinsod and E. Auerbach de scribed four cases of retrobulbar neuritis in disseminated sclerosis in which the kinetics of the ERG recovery was increased and the steady state achieved later than usual. It was also found that the amplitudes of the indi vidual ERGs were supernormal both at each phase of the recovery, and at the steady state. These findings disappeared after the return of normal vision. In two cases the supernormal ERG, together with the in creased kinetics in the recovery, preceded the ophthalmoscopically detectable atrophy of the optic nerve by several weeks. The find ings are explained hypothetically on the basis of rivalry between impulses initiated in the retina, and those descending from the CNS via centrifugal fibers. Drs. J. Reif and O. Kurz described a con secutive group of cases with juvenile retinoschises. These cases were characterized by absence of hereditary influence, equal in volvement of the sexes, and predominance of myopia. Lamellar holes were found in the majority of cases. Dr. H. Zauberman measured the tensile strength of chorioretinal lesions produced by photocoagulation, diathermy and cryothermy, in the region of the tapetum lucidum of cats' eyes. Two days after the application of the lesions, the adhesion was of 15 to 40 mg for all the lesions; after the 7th day there
MAY, 1970
was a gradual increase in the adhesion until it reached a maximum value of 183 to 365 mg by the 21st day. Thereafter no further increase was recorded. In untreated areas the adhesion strength was 60 to 90 mg. The measured adhesion strength was highest, al though slightly so, for photocoagulation, less for diathermy, and least for cryothermy. The clinical features of 27 cases showing retinal detachment due to contusion injury of the globe or surrounding tissues, were described by Dr. S. Zonis. Most of the cases were below 40 years of age, and men were chiefly affected. In one patient the visual im pairment appeared 12 years after the blow. Dr. S. Merin, Mrs. H. Rowe, and Dr. E. Auerbach, in a report of the ERG in retinal detachment showed that generally the ampli tudes of the ERG in the affected eyes were found to decrease with increase both in the extent and the duration of detachment. The chances for successful surgical re-at tachment as well as for visual return, were better when the ERG amplitudes were great er. In the fellow eyes examined, a subnormal ERG was obtained in the unaffected eye of 25 out of 26 eyes, while the ERG was prac tically normal in 17 out of 18 fellow eyes without myopia or degenerative changes. Dr. M. Romen described 34 eyes with ret inal detachment in which two encircling supramid strings were placed isolating the holes from both the central and the periph eral parts of the retina. In 82% of cases with several retinal and vitreous manifesta tions, the results were successful. Dr. Y. Hauer described the Marcus Gunn escape phenomenon following cerclage oper ations for retinal detachment and ascribed the phenomenon to the constriction of the posterior ciliary nerve fibres. Dr. S. Hyams, in a study of asymptomatic retinal breaks in 73 eyes untreated during a period of six months to three years, found that during this period only one eye devel oped retinal detachment. The clinical significance of photopsies were studied by Dr. E. Neumann in 7000
VOL. 69. NO. 5
MEETINGS, CONFERENCES, SYMPOSIA
881
consecutive eye-clinic patients of whom 238 complained of photopsies in one or both eyes (290 eyes). One third of these patients had myopia. The duration of the photopsies varied from one day to 20 years. Repeated examinations with the Goldmann three-mir ror contact lens, during an average followup period of two years, revealed posterior vitre ous detachment in 80% of the eyes, retinal breaks in only nine eyes, and vitreo-retinal pull in five other eyes. It was concluded that the complaint of photopsies in the vast ma jority of cases indicates a clinical entity un related to retinal detachment.
the long-term effect of systemic steroids on intraocular pressure and outflow, resistance together with the genetic pattern in 60 pa tients suffering from different systemic dis eases. In contrast to the results described in the literature, the effect on the intraocular pressure seems dependent on the dose, and not on the duration of the treatment with systemic steroids. A striking similarity in re sponse was obtained when the steroids were exhibited topically. The genetic determina tion of this response was confirmed by study of the effect of topically applied steroids to female members of the families.
Dr. R. Sachs reported on 101 cases of pseudo-exfoliation of the lens capsule. These cases constituted 8.75% of 1154 consecutive cases operated on for cataract. It was shown that the prevalence increased with age and differed widely between different ethnic groups. Of 187 Yemenite Jews, 25% showed the condition, while of 406 Ashkenazi Jews, only 2% were affected. Almost half of the patients had primary or secondary glaucoma. The electroretinogram as a diagnostic tool in macular degeneration, was discussed by Drs. S. Merin and E. Auerbach, the ERG being measured during light and dark adap tation in 63 patients in whom the clinical diagnosis was macular degeneration. It was confirmed that while eyes with acquired or senile macular degeneration showed a practi cally normal ERG, those with heredo-macular degeneration frequently showed a dim inution of the photopic component of the ERG, which was often severe, and color vision defect. Dr. J. Scharf reported on orbital matastasis of malignant pheochromacytoma in a 39year-old woman. The exophthalmus ap peared nine-and-one-half years following the onset of the disease. Massage of the globe provoked a significant rise in blood pressure. Dr. E. Meyer gave a detailed clinicopathological report on three cases of pseudoglioma, which included Coat's disease, metastatic endophthalmitis, and retinal dysplasia. Drs. V. Godel and V. Feiler-Of ry studied
Dr. M. Ivry discussed the pathogenetic re lationship between vitreoretinal, adhesions and lattice formation, and concluded that lattice formation more than other forms of pre-hole retinal degeneration, was associated with vitreoretinal adhesions. The conclusion was arrived at by a consideration of the find ings in 62 fellow eyes. Dr. Y. R. Barishak gave a report on the prevalence of retinal holes in 211 necropsy eyes. Breaks were discovered in 8.8% of cases from birth till 90 years of age, and in 13.5% of cases above 40 years of age. Tears were discovered in four eyes, chiefly at the ora; while holes were noted in nine eyes, again chiefly at the ora. While tears were fre quently associated only with cystoid degenera tion, holes were as well noted together with lattice degeneration and paving-stone de generation. Although a posterior vitreous de tachment was noted in all the eyes presenting breaks, no focal vitreoretinal adhesions could be seen grossly. In tears submitted to his tologie examination, the evidence is that vit reous pulling is the most important patho genetic factor. It is of interest, in view of the relative rarity with which oral as com pared to equatorial holes, lead to detachment that only with the former were surrounding choroidoretinal adhesions found. No uni form choroidal change was noted. In the de velopment of nonoperculated holes the main causes are intraretinal, probably vascular. In an examination of 100 aphakic, asymp-
AMERICAN JOURNAL OF OPHTHALMOLOGY
882
tomatic, nonmyopic eyes, in which the Goldmann three-mirror lens was used, Dr. Z. Friedman noted complete or partial detach ment of the posterior vitreous face in 80 eyes, retinal breaks in six eyes, and retinoschisis in 14 eyes. I. C. Michaelson
HAY, 1970
eye for a year, using the untreated eye as a control, the data, analyzed statistically, showed a significant difference between the treated eye, and the un treated eye. The individuals studied were those in whom myopia was progressing at a fairly rapid rate prior to treatment. The control eye continued to progress at approximately the same rate, whereas the treated eye did not progress in an increase of myopia. Discussion will be opened by Robert D. Reinecke, Albany, New York. LIMITATIONS OF THE COVER TEST I N THE
AMA SECTION ON OPHTHALMOLOGY
DETECTION OF STRABISMUS
The 1970 meeting of the Section on Oph thalmology of the American Medical As sociation will be held in Chicago June 21 through 25, 1970. Those who will be making presentations to the group, and brief ab stracts of their material, are as follows: MONDAY, J U N E 22,
9:00 A.M. OPHTHALMOSCOPIC
MONITORING
RETINAL VASCULATURE I N
OF THE
PREMATURITY
This paper will be presented by Guy G. O'Grady, John T. Flynn, and Salvatore Cantolino, Miami, Florida. Constriction of retinal vessels is a sign of oxy gen toxicity in premature animals. It is suggested that ophthalmoscopic examination of the calibre of retinal vessels might be a convenient means of monitoring oxygen administration to the premature. To test the feasibility of such monitoring, daily examination with the indirect ophthalmoscope was performed on all babies receiving oxygen in the premature nursery of the Jackson Memorial Hos pital over the past year. Serial fundus photographs were taken and fluorescein angiography and slit lamp examinations performed where possible. The results were correlated with arterial blood gas de terminations. Discussion will be opened by Arnall Patz, Baltimore, Maryland. THE
EFFECT
OF A T R O P I N E
ON PROGRES
SIVE M Y O P I A OF C H I L D H O O D
T h i s paper will be presented by Robert H . Bedrossian, Vancouver, Washington. After 75 children, aged 8 to 13, used atropine daily in one eye for a year, and then in the opposite
This paper will be presented by Paul E. Romano, Chicago, Illinois, and Gunter K. von Noorden, Baltimore, Maryland. Although many think the cover test may detect a minimal deviation of one to four prism diopters, such observations are unsupported by experimental evidence. Therefore, an experiment was performed in which observers attempted to detect artificially induced saccadic movements ranging from zero to four prism diopters, simulating the clinical use of the cover test. Ten experienced observers consis tently detected movements of two prism diopters or more without error. Smaller movements were de tected with decreasing regularity. Statistical ex amination of the data revealed that the cover test is not reliable for detecting strabismus where the de viation is less than two prism diopters. Discussion will be opened by Hermann M. Burian, Iowa City, Iowa. FOVEOLAR SPLINTERS AND MACULAR W I S P S
This paper will be presented by Louis Daily, Jr., Houston, Texas. Biomicroscopically, in focal illumination through the Goldmann contact lens, in five adult eyes, a splinter of retinal tissue was found protruding from the foveal pit, and in two eyes wisps of white tissue from the macular surface. Detachment of the posterior hyaloid membrane of the vitreous from the macula was present in each case. In elderly pa tients, the vitreous was collapsed. Visual acuity of these eyes was reduced little or none. Some patients complained of slight distortion of vision of the affected eye. Three out of the five patients under age 40 gave a history of trauma. One had healed chorioretinitis not involving fovea, and one gave no history of ocular disease or injury. Traction of the de taching posterior hyaloid membrane on the retina probably produces the previously unreported splin ter and wisps. Discussion will be opened by Ephraim Friedman, Boston, Massachusetts.
T H E N E W ENGLAND OPHTHALMOLOGICAL SOCIETY The 511th meeting of the NEOS was opened by Dr. G. Sullivan, January 21, 1970, in Boston. Dr. C. K. Beyer presented help ful hints on the appropriate plastic surgical procedures to be employed in the common ophthalmic eyelid procedures. He empha sized the utility and safety of using scierai shells while working on the eyelids. As can cer cases were presented, Dr. M. Schulz advocated a trial of radiation whenever the biopsy warranted radiation. Radiation should precede rather than follow surgery. Dr. C. E. Iliff believes forehead flaps to orbital defects should be avoided where possible. The afternoon session at the Museum of Science was chaired by Dr. G. Sullivan. Dr. S. D. Hecht presented an upper to lower eyelid, full-thickness sharing technique. He creates a bridge of the upper tarsus by bringing a full-thickness flap of skin, orbicularis, levator and conjunctiva down to fill the lower eyelid defect. After a suitable healing time, he separates the flap. The remarkable features include no ptosis or lagophthalmos and no vertical tropia. He was unable to ex plain why the complications did not occcur, a pleasant position to be in. Dr. M. Schulz, Chief of Radiotherapy at Massachusetts General Hospital, favors radiotherapy over surgery for skin cancer about the eyelids, claiming less cosmetic de ficiency. He reported a 90% success rate when radiotherapy is used on small carci nomas. If the tumor is large, inavding the orbit or fixed, then only a 33% success rate was present. Throughout the day, there re mained unchanged those surgeons who fa vored surgery in difficult cases, and those radiologists and some ophthalmologists who favored radiotherapy. Both agreed that bi opsy was a prerequisite to all treatment. Dr. Schulz reported the succcessful use of a lead scierai shell which permits the specific appli
M.D. 32
cation of a P impregnated template to treat tumors of either the tarsal or bulbar conjunctiva. Blepharoptosis treatment was reviewed by Dr. C. C. Johnson who emphasized the im portance of a suitably placed eyelid fold. Dr. C. K. Beyer reviewed the approaches to treat exposed and extruded orbital implants. Although most methods are successful in the orginators hands, he feels the small glass beads offer flexibility in application, both as to site and amount. Drs. Reinecke and Carroll reviewed the complications and care of silicone lacrimal tubes. The sniffing patient (while occluding his naris) keeps the silicone tube patent and clean, preventing several complications. The complications were numerous, but all of a trival nature. Persistence of the doctor and patient yield a high success rate. A kaleidoscope of plastic surgical proce dures of the eye was presented by Dr. Charles E. Iliff of Baltimore. His lucid teaching, ac cented with appropriate examples of photos and movies, delighted and taught the audi ence new skills in eye plastic care. Following dinner, Dr. Raymond Robillard, President, Federation of Medical Spe cialists of Quebec, reviewed the effectiveness of the bargaining power of physicians' unions in Canada. He predicted national health insurance for all in the United States within the next five years. Robert D. Reinecke T H E ISRAEL OPHTHALMOLOGICAL SOCIETY The 7th symposial meeting of the Israel Ophthalmological Society was held in Jeru salem March, 12 to 14, 1970, under the chair manship of Prof. Otto Kurz. The main topic of discussion was the prevention of retinal detachment. Dr. G. Meyer-Schwickerath, West Ger many, in discussing the closure of retinal 877
878
AMERICAN JOURNAL OF OPHTHALMOLOGY
holes, emphasized that the most satisfactory method is by means of photocoagulation which has all the advantages of diathermy and cryocoagulation without having their disadvantages. Dr. J. François, Belgium, in a general re view, emphasized that the benefit of prophy lactic treatment of retinal detachment is no longer in doubt. He indicated the conditions requiring treatment and those, including nonprogressive dischisis and degeneration without hole formation, in which treatment is not indicated. In 3653 cases prophylactically treated, only 140 cases of subsequent detachment occurred (3.8%), and less than 1% were the result of the treatment. Drs. B. R. Straatsma, J. T. Pearlman and R. Y. Foos, California, gave a general re view of the circumstances of peripheral ret inal degenerations and presented a classifi cation of these changes. The general ana tomical features of the retinal periphery were described, emphasis being placed on the retinal thickness in this area being but 0.1 mm. The classification is based on pathogenetic consideration, depending on whether the process is trophic, tractional, or a com bination of both ; partly anatomical, depend ing on whether the inner, middle or outer retinal layers are involved ; and partly patho logic. Precise information regarding these degeneration can make possible the assess ment of the pathophysiologic implications of retinal abnormalities. In a comprehensive description, Dr. Har vey Lincoff, United States, surveyed the en circling operation for retinal detachment with particular regard to his modifications of the Custodis procedure, and indicated their mutual dependence in certain cases. The necessity, in these cases, of an encircling procedure, was indicated and description given of innovations designed to obviate the complications of constriction of the globe. Lincoff described the methods employed in his procedure. He reported that 23% of cases had encircular constriction, and that in half of these cases drainage was not neces
MAY, 1970
sary, a normal aqueous outflow being pres ent. Drainage was indicated when there was old fluid with inferior holes, and where, because of giant tears or massive preretinal retraction, it is intended to use intravitreal injection. The technique used was described in detail. Dr. L. G. Fison, England, reviewed the main theories of the formation of the subretinal fluid, and in their light discussed the treatment of the subretinal fluid in opera tions for retinal detachment. Dr. R. Klöti, Switzerland, exhibited a film demonstrating the preventive closure of retinal holes, using photocoagulation and cryopexy ; as draining methods, if needed for retinal detachment, he uses katholysis punc ture, incision in a scierai bed, or full-thick ness incision on the central side of a scierai buckle. The main steps of his surgical meth ods were shown, with special emphasis on the fascia lata technique in a case of a cen tral retinal detachment, caused by a macular hole. Dr. R. K. Abraham, Los Angeles, de scribed the results of cryoretinopexy on 632 eyes with retinal holes and degeneration. In all instances the adhesive isolation of the treated lesions was excellent. There were two ensuing detachments (an incidence of 0.32%). In all cases the macula and vitreous body were unaffected. Dr. A. I. Friedman, of England, discussed pathogenesis and symptomatology of 33 cases of chiasmal compression. In all cases, including those with normal neurosurgical findings, the diagnosis had been confirmed by means of repeated central visual fields, using the visual field analyzer. In a description of fluorescein studies in retinal detachment, Dr. E. Rosen, England, showed in simple retinal detachment neovascularization, microaneurysm formation, and saccular capillary dilatation close to the edge of retinal holes. The later phase showed gross tissue staining with fluorescein. With a detachment preceded by venous occlusion, the main feature was avascularity of the
VOL. 69, NO. S
MEETINGS, CONFERENCES, SYMPOSIA
retina in the region of the retinal holes. No late phase staining of the retina or subretinal fluid was noted. In contrast, the fluorescein photography features of retinal detachment due to malignant melanoma were demon strated. The anatomical evolution of scierai pock ets was discussed by Dr. Philippe Sourdille of France. The advantages of this method were described, particular emphasis being laid on the extensiveness of the area that can be indented, the evenness of the indentations and its slow decrease following the period of choroidoretinal scarring. Drs. I. C. Michaelson and R. Stein gave a report on the Israel cooperative study in the prevention of retinal detachment, being carried out with the cooperation of all heads of eye departments in Israel. This study has continued since 1960 and has as its primary purposes: first, the assessment of the inci dence of retinal detachment in defined popu lation group during a number of years, and the effect on this incidence of a known num ber of prophylactic measures ; second, a study of the natural history of detachment retinopathy. Monthly lists consisting of nominal roles of all cases of preventive treat ment and of all cases of idiopathic detach ment are centralized for recording from each of the 12 departments. These lists give some general information on the patient, informa tion regarding the situation, shape, and num ber of the retinal holes, and afford data re garding:
879
6. The number of aphakic myopic eyes treated preventively. The average incidence of idiopathic retinal detachment between 1962 and 1968 was 8.9 per 100,000 of the population. The percent age of "second" to "first" eyes dropped dur ing the years of observation from about 10 to 4.2%. The formula for estimating retinal detachment/retinal hole ratio was discussed, and described. It was emphasized that basic to an understanding of retinal hole/retinal detachment relationship is information re garding the prevalence of retinal holes with out detachment in defined eye populations such as myopic, "second," and aphakic eyes. Such prevalence studies were reported on. A series of tables showing detachment/hole probability ratios wre demonstrated, having reference to the shape, position and size of the holes, and to the general parameter of refraction and of occurrence of retinal de tachment in the other eye.
Dr. S. Merin gave a report from the na tional cooperative study in the prevention of retinal detachment, covering a period of seven years with respect to the fate of the fellow eye. In 1962, before prevention mea sures on a national scale were introduced, 10.9% of fellow eyes developed retinal de tachment. Because of preventive measures, the percentage of second eye detachments fell in Israel in 1968 to 4.2%, probably the lowest reported figure. This figure includes 1.3% of detached second eyes where the first eye detachment occurred before 1960, in the 1. The total number of eyes operated on period when relatively little preventive treat ment was carried out. There must, however, for retinal detachment. 2. The number of second eyes in the total always remain a hard core of unpreventable number of eyes operated on for retinal de detachments in which the time period be tween hole formation and retinal detachment tachment. 3. The number of aphakic myopic eyes in • is too short for the hole to be detected by the total number of eyes operated on for any routine method. retinal detachment. Dr. H. Savir described a posterior sub4. The number of preventively treated capsular cupuliform cataract, characteristi eyes. cally found in 20% of eyes operated on for 5. The number of "second" eyes treated retinal detachment. preventively. Drs. E. Berman, H. Zauberman and G.
880
AMERICAN JOURNAL OF OPHTHALMOLOGY
Bach described a sensitive method for mea suring, in the cat, the strength of the adhesion between the sensory retina and the pigment epithelial cell layer. The energy required to separate the two layers, using strips of 3 mm width, was calculated from recording made on a tensiometer. These values were found to be 8.2 ± 1.3 ergs/cm a in the tapetum lucidum region, and 18.8 ± 1 . 8 ergs/cm 2 in the pigmented region. These experiments suggest that the adhesive forces may be mediated either by the delicate processes of the pigment epithelium, or by the extracellu lar acid mucopolysaccharides present in the matrix in which the photoreceptor cells are embedded. Drs. M. Feinsod and E. Auerbach de scribed four cases of retrobulbar neuritis in disseminated sclerosis in which the kinetics of the ERG recovery was increased and the steady state achieved later than usual. It was also found that the amplitudes of the indi vidual ERGs were supernormal both at each phase of the recovery, and at the steady state. These findings disappeared after the return of normal vision. In two cases the supernormal ERG, together with the in creased kinetics in the recovery, preceded the ophthalmoscopically detectable atrophy of the optic nerve by several weeks. The find ings are explained hypothetically on the basis of rivalry between impulses initiated in the retina, and those descending from the CNS via centrifugal fibers. Drs. J. Reif and O. Kurz described a con secutive group of cases with juvenile retinoschises. These cases were characterized by absence of hereditary influence, equal in volvement of the sexes, and predominance of myopia. Lamellar holes were found in the majority of cases. Dr. H. Zauberman measured the tensile strength of chorioretinal lesions produced by photocoagulation, diathermy and cryothermy, in the region of the tapetum lucidum of cats' eyes. Two days after the application of the lesions, the adhesion was of 15 to 40 mg for all the lesions; after the 7th day there
MAY, 1970
was a gradual increase in the adhesion until it reached a maximum value of 183 to 365 mg by the 21st day. Thereafter no further increase was recorded. In untreated areas the adhesion strength was 60 to 90 mg. The measured adhesion strength was highest, al though slightly so, for photocoagulation, less for diathermy, and least for cryothermy. The clinical features of 27 cases showing retinal detachment due to contusion injury of the globe or surrounding tissues, were described by Dr. S. Zonis. Most of the cases were below 40 years of age, and men were chiefly affected. In one patient the visual im pairment appeared 12 years after the blow. Dr. S. Merin, Mrs. H. Rowe, and Dr. E. Auerbach, in a report of the ERG in retinal detachment showed that generally the ampli tudes of the ERG in the affected eyes were found to decrease with increase both in the extent and the duration of detachment. The chances for successful surgical re-at tachment as well as for visual return, were better when the ERG amplitudes were great er. In the fellow eyes examined, a subnormal ERG was obtained in the unaffected eye of 25 out of 26 eyes, while the ERG was prac tically normal in 17 out of 18 fellow eyes without myopia or degenerative changes. Dr. M. Romen described 34 eyes with ret inal detachment in which two encircling supramid strings were placed isolating the holes from both the central and the periph eral parts of the retina. In 82% of cases with several retinal and vitreous manifesta tions, the results were successful. Dr. Y. Hauer described the Marcus Gunn escape phenomenon following cerclage oper ations for retinal detachment and ascribed the phenomenon to the constriction of the posterior ciliary nerve fibres. Dr. S. Hyams, in a study of asymptomatic retinal breaks in 73 eyes untreated during a period of six months to three years, found that during this period only one eye devel oped retinal detachment. The clinical significance of photopsies were studied by Dr. E. Neumann in 7000
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consecutive eye-clinic patients of whom 238 complained of photopsies in one or both eyes (290 eyes). One third of these patients had myopia. The duration of the photopsies varied from one day to 20 years. Repeated examinations with the Goldmann three-mir ror contact lens, during an average followup period of two years, revealed posterior vitre ous detachment in 80% of the eyes, retinal breaks in only nine eyes, and vitreo-retinal pull in five other eyes. It was concluded that the complaint of photopsies in the vast ma jority of cases indicates a clinical entity un related to retinal detachment.
the long-term effect of systemic steroids on intraocular pressure and outflow, resistance together with the genetic pattern in 60 pa tients suffering from different systemic dis eases. In contrast to the results described in the literature, the effect on the intraocular pressure seems dependent on the dose, and not on the duration of the treatment with systemic steroids. A striking similarity in re sponse was obtained when the steroids were exhibited topically. The genetic determina tion of this response was confirmed by study of the effect of topically applied steroids to female members of the families.
Dr. R. Sachs reported on 101 cases of pseudo-exfoliation of the lens capsule. These cases constituted 8.75% of 1154 consecutive cases operated on for cataract. It was shown that the prevalence increased with age and differed widely between different ethnic groups. Of 187 Yemenite Jews, 25% showed the condition, while of 406 Ashkenazi Jews, only 2% were affected. Almost half of the patients had primary or secondary glaucoma. The electroretinogram as a diagnostic tool in macular degeneration, was discussed by Drs. S. Merin and E. Auerbach, the ERG being measured during light and dark adap tation in 63 patients in whom the clinical diagnosis was macular degeneration. It was confirmed that while eyes with acquired or senile macular degeneration showed a practi cally normal ERG, those with heredo-macular degeneration frequently showed a dim inution of the photopic component of the ERG, which was often severe, and color vision defect. Dr. J. Scharf reported on orbital matastasis of malignant pheochromacytoma in a 39year-old woman. The exophthalmus ap peared nine-and-one-half years following the onset of the disease. Massage of the globe provoked a significant rise in blood pressure. Dr. E. Meyer gave a detailed clinicopathological report on three cases of pseudoglioma, which included Coat's disease, metastatic endophthalmitis, and retinal dysplasia. Drs. V. Godel and V. Feiler-Of ry studied
Dr. M. Ivry discussed the pathogenetic re lationship between vitreoretinal, adhesions and lattice formation, and concluded that lattice formation more than other forms of pre-hole retinal degeneration, was associated with vitreoretinal adhesions. The conclusion was arrived at by a consideration of the find ings in 62 fellow eyes. Dr. Y. R. Barishak gave a report on the prevalence of retinal holes in 211 necropsy eyes. Breaks were discovered in 8.8% of cases from birth till 90 years of age, and in 13.5% of cases above 40 years of age. Tears were discovered in four eyes, chiefly at the ora; while holes were noted in nine eyes, again chiefly at the ora. While tears were fre quently associated only with cystoid degenera tion, holes were as well noted together with lattice degeneration and paving-stone de generation. Although a posterior vitreous de tachment was noted in all the eyes presenting breaks, no focal vitreoretinal adhesions could be seen grossly. In tears submitted to his tologie examination, the evidence is that vit reous pulling is the most important patho genetic factor. It is of interest, in view of the relative rarity with which oral as com pared to equatorial holes, lead to detachment that only with the former were surrounding choroidoretinal adhesions found. No uni form choroidal change was noted. In the de velopment of nonoperculated holes the main causes are intraretinal, probably vascular. In an examination of 100 aphakic, asymp-
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tomatic, nonmyopic eyes, in which the Goldmann three-mirror lens was used, Dr. Z. Friedman noted complete or partial detach ment of the posterior vitreous face in 80 eyes, retinal breaks in six eyes, and retinoschisis in 14 eyes. I. C. Michaelson
HAY, 1970
eye for a year, using the untreated eye as a control, the data, analyzed statistically, showed a significant difference between the treated eye, and the un treated eye. The individuals studied were those in whom myopia was progressing at a fairly rapid rate prior to treatment. The control eye continued to progress at approximately the same rate, whereas the treated eye did not progress in an increase of myopia. Discussion will be opened by Robert D. Reinecke, Albany, New York. LIMITATIONS OF THE COVER TEST I N THE
AMA SECTION ON OPHTHALMOLOGY
DETECTION OF STRABISMUS
The 1970 meeting of the Section on Oph thalmology of the American Medical As sociation will be held in Chicago June 21 through 25, 1970. Those who will be making presentations to the group, and brief ab stracts of their material, are as follows: MONDAY, J U N E 22,
9:00 A.M. OPHTHALMOSCOPIC
MONITORING
RETINAL VASCULATURE I N
OF THE
PREMATURITY
This paper will be presented by Guy G. O'Grady, John T. Flynn, and Salvatore Cantolino, Miami, Florida. Constriction of retinal vessels is a sign of oxy gen toxicity in premature animals. It is suggested that ophthalmoscopic examination of the calibre of retinal vessels might be a convenient means of monitoring oxygen administration to the premature. To test the feasibility of such monitoring, daily examination with the indirect ophthalmoscope was performed on all babies receiving oxygen in the premature nursery of the Jackson Memorial Hos pital over the past year. Serial fundus photographs were taken and fluorescein angiography and slit lamp examinations performed where possible. The results were correlated with arterial blood gas de terminations. Discussion will be opened by Arnall Patz, Baltimore, Maryland. THE
EFFECT
OF A T R O P I N E
ON PROGRES
SIVE M Y O P I A OF C H I L D H O O D
T h i s paper will be presented by Robert H . Bedrossian, Vancouver, Washington. After 75 children, aged 8 to 13, used atropine daily in one eye for a year, and then in the opposite
This paper will be presented by Paul E. Romano, Chicago, Illinois, and Gunter K. von Noorden, Baltimore, Maryland. Although many think the cover test may detect a minimal deviation of one to four prism diopters, such observations are unsupported by experimental evidence. Therefore, an experiment was performed in which observers attempted to detect artificially induced saccadic movements ranging from zero to four prism diopters, simulating the clinical use of the cover test. Ten experienced observers consis tently detected movements of two prism diopters or more without error. Smaller movements were de tected with decreasing regularity. Statistical ex amination of the data revealed that the cover test is not reliable for detecting strabismus where the de viation is less than two prism diopters. Discussion will be opened by Hermann M. Burian, Iowa City, Iowa. FOVEOLAR SPLINTERS AND MACULAR W I S P S
This paper will be presented by Louis Daily, Jr., Houston, Texas. Biomicroscopically, in focal illumination through the Goldmann contact lens, in five adult eyes, a splinter of retinal tissue was found protruding from the foveal pit, and in two eyes wisps of white tissue from the macular surface. Detachment of the posterior hyaloid membrane of the vitreous from the macula was present in each case. In elderly pa tients, the vitreous was collapsed. Visual acuity of these eyes was reduced little or none. Some patients complained of slight distortion of vision of the affected eye. Three out of the five patients under age 40 gave a history of trauma. One had healed chorioretinitis not involving fovea, and one gave no history of ocular disease or injury. Traction of the de taching posterior hyaloid membrane on the retina probably produces the previously unreported splin ter and wisps. Discussion will be opened by Ephraim Friedman, Boston, Massachusetts.