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A New Group of Cycloplegic Drugs* Further studies
NOTES, CASES, INSTRUMENTS
110
cases responded to vitamin A, given in high doses over many weeks. One child with Bitot's spots and night blindness, as well as signs of vitamin-B de ficiency, was seen and he responded promptly to therapy.4 Metivier reviewed the literature and found reports of the same experiences by Palmer in Assam, Sie-Boen-Lian in Java, Aykroyd in India, Wilson in Egypt, and Nicholls in Ceylon. They all reported cases of Bitot's spots and other forms of xerosis conjunctiva that were resistant to vitamin-A therapy.4 It should be reiterated that these observa tions were made on natives from tropical countries. They were exposed to strong sun light for many years. Many of them probably
had been on inadequate diets for long periods of their lives. These and other factors ap parently caused a form of xerosis conjunc tiva which was refractory to treatment with vitamin A. SUMMARY
Two cases of Bitot's spots without night blindness are reported in well-nourished young men. Neither case improved under vitamin-A therapy. There are several reports of xerosis con junctiva occurring in natives of tropical countries, in whom there was no response to vitamin-A therapy. The presence of Bitot's spots cannot be considered as indicative of vitamin-A deficiency in every case. U. S. Army Hospital.
REFERENCES
1. Berens, C.: The Eye and Its Diseases. Philadelphia, Saunders, 1950, pp. 397-398. 2. Berliner, M.: Biomicroscopy of the Eye. New York, Hoeber, 1949, pp. 166-168. 3. Tassman, I.: The Eye Manifestations of Internal Diseases. St. Louis, Mosby, 1946, pp. 514-516. 4. Metivier, V.: Bitot's spots in Trinidad. Am. J. Ophth. 24:1029-1034 (June) 1941. 5. Cecil, R., and Loeb, R.: A Textbook of Medicine. Philadelphia, Saunders, 1951, pp. 568-571. 6. Kyser, F.: Therapeutics in Internal Medicine. New York, Nelson, 1950, pp. 290-292. 7. Duncan, G.: Diseases of Metabolism. Philadelphia, Saunders, 1942, pp. 388-400.
A NEW GROUP O F CYCLOPLEGIC DRUGS* FURTHER STUDIES IRWIN H.
STOLZAR,
M.D.
Cleveland, Ohio My interest in a new group of cycloplegic drugs was stimulated by a report by Priest ley and Medine1 in 1951. Their report con cerned itself with Compound 75 G.T.* We undertook a comparative study of the cyclo plegic effects of this compound and two other related compounds of the same series, Compound 92 G.T. and 93 G.T.* *From the Division of Ophthalmology, Depart ment of Surgery, Western Reserve University School of Medicine, and the University Hospitals of Cleveland. Presented before the Cleveland Ophthalmological Club, November, 1951. t Schieffelin and Company, New York. t Supplied through the courtesy of E. W. Blanch-
These compounds are members of a series of new antispasmodic agents belonging to a class of basic esters of substituted phenylacetic acids, the structure and preparation of which are to be reported elsewhere. As will be shown, these compounds more closely ap proximate the ideal cycloplegic drug than any in common use at the present time. The ideal cycloplegic drug would be one possessing the following properties: (1) Rapid effect, (2) extensive depression of accommodation for a sufficiently long period as to permit ade quate refraction, (3) prompt recovery, (4) dissociation of mydriatic and cycloplegic effect, and (5) no local or systemic sidereactions. In this study the drugs were used in 0.5percent concentration in a boric-acid borate ard, Ph.D., Director of Research, Schieffelin anc Company.
NOTES, CASES, INSTRUMENTS
111
TABLE 1 CYCLOPLEGIC EFFECTS
75
92
93
80 cases 1.03D.
50 cases 1.0D.
50 cases 1.0D.
Compound G.T. Average residual accommo dation 1 hr. after instillation Residual accommodation by age groups 10-20 years 20-30 30-40 Range of residual accommo dation (diopters) 0.50 0.75 1.00 1.25 1.50 1.75
28 cases 29 cases 23 cases
1.14D. 0.97D. 0.97D.
2.5% 13.7% 55.0% 27.5% 1.3%
■ 15 cases 19 cases 16 cases
26% 50% 24%
1.03D. 1.06D. 0.88D.
21 cases 15 cases 14 cases
1.05D. 0.95D. l.OOD.
32% 46% 14% 6% 2%
buffer, pH about 5.7, with 1:50,000 Table 1 demonstrates the cycloplegic ef zephiran as a preservative. Two drops were fects of these three compounds. It is seen instilled in the conjunctival cul-de-sac five that the average residual cycloplegia for all minutes apart, refraction being done one cases is about one diopter. Particularly sig hour after the initial instillation. The resid nificant is the marked depression of accom ual accommodation was measured, after modation in the age group of 10 to 20 years. correction of the distance refractive error, by The range was found to be from 1.03 diop determining the near point of accommoda ters with Compound 92 to 1.14 diopters with tion. In no instance in this study of 180 cases Compound 75. In the other age groups the was any evidence of general or local toxicity range was from 0.88 diopters to 1.06 diop encountered. ters. Maximal cycloplegia was rapidly induced No direct comparisons of residual accom (within 30 minutes in some cases) and modation were made against homatropinereached a maximum within 45 to 60 minutes. paredrine cycloplegia which has been our Restoration of accommodative power with usual routine. However, it was found that, in out the use of a miotic occurred usually be many cases previously refracted with homattween four and 12 hours. In a comparatively ropine and paredrine in combination, the few cases the ability to read was delayed for cycloplegic action with the drugs of this new about 24 hours. The recovery from the cyclo series was either equal to or more profound plegic effect was considerably more rapid than with the homatropine-paredrine combi than that experienced with either homatro- nation. Figures taken from the papers by pine or homatropine-paredrine combination Marron 2 and Moncrieff and Scheribel3 indi where a delay of 24 to 48 hours is not too cate a residual accommodation of 1.9 diop unusual. ters with atropine and 1.6 diopters with hoThe mydriatic effect was also rapidly matropine. Our findings, as has been shown, manifested (often within 15 minutes) and indicate a considerably greater cycloplegic maximal within 45 minutes. Recovery from effect with this new series of drugs. the mydriatic effect was slower than from SUMMARY the cycloplegic effect, usually within 24 to 48 hours. No instance of increased intraocu The reported new compounds, Compounds lar pressure was found as the result of the 75 G.T., 92 G.T., and 93 G.T., offer the mydriatic effect. nearest approach to the ideal cycloplegic of
112
NOTES, CASES, INSTRUMENTS
any drug now in use or recently reported. Their action is prompt (within 45 to 60 min utes for maximum cycloplegia), the accom modation is markedly depressed (average residual about 1.00 diopter), and the recov ery is prompt (usually within four to 12 hours). These compounds depart from the ideal in their mydriatic effect which, how ever, is not objectionable when compared to the advantages indicated.
One of these compounds will soon be re leased for office use.* It is believed that these drugs may successfully replace, or will cer tainly be a useful adjunct, to the use of homatropine and even atropine for routine office refraction. 831 National City Bank Building (14). * "Cyclogyl," Personal communication from Dr. E. W. Blanchard.
REFERENCES
1. Priestley, B. S., and Medine, M. M.: A new mydriatic and cycloplegic drug. Am. J. Ophth., 34:572-575 (Apr.) 1951. 2. Marron, J.: Cycloplegia and mydriasis by use of atropine, scopolamine, and homatropine-paredrine. Arch. Ophth., 23 :340-350 (Feb.) 1940. 3. Moncrieff, W. F., and Scheribel, K. J.: Further studies concerning homatropine cycloplegia and paredrine with special reference to rate of accommodative recovery. Am. J. Ophth. 25 :839-843 (July) 1942.
E Y E AND O T H E R HANDICAPS* THEIR
RELATION
TO
PERFORMANCE
ON
A
VISUAL MOTOR GESTALT TEST T H O M A S H.
EAMES,
M.D.
Boston, Massachusetts
While using the Bender visual motor gestalt test in exploring personality factors among reading failures, some of whom had severe eye and visual defects, I questioned whether these handicaps were impairing the validity of the test. It seemed possible that visual-ocular difficulties might account for some inadequacy of perception of the gestalt configurations and that defects and deficien cies of the drawing arm, forearm, and hand might interfere with the reproduction of the pattern as perceived. In such cases the test would be detecting physical def ectiveness as well as personality factors. Fifty persons, who were reading failures and who had been given the Bender test, were examined for vision, refraction, binocular vision, the speed of object percep tion, lateral dominance of eye and hand, and defects of the drawing arm, forearm, and * From the School of Education, Boston Uni versity.
hand. The median age of the group was eight years, four months and the median intelli gence quotient was 100. As usual, among reading failures, 80 percent were boys and 20 percent were girls. Visual measurements were made with the refractive correction in use and refractive errors were counted present only when they were of one diopter or more. For the sake of simplicity, muscular imbalances, fusion deficiencies, suppression, and so forth were grouped together as "defects of binocular vision." The speed of object perception was measured according to the method previously described by me. 1 ' 2 The Bender test3 consists of the presenta tion of nine cards, one at a time, each having a gestalt figure on it. The individual under test is instructed to copy each of the designs as he sees it. Interpretation is not specific with right and wrong answers, as in the case of most intelligence and achievement tests. Instead the examiner studies the subject's drawings, classifies their characteristics under fairly flexible headings, and interprets them in the light of his knowledge of gestalt principles, personality dynamics, and maturational level. The present study compares the frequency
110
cases responded to vitamin A, given in high doses over many weeks. One child with Bitot's spots and night blindness, as well as signs of vitamin-B de ficiency, was seen and he responded promptly to therapy.4 Metivier reviewed the literature and found reports of the same experiences by Palmer in Assam, Sie-Boen-Lian in Java, Aykroyd in India, Wilson in Egypt, and Nicholls in Ceylon. They all reported cases of Bitot's spots and other forms of xerosis conjunctiva that were resistant to vitamin-A therapy.4 It should be reiterated that these observa tions were made on natives from tropical countries. They were exposed to strong sun light for many years. Many of them probably
had been on inadequate diets for long periods of their lives. These and other factors ap parently caused a form of xerosis conjunc tiva which was refractory to treatment with vitamin A. SUMMARY
Two cases of Bitot's spots without night blindness are reported in well-nourished young men. Neither case improved under vitamin-A therapy. There are several reports of xerosis con junctiva occurring in natives of tropical countries, in whom there was no response to vitamin-A therapy. The presence of Bitot's spots cannot be considered as indicative of vitamin-A deficiency in every case. U. S. Army Hospital.
REFERENCES
1. Berens, C.: The Eye and Its Diseases. Philadelphia, Saunders, 1950, pp. 397-398. 2. Berliner, M.: Biomicroscopy of the Eye. New York, Hoeber, 1949, pp. 166-168. 3. Tassman, I.: The Eye Manifestations of Internal Diseases. St. Louis, Mosby, 1946, pp. 514-516. 4. Metivier, V.: Bitot's spots in Trinidad. Am. J. Ophth. 24:1029-1034 (June) 1941. 5. Cecil, R., and Loeb, R.: A Textbook of Medicine. Philadelphia, Saunders, 1951, pp. 568-571. 6. Kyser, F.: Therapeutics in Internal Medicine. New York, Nelson, 1950, pp. 290-292. 7. Duncan, G.: Diseases of Metabolism. Philadelphia, Saunders, 1942, pp. 388-400.
A NEW GROUP O F CYCLOPLEGIC DRUGS* FURTHER STUDIES IRWIN H.
STOLZAR,
M.D.
Cleveland, Ohio My interest in a new group of cycloplegic drugs was stimulated by a report by Priest ley and Medine1 in 1951. Their report con cerned itself with Compound 75 G.T.* We undertook a comparative study of the cyclo plegic effects of this compound and two other related compounds of the same series, Compound 92 G.T. and 93 G.T.* *From the Division of Ophthalmology, Depart ment of Surgery, Western Reserve University School of Medicine, and the University Hospitals of Cleveland. Presented before the Cleveland Ophthalmological Club, November, 1951. t Schieffelin and Company, New York. t Supplied through the courtesy of E. W. Blanch-
These compounds are members of a series of new antispasmodic agents belonging to a class of basic esters of substituted phenylacetic acids, the structure and preparation of which are to be reported elsewhere. As will be shown, these compounds more closely ap proximate the ideal cycloplegic drug than any in common use at the present time. The ideal cycloplegic drug would be one possessing the following properties: (1) Rapid effect, (2) extensive depression of accommodation for a sufficiently long period as to permit ade quate refraction, (3) prompt recovery, (4) dissociation of mydriatic and cycloplegic effect, and (5) no local or systemic sidereactions. In this study the drugs were used in 0.5percent concentration in a boric-acid borate ard, Ph.D., Director of Research, Schieffelin anc Company.
NOTES, CASES, INSTRUMENTS
111
TABLE 1 CYCLOPLEGIC EFFECTS
75
92
93
80 cases 1.03D.
50 cases 1.0D.
50 cases 1.0D.
Compound G.T. Average residual accommo dation 1 hr. after instillation Residual accommodation by age groups 10-20 years 20-30 30-40 Range of residual accommo dation (diopters) 0.50 0.75 1.00 1.25 1.50 1.75
28 cases 29 cases 23 cases
1.14D. 0.97D. 0.97D.
2.5% 13.7% 55.0% 27.5% 1.3%
■ 15 cases 19 cases 16 cases
26% 50% 24%
1.03D. 1.06D. 0.88D.
21 cases 15 cases 14 cases
1.05D. 0.95D. l.OOD.
32% 46% 14% 6% 2%
buffer, pH about 5.7, with 1:50,000 Table 1 demonstrates the cycloplegic ef zephiran as a preservative. Two drops were fects of these three compounds. It is seen instilled in the conjunctival cul-de-sac five that the average residual cycloplegia for all minutes apart, refraction being done one cases is about one diopter. Particularly sig hour after the initial instillation. The resid nificant is the marked depression of accom ual accommodation was measured, after modation in the age group of 10 to 20 years. correction of the distance refractive error, by The range was found to be from 1.03 diop determining the near point of accommoda ters with Compound 92 to 1.14 diopters with tion. In no instance in this study of 180 cases Compound 75. In the other age groups the was any evidence of general or local toxicity range was from 0.88 diopters to 1.06 diop encountered. ters. Maximal cycloplegia was rapidly induced No direct comparisons of residual accom (within 30 minutes in some cases) and modation were made against homatropinereached a maximum within 45 to 60 minutes. paredrine cycloplegia which has been our Restoration of accommodative power with usual routine. However, it was found that, in out the use of a miotic occurred usually be many cases previously refracted with homattween four and 12 hours. In a comparatively ropine and paredrine in combination, the few cases the ability to read was delayed for cycloplegic action with the drugs of this new about 24 hours. The recovery from the cyclo series was either equal to or more profound plegic effect was considerably more rapid than with the homatropine-paredrine combi than that experienced with either homatro- nation. Figures taken from the papers by pine or homatropine-paredrine combination Marron 2 and Moncrieff and Scheribel3 indi where a delay of 24 to 48 hours is not too cate a residual accommodation of 1.9 diop unusual. ters with atropine and 1.6 diopters with hoThe mydriatic effect was also rapidly matropine. Our findings, as has been shown, manifested (often within 15 minutes) and indicate a considerably greater cycloplegic maximal within 45 minutes. Recovery from effect with this new series of drugs. the mydriatic effect was slower than from SUMMARY the cycloplegic effect, usually within 24 to 48 hours. No instance of increased intraocu The reported new compounds, Compounds lar pressure was found as the result of the 75 G.T., 92 G.T., and 93 G.T., offer the mydriatic effect. nearest approach to the ideal cycloplegic of
112
NOTES, CASES, INSTRUMENTS
any drug now in use or recently reported. Their action is prompt (within 45 to 60 min utes for maximum cycloplegia), the accom modation is markedly depressed (average residual about 1.00 diopter), and the recov ery is prompt (usually within four to 12 hours). These compounds depart from the ideal in their mydriatic effect which, how ever, is not objectionable when compared to the advantages indicated.
One of these compounds will soon be re leased for office use.* It is believed that these drugs may successfully replace, or will cer tainly be a useful adjunct, to the use of homatropine and even atropine for routine office refraction. 831 National City Bank Building (14). * "Cyclogyl," Personal communication from Dr. E. W. Blanchard.
REFERENCES
1. Priestley, B. S., and Medine, M. M.: A new mydriatic and cycloplegic drug. Am. J. Ophth., 34:572-575 (Apr.) 1951. 2. Marron, J.: Cycloplegia and mydriasis by use of atropine, scopolamine, and homatropine-paredrine. Arch. Ophth., 23 :340-350 (Feb.) 1940. 3. Moncrieff, W. F., and Scheribel, K. J.: Further studies concerning homatropine cycloplegia and paredrine with special reference to rate of accommodative recovery. Am. J. Ophth. 25 :839-843 (July) 1942.
E Y E AND O T H E R HANDICAPS* THEIR
RELATION
TO
PERFORMANCE
ON
A
VISUAL MOTOR GESTALT TEST T H O M A S H.
EAMES,
M.D.
Boston, Massachusetts
While using the Bender visual motor gestalt test in exploring personality factors among reading failures, some of whom had severe eye and visual defects, I questioned whether these handicaps were impairing the validity of the test. It seemed possible that visual-ocular difficulties might account for some inadequacy of perception of the gestalt configurations and that defects and deficien cies of the drawing arm, forearm, and hand might interfere with the reproduction of the pattern as perceived. In such cases the test would be detecting physical def ectiveness as well as personality factors. Fifty persons, who were reading failures and who had been given the Bender test, were examined for vision, refraction, binocular vision, the speed of object percep tion, lateral dominance of eye and hand, and defects of the drawing arm, forearm, and * From the School of Education, Boston Uni versity.
hand. The median age of the group was eight years, four months and the median intelli gence quotient was 100. As usual, among reading failures, 80 percent were boys and 20 percent were girls. Visual measurements were made with the refractive correction in use and refractive errors were counted present only when they were of one diopter or more. For the sake of simplicity, muscular imbalances, fusion deficiencies, suppression, and so forth were grouped together as "defects of binocular vision." The speed of object perception was measured according to the method previously described by me. 1 ' 2 The Bender test3 consists of the presenta tion of nine cards, one at a time, each having a gestalt figure on it. The individual under test is instructed to copy each of the designs as he sees it. Interpretation is not specific with right and wrong answers, as in the case of most intelligence and achievement tests. Instead the examiner studies the subject's drawings, classifies their characteristics under fairly flexible headings, and interprets them in the light of his knowledge of gestalt principles, personality dynamics, and maturational level. The present study compares the frequency