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A Successful Hummelsheim Operation1
NOTES, CASES, INSTRUMENTS A SUCCESSFUL HUMMELSHEIM OPERATION* DON M. SMART, M.D. Dallas, Texas AND D A N I E L SNYDACKER,
M.D.
Chicago, Illinois Since Hummelsheim described the opera tion of transplanting the tendons of the su perior and inferior recti to augment the action of a paretic lateral rectus, 1 it has been modified by many surgeons including O'Con nor, Gifford, Peter, and Gibson. Callahan has presented evidence that it is not the transplantation of a part of the superior and inferior recti to the insertion of the lateral rectus that accomplishes abduction of the eyeball, but rather resection of the lateral rectus combined with recession of the medial rectus which produces the result. 2 T h e present case is interesting in that a pure Hummelsheim procedure resulted in re storing considerable abductive power to a previously paralyzed lateral rectus. C A S E REPORT
R. M., a 36-year-old Negro, was first seen at the Illinois Eye and Ear Infirmary of the University of Illinois on August 22, 19SS. He gave a history of diplopia of one-year duration and stated that his eyes had crossed since that time and that they were * From the Department of Ophthalmology of the Illinois Eye and Ear Infirmary, University of Illi nois College of Medicine. Presented before the Chicago Ophthalmological Society, November 18, 1957.
89
gradually becoming more crossed. Corrected visual acuity was 20/30 in the right eye and 20/20 in the left. Examination showed an esotropia of SO degrees' which was slightly greater with the right eye fixing. There was no abduction of the right eye beyond the midline, and the left eye showed a definite weakness of abduction. The blood and spinal fluid serology were positive. Neurologic examination was negative except for the paralysis of the right lateral rectus and weak ness of the left lateral rectus. There was no change in the extraocular muscle function following an extensive course of penicillin therapy. It was felt that surgery was indicated, and on March 28, 1956, a 10-mm. resection of- the right lateral rectus and a four-mm. recession of the right medial rectus were done. The esotropia was improved, but a residual convergence of 25 prism diopters for distance and 30 prism diopters for near remained with no abduction past the midline. On May 10, 1956, a five-mm. recession of the left medial rectus was performed without objective or subjective improvement. After allowing for postoperative stabilization, a Hummelsheim operation of the right eye was done on November 15, 1956. At operation the previously resected right lateral rectus was isolated and the adhesions from the previous operation were freed with little difficulty. Lateral slips from both the superior and inferior recti were brought to just behind the insertion of the lateral rectus. They were sutured to this site, and the lateral rectus was ad vanced two mm. without resection. No more was done purposely so that the effect of the transplanta tion alone could be compared with the effect of the previous resection and recessions. From the first postoperative day the eyes were straight for distance and near by the cover test. The eyes remained straight and when seen five months after surgery the right eye could be ab ducted 20 degrees. By cross-cover measurements, there were six prism diopters of esophoria at dis tance and three prism diopters of esophoria at near. Ten months after surgery the right eye could be abducted 30 degrees.
Figs. 1, 2 and 3* (Smart and Snydacker). One month before Hummelsheim operation. (Fig. 1) Right lateral gaze. (Fig. 2) Straight-ahead position. (Fig. 3) Left lateral gaze. * The preoperative photographs were taken by Martin Urist, M.D., and the postoperative photographs were taken by Mr. Louis Pedigo.
90
NOTES, CASES, I N S T R U M E N T S
Figs. 4, 5, and 6 (Smart and Snydacker). Six months after Hummelsheim operation. (Fig. 4) Right lateral gaze. (Fig. 5) Straight-ahead position. (Fig. 6) Left lateral gaze. SUMMARY
This case is presented to show that trans plantation of one half of the superior rectus and one half of the interior rectus to the
insertion of the lateral rectus can be an effec tive procedure in selected cases. 219 Dallas East Medical Center (18). Ill North Wabash (2).
REFERENCES 1. Hummelsheim, E.: Weitere Erfahrungen mit partieller Sehnen iiber pflanzung an den Augenmuskeln. Arch. f. Augenh., 62:71-74, 1908. 2. Callahan, A.: Surgery of the Eve: Diseases. Springfield, III., Thomas, 1956.
EMBOLI O F T H E CENTRAL RETINAL ARTERY AFTER MITRAL COMMISSUROTOMY* C. HOURLAY-STASSART, M.D., G. LAVERGNE,
and
M.D.
Liege, Belgium (Translated by David Shoch, M.D., Chicago, Illinois) An arterial embolus is a relatively fre quent complication of mitral stenosis. This accident can occur spontaneously, outside of periods of complete asystole, without emo tional upset or effort. It is in the area of the left middle cerebral artery that the embolus is most frequently lodged. Emboli in periph eral arteries are more uncommon and are found, in general, in the legs. Localization in the central retinal artery is even more rare. Von Graefe described this in 1859 and attributed it to a cardiac lesion. Mitral commissurotomy is a procedure which consists of stretching the stenosed valve by means of a finger. It is performed on valves which have calcareous concretions on them and which frequently liberate emboli to * From the Ophthalmologic Clinic of the Univer sity of Liege, Prof. R. Weekers.
different areas (H. E. Bolton, et al., 1952). Two of these interest the ophthalmologist: (a) localization in a nutrient vessel of the optic nerves (J. E. Alfano, et al., 1957), and (b) localization in a central retinal artery which to our knowledge has not been de scribed up to now. We should like to report two such cases. CASE REPORTS CASE 1
L. Adolphe, aged 31 years, had acute polyarticular rheumatic fever in 1942 without sequelae until 1953 when he had his first attack of pulmonary edema. A diagnosis of mitral stenosis was made and the patient became unable to work because of increasing dyspnea and further attacks of pulmonary edema. In March, 1955, a mitral commissurotomy was performed, the surgeon noting calcifications on the valve. On awakening the patient noted that he could not see out of his right eye. Vision was reduced to light perception, the fundus showed a pale disc, arteries very narrowed, a pale edema of the posterior pole, a red spot in the macula surrounded by fine hemorrhages and small exudates. A diag nosis of spasm of the right central retinal artery was made. The patient left the hospital on April 7th and was seen on the eye service on May 9th. The right eye was blind, the disc atrophic, and the narrowed arterioles converted to white cords. There were scattered areas of degeneration in the papillomacular area and the macula, still red, seemed to show a hole.
M.D.
Chicago, Illinois Since Hummelsheim described the opera tion of transplanting the tendons of the su perior and inferior recti to augment the action of a paretic lateral rectus, 1 it has been modified by many surgeons including O'Con nor, Gifford, Peter, and Gibson. Callahan has presented evidence that it is not the transplantation of a part of the superior and inferior recti to the insertion of the lateral rectus that accomplishes abduction of the eyeball, but rather resection of the lateral rectus combined with recession of the medial rectus which produces the result. 2 T h e present case is interesting in that a pure Hummelsheim procedure resulted in re storing considerable abductive power to a previously paralyzed lateral rectus. C A S E REPORT
R. M., a 36-year-old Negro, was first seen at the Illinois Eye and Ear Infirmary of the University of Illinois on August 22, 19SS. He gave a history of diplopia of one-year duration and stated that his eyes had crossed since that time and that they were * From the Department of Ophthalmology of the Illinois Eye and Ear Infirmary, University of Illi nois College of Medicine. Presented before the Chicago Ophthalmological Society, November 18, 1957.
89
gradually becoming more crossed. Corrected visual acuity was 20/30 in the right eye and 20/20 in the left. Examination showed an esotropia of SO degrees' which was slightly greater with the right eye fixing. There was no abduction of the right eye beyond the midline, and the left eye showed a definite weakness of abduction. The blood and spinal fluid serology were positive. Neurologic examination was negative except for the paralysis of the right lateral rectus and weak ness of the left lateral rectus. There was no change in the extraocular muscle function following an extensive course of penicillin therapy. It was felt that surgery was indicated, and on March 28, 1956, a 10-mm. resection of- the right lateral rectus and a four-mm. recession of the right medial rectus were done. The esotropia was improved, but a residual convergence of 25 prism diopters for distance and 30 prism diopters for near remained with no abduction past the midline. On May 10, 1956, a five-mm. recession of the left medial rectus was performed without objective or subjective improvement. After allowing for postoperative stabilization, a Hummelsheim operation of the right eye was done on November 15, 1956. At operation the previously resected right lateral rectus was isolated and the adhesions from the previous operation were freed with little difficulty. Lateral slips from both the superior and inferior recti were brought to just behind the insertion of the lateral rectus. They were sutured to this site, and the lateral rectus was ad vanced two mm. without resection. No more was done purposely so that the effect of the transplanta tion alone could be compared with the effect of the previous resection and recessions. From the first postoperative day the eyes were straight for distance and near by the cover test. The eyes remained straight and when seen five months after surgery the right eye could be ab ducted 20 degrees. By cross-cover measurements, there were six prism diopters of esophoria at dis tance and three prism diopters of esophoria at near. Ten months after surgery the right eye could be abducted 30 degrees.
Figs. 1, 2 and 3* (Smart and Snydacker). One month before Hummelsheim operation. (Fig. 1) Right lateral gaze. (Fig. 2) Straight-ahead position. (Fig. 3) Left lateral gaze. * The preoperative photographs were taken by Martin Urist, M.D., and the postoperative photographs were taken by Mr. Louis Pedigo.
90
NOTES, CASES, I N S T R U M E N T S
Figs. 4, 5, and 6 (Smart and Snydacker). Six months after Hummelsheim operation. (Fig. 4) Right lateral gaze. (Fig. 5) Straight-ahead position. (Fig. 6) Left lateral gaze. SUMMARY
This case is presented to show that trans plantation of one half of the superior rectus and one half of the interior rectus to the
insertion of the lateral rectus can be an effec tive procedure in selected cases. 219 Dallas East Medical Center (18). Ill North Wabash (2).
REFERENCES 1. Hummelsheim, E.: Weitere Erfahrungen mit partieller Sehnen iiber pflanzung an den Augenmuskeln. Arch. f. Augenh., 62:71-74, 1908. 2. Callahan, A.: Surgery of the Eve: Diseases. Springfield, III., Thomas, 1956.
EMBOLI O F T H E CENTRAL RETINAL ARTERY AFTER MITRAL COMMISSUROTOMY* C. HOURLAY-STASSART, M.D., G. LAVERGNE,
and
M.D.
Liege, Belgium (Translated by David Shoch, M.D., Chicago, Illinois) An arterial embolus is a relatively fre quent complication of mitral stenosis. This accident can occur spontaneously, outside of periods of complete asystole, without emo tional upset or effort. It is in the area of the left middle cerebral artery that the embolus is most frequently lodged. Emboli in periph eral arteries are more uncommon and are found, in general, in the legs. Localization in the central retinal artery is even more rare. Von Graefe described this in 1859 and attributed it to a cardiac lesion. Mitral commissurotomy is a procedure which consists of stretching the stenosed valve by means of a finger. It is performed on valves which have calcareous concretions on them and which frequently liberate emboli to * From the Ophthalmologic Clinic of the Univer sity of Liege, Prof. R. Weekers.
different areas (H. E. Bolton, et al., 1952). Two of these interest the ophthalmologist: (a) localization in a nutrient vessel of the optic nerves (J. E. Alfano, et al., 1957), and (b) localization in a central retinal artery which to our knowledge has not been de scribed up to now. We should like to report two such cases. CASE REPORTS CASE 1
L. Adolphe, aged 31 years, had acute polyarticular rheumatic fever in 1942 without sequelae until 1953 when he had his first attack of pulmonary edema. A diagnosis of mitral stenosis was made and the patient became unable to work because of increasing dyspnea and further attacks of pulmonary edema. In March, 1955, a mitral commissurotomy was performed, the surgeon noting calcifications on the valve. On awakening the patient noted that he could not see out of his right eye. Vision was reduced to light perception, the fundus showed a pale disc, arteries very narrowed, a pale edema of the posterior pole, a red spot in the macula surrounded by fine hemorrhages and small exudates. A diag nosis of spasm of the right central retinal artery was made. The patient left the hospital on April 7th and was seen on the eye service on May 9th. The right eye was blind, the disc atrophic, and the narrowed arterioles converted to white cords. There were scattered areas of degeneration in the papillomacular area and the macula, still red, seemed to show a hole.