American Medical Association Section on Ophthalmology—1978

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MEETINGS, CONFERENCES, SYMPOSIA

by isotopic tracer yielding better under­ standing in the mechanisms of contusion injury and endophthalmitis as well as more physiologic variations. Howard, Breg, Warburton, Miller, and McKeown, acknowledging that most retinoblastoma patients do not have chromo­ somal abnormalities, proceeded to dem­ onstrate unilateral or bilateral tumors associated with partial deletion of the long arm of chromosome 13. Earlier studies lumping the D-group chromosomes to­ gether and without the assistance of banding underestimated the chromoso­ mal role. Small segments of 13q were missing only in a few of the cells studied. It is necessary to examine many cells of various tissues and to use banding to understand the heredity of this neoplasm. Nearly 15% of children with 13q defects have retinoblastoma and may be retarded. Burns, Conner, and Gipson reported on Schnyder's crystalline corneal dystrophy with its central ring-like deposits of cho­ lesterol and marked circulus lipidis. These patients have active cholesterol up­ take in the cornea; thus the dystrophy depends on abnormalities of blood lipid metabolism as well as autosomal domi­ nant defects in keratocytes. Harley, Rodriques, and Crawford re­ ported histologic verification of the unu­ sual congenital fibrosis syndrome involv­ ing one or all extraocular muscles. Family histories established an autosomal pat­ tern. Hope, Potts, and Keeney analyzed 200 serially examined low-vision pa­ tients, revealing poor correlation between distance acuity and near aid need, prefer­ ence for stand magnification with increas­ ing age, best acceptance in early and mid life, and rejection for nonoptical reasons reaching 5% to 10% in late life. Kearns, Siekert, and Sundi reported superior oph­ thalmic and neurologic results with a new neurosurgical anastomosis of the superfiical temporal artery to the middle cerebral artery instead of attacking the impaired

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ipsilateral common carotid; 121 patients undergoing this technique faired better than those with more traditional carotid surgery. Kennedy stressed arterial embolization for progressive hemangioma in infancy but used silicone spheres by cath­ eter. Weinstein and Rylander, in an exper­ imental study of macular photocoagulation in 12 monkeys and one human (in whom enucleation was to be performed for a peripheral melanoma), demonstrated remarkable correlation between histolog­ ic findings and visually evoked poten­ tials. Spaeth and Barber, one of the several teams simultaneously and independent­ ly discovering homocystinuria, ranged widely into the philosophic approach to genetically influenced diseases, stressing interrelationships of multiple gene de­ fects and environmental overlay. Forbes presented a new limbal suspension to avoid collapse of the globe during intrao­ cular surgery. A dramatic report by Troutman and Swinger analyzed their first 16 patients receiving keratophakia by the Jose Barraquer technique with a slight increase in complications. The intracorneal surgical site, exterior to the chambers of the eye, is however, an enormous safe­ guard in this physiologic approach. The new president, Phinizy Calhoun, Jr., of Atlanta, follows a responsible pat­ tern created by the retiring president, Sam McPherson, Jr. Six new associate mem­ bers were introduced. The coveted Howe Medal was awarded to Rodman Irvine. A R T H U R H. K E E N E Y

AMERICAN MEDICAL ASSOCIATION S E C T I O N ON OPHTHALMOLOGY—1978 The Section on Ophthalmology of the American Medical Association met in conjunction with the AMA's 127th Annu­ al Convention in St. Louis, June 20 and 21, 1978.

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The chairman of the Section, Thomas D. Duane, called the meeting to order Tuesday, June 20, in the new St. Louis Convention Center. The opening paper, by Manus C. Kraff, Donald R. Sanders, and Howard L. Lieberman, was entitled "The effect of phacoemulsification on the corneal endothelium." Dr. Kraff, who read the paper, indicated that the loss of endothelial cell density is 34% in phacoemulsified eyes, as compared to a 17% loss in eyes undergoing intracapsular cataract extraction; the loss rate in­ creases with ultrasound times greater than two minutes. In discussing this pa­ per, Thomas O. Wood, stressed that the endothelium is "forgiving" in nature and that specular microscopy has permitted eye surgeons to be bolder than ever be­ fore. Barry J. Wolstan, Robert C. Ramsay, David E. E ifrig, and William H. Knobloch, reported on "Visual prognosis fol­ lowing removal of intraocular foreign bodies." They noted a prognosis of ap­ proximately 50% for good visual acuity in their series, essentially changed from studies before the era of techniques such as microsurgery and pars plana vitrectomy. Glen P. Johnston noted that im­ proved methods of diagnosis and therapy tend to be significantly more expensive than the traditional ones. "Neuro-oculo-cutaneous hamartomatosis—A pedigree," was presented by Thomas R. Pheasant, Richard E. Gold­ berg, Jerry A. Shields, and Larry E. Magargal. Harold F. Falls, who discussed this presentation, suggested that these manifestations probably represent de­ layed development. Thomas O. Wood reported on "Trifluo­ rothymidine in resistant dendritic ul­ cers." He noted that corticosteroids did not retard healing of ulcers treated with this compound. In discussion, Stephen R. Waltman agreed that trifluorothymidine is an extremely effective agent.

SEPTEMBER, 1978

Kenneth B. Mitchell, Theodore Krupin, Mark F. Johnson, and Bernard Becker reported on the "Long-term response fol­ lowing peripheral iridectomy in angleclosure glaucoma." They showed that peripheral iridectomies are safe and effective even over a long period of time. George L. Spaeth agreed that most, but not all, patients with acute, narrowangle glaucoma required iridectomy. Barry A. Maltzman discussed "Extend­ ed wear contact lenses," reporting that 84 of his 100 patients were able to wear lenses successfully. Oliver H. Dabezies, noted that new lenses for extended wear are to be released soon. To open the afternoon session, Dr. Duane gave the Chairman's Address, en­ titled "The Section on Ophthalmology of the AMA. The phoenix phenomenon." Dr. Duane reviewed the history of the Section. Most of the great contributors to American ophthalmology have served the Section. However, the composition of the Section Councils was changed drastically by the AMA in 1977; as a result the continuation of the Section's activities was threatened. However, at a meeting June 19, 1978, the Section Council deter­ mined that the Section would continue to be a viable organization, which would conduct a scientific program. The pro­ gram would either remain as part of the annual AMA meetings or would be held in conjunction with the American Acade­ my of Ophthalmology. Dr. Duane noted that the major prob­ lems facing ophthalmology today includ­ ed the delivery of health care, research, and education. H e stressed that ophthal­ mologists working together with the AMA could have a voice in all of these areas. He concluded by emphasizing that the AMA needs ophthalmology and that ophthal­ mology needs the AMA. The scientific program continued with a presentation by M. Madison Slusher and William E. Hutton, "Vitreous instru-

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mentation in anterior segment trauma and reconstruction." This surgical technique has permitted successful results in a wide variety of situations. In discussing this paper, Nicholas Douvas restated the ob­ jective of vitrectomy in trauma as the performing of definitive surgery as a onestage technique. Byron Smith and Richard L. Petrelli reported on "Dermis-fat graft for the cor­ rection of the exposed orbital implant." This method has the advantage of correct­ ing cosmetically significant enopthalmos in anophthalmic patients. Charles R. Leone, Jr., discussed this paper, pointing out that previously held views concerning absorption necrosis and nonvascularization of fat grafts have been disproven by this work. He noted, however, that he still prefers the scleral patch graft for most cases. B. Allen Watson discussed "Early sur­ gery and congenital esotropia," demon­ strating a computer-assisted linear analy­ sis to develop his data. Of his 54 subjects, 29% achieved stereopsis. The paper was discussed by Marshall M. Parks, who emphasized that not all patients with con­ genital esotropia with peripheral fusion obtain stereopsis. G. S. Guggino reported on "Six-mil­ limeter bimedial recession in congeni­ tal large angle esotropia," indicating that this was reserved for patients with meas­ urements of 60 prism diopters or greater. Of his 45 subjects, 43 were corrected with less than 10 prism diopters of esotropia, and there were no overcorrections. Eugene M. Helveston, who discussed this work, agreed with the recommendation for performing early surgery (5 to 12 months of age). He also pointed out that the insertion of the medial rectus muscle frequently varied from 3 to 6 mm in infants; the average was 4.4 mm. "The surgical treatment of accommoda­ tive esotropia," presented by David Mittelman and Martin J. Urist, described

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good results in recessing one medial rec­ tus muscle in patients who are not fully corrective with miotics or bifocals. Dis­ cussant James E. Miller agreed that there is an occasional need for surgery in these patients. "The corneal endothelium and intrao­ cular lens implantation. Specular micro­ scopic studies," was described by Manus C. Kraff, Donald R. Sanders, and Howard L. Lieberman. Although they found only a small increase in endothelial cell loss compared to eyes undergoing intracapsular cataract extraction alone as long as the trauma to the endothelium was estimated to be mild, the rate of loss increased twoto threefold in patients who suffered moderate endothelial cell trauma. The discussant, Robert C. Drews, noted that some workers had found as much as a sixfold endothelial cell loss rate with "difficult" cases as opposed to "easy" cases. On Wednesday, June 2 1 , a postgradu­ ate course, entitled "Ophthalmology for the non-ophthalmologist," was given by Thomas Behrendt, course director, Ed­ ward A. Jaeger, and J. Wallace McMeel, Jr. This course was well attended by family practitioners and others interested in ophthalmology. The Section on Ophthalmology contin­ ued with a paper by Ramesh C. Tripathi and Frank W. Newell, "A clinicopathologic study of vitreous opacities in amyloidosis." They noted the presence of pecu­ liar vitreous footplates attached to the posterior surface of the lens in their pa­ tients. The discussant, Thomas D. Duane, emphasized the importance of a conjunctival biopsy when this diagnosis is being considered. "Venostasis retinopathy," was describ­ ed by Charles R. Beyrer, who agreed with the original description of this entity distinguishing it from hemorrhagic reti­ nopathy. Venostasis retinopathy, as de­ scribed by Hayreh, is a benign self-

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limiting disease that rarely leads to hemorrhagic retinopathy. Barry E. Wright and Alan C. Bird pre­ sented material on "Placoid pigment epitheliopathy and Harada's disease," which they consider to be a clinical continuum. This paper, which received the Section's award and a prize of $250 for the best paper of the meeting, emphasized the fluorescein angiographic similarities of both conditions with nonfilling of the choriocapillaris leading to ischemic changes in the retinal pigment epithelium. In dis­ cussing this paper, Froncie A. Gutman noted a few obvious clinical differences between the two conditions, especially the self-limiting nature of placoid pig­ ment epitheliopathy as opposed to the chronic recurrent aspect of Harada's dis­ ease. Hernando Zegarra, James Conforto, Edward M. Chester, Robert T. Spector, and John Hines described clinical and hematologic correlations of "Leukemic retinopathy." They pointed out that there was no definite correlation between the clinical status of the patient and the ap­ pearance of the retinopathy. Walter R. Stafford, the discussant, stressed the com­ mon occurrence of ocular involvement in leukemia. Robert A. Schimek described, "Oph­ thalmic manifestations of visceral larva migrans." He emphasized that the ELISA test is the most reliable study for the diagnosis of this disorder. Ramesh C. Tripathi discussed the differences be­ tween the ocular manifestations of toxocariasis and visceral larva migrans, stress­ ing that they were rare in the latter in­ stance. Donald R. May, Gholam A. Peymen, Motilal Raichand, and Michael L. Klein reported on "Randomized prospective study of xenon arc panretinal photocoagulation for central retinal vein occlusion." The discussant, Stuart Fine, emphasized the large areas of nonprofusion of retinal

SEPTEMBER, 1978

capillaries as the basis of the neovascular glaucoma. W. Rex Hawkins described "Macular pucker following retinal detachment surgery." Careful fundus examination showed open retinal holes in eight of his 26 patients. Seven of these had scleral buckles and underwent revision of their scleral buckles; all improved. In discuss­ ing this paper, Edward Okun agreed that unclosed breaks may explain some cases of macular pucker because of residual fluid permitting preretinal and subretinal cellular migration. He stressed the impor­ tance of closure of all retinal breaks in this as in other cases of retinal detach­ ments. Stuart L. Fine reported on "Random­ ized clinical trials for branch vein, senile macular degeneration, and presumed oc­ ular histoplasmosis syndrome." He an­ nounced that five centers are currently studying these conditions and are pres­ ently enrolling patients in order to deter­ mine the therapeutic effectiveness of photocoagulation. The Scientific Program concluded with a splendid symposium, "Glaucoma filter­ ing surgery," moderated by Bernard Becker. The Distinguished Foreign Guest, Peter Gordon Watson of Cam­ bridge, England, was introduced by Dr. Duane. Mr. Watson's presentation, "Trabeculectomy and the pathophysiology of glaucoma," was the first Parker Heath Memorial Lecture. He presented the re­ sults of trabeculectomy on 416 patients with various forms of glaucoma. The suc­ cess rate of controlling increased intrao­ cular pressure was high and complica­ tions were extremely low. His pathologic studies in these cases revealed extracellu­ lar accumulation of material clogging up the trabecular meshwork with loss of the normal vacuolar system. Trabeculectomy apparently permits the autoregulatory mechanism of the eye to be restored, leading to the conclusion that trabeculec-

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tomy is an effective form of treatment for patients with chronic primary glaucoma. Mr. Watson ended by recommending that "the patient with chronic, open-angle glaucoma not easily controlled with pilocarpine 2% given three times daily should have trabeculectomy because it is a safe and predictable procedure." The symposium continued with a re­ port, "Use of setons in filtering surgery," b y Theodore Krupin. Dr. Krupin indicat­ ed that use of a pressure sensitive glauco­ ma valve implant had controlled intrao­ cular pressure in 16 of 25 patients. All these patients previously had surgical failures. Of 24 patients with neovascular glaucoma, 17 had intraocular pressure controlled as well by this technique. Har­ old G. Scheie presented his data, "Iridectomy with scleral cautery. Its use over a period of 25 years." The success rate of

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25% was achieved in patients with chron­ ic glaucoma. Dr. Scheie now uses a scleral flap with a highly beveled incision, clos­ ing this with a single 10-0 nylon suture under the conjunctival flap. George L. Spaeth presented "Combined cataract and glaucoma surgery," stating that those at greatest risk with glaucoma and cata­ ract were those with pathologic cupping of the disk. The transient increase in intraocular pressure in the early postoper­ ative period may produce significant vis­ ual field loss in these patients. The session closed on a note of hope­ fulness despite the recent reorganization of the Section on Ophthalmology. The present officers are: Thomas D. Duane, chairman; Theodore Steinberg, vice chairman; and Oliver Dabezies, secretary. G E O R G E W. W E I N S T E I N

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M.D.

Editor-in-Chief AMERICAN JOURNAL O F OPHTHALMOLOGY