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An Unusual Contact Lens Complication
NOTES, CASES, INSTRUMENTS steadily while seeing through her contact lenses for two hours, then through her regular glasses for one hour while the lenses rested in the cul-de-sacs. At the end of the hour she pushed them back over the cornea and removed her glasses. A 51-year-old patient with one and one-half diopters of myopia found that bifocals were not necessary because she wore the contact lenses for everything except reading, at which time she could push the lenses aside and allow the print to come into focus. Several patients were in the habit of taking naps during the day. This would have been hazardous if the lenses had been left on the corneas during sleep but they were pushed into the cul-de-sacs tempo rarily, with no inconvenience. Several older patients found insertion and re moval of their lenses an ordeal. The technique of wearing them under the eyelids instead of remov ing them allowed these patients the ease of only one insertion in the morning and one removal at night. 478 Peachtree Street
(8).
AN U N U S U A L CONTACT L E N S COMPLICATION DAVID D. MICHAELS,
M.D.
AND GEORGE S. Z U G S M I T H ,
M.D.
San Pedro, California The increasing popularity of contact lenses has brought to light a number of complications associated with their use.1"3 Most of these complications tend to be minor in nature and can be relieved by modifica tions in or temporary removal of the lens. The present case illustrates a rather unusual complication and points to prevention of its recurrence. CASE REPORT
Mrs. L. P. a 20-year-old secretary, was seen on May 11, 1962, with the complaint of swelling of the right upper lid. She had noted this about three weeks before and became concerned when it in creased in size despite the application of heat and local medication. There had been no pain, tearing or other subjective symptoms. Ocular examination showed 20/20 vision in each eye with a moderate myopic correction. There was
1057
a firm swelling along the lateral edge of the right superior lid fold. The nodule measured approxi mately one cm. in diameter and was slightly tender to palpation. Eversion of the lid revealed the nodule to be covered by smooth conjunctiva. The posterior edge of the tumor could not be seen or felt and ap peared to extend upward and backward into the orbit. The remainder of the eye examination showed essentially normal findings. The patient stated that she had worn contact lenses since 1959 but had discontinued wearing them about two weeks ago because she felt that they might aggravate the lid swelling. On further ques tioning she added that approximately 13 months previously she had lost the right contact lens which she had never found. In due course she obtained another lens and had worn it comfortably until the present. The patient was hospitalized. A preoperative X-ray film was nonrevealing. The next morning, under general anesthesia, the lesion was explored. A horizontal incision into the conj uncti val aspect of the nodule was immediately followed by the presentation of a somewhat battered and cloudy, but otherwise not unusual, corneal contact lens. The lens, whose concave surface faced the globe, was delivered from the lips of the incision without difficulty. There were no adhesions to the surround ing tissue. A small specimen from the inner lining of the nodule showed nonspecific granulation tissue. The wound was closed with two interrupted catgut sutures. Healing proceeded uneventfully and the swelling disappeared. The only after-effect was that the patient now absolutely refuses to wear her con tact lenses. In retrospect, the patient stated that, on one oc casion about one or two months after she lost the lens, she had had a vague foreign-body sensation. She had not felt it important enough to report to her doctor. On one occasion the eye was said to be injected and perhaps swollen. The wearing time of the replacement lens approximated that of the lens in the other eye, with no undue symptoms. COMMENT
In reconstructing the possible course of events, it is supposed that the lens originally became lodged in the superior fornix where, after a period of time, it produced a small abscess. When the abscess ruptured, the wound may have provided an entrance point for the lens which, by erosion and the ac tion of the lids, then insinuated itself into the lid tissue. Granulation tissue eventually closed the wound behind it. It is difficult to imagine any other form of entrance into the lid tissue proper. The possibility of a "lost" contact lens
1058
NOTES, CASES, INSTRUMENTS
becoming embedded in the superior fornix without the patient's awareness is not infre quent. Indeed one of us remembers hunting for one of his own lenses for two hours be fore realizing ( b y logic rather than feeling) that the lens w a s in the upper fornix. T h e present case, however, is the first, as far as we know, in which such a lens has (1) been "lost" for over a year and ( 2 ) ac tually been incarcerated in the lid tissue. I t demonstrates that in cases of "lost" lenses it is a good idea to look in the fornix as well
as in the contact-lens case (where two lenses often stick together). 1350 West Seventh Street. ADDENDUM
Since our paper was submitted for publication, Green described a similar case (AMA Arch. Ophth., 69:23-24 (Jan.), 1963). In Green's case the lens had been embedded for 10 months but, unlike ours, the lens had not actually become incarcerated in the lid tissue. Moreover, in Green's case there was an in tractable conjunctivitis which was absent in ours. This may have been due to the different locations of the "lost" lenses.
REFERENCES
1. Lansche, R. K., and Lee, R. C : Acute complications from present day corneal contact lenses. AMA Arch. Ophth., 64:275, 1960. 2. Vida, F. L.: Medical complications of contact lenses. Internat. Ophth. Clin., 1:495 (Sept.) 1960. 3. Dixon, J. M., and Lawaczeck, E. : Changes in the eye and adnexa due to corneal lenses. Exhibit Penn. Acad. Ophth., May, 1962.
DEMYELINATING DISEASE O F T H E O P T I C TRACT* ARNOLD D. PEARLSTONE,
M.D.
Fairfield, Connecticut The visual field defect resulting from le sions of the optic tract is characteristically described as a homonymous hemianopia which is incomplete, incongruous and has sloping margins.1*3 The field changes usu ally begin in one quadrant and the incon gruity may be so marked as to present a quadrantic defect on one side and little or no defect on the other.2 While primary lesions of the optic tract are rare, they have been seen with glioma and the demyelinating diseases.3 Traquair states : "the lesions of multiple sclerosis af fect the tracts in the same way as the optic nerves or chiasma and produce field changes which resemble in behavior those of ordinary acute retrobulbar neuritis. Homonymous hemianopic defects, varying in extent from * From the United States Naval Hospital, Guantanamo Bay, Cuba. The opinions or assertions con tained herein are those of the author and are not to be construed as official or as necessarily reflect ing the views of the Medical Department of the Navy or the Naval Service at large.
small hemianopic central scotomas to the loss of a quadrant or of half the field occur and central vision is involved. Apart from their hemianopic character these field changes do not differ in onset or course from those described under multiple sclero sis affecting other parts of the visual path way . . ." A review of the recent American ophthal mic literature failed to reveal any case re ports of demyelinating disease of the optic tract. The following case is presented as an example of the clinical course of a probable demyelinating tract lesion. CASE REPORT
This 21-year-old white man was first seen in the eye clinic of this hospital on March 30, 1961, with complaint of decreased vision of the right eye for one week. Ocular examination was within nor mal limits. The vision was: R.E., 20/200; L.E., 20/20. A centrait visual field examination revealed an inferior temporal quadrantic defect on the right and suggested a homonymous change in the left eye (fig. 1). The patient was admitted on March 31 for further studies and evaluation. Physical examination on admission revealed a well-developed, well-nourished white man whose physical findings were all within the limits of nort Only central visual field examinations were per formed because a perimeter was not available.
(8).
AN U N U S U A L CONTACT L E N S COMPLICATION DAVID D. MICHAELS,
M.D.
AND GEORGE S. Z U G S M I T H ,
M.D.
San Pedro, California The increasing popularity of contact lenses has brought to light a number of complications associated with their use.1"3 Most of these complications tend to be minor in nature and can be relieved by modifica tions in or temporary removal of the lens. The present case illustrates a rather unusual complication and points to prevention of its recurrence. CASE REPORT
Mrs. L. P. a 20-year-old secretary, was seen on May 11, 1962, with the complaint of swelling of the right upper lid. She had noted this about three weeks before and became concerned when it in creased in size despite the application of heat and local medication. There had been no pain, tearing or other subjective symptoms. Ocular examination showed 20/20 vision in each eye with a moderate myopic correction. There was
1057
a firm swelling along the lateral edge of the right superior lid fold. The nodule measured approxi mately one cm. in diameter and was slightly tender to palpation. Eversion of the lid revealed the nodule to be covered by smooth conjunctiva. The posterior edge of the tumor could not be seen or felt and ap peared to extend upward and backward into the orbit. The remainder of the eye examination showed essentially normal findings. The patient stated that she had worn contact lenses since 1959 but had discontinued wearing them about two weeks ago because she felt that they might aggravate the lid swelling. On further ques tioning she added that approximately 13 months previously she had lost the right contact lens which she had never found. In due course she obtained another lens and had worn it comfortably until the present. The patient was hospitalized. A preoperative X-ray film was nonrevealing. The next morning, under general anesthesia, the lesion was explored. A horizontal incision into the conj uncti val aspect of the nodule was immediately followed by the presentation of a somewhat battered and cloudy, but otherwise not unusual, corneal contact lens. The lens, whose concave surface faced the globe, was delivered from the lips of the incision without difficulty. There were no adhesions to the surround ing tissue. A small specimen from the inner lining of the nodule showed nonspecific granulation tissue. The wound was closed with two interrupted catgut sutures. Healing proceeded uneventfully and the swelling disappeared. The only after-effect was that the patient now absolutely refuses to wear her con tact lenses. In retrospect, the patient stated that, on one oc casion about one or two months after she lost the lens, she had had a vague foreign-body sensation. She had not felt it important enough to report to her doctor. On one occasion the eye was said to be injected and perhaps swollen. The wearing time of the replacement lens approximated that of the lens in the other eye, with no undue symptoms. COMMENT
In reconstructing the possible course of events, it is supposed that the lens originally became lodged in the superior fornix where, after a period of time, it produced a small abscess. When the abscess ruptured, the wound may have provided an entrance point for the lens which, by erosion and the ac tion of the lids, then insinuated itself into the lid tissue. Granulation tissue eventually closed the wound behind it. It is difficult to imagine any other form of entrance into the lid tissue proper. The possibility of a "lost" contact lens
1058
NOTES, CASES, INSTRUMENTS
becoming embedded in the superior fornix without the patient's awareness is not infre quent. Indeed one of us remembers hunting for one of his own lenses for two hours be fore realizing ( b y logic rather than feeling) that the lens w a s in the upper fornix. T h e present case, however, is the first, as far as we know, in which such a lens has (1) been "lost" for over a year and ( 2 ) ac tually been incarcerated in the lid tissue. I t demonstrates that in cases of "lost" lenses it is a good idea to look in the fornix as well
as in the contact-lens case (where two lenses often stick together). 1350 West Seventh Street. ADDENDUM
Since our paper was submitted for publication, Green described a similar case (AMA Arch. Ophth., 69:23-24 (Jan.), 1963). In Green's case the lens had been embedded for 10 months but, unlike ours, the lens had not actually become incarcerated in the lid tissue. Moreover, in Green's case there was an in tractable conjunctivitis which was absent in ours. This may have been due to the different locations of the "lost" lenses.
REFERENCES
1. Lansche, R. K., and Lee, R. C : Acute complications from present day corneal contact lenses. AMA Arch. Ophth., 64:275, 1960. 2. Vida, F. L.: Medical complications of contact lenses. Internat. Ophth. Clin., 1:495 (Sept.) 1960. 3. Dixon, J. M., and Lawaczeck, E. : Changes in the eye and adnexa due to corneal lenses. Exhibit Penn. Acad. Ophth., May, 1962.
DEMYELINATING DISEASE O F T H E O P T I C TRACT* ARNOLD D. PEARLSTONE,
M.D.
Fairfield, Connecticut The visual field defect resulting from le sions of the optic tract is characteristically described as a homonymous hemianopia which is incomplete, incongruous and has sloping margins.1*3 The field changes usu ally begin in one quadrant and the incon gruity may be so marked as to present a quadrantic defect on one side and little or no defect on the other.2 While primary lesions of the optic tract are rare, they have been seen with glioma and the demyelinating diseases.3 Traquair states : "the lesions of multiple sclerosis af fect the tracts in the same way as the optic nerves or chiasma and produce field changes which resemble in behavior those of ordinary acute retrobulbar neuritis. Homonymous hemianopic defects, varying in extent from * From the United States Naval Hospital, Guantanamo Bay, Cuba. The opinions or assertions con tained herein are those of the author and are not to be construed as official or as necessarily reflect ing the views of the Medical Department of the Navy or the Naval Service at large.
small hemianopic central scotomas to the loss of a quadrant or of half the field occur and central vision is involved. Apart from their hemianopic character these field changes do not differ in onset or course from those described under multiple sclero sis affecting other parts of the visual path way . . ." A review of the recent American ophthal mic literature failed to reveal any case re ports of demyelinating disease of the optic tract. The following case is presented as an example of the clinical course of a probable demyelinating tract lesion. CASE REPORT
This 21-year-old white man was first seen in the eye clinic of this hospital on March 30, 1961, with complaint of decreased vision of the right eye for one week. Ocular examination was within nor mal limits. The vision was: R.E., 20/200; L.E., 20/20. A centrait visual field examination revealed an inferior temporal quadrantic defect on the right and suggested a homonymous change in the left eye (fig. 1). The patient was admitted on March 31 for further studies and evaluation. Physical examination on admission revealed a well-developed, well-nourished white man whose physical findings were all within the limits of nort Only central visual field examinations were per formed because a perimeter was not available.