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Apparent Sympathetic Ophthalmia, Nine Months after Enucleation, with Implantation of Gold Ball in Tenon's Capsule
WASP-STING
sphincter. It is not to be proven out ot hand that this change might be the cause of the mydriasis. On the other hand, it i s not impossible that the nerve fibers, as well as the sphincter,
KERATITIS
are affected by the wasp's toxin, produce the dilatation of the The insensitivity of the cornea also well be traced to lesions nerves due to toxic action.
497
and so pupil. might of the
APPARENT SYMPATHETIC OPHTHALMIA, N I N E MONTHS AFTER ENUCLEATION, WITH I M P L A N T A T I O N OF GOLD BALL IN TENON'S CAPSULE. ,
DAVID N. D E N N I S ,
M.D.,
ERIE, PA. • ball
tnls 6ye
case recurring attacks of inflammation and increased tension in the remainare d UP under general and local medication without removal of the implanted
. The following case shows several interesting features: A sympathetic secondary glaucoma, starting nine months after enucleation. -Lhe irritating eye removed within two weeks of injury. The recurrence of these attacks of secondary glaucoma, and their final subsidence, leaving a perfect field of vision, and an unusually high percen tage. of vision—20/10. Did the implantation of an artificial oail play any part in producing, or inCIn 5 ' . t h e relapses? In view of the r" rnu LWork a n d t h e v i e w s Drought out by this work, as shown in various papers read and published within the f , ™ years, I think no connection can be found. If the sympathetic inflammation had ueen a true iridocyclitis with exudates, J question whether one would have had ™e courage to allow the implantation d i p ™ 3 1 " i n ' E v e n u n d e r these conflit'ons, m the light of our changed theories, would the presence of the iVnPJantation make any difference in the course of the inflammation; provided l e J ; ° U r l e ' } h a t t h e operation of enucnerT fd, b e e n d o n e w e l l > *• e - the nerve cut far back and the artificial
CASE.—A. H., aged 17, I first saw on May 18, 1913, twenty-four hours after he had been struck in the right eye by a piece of steel broken from a hammer he was using. A local physician had tried the magnet in an effort to remove a possible foreign body. There was some doubt as to a foreign body being present. Inspection showed a small central penetrating wound of the cornea, with some pericorneal injection. There was a slight hypopyon present; the lens was opaque, and there was only light perception. The vision of the left eye was 20/10. The X-ray localized a foreign body 2 mm. by 2 mm., deep in the vitreous chamber. Little encouragement was given in regard to saving any vision, or even as to saving the eyeball, but the family desired to have the foreign body re moved and an effort made to save the ball. Haab's magnet was used to bring the particle forward in the vitreous, then the smaller hand magnet was used to work the metal into the anterior chamber. The chamber was then opened, emptying the hypopyon, and the steel was extracted thru the open ing. r Perly anchored in capsule ?° Tenon's The eye remained reasonably quiet until May 31, 1913, when there was a t i o n n ^l lgf ha v . S e r ta0, Sbe ed onarrated, the quesoSi^ 4h l> s s i b i l i ft i t s Possible focal recurrence of the hypopyon, the ball dimin'.f J t PX° r a y y I think can be quite tender to touch, and more or less t e S ?JA S ■ U S"e s w e rlaminations of the pain complained of. e a« t L ' " negative, as well The left eye showed normal tension, as the examination of the tonsils. and a vision of 20/10. The patient was
498
DAVID N. DENNIS
urged to have the injured ball removed. This was done and a gold ball implant ed in Tenon's capsule. There was no undue reaction following the operation; the healing was smooth and unevent ful; the left eye remained quiet; there was no dread of light or change in the vision of 20/10. He was discharged from the hos pital on June 7, 1913. He returned la ter for inspection and adjustment of an artificial eye. At these visits, the vision remained 20/10 in the left eye and everything was perfectly quiet. On February 17, 1914, he reported an alarming drop in vision. Four or five days before the visit, he first noticed a halo around artificial lights, then the drop in vision. Inspection showed no pericorneal injection; the pupil was dilated but active. There were many points of exudate on Descemet's mem brane, but no exudate in the pupillary area, or in the vitreous. The tension was taken with the Schiotz instrument, and registered 30 mgm. The field of vision showed a full, normal field, but the blind spot area was very much en larged. The accommodation showed a recession of the near point. The patient entered the hospital, where pilocarpin sweats and inunctions of mercurial ointment were used sys tematically, and homatropin and eserin were used alternately, locally. On March 9, 1914, the eye was per fectly quiet. The tension was 12 mm., and the vision 20/10. He was discharged from the hospital. He again reported on April 29, 1915,' stating that two days before there had been some pain in the eye, headache, a halo around the lights and some drop in vision. Inspection showed no peri corneal injection; the vision 20/15 and a recession of the near point. The pu pil was active, and there were a few points of exudate on Descemet's membrane. The deep media of the eye were clear. The tension again registered high— 27 mgm. The patient again entered the hospital, where pilocarpin
sweats and inunctions were used; and locally a very weak solution of scopolamin alternately with eserin, and the use of subconjunctival injections of normal saline. On May 14, 1915, the eye being quiet, the vision 20/10 and1 the tension regis tering 18 mm., the patient was dis charged. He was seen at various times after wards, the eye found quiet and the tension normal, until September 17, 1917; when he reported, complaining of a drop in vision, some pain, a halo around lights and a recession of the near point. The vision was 20/15; the tension registered 35 mgm. He entered the hospital, where I instituted the same plan of treatment as was used be fore. On September 26, 1917, the tension registered 18 mm., the exudate on Descemet's membrane had cleared; and the vision had returned to 20/10. The field of vision was normal; there was no enlargement of the normal blind spot, and the accommodation was normal. He was discharged from the hospital. In this case, the lymphocyte count was made as described by Gradle in the Archives of Ophthalmology, page 567, Volume 39. The count was made before the injured eye was enucleated, and several times during each period of inflammation. The characteristic increase in the small lymphocytes, and the decrease in the polymorphonuclears, was not shown at any time. I have frequently seen these findings in traumatic irido-cyclitis. In condi tions of this kind, the count is a help and should be made. When found positive, it becomes a decided help in deciding the best plan to pursue in these often puzzling cases. I have examined the patient once or twice since and the eye was found normal in every respect. A recent let ter from him states that he is able to use his eye comfortably for near work, and his distant vision is clear.
sphincter. It is not to be proven out ot hand that this change might be the cause of the mydriasis. On the other hand, it i s not impossible that the nerve fibers, as well as the sphincter,
KERATITIS
are affected by the wasp's toxin, produce the dilatation of the The insensitivity of the cornea also well be traced to lesions nerves due to toxic action.
497
and so pupil. might of the
APPARENT SYMPATHETIC OPHTHALMIA, N I N E MONTHS AFTER ENUCLEATION, WITH I M P L A N T A T I O N OF GOLD BALL IN TENON'S CAPSULE. ,
DAVID N. D E N N I S ,
M.D.,
ERIE, PA. • ball
tnls 6ye
case recurring attacks of inflammation and increased tension in the remainare d UP under general and local medication without removal of the implanted
. The following case shows several interesting features: A sympathetic secondary glaucoma, starting nine months after enucleation. -Lhe irritating eye removed within two weeks of injury. The recurrence of these attacks of secondary glaucoma, and their final subsidence, leaving a perfect field of vision, and an unusually high percen tage. of vision—20/10. Did the implantation of an artificial oail play any part in producing, or inCIn 5 ' . t h e relapses? In view of the r" rnu LWork a n d t h e v i e w s Drought out by this work, as shown in various papers read and published within the f , ™ years, I think no connection can be found. If the sympathetic inflammation had ueen a true iridocyclitis with exudates, J question whether one would have had ™e courage to allow the implantation d i p ™ 3 1 " i n ' E v e n u n d e r these conflit'ons, m the light of our changed theories, would the presence of the iVnPJantation make any difference in the course of the inflammation; provided l e J ; ° U r l e ' } h a t t h e operation of enucnerT fd, b e e n d o n e w e l l > *• e - the nerve cut far back and the artificial
CASE.—A. H., aged 17, I first saw on May 18, 1913, twenty-four hours after he had been struck in the right eye by a piece of steel broken from a hammer he was using. A local physician had tried the magnet in an effort to remove a possible foreign body. There was some doubt as to a foreign body being present. Inspection showed a small central penetrating wound of the cornea, with some pericorneal injection. There was a slight hypopyon present; the lens was opaque, and there was only light perception. The vision of the left eye was 20/10. The X-ray localized a foreign body 2 mm. by 2 mm., deep in the vitreous chamber. Little encouragement was given in regard to saving any vision, or even as to saving the eyeball, but the family desired to have the foreign body re moved and an effort made to save the ball. Haab's magnet was used to bring the particle forward in the vitreous, then the smaller hand magnet was used to work the metal into the anterior chamber. The chamber was then opened, emptying the hypopyon, and the steel was extracted thru the open ing. r Perly anchored in capsule ?° Tenon's The eye remained reasonably quiet until May 31, 1913, when there was a t i o n n ^l lgf ha v . S e r ta0, Sbe ed onarrated, the quesoSi^ 4h l> s s i b i l i ft i t s Possible focal recurrence of the hypopyon, the ball dimin'.f J t PX° r a y y I think can be quite tender to touch, and more or less t e S ?JA S ■ U S"e s w e rlaminations of the pain complained of. e a« t L ' " negative, as well The left eye showed normal tension, as the examination of the tonsils. and a vision of 20/10. The patient was
498
DAVID N. DENNIS
urged to have the injured ball removed. This was done and a gold ball implant ed in Tenon's capsule. There was no undue reaction following the operation; the healing was smooth and unevent ful; the left eye remained quiet; there was no dread of light or change in the vision of 20/10. He was discharged from the hos pital on June 7, 1913. He returned la ter for inspection and adjustment of an artificial eye. At these visits, the vision remained 20/10 in the left eye and everything was perfectly quiet. On February 17, 1914, he reported an alarming drop in vision. Four or five days before the visit, he first noticed a halo around artificial lights, then the drop in vision. Inspection showed no pericorneal injection; the pupil was dilated but active. There were many points of exudate on Descemet's mem brane, but no exudate in the pupillary area, or in the vitreous. The tension was taken with the Schiotz instrument, and registered 30 mgm. The field of vision showed a full, normal field, but the blind spot area was very much en larged. The accommodation showed a recession of the near point. The patient entered the hospital, where pilocarpin sweats and inunctions of mercurial ointment were used sys tematically, and homatropin and eserin were used alternately, locally. On March 9, 1914, the eye was per fectly quiet. The tension was 12 mm., and the vision 20/10. He was discharged from the hospital. He again reported on April 29, 1915,' stating that two days before there had been some pain in the eye, headache, a halo around the lights and some drop in vision. Inspection showed no peri corneal injection; the vision 20/15 and a recession of the near point. The pu pil was active, and there were a few points of exudate on Descemet's membrane. The deep media of the eye were clear. The tension again registered high— 27 mgm. The patient again entered the hospital, where pilocarpin
sweats and inunctions were used; and locally a very weak solution of scopolamin alternately with eserin, and the use of subconjunctival injections of normal saline. On May 14, 1915, the eye being quiet, the vision 20/10 and1 the tension regis tering 18 mm., the patient was dis charged. He was seen at various times after wards, the eye found quiet and the tension normal, until September 17, 1917; when he reported, complaining of a drop in vision, some pain, a halo around lights and a recession of the near point. The vision was 20/15; the tension registered 35 mgm. He entered the hospital, where I instituted the same plan of treatment as was used be fore. On September 26, 1917, the tension registered 18 mm., the exudate on Descemet's membrane had cleared; and the vision had returned to 20/10. The field of vision was normal; there was no enlargement of the normal blind spot, and the accommodation was normal. He was discharged from the hospital. In this case, the lymphocyte count was made as described by Gradle in the Archives of Ophthalmology, page 567, Volume 39. The count was made before the injured eye was enucleated, and several times during each period of inflammation. The characteristic increase in the small lymphocytes, and the decrease in the polymorphonuclears, was not shown at any time. I have frequently seen these findings in traumatic irido-cyclitis. In condi tions of this kind, the count is a help and should be made. When found positive, it becomes a decided help in deciding the best plan to pursue in these often puzzling cases. I have examined the patient once or twice since and the eye was found normal in every respect. A recent let ter from him states that he is able to use his eye comfortably for near work, and his distant vision is clear.