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Belgian Ophthalmological Society
SOCIETY PROCEEDINGS Reports for this department should be sent at the earliest date practicable to Dr. Harry S. Gradle, 22 Kast Washington Street, Chicago, Illinois. These reports should present briefly the important scientific papers and discussions. BELGIAN OPHTHALMOLOGICAL SOCIETY. N o v e m b e r 30th, 1919. Translated by Dr. M. W. Fredrick. W o u n d of the Superior Rectus. M- -VI. 1.KIT.AT, Liege, s h o w e d a m a n w h o had been s t r u c k in the left eye With a knife a year previously. The blade had entered j u s t above the outer end of the e y e b r o w and had p e n e t r a t e d " i t o the orbit. A week after the assault the knife point bent on the Hat w a s recovered from the wound, l.eplat s a w t h e p a t i e n t a m o n t h later and found i n c o m p l e t e ptosis, the eye t u r n e d d o w n w a r d s , diplopia beyond •'5°, fuudus intact. As t h e r e was no i m p r o v e m e n t I-eplat tried an a d v a n c e ment of the superior rectus in September, but was u n a b l e to carry it out, as the part id" the muscle which was accessible- had been c h a n g e d into cicatriC| al tissue which w a s a d h e r e n t to the globe. I here is more t h a n an insufficiency °f the s u p e r i o r rectus to be considered, as the eye is displaced d o w n w a r d s . Hie a u t h o r t h i n k s t h a t the knife point bent on itself p u s h e d the eye d o w n w a r d s w i t h g r e a t violence, t e a r i n g the <-'hcck l i g a m e n t s of the s u p e r i o r and internal recti, t h u s a c c o u n t i n g for the permanence, of the eetopia of the globe. } o r e m e d y this condition the a u t h o r ' " t e n d s to pass a d o u b l e - a r m e d thread t h r u the slum]) of the superior rectus as far back as lie can, and to lead the t h r e a d s a l o n g the sides of the levator muscle as far as the orbital m a r g i n , w h e r e t h e needles are passed t h r u the s k i n and the t h r e a d s fastened to the forehead. In this w a y lie h o p e s to raise the eye and to keep it in its new position by m e a n s of cieatricial b a n d s which will form a r o u n d the t h r e a d s and a d h e r e to the periosteum of the orbital m a r g i n .
A Case of Traumatic Glaucoma. TIIIUKRT, 1-iege, p r e s e n t e d a case of t r a u m a t i c glaucoma c o m i n g on t w o weeks after a simple c o n t u s i o n in the n e i g h b o r h o o d of the u p p e r lid. T h e onset s e e m s to have been favored by u n u s u a l physical exertion with ihe b o d y bent forward, the eye being predisposed to increased tension by the contusion. T h e increased tension was of 42 d a y s ' d u r a t i o n , without c h a n g e in the pupil or contraction of the visual field. While in the r e c u m b e n t position the tension was 12 millimeters h i g h e r than in the s i t t i n g position. T h i s difference is explained by tlie g r e a t e r How of blood to the head', the eye h a v i n g lost its p o w e r of v a s o m o t o r regulation. U n d e r the same conditions normal per •ons show no increase of tension, so t h a t one is forced to a s s u m e a lesion of the s y m p a t h e t i c ocular center of the eye. In all probability there was a t e a r i n g of the zonula of Zinn. The origin of the g l a u c o m a t o u s s y m p t o m s is to be s o u g h t in the v a s o m o t o r paralysis which g a v e rise to a repletion of the choroidal and ciliary s p o n g e with h y p e r s e c r e t i o n of a q u e o u s h u m o r and o b s t r u c t i o n of the different lymphatic vessels. Hole in the Papilla. V A N T.INT, Hrusscls. A painter, t h i r t y y e a r s old, showed an absolute central s c o t o m a , of small size, the result of a r e t r o m a c u l a r h e m o r r h a g e . W i t h the o p h t h a l m o s c o p e an atypical excavation in the t e m p o r a l part of the papilla w a s discovered, occupying about one-sixth of the entire papillary surface. T h i s excavation b o r e no relation to the m a e u l a r lesion, a n d w a s probably congenital. Varicocele of the Orbit. Y . w T.INT showed p a t i e n t of t h i r t y five with the classical s y m p t o m s of varicose dilatation of the veins of the orbit, with i n t e r m i t t e n t c n o p h t h a l m u s
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and e x o p h t h a l m u s . O p e r a t i o n w a s indicated by the pains a c c o m p a n y i n g the exophthalmus. D i s c u s s i n g the latter case L a g r a n g e s t a t e d t h a t in a similar case he had opened into the orbit t h r u a K r o e n l e i n boneflap and resected a l a r g e piece of the o p h t h a l m i c vein. O n e c a n n o t take the whole vein out, b u t by r e m o v i n g several b r a n c h e s a n d replacing t h e m with fibrous tissue t h e ebb and flow in the vein, which give rise to the i n t e r m i t t e n t e x o p h t h a l m u s , is b r o u g h t to a standstill. Hemiatrophy of the Face and Ocular Symptoms. W E E K E R S , Liege, r e p o r t e d a case of h e m i a t r o p h y of the face in which a c h r o n i c r e c u r r e n t irido-cyclitis w a s also p r e s e n t . liolh c o n d i t i o n s w e r e due to a lesion of the t r i g e m i n u s . T h e a u t h o r calls a t t e n t i o n to the p a t h o g e n i c i m p o r t a n c e of the t r i g e m i n u s in certain forms of irido-cyclitis. In the case reported the p a t h o g e n e s i s is evident on a c c o u n t of the coexisting skin and bone lesions, but the relation is not a l w a y s so p r o n o u n c e d . T h a t this is a fact is p r o v e d by the n u m b e r of cases of p o s t g r i p p a l n e u r o p a r a l y t i c keratitis which occurred d u r i n g the epidemic of influenza which raged after. the conclusion of the war a n d the signi n g of the armistice. T h e corneal lesions s h o w e d wide varieties, but m a n y of t h e m w e r e associated with iritis and irido-cyclitis. In some cases the corneal lesions w e r e so slight t h a t t h e y w e r e o v e r w h e l m e d by the severity of the irido-cyclitis. T h e p a t h o g e n e s i s of this form of irido-cyclitis easily escaped r e c o g n i t i o n . A consideration of tliese facts leads to the conclusion t h a t t h e r e e x i s t s a form of irido-cyclitis d u e to an a l t e r a t i o n in the n u t r i t i o n of the globe with the t r i g e m i n u s as the u n d e r l y i n g cause. It is readily u n d e r stood that an infectious disease like influenza m a y b r i n g on an irido-cyclitis directly t h r u microbic m e t a s t a s i s in the uvca, a lesion of the t r i g e m i n u s being the precursor. Conclusion: In the presence of these r a t h e r frequent forms of iridocyclitis with u n k n o w n etiology one should not forget a possible lesion of the t r i g e m i n u s , and to look for the
s y m p t o m s which indicate a lesion of this nerve, such as a n e s t h e s i a of the cornea, of t h e skin of t h e forehead, etc. Suture of Orbito-ocular W o u n d s and D e e p Regional Anesthesia. I ) E LAPEKSONNE, P a r i s , advises the use of a p r i m a r y s u t u r e in all orbitoo c u l a r w o u n d s t h a t a r e quite recent. T o b e t t e r define the time he gives less t h a n t w e n t y - f o u r h o u r s for ocular w o u n d s , and less t h a n forty-eight h o u r s for orbito-palpebral w o u n d s . In all t h e s e cases m e t h o d i c local or regional a n e s t h e s i a is called for. The solution used to p r o d u c e t h e a n e s t h e s i a is an adrenalised 4 % novococain solution w i t h the following formula : Novocain 0.08 A d r e n a l i n 1/1,000 2 drops Distilled w a t e r 2 ce. P u t up in sterilized a m p o u l e s . T o p r o d u c e a n e s t h e s i a of the globe a s t r a i g h t needle is inserted 3'/> centim e t e r s beyond the inferior orbital m a r gin. following a vertical line d r a w n from the external c o m m i s s u r e . E n t e r ing at the level of the bone the needle is c o n t i n u e d u p w a r d s and i n w a r d s , crosses the optic nerve a n d reaches the •apex of the orbit in the n e i g h b o r h o o d of the ciliary g a n g l i o n . T h e direction of the p o i n t is c h a n g e d slightly a n d t w o or t h r e e cc. are injected into the cellular tissue s u r r o u n d i n g the g a n g lion and the ciliary nerves. After a wait of 15 m i n u t e s the operation m a y proceed. A n e s t h e s i a of the s e n s o r y nerves of the orbit is produced as follows: l . - - l r o r the nasal a needle four a n d one half c e n t i m e t e r s long is i n t r o d u c e d j u s t below the pulley of the s u p e r i o r oblique a n d pushed to the apex of t h e orbit following t h e s u p e r i o r i n t e r n a l angle. T w o cc. of the solution are injected. 2.—For both the frontal and the lacrimal nerves one injection is e n o u g h . O n e should not try to reach the n e r v e s at the apex of the orbit but at the top w h e r e t h e y come t h r u the sphenoidal fissure at the e x t e r n a l part. Closely following the external orbital m a r g i n and j u s t below the external palpebral l i g a m e n t a needle four and p n e half c e n t i m e t e r s l o n g is inserted in c o n t a c t
SOCIETY P R O C E E D I N G S
with the bony external wall which bends backward and inwards. 3.—For the suborbital the point of entry is one and one half centimeters bejow the infraorbital margin, at the middle of the palpebral fissure. The needle directed upwards and inwards will strike a small depression in the bone, the foramen infraorbitale. When this is entered the patient feels a sharp Pain in the teeth and the upper lip. In some cases one has to reach the superior maxillary in the orbital groove by pushing the needle along the inferior wall to the apex of the orbit. This regional anesthesia is supplemented by lesser injections under the conjunctiva. Subcutaneous infiltration in forehead, cheek, and temporo-malar region make veritable barrages. The Use of these is apparent when we consider that recurrent terminal branches °f the inferior maxillary nerve are distributed to this, the skin of the lastnamed region. Improvement of Our Surgical Armamentarium. LANDOLT, Paris, has for years been busy with the improvement of our surgical armamentarium in his characteristic serious and logical way. Instead of trying to change a few instruments whose shortcomings are obvious he has gone to the root of the question by seeking what is peculiarly adapted to ocular surgery, and in what this differs from that which is useful in general surgery. To do this he has established the leading principles of ocular surgery, whence the form and the use of the instruments would follow. Hjs basic ideas are: the organ With which we are dealing is so small, so sensitive, so mobile, and the operations practised on it so minute that our instruments as well as their manipulation require a delicacy and a precision much beyond the requirements of general surgery. Many of the instruments m general use are too heavy and too pross; the catches in certain forceps are too stiff to be operated without effort, thus defeating the delicacy demanded by the character of the operations. To obtain the precision and
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sureness demanded by ocular surgery the fifth finger should rest on the orbital margin and the bulbs of the other fingers should be very near the active part of the instrument. This is not possible with the present form of most of our instruments, as the distance between the handle and the active part of the instrument is much too long. The author exhibited a number of instruments modified according to these views, and accentuated their advantages by comparing them with the improper models in general use. For instance, the handles should be of aluminum slightly adherent, clinging instead of slippery, heavy steel; they should also be rectangular instead of square. Bistouries, curettes, cystitomes, Taylor loops, etc., should all have short, flat handles, lying well in the hand; the author's lance should have a short, curved handle, with the blade shaped like the ace of spades instead of a triangle. Rather short forceps, some with teeth set obliquely, and all with very soft catches, were also shown. Special mention was made of the author's needle holder, which had no catch, but graduated pressure; his palpebral plaque which follows the outline of the globe exactly and stretches the lid equally in its entire width; his syringe for injecting into the nasal canal, short and easily handled; his needles for muscular advancement, and his double curved scissors for enucleation, which do away with the muscle hook. The author regrets that the efforts of a single individual are insufficient to change custom and bring about the changes so desirable in our armamentarium, and invites the profession at large to associate themselves with him in suggesting and demanding rational instruments from the makers. Decompression Operation in the Treatment of Chronic Glaucoma. I.AGRANGI;, Bordeaux. The decompression operation which reduces hypertontis is the subconjunctival fistulisation of the anterior chamber. This can be achieved in various ways, and the question is as to which is the
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best w a y . T h e choice is d e t e r m i n e d by t h e a n a t o m y of t h e sclero-corneal limbus, where w c find a sclero-corneal r i n g 1.75 m m . wide if w e m e a s u r e from the zone of d e t a c h a b l e c o n j u n c t i v a t o the s u m m i t of t h e a n g l e of infiltration. T h i s r i n g should be divided into t w o zones, a sclero-corneal zone, a n d a p r o p e r l y socalled scleral zone. T h i s latter h a s a w i d t h of o n e millimeter, and it is in this t h a t t h e excision should be practised. T h e r e a r e t h r e e r e a s o n s for restricting t h e scleral r e s e c t i o n s t o this z o n e : 1. It is best t o o p e r a t e in t h e sclera only, a s this tissue is fixed in i t s form and n o t disposed t o proliferate. 2. It is j u s t over t h e filtration zone, which is t h e lattice work, as it were, in the t r a p which covers the canal of S c h l e m m . 3. B y k e e p i n g t o this r e gion o n e avoids w o u n d i n g t h e cornea which m i g h t choke the orifice with its g r a n u l a t i o n s , a n d o n e r e s p e c t s t h e ciliary body which reacts" violently w h e n irritated. T h e r e a r e , therefore, a n a t omic, physiologic a n d surgical r e a s o n s for selecting this place for t h e fistula, and a piece one millimeter in width, at the m o s t , a n d t w o o r three millimeters in length should be resected with scissors, (iraefe knife, and p u n c h ; t h e t r e p h i n e should n o t be used, as its action c a n n o t be confined to the scleral b a n d , a n d it is a p t to slip over to t h e ciliary body o r t h e cornea. T h e a u t h o r s h o w e d in several specimens h o w often and how seriously t h e s e t w o bodies are injured by t h e u s e of the t r e p h i n e . P a s s i n g from t h e choice of m e t h o d the question arises w h e t h e r fistulisalion of the a n t e r i o r c h a m b e r is really accomplished, and w h e t h e r a d u r a b l e normalisation of t h e g l a u c o m a t o u s eye is obtained. T h e a u t h o r is very positive on this point, a n d a s s e r t s t h a t it is indeed rare t h a t t h e operation of sclerecto-iridectomy, a c c o r d i n g to his m e t h o d , does n o t give t h e desired normalisation ; the r e s u l t a n t sear is s o m e t i m e s flat, s o m e t i m e s ampttlliform. W h e n an anipulliform scar results, and this is often t h e case (seven t i m e s in t h e last sixteen cases which the a u t h o r h a s to add t o those a l r e a d y published) an orifice is visible which
u n d o u b t e d l y ' establishes c o m m u n i c a tion between t h e a n t e r i o r c h a m b e r a n d the subconjunctival spaces. ' T o prove this L a g r a n g e h a s twice c u t i n t o the — a m p o u l e a n d seen t h e a n t e r i o r c h a m b e r e m p t y itself in a few m i n u t e s . T h e a u t h o r feels justified by an experience of sixteen y e a r s in a s s e r t i n g t h a t decompression of t h e g l a u c o m a t o u s eye is i n v a r i a b l y accomplished b y subcon- ' junctival s c l e r e c t o m y in t h e limbus, and w a r n s a g a i n s t t h e u s e of t h e trephine. ' Contribution Elliot. HAMHRF.SIN,
to
the Trephining
Brussels, has
of
practised
t r e p h i n i n g a c c o r d i n g t o Elliot forty times. l i e c u t s a large flap t h r u t h e entire t h i c k n e s s of t h e conjunctiva, t a k i n g care n o t to touch t h e limbus, anl a l w a y s s e w s t h e flap. T h e d a y foll o w i n g t h e operation a s t r o n g solution of a t r o p i n is instilled. H e has never h a d a single complication which m i g h t b r i n g t h e o p e r a t i o n i n t o discredit. In his s t a t i s t i c s he includes only those cases which he h a s been able t o follow u p for a year. I n simple glaucoma 5 5 % of cures resulted. In chronic inflammatory g l a u c o m a t h e r e s u l t s w e r e very e n c o u r a g i n g . Six out of seven cases t h a t w e r e t r e p h i n e d were cured. H e a l w a y s does a total iridectomy. In acute g l a u c o m a trep h i n i n g is highly a d v a n t a g e o u s . It can be done u n d e r local anesthesia, is n o t d a n g e r o u s , a n d can be carried o u t when the a n t e r i o r c h a m b e r is a b s e n t a n d t h e pupil dilated t o t h e m a x i m u m . T h e r e is n o t r o u b l e s o m e bleeding while d o i n g an iridectomy, a n d the p o s t o p e r a t i v e a s t i g m a t i s m is reduced to t h e minim u m . T h e a u t h o r h a s also t r e p h i n e d in a case of bilateral h e t n o r r h a g i c g l a u c o m a ; in these cases o n e should touch the iris as little a s possible. D I S C U S S I O N . — L e b o u c q , G a n d , does not doubt t h a t t h e s c l e r e c t o m y of L a g r a n g e , a n d t h e modifications of this operation introduced by Rlliot a n d o t h e r s , often p r o d u c e an i m p r o v e m e n t in g l a u c o m a , but he t h i n k s t h a t t h e principle on which it is based calls for caution. T h e principle i s : t h e increase of tension is 'due to an o b s t r u c -
SOCIETY PROCEEDINGS
tion to the elimination of the aqueous humor; that the obstruction is removed by an opening- in the sclera thru which the aqueous may escape. Laboratory researches are not necessary to prove. the inexactness of this view; by purely clinical methods one can determine: 1. In most cases of glaucoma the anterior chamber is reduced in size, in many to nothing; there is, therefore, no obstacle to the outflow of the aqueous. 2. Some eyes on which a sclercctomy has been done remain soft even after the opening has closed; others get hard again very soon after the operation before the opening has had time to close. The fistula, therefore, supposing that it did exist, which is a matter of grave doubt, seems to play a very unimportant part. In former times we used to swear by iridectomy, the operation which made Graefe famous. Statistics showed surprising results, but the modus operandi of this irrational operation could never be explained. Then iridectomy was decried as useless and something else invented. Today the fashion demands sclerectomy; well, let us go ahead with our sclerectomies. Lagrange, answering the preceding gentleman: "Our colleague says the anterior chamber is often obliterated in glaucoma, and the elimination of the aqueous is very easy, lie says he canHot understand why under such conditions one should make so much of the faulty excretion of the aqueous in the pathogenesis of glaucoma, and then reports eases of sclerectomy by Trephining which have been so eminently satisfactory. I shall answer seriatim his three points, as they seem to embody all his objections. 1. The anterior chamber is suppi issed in glaucoma when the aqueous has been secreted in abnormal quantities in the region of the ciliary processes; the swollen vitreous pushes the lens forward, the iris is crowded against the cornea, Fontana's space is obliterated, and to the hypersecretion of the aqueous is added a defective elimination. There is nothing there which is not perfectly clear. 2. The pathogenic theory of glau-
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coma is no longer obscure; it was laid down by Bonders; the glaucoma has its start in an excitation of the sympathetic vasomotor setting up a hypersecretion in the gland of the aqueous humor. Just as the cheeks flush when one has been insulted, just so the ciliary nerves of the glaucomatous subject speed up after a deep emotion or an excitement of a psychic, moral, or physiologic nature. In the beginning then' is always some nervous excitement underlying every glaucoma, and all glaucomatous subjects have a neuropathic strain in them. After an eye has been the scat of several outbreaks the media are altered, and the filtration angle is clogged with waste, dross and debris of dead cells and extravasated blood cells; the drain at the angle of filtration ceases to play its part. To the hypersecretion is added hypoexcretion, especially in angiosclerotics in whom the sclera is very rigid and the vessels without elasticity. Hypersecretion thru excitation of the sympathetic hypoexcretion in angiosclerotic eyes, such are the features of the pathogenesis of glaucoma; and there, again, there is surely nothing obscure. 3. There is no gainsaying the fact that trephining gives results, and I take pleasure in accepting this as further proof of the value of the ns~ tulising method. But it exposes one to accidents which I need not again enumerate, and these accidents, many in number, consisting either in infection or wounding of the ciliary body, should convince the partisans of the tistulising method that the safest method is that which uses scissors, knife, and punch to remove the piece of sclera. I prefer, naturally, my own method, but there arc a number of others of merit, such as those of Holth, jacqucau, Coppez, Ferroni, etc. Tre> phining is the most defective method for producing fistulisation." Observations With Gullstrand's Lamp. GAI.UCMAKRTS AND KLEEFELD, Brussels, showed a series of drawings representing the normal and abnormal aspects of the anterior parts of the eye, as seen with Gullstrand's lamp.
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Projection of Cinematographic Films. IT. COPPEZ, Brussels, showed : 1. A film lent hy Barraquer of Barcelona, depicting Phacoerisis, which is a new method of extracting the crystalline lens with the aid of a suction cup which engages the anterior capsule (jf the lens. 2. Coppez then showed a film demonstrating the way in which ocular accidents occur in the porphyry quarries. The different categories of quarrymen are shown, and the visual requirements for each category are given. Me lays special stress on the careless manner in which these workmen protect their eyes, with poorly fitting glasses and lenses which have heconie half opaque by numerous scratches. Besides, some of the quarrymen, such as hewers and rippers, are required to make such violent body movements that the wearing of protecting glasses is out of the question. A detailed paper will he written later on this very interesting subject. 3. Coppez presented four miners with generalised nystagmic neurosis; the particulars in these cases were furnished by Dr. Rutten who had these men under observation. Wound of the Cornea by a Chestnut Burr. . LEPLAT, Liege, reported a case which is rather rare in this country, that of a wound of the cornea due. to a chestnut burr which had fallen off the tree. Eight spines had penetrated into the cornea, two passing entirely thru that body. The extraction was easily accomplished with the aid of a cataract knife, and the eye. healed rapidly without complication. Genesis of the Atypical Central and Paracentral Colobomata. VAN DUYSE, (land. The lissural origin cannot be denied since the histologie analysis showed retinal folds at the edge of these colobomata (1H9S). Referring to the deep atypical retroequatorial pit found by him in the embryo of a calf in 1900, and the lesser ones found by Szily, Wolfnun, and Meissner, the author wonders whether
in a microphlhalmic eye a peduncular artery (which sometimes gives off two or three branches) might not on leaving the optic groove give rise to a secondary pitting in the annular fissure at the anterior border of the retinal calyx thru a branch anastomosing with the hyaloid plexus. There are other anatomic considerations besides a fissure between the two layers of the secondary ocular vesicle which might explain the nature of some colobomatous areas: 1. Aplasia of the pigment epithelium of the choroid, as seen in a chick embryo by Seefelder; 2. A lacuna in the pigment epithelium thru which the choroidal mesoderm has proliferated and then spread out in the subretinal space (Bergmeister) ; 3. Localized proliferation of the glia disuniting the pigment epithelium to reach the aplasic choroid ((]. M. Van Duyse), all of which give rise to colobomatous areas of atypical character in the colobomatous eyes of the microphthalmie or eyclopcan kind. Chondroepithelioma of the Lacrimal Gland (Mixed Tumor). BKAXDES, Antwerp, and
VAN DUYSE,
(iand. The tumor first showed itself in 1911, the first symptom being a slight adduction of the left eye with intermittent diplopia. In the neighborhood of the orbital lacrimal gland a small hard mass could be felt; this was movable, not painful to the touch, and not adherent to the skin. The history of the patient was negative, no neoplastic antecedents, no syphilis or tuberculosis. The tumor did not show any progress until 1917, when it began to grow so rapidly (hat the eye was forced out of the orbit. When Brandes again saw the patient in December, 1918, the tumor had increased to the size of an orange, the eye was lying on the cheek, but no arterial pulsation could be felt in the tumor. Brandes made a large incision thru the eyebrow, detached the orbital fascia and came upon a well encapsulated tumor, soft, and nonadherent. It was an easy matter to shell it out of the orbit, and after checking the bleeding and
SOCIETY PROCEEDINGS s e w i n g in layers h e a l i n g took place per primam. T h e eye. was not touched, and after r e p l a c i n g it in the orbit it w a s held in place by a p r e s s u r e bandage. A t t h e end of six w e e k s the functions of the eye had r e t u r n e d to normal. T h e e y e b r o w had g r o w n ■Jack, and there w a s no t r a c e of the surgical i n t e r v e n t i o n . H a v i n g t h u s r e m o v e d the t u m o r in t o t o from t h e orbit B r a n d e s q u e s t i o n s w h e t h e r a local recurrence m i g h t occur, or w h e t h e r this t u m o r m i g h t give n s e to m e t a s t a s e s . V a n D u y s e e x a m ined the t u m o r and described it as a c h o n d r o e p i t h e l i o m a with prepondera n c e of t h e epithelial e l e m e n t s . It is the latter c o m p o n e n t which m a k e s one fear a r e c u r r e n c e .
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break of g l a u c o m a in Jlambi»csin's pat i e n t s is n e u r o p a t h y , a peculiar excitability of the s y m p a t h e t i c , roused into action by the e x c i t e m e n t of an ocular e x a m i n a t i o n . O n e r e m a r k struck me very forcibly, t h a t he could not consider an i r i d e c t o m y in these cases of a c u t e g l a u c o m a . T o me it seems t h a t i r i d e c t o m y is a l w a y s the o p e r a t i o n indicated in acute g l a u c o m a ; this is one of the clinical s t a n d b y s t h a t w e owe to von fjraefc, and I think it poor j u d g m e n t to m a k e a clean sweep of the results o b t a i n e d with this o p e r a t i o n . T h e road of p r o g r e s s is hard and long e n o u g h , and we should carefully t r e a s u r e w h a t we have acquired. A c u t e g l a u c o m a , i r i d e c t o m y ; sclerect o m y should be reserved for chronic g l a u c o m a . T h i s is a point which I shall never tire of insisting on."
T w o Cases of Glaucoma From H o m a tropin. _ H A M U R E S I N , B r u s s e l s , r e p o r t s t h e Trepanation of the O s U n g u i s and Placing of a Rubber Drain in histories of t w o w o m e n of a b o u t fortyChronic Dacryocystitis. eight, with three d i o p t e r s of h y p e r m e tropia, in w h o m acute g l a u c o m a came V A N L I N T , Brussels. T h e skin on after instilling h o m a t r o p i n . In both a r o u n d the lacrimal sac is a n e s t h e t i s e d cases the pupil w a s of a v e r a g e w i d t h by s u b c u t a n e o u s injection of a 1% sobefore the h o m a t r o p i n w a s instilled, the lution of cocain. T h e m u c o s a a r o u n d reflexes w e r e good, and t h e r e w a s no the m i d d l e t u r b i n a t e is a n e s t h e t i s e d sign of h y p e r t e n s i o n . Both cases w e r e with 10% cocain. A g a u z e pledget is treated with t r e p h i n i n g a c c o r d i n g to packed into the middle m e a t u s to p r e Elliot's m e t h o d , with total iridectomy, vent w o u n d i n g of the s e p t u m by the and both recovered. T h e p r e d i s p o s i n g t r e p a n . A skin incision similar to that causes were age and h y p c r m e t r o p i a . A made for e x t i r p a t i o n of the lacrimal sac further s t u d y of the different m y d r i - is made, and the edges of the w o u n d atics used to p r o d u c e m y d r i a s i s for held a p a r t with Meller or Axenfeld o p h t h a l m o s c o p i c e x a m i n a t i o n (cocain, r e t r a c t o r s . T h e lacrimal sac is inh o m a t r o p i n , e u p h t h a l m i n ) , s h o w s t h a t cised from top to b o t t o m t o w a r d s its they m a y all give rise to a c u t e glau- o u t e r end w i t h a bistoury, t h u s l a y i n g coma in a p r e d i s p o s e d subject. the sac wide open. T h e a n t e r i o r a n d DISCUSSION.— Lagrange, B o r d e a u x . internal walls are then excised. T h e then r e m a r k e d : "I would like to say r e t r a c t o r is then removed and the treto our colleague that 1 consider it very pan placed in the lower p a r t of the exceptional that g l a u c o m a m a y be cavity in such a w a y that the h a n d l e rests on t h e middle of the s u p e r i o r caused by a m y d r i a t i c , and I base m y opinion on the fact t h a t in the clinic arch. I n this position t h e os u n g u i s is of B o r d e a u x we used h o m a t r o p i n even perforated with r o t a t o r y m o v e m e n t s of to excess in the courses on o p h t h a l - the t r e p a n . T h e g a u z e p a c k i n g is then nioscopy, in spite of which ] have r e m o v e d from the nose. T h e e n s u i n g never seen a case of g l a u c o m a super- h e m o r r h a g e is stilled by p a s s i n g a s t r i p vene. Before me Badal used atropiu of g a u z e in a P e a n forceps which is freely t o dilate t h e p u p i l ; d u r i n g the passed t h r u the o p e n i n g m a d e in the t w e n t y - s e v e n y e a r s I w a s in his ser- <>s u n g u i s u n d e r the g u i d a n c e of a pair vice not a single case of g l a u c o m a oc- of dissecting forceps passed from above curred. ' T h e real reason for the out- t h r u the o p e n i n g . W h e n the bleeding
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BELGIAN OPHTHALMOLOGICAL. SOCIETY
has been stopped a rubber drain four or five millimeters in diameter with a flaring upper end is attached to the gauze strip with a silken thread and the strip is drawn into the nose by an assistant. The drain is in place when its end is visible in the aperture. The silken thread is then cut, the gauze strip cut thru as it enters the sac, and what remains is drawn thru the nose. To prevent further hemorrhage the nose is plugged with gauze strips. The drain is shortened in the sac, the wound closed by endermic suture, and a pressure bandage applied. On the following day the bandage is renewed and the gauze removed from the nose. The patient is warned against touching the drain. After the fourth day the dressing is omitted. On the eighth day physiologic serum is injected thru the lacriinal point, and the drain is withdrawn on the tenth to fifteenth day. For several weeks, the lacrimal injection should be continued every week thru the newly formed lacrimal passages. New Observations of the Occupational Nystagmus of Miners. RUTTEN, Liege, in explanation of the lilin shown by Coppez of four miners with generalised nystagmus, stated that this condition represents a disturbance of the equilibrium, and is not due to insufficient illumination nor the abnormal position of the eye during work. Nystagmus of the body may even exist without ocular nystagmus, and may be accompanied by motor troubles of the eyelids, of the muscles of the face, the neck, the trunk, the limbs, sometimes even by a hypoesthesia of the skin and mucous membranes, hemeralopia, photophobia, amblyopia, functional depression of the other organs of sense, and, lastly, trophic disturbances. CHICAGO OPHTHALMOLOGICAL SOCIETY. November 17, 1919. Compensation for Loss of Vision. DR. HARRY S. GRADLE, on behalf of a committee submitted a temporary scheme, as a basis of compensation for
partial or total loss of vision; which could be utilized until such time as the committee of the Ophthalmological Section of the American Medical Association made its report. There were several fundamental things that were to be decided on as absolutely essential, before formulating a basis for compensation. First, all vision is to be measured at a distance of twenty feet, using the illiterate E chart of Snellcn. The committee was making up a series of charts recording vision of 20/20 up to 20/200. Second, at least two months shall elapse between the disappearance of the last visible trace of inflammation and the time of examination upon which the report is to be based. In other words, an injury to the eye is to have as much chance as possible to quiet down. Third, the best possible vision, with or without correcting glasses, shall be used; provided there be not a difference of more than 4 D. spherical refraction between the two eyes. If the difference is more than 4 D. spherical refraction, the best vision of the injured eye without glasses shall be the basis of compensation. Fourth, normal vision is considered as 100. Industrial blindness is 20/200 or less, and shall count as 10. Loss of an eyeball shall count as zero. In other words, the committee decided that 20/200 be the least possible vision with which the average individual can carry on his occupation; that industrial blindness does not entitle an individual to the same compensation as complete loss of an eyeball. The individual gets 10 per cent for losing an eyeball in addition to loss of industrial vision. The vision is recorded by the Snellen test, corresponding to visual efficiency in terms of 100, and the inverse of that or the visual loss in terms of 100. The State law fixes the amount of compensation approximately to oneyear's salary. If a man has been injured in one eye and his vision is 20/40 for that one eye, he has a visual efficiency of 89 and is entitled to 11 per cent compensation.
A Case of Traumatic Glaucoma. TIIIUKRT, 1-iege, p r e s e n t e d a case of t r a u m a t i c glaucoma c o m i n g on t w o weeks after a simple c o n t u s i o n in the n e i g h b o r h o o d of the u p p e r lid. T h e onset s e e m s to have been favored by u n u s u a l physical exertion with ihe b o d y bent forward, the eye being predisposed to increased tension by the contusion. T h e increased tension was of 42 d a y s ' d u r a t i o n , without c h a n g e in the pupil or contraction of the visual field. While in the r e c u m b e n t position the tension was 12 millimeters h i g h e r than in the s i t t i n g position. T h i s difference is explained by tlie g r e a t e r How of blood to the head', the eye h a v i n g lost its p o w e r of v a s o m o t o r regulation. U n d e r the same conditions normal per •ons show no increase of tension, so t h a t one is forced to a s s u m e a lesion of the s y m p a t h e t i c ocular center of the eye. In all probability there was a t e a r i n g of the zonula of Zinn. The origin of the g l a u c o m a t o u s s y m p t o m s is to be s o u g h t in the v a s o m o t o r paralysis which g a v e rise to a repletion of the choroidal and ciliary s p o n g e with h y p e r s e c r e t i o n of a q u e o u s h u m o r and o b s t r u c t i o n of the different lymphatic vessels. Hole in the Papilla. V A N T.INT, Hrusscls. A painter, t h i r t y y e a r s old, showed an absolute central s c o t o m a , of small size, the result of a r e t r o m a c u l a r h e m o r r h a g e . W i t h the o p h t h a l m o s c o p e an atypical excavation in the t e m p o r a l part of the papilla w a s discovered, occupying about one-sixth of the entire papillary surface. T h i s excavation b o r e no relation to the m a e u l a r lesion, a n d w a s probably congenital. Varicocele of the Orbit. Y . w T.INT showed p a t i e n t of t h i r t y five with the classical s y m p t o m s of varicose dilatation of the veins of the orbit, with i n t e r m i t t e n t c n o p h t h a l m u s
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BELGIAN OPHTHALMOLOGICAL SOCIETY
and e x o p h t h a l m u s . O p e r a t i o n w a s indicated by the pains a c c o m p a n y i n g the exophthalmus. D i s c u s s i n g the latter case L a g r a n g e s t a t e d t h a t in a similar case he had opened into the orbit t h r u a K r o e n l e i n boneflap and resected a l a r g e piece of the o p h t h a l m i c vein. O n e c a n n o t take the whole vein out, b u t by r e m o v i n g several b r a n c h e s a n d replacing t h e m with fibrous tissue t h e ebb and flow in the vein, which give rise to the i n t e r m i t t e n t e x o p h t h a l m u s , is b r o u g h t to a standstill. Hemiatrophy of the Face and Ocular Symptoms. W E E K E R S , Liege, r e p o r t e d a case of h e m i a t r o p h y of the face in which a c h r o n i c r e c u r r e n t irido-cyclitis w a s also p r e s e n t . liolh c o n d i t i o n s w e r e due to a lesion of the t r i g e m i n u s . T h e a u t h o r calls a t t e n t i o n to the p a t h o g e n i c i m p o r t a n c e of the t r i g e m i n u s in certain forms of irido-cyclitis. In the case reported the p a t h o g e n e s i s is evident on a c c o u n t of the coexisting skin and bone lesions, but the relation is not a l w a y s so p r o n o u n c e d . T h a t this is a fact is p r o v e d by the n u m b e r of cases of p o s t g r i p p a l n e u r o p a r a l y t i c keratitis which occurred d u r i n g the epidemic of influenza which raged after. the conclusion of the war a n d the signi n g of the armistice. T h e corneal lesions s h o w e d wide varieties, but m a n y of t h e m w e r e associated with iritis and irido-cyclitis. In some cases the corneal lesions w e r e so slight t h a t t h e y w e r e o v e r w h e l m e d by the severity of the irido-cyclitis. T h e p a t h o g e n e s i s of this form of irido-cyclitis easily escaped r e c o g n i t i o n . A consideration of tliese facts leads to the conclusion t h a t t h e r e e x i s t s a form of irido-cyclitis d u e to an a l t e r a t i o n in the n u t r i t i o n of the globe with the t r i g e m i n u s as the u n d e r l y i n g cause. It is readily u n d e r stood that an infectious disease like influenza m a y b r i n g on an irido-cyclitis directly t h r u microbic m e t a s t a s i s in the uvca, a lesion of the t r i g e m i n u s being the precursor. Conclusion: In the presence of these r a t h e r frequent forms of iridocyclitis with u n k n o w n etiology one should not forget a possible lesion of the t r i g e m i n u s , and to look for the
s y m p t o m s which indicate a lesion of this nerve, such as a n e s t h e s i a of the cornea, of t h e skin of t h e forehead, etc. Suture of Orbito-ocular W o u n d s and D e e p Regional Anesthesia. I ) E LAPEKSONNE, P a r i s , advises the use of a p r i m a r y s u t u r e in all orbitoo c u l a r w o u n d s t h a t a r e quite recent. T o b e t t e r define the time he gives less t h a n t w e n t y - f o u r h o u r s for ocular w o u n d s , and less t h a n forty-eight h o u r s for orbito-palpebral w o u n d s . In all t h e s e cases m e t h o d i c local or regional a n e s t h e s i a is called for. The solution used to p r o d u c e t h e a n e s t h e s i a is an adrenalised 4 % novococain solution w i t h the following formula : Novocain 0.08 A d r e n a l i n 1/1,000 2 drops Distilled w a t e r 2 ce. P u t up in sterilized a m p o u l e s . T o p r o d u c e a n e s t h e s i a of the globe a s t r a i g h t needle is inserted 3'/> centim e t e r s beyond the inferior orbital m a r gin. following a vertical line d r a w n from the external c o m m i s s u r e . E n t e r ing at the level of the bone the needle is c o n t i n u e d u p w a r d s and i n w a r d s , crosses the optic nerve a n d reaches the •apex of the orbit in the n e i g h b o r h o o d of the ciliary g a n g l i o n . T h e direction of the p o i n t is c h a n g e d slightly a n d t w o or t h r e e cc. are injected into the cellular tissue s u r r o u n d i n g the g a n g lion and the ciliary nerves. After a wait of 15 m i n u t e s the operation m a y proceed. A n e s t h e s i a of the s e n s o r y nerves of the orbit is produced as follows: l . - - l r o r the nasal a needle four a n d one half c e n t i m e t e r s long is i n t r o d u c e d j u s t below the pulley of the s u p e r i o r oblique a n d pushed to the apex of t h e orbit following t h e s u p e r i o r i n t e r n a l angle. T w o cc. of the solution are injected. 2.—For both the frontal and the lacrimal nerves one injection is e n o u g h . O n e should not try to reach the n e r v e s at the apex of the orbit but at the top w h e r e t h e y come t h r u the sphenoidal fissure at the e x t e r n a l part. Closely following the external orbital m a r g i n and j u s t below the external palpebral l i g a m e n t a needle four and p n e half c e n t i m e t e r s l o n g is inserted in c o n t a c t
SOCIETY P R O C E E D I N G S
with the bony external wall which bends backward and inwards. 3.—For the suborbital the point of entry is one and one half centimeters bejow the infraorbital margin, at the middle of the palpebral fissure. The needle directed upwards and inwards will strike a small depression in the bone, the foramen infraorbitale. When this is entered the patient feels a sharp Pain in the teeth and the upper lip. In some cases one has to reach the superior maxillary in the orbital groove by pushing the needle along the inferior wall to the apex of the orbit. This regional anesthesia is supplemented by lesser injections under the conjunctiva. Subcutaneous infiltration in forehead, cheek, and temporo-malar region make veritable barrages. The Use of these is apparent when we consider that recurrent terminal branches °f the inferior maxillary nerve are distributed to this, the skin of the lastnamed region. Improvement of Our Surgical Armamentarium. LANDOLT, Paris, has for years been busy with the improvement of our surgical armamentarium in his characteristic serious and logical way. Instead of trying to change a few instruments whose shortcomings are obvious he has gone to the root of the question by seeking what is peculiarly adapted to ocular surgery, and in what this differs from that which is useful in general surgery. To do this he has established the leading principles of ocular surgery, whence the form and the use of the instruments would follow. Hjs basic ideas are: the organ With which we are dealing is so small, so sensitive, so mobile, and the operations practised on it so minute that our instruments as well as their manipulation require a delicacy and a precision much beyond the requirements of general surgery. Many of the instruments m general use are too heavy and too pross; the catches in certain forceps are too stiff to be operated without effort, thus defeating the delicacy demanded by the character of the operations. To obtain the precision and
363
sureness demanded by ocular surgery the fifth finger should rest on the orbital margin and the bulbs of the other fingers should be very near the active part of the instrument. This is not possible with the present form of most of our instruments, as the distance between the handle and the active part of the instrument is much too long. The author exhibited a number of instruments modified according to these views, and accentuated their advantages by comparing them with the improper models in general use. For instance, the handles should be of aluminum slightly adherent, clinging instead of slippery, heavy steel; they should also be rectangular instead of square. Bistouries, curettes, cystitomes, Taylor loops, etc., should all have short, flat handles, lying well in the hand; the author's lance should have a short, curved handle, with the blade shaped like the ace of spades instead of a triangle. Rather short forceps, some with teeth set obliquely, and all with very soft catches, were also shown. Special mention was made of the author's needle holder, which had no catch, but graduated pressure; his palpebral plaque which follows the outline of the globe exactly and stretches the lid equally in its entire width; his syringe for injecting into the nasal canal, short and easily handled; his needles for muscular advancement, and his double curved scissors for enucleation, which do away with the muscle hook. The author regrets that the efforts of a single individual are insufficient to change custom and bring about the changes so desirable in our armamentarium, and invites the profession at large to associate themselves with him in suggesting and demanding rational instruments from the makers. Decompression Operation in the Treatment of Chronic Glaucoma. I.AGRANGI;, Bordeaux. The decompression operation which reduces hypertontis is the subconjunctival fistulisation of the anterior chamber. This can be achieved in various ways, and the question is as to which is the
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best w a y . T h e choice is d e t e r m i n e d by t h e a n a t o m y of t h e sclero-corneal limbus, where w c find a sclero-corneal r i n g 1.75 m m . wide if w e m e a s u r e from the zone of d e t a c h a b l e c o n j u n c t i v a t o the s u m m i t of t h e a n g l e of infiltration. T h i s r i n g should be divided into t w o zones, a sclero-corneal zone, a n d a p r o p e r l y socalled scleral zone. T h i s latter h a s a w i d t h of o n e millimeter, and it is in this t h a t t h e excision should be practised. T h e r e a r e t h r e e r e a s o n s for restricting t h e scleral r e s e c t i o n s t o this z o n e : 1. It is best t o o p e r a t e in t h e sclera only, a s this tissue is fixed in i t s form and n o t disposed t o proliferate. 2. It is j u s t over t h e filtration zone, which is t h e lattice work, as it were, in the t r a p which covers the canal of S c h l e m m . 3. B y k e e p i n g t o this r e gion o n e avoids w o u n d i n g t h e cornea which m i g h t choke the orifice with its g r a n u l a t i o n s , a n d o n e r e s p e c t s t h e ciliary body which reacts" violently w h e n irritated. T h e r e a r e , therefore, a n a t omic, physiologic a n d surgical r e a s o n s for selecting this place for t h e fistula, and a piece one millimeter in width, at the m o s t , a n d t w o o r three millimeters in length should be resected with scissors, (iraefe knife, and p u n c h ; t h e t r e p h i n e should n o t be used, as its action c a n n o t be confined to the scleral b a n d , a n d it is a p t to slip over to t h e ciliary body o r t h e cornea. T h e a u t h o r s h o w e d in several specimens h o w often and how seriously t h e s e t w o bodies are injured by t h e u s e of the t r e p h i n e . P a s s i n g from t h e choice of m e t h o d the question arises w h e t h e r fistulisalion of the a n t e r i o r c h a m b e r is really accomplished, and w h e t h e r a d u r a b l e normalisation of t h e g l a u c o m a t o u s eye is obtained. T h e a u t h o r is very positive on this point, a n d a s s e r t s t h a t it is indeed rare t h a t t h e operation of sclerecto-iridectomy, a c c o r d i n g to his m e t h o d , does n o t give t h e desired normalisation ; the r e s u l t a n t sear is s o m e t i m e s flat, s o m e t i m e s ampttlliform. W h e n an anipulliform scar results, and this is often t h e case (seven t i m e s in t h e last sixteen cases which the a u t h o r h a s to add t o those a l r e a d y published) an orifice is visible which
u n d o u b t e d l y ' establishes c o m m u n i c a tion between t h e a n t e r i o r c h a m b e r a n d the subconjunctival spaces. ' T o prove this L a g r a n g e h a s twice c u t i n t o the — a m p o u l e a n d seen t h e a n t e r i o r c h a m b e r e m p t y itself in a few m i n u t e s . T h e a u t h o r feels justified by an experience of sixteen y e a r s in a s s e r t i n g t h a t decompression of t h e g l a u c o m a t o u s eye is i n v a r i a b l y accomplished b y subcon- ' junctival s c l e r e c t o m y in t h e limbus, and w a r n s a g a i n s t t h e u s e of t h e trephine. ' Contribution Elliot. HAMHRF.SIN,
to
the Trephining
Brussels, has
of
practised
t r e p h i n i n g a c c o r d i n g t o Elliot forty times. l i e c u t s a large flap t h r u t h e entire t h i c k n e s s of t h e conjunctiva, t a k i n g care n o t to touch t h e limbus, anl a l w a y s s e w s t h e flap. T h e d a y foll o w i n g t h e operation a s t r o n g solution of a t r o p i n is instilled. H e has never h a d a single complication which m i g h t b r i n g t h e o p e r a t i o n i n t o discredit. In his s t a t i s t i c s he includes only those cases which he h a s been able t o follow u p for a year. I n simple glaucoma 5 5 % of cures resulted. In chronic inflammatory g l a u c o m a t h e r e s u l t s w e r e very e n c o u r a g i n g . Six out of seven cases t h a t w e r e t r e p h i n e d were cured. H e a l w a y s does a total iridectomy. In acute g l a u c o m a trep h i n i n g is highly a d v a n t a g e o u s . It can be done u n d e r local anesthesia, is n o t d a n g e r o u s , a n d can be carried o u t when the a n t e r i o r c h a m b e r is a b s e n t a n d t h e pupil dilated t o t h e m a x i m u m . T h e r e is n o t r o u b l e s o m e bleeding while d o i n g an iridectomy, a n d the p o s t o p e r a t i v e a s t i g m a t i s m is reduced to t h e minim u m . T h e a u t h o r h a s also t r e p h i n e d in a case of bilateral h e t n o r r h a g i c g l a u c o m a ; in these cases o n e should touch the iris as little a s possible. D I S C U S S I O N . — L e b o u c q , G a n d , does not doubt t h a t t h e s c l e r e c t o m y of L a g r a n g e , a n d t h e modifications of this operation introduced by Rlliot a n d o t h e r s , often p r o d u c e an i m p r o v e m e n t in g l a u c o m a , but he t h i n k s t h a t t h e principle on which it is based calls for caution. T h e principle i s : t h e increase of tension is 'due to an o b s t r u c -
SOCIETY PROCEEDINGS
tion to the elimination of the aqueous humor; that the obstruction is removed by an opening- in the sclera thru which the aqueous may escape. Laboratory researches are not necessary to prove. the inexactness of this view; by purely clinical methods one can determine: 1. In most cases of glaucoma the anterior chamber is reduced in size, in many to nothing; there is, therefore, no obstacle to the outflow of the aqueous. 2. Some eyes on which a sclercctomy has been done remain soft even after the opening has closed; others get hard again very soon after the operation before the opening has had time to close. The fistula, therefore, supposing that it did exist, which is a matter of grave doubt, seems to play a very unimportant part. In former times we used to swear by iridectomy, the operation which made Graefe famous. Statistics showed surprising results, but the modus operandi of this irrational operation could never be explained. Then iridectomy was decried as useless and something else invented. Today the fashion demands sclerectomy; well, let us go ahead with our sclerectomies. Lagrange, answering the preceding gentleman: "Our colleague says the anterior chamber is often obliterated in glaucoma, and the elimination of the aqueous is very easy, lie says he canHot understand why under such conditions one should make so much of the faulty excretion of the aqueous in the pathogenesis of glaucoma, and then reports eases of sclerectomy by Trephining which have been so eminently satisfactory. I shall answer seriatim his three points, as they seem to embody all his objections. 1. The anterior chamber is suppi issed in glaucoma when the aqueous has been secreted in abnormal quantities in the region of the ciliary processes; the swollen vitreous pushes the lens forward, the iris is crowded against the cornea, Fontana's space is obliterated, and to the hypersecretion of the aqueous is added a defective elimination. There is nothing there which is not perfectly clear. 2. The pathogenic theory of glau-
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coma is no longer obscure; it was laid down by Bonders; the glaucoma has its start in an excitation of the sympathetic vasomotor setting up a hypersecretion in the gland of the aqueous humor. Just as the cheeks flush when one has been insulted, just so the ciliary nerves of the glaucomatous subject speed up after a deep emotion or an excitement of a psychic, moral, or physiologic nature. In the beginning then' is always some nervous excitement underlying every glaucoma, and all glaucomatous subjects have a neuropathic strain in them. After an eye has been the scat of several outbreaks the media are altered, and the filtration angle is clogged with waste, dross and debris of dead cells and extravasated blood cells; the drain at the angle of filtration ceases to play its part. To the hypersecretion is added hypoexcretion, especially in angiosclerotics in whom the sclera is very rigid and the vessels without elasticity. Hypersecretion thru excitation of the sympathetic hypoexcretion in angiosclerotic eyes, such are the features of the pathogenesis of glaucoma; and there, again, there is surely nothing obscure. 3. There is no gainsaying the fact that trephining gives results, and I take pleasure in accepting this as further proof of the value of the ns~ tulising method. But it exposes one to accidents which I need not again enumerate, and these accidents, many in number, consisting either in infection or wounding of the ciliary body, should convince the partisans of the tistulising method that the safest method is that which uses scissors, knife, and punch to remove the piece of sclera. I prefer, naturally, my own method, but there arc a number of others of merit, such as those of Holth, jacqucau, Coppez, Ferroni, etc. Tre> phining is the most defective method for producing fistulisation." Observations With Gullstrand's Lamp. GAI.UCMAKRTS AND KLEEFELD, Brussels, showed a series of drawings representing the normal and abnormal aspects of the anterior parts of the eye, as seen with Gullstrand's lamp.
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Projection of Cinematographic Films. IT. COPPEZ, Brussels, showed : 1. A film lent hy Barraquer of Barcelona, depicting Phacoerisis, which is a new method of extracting the crystalline lens with the aid of a suction cup which engages the anterior capsule (jf the lens. 2. Coppez then showed a film demonstrating the way in which ocular accidents occur in the porphyry quarries. The different categories of quarrymen are shown, and the visual requirements for each category are given. Me lays special stress on the careless manner in which these workmen protect their eyes, with poorly fitting glasses and lenses which have heconie half opaque by numerous scratches. Besides, some of the quarrymen, such as hewers and rippers, are required to make such violent body movements that the wearing of protecting glasses is out of the question. A detailed paper will he written later on this very interesting subject. 3. Coppez presented four miners with generalised nystagmic neurosis; the particulars in these cases were furnished by Dr. Rutten who had these men under observation. Wound of the Cornea by a Chestnut Burr. . LEPLAT, Liege, reported a case which is rather rare in this country, that of a wound of the cornea due. to a chestnut burr which had fallen off the tree. Eight spines had penetrated into the cornea, two passing entirely thru that body. The extraction was easily accomplished with the aid of a cataract knife, and the eye. healed rapidly without complication. Genesis of the Atypical Central and Paracentral Colobomata. VAN DUYSE, (land. The lissural origin cannot be denied since the histologie analysis showed retinal folds at the edge of these colobomata (1H9S). Referring to the deep atypical retroequatorial pit found by him in the embryo of a calf in 1900, and the lesser ones found by Szily, Wolfnun, and Meissner, the author wonders whether
in a microphlhalmic eye a peduncular artery (which sometimes gives off two or three branches) might not on leaving the optic groove give rise to a secondary pitting in the annular fissure at the anterior border of the retinal calyx thru a branch anastomosing with the hyaloid plexus. There are other anatomic considerations besides a fissure between the two layers of the secondary ocular vesicle which might explain the nature of some colobomatous areas: 1. Aplasia of the pigment epithelium of the choroid, as seen in a chick embryo by Seefelder; 2. A lacuna in the pigment epithelium thru which the choroidal mesoderm has proliferated and then spread out in the subretinal space (Bergmeister) ; 3. Localized proliferation of the glia disuniting the pigment epithelium to reach the aplasic choroid ((]. M. Van Duyse), all of which give rise to colobomatous areas of atypical character in the colobomatous eyes of the microphthalmie or eyclopcan kind. Chondroepithelioma of the Lacrimal Gland (Mixed Tumor). BKAXDES, Antwerp, and
VAN DUYSE,
(iand. The tumor first showed itself in 1911, the first symptom being a slight adduction of the left eye with intermittent diplopia. In the neighborhood of the orbital lacrimal gland a small hard mass could be felt; this was movable, not painful to the touch, and not adherent to the skin. The history of the patient was negative, no neoplastic antecedents, no syphilis or tuberculosis. The tumor did not show any progress until 1917, when it began to grow so rapidly (hat the eye was forced out of the orbit. When Brandes again saw the patient in December, 1918, the tumor had increased to the size of an orange, the eye was lying on the cheek, but no arterial pulsation could be felt in the tumor. Brandes made a large incision thru the eyebrow, detached the orbital fascia and came upon a well encapsulated tumor, soft, and nonadherent. It was an easy matter to shell it out of the orbit, and after checking the bleeding and
SOCIETY PROCEEDINGS s e w i n g in layers h e a l i n g took place per primam. T h e eye. was not touched, and after r e p l a c i n g it in the orbit it w a s held in place by a p r e s s u r e bandage. A t t h e end of six w e e k s the functions of the eye had r e t u r n e d to normal. T h e e y e b r o w had g r o w n ■Jack, and there w a s no t r a c e of the surgical i n t e r v e n t i o n . H a v i n g t h u s r e m o v e d the t u m o r in t o t o from t h e orbit B r a n d e s q u e s t i o n s w h e t h e r a local recurrence m i g h t occur, or w h e t h e r this t u m o r m i g h t give n s e to m e t a s t a s e s . V a n D u y s e e x a m ined the t u m o r and described it as a c h o n d r o e p i t h e l i o m a with prepondera n c e of t h e epithelial e l e m e n t s . It is the latter c o m p o n e n t which m a k e s one fear a r e c u r r e n c e .
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break of g l a u c o m a in Jlambi»csin's pat i e n t s is n e u r o p a t h y , a peculiar excitability of the s y m p a t h e t i c , roused into action by the e x c i t e m e n t of an ocular e x a m i n a t i o n . O n e r e m a r k struck me very forcibly, t h a t he could not consider an i r i d e c t o m y in these cases of a c u t e g l a u c o m a . T o me it seems t h a t i r i d e c t o m y is a l w a y s the o p e r a t i o n indicated in acute g l a u c o m a ; this is one of the clinical s t a n d b y s t h a t w e owe to von fjraefc, and I think it poor j u d g m e n t to m a k e a clean sweep of the results o b t a i n e d with this o p e r a t i o n . T h e road of p r o g r e s s is hard and long e n o u g h , and we should carefully t r e a s u r e w h a t we have acquired. A c u t e g l a u c o m a , i r i d e c t o m y ; sclerect o m y should be reserved for chronic g l a u c o m a . T h i s is a point which I shall never tire of insisting on."
T w o Cases of Glaucoma From H o m a tropin. _ H A M U R E S I N , B r u s s e l s , r e p o r t s t h e Trepanation of the O s U n g u i s and Placing of a Rubber Drain in histories of t w o w o m e n of a b o u t fortyChronic Dacryocystitis. eight, with three d i o p t e r s of h y p e r m e tropia, in w h o m acute g l a u c o m a came V A N L I N T , Brussels. T h e skin on after instilling h o m a t r o p i n . In both a r o u n d the lacrimal sac is a n e s t h e t i s e d cases the pupil w a s of a v e r a g e w i d t h by s u b c u t a n e o u s injection of a 1% sobefore the h o m a t r o p i n w a s instilled, the lution of cocain. T h e m u c o s a a r o u n d reflexes w e r e good, and t h e r e w a s no the m i d d l e t u r b i n a t e is a n e s t h e t i s e d sign of h y p e r t e n s i o n . Both cases w e r e with 10% cocain. A g a u z e pledget is treated with t r e p h i n i n g a c c o r d i n g to packed into the middle m e a t u s to p r e Elliot's m e t h o d , with total iridectomy, vent w o u n d i n g of the s e p t u m by the and both recovered. T h e p r e d i s p o s i n g t r e p a n . A skin incision similar to that causes were age and h y p c r m e t r o p i a . A made for e x t i r p a t i o n of the lacrimal sac further s t u d y of the different m y d r i - is made, and the edges of the w o u n d atics used to p r o d u c e m y d r i a s i s for held a p a r t with Meller or Axenfeld o p h t h a l m o s c o p i c e x a m i n a t i o n (cocain, r e t r a c t o r s . T h e lacrimal sac is inh o m a t r o p i n , e u p h t h a l m i n ) , s h o w s t h a t cised from top to b o t t o m t o w a r d s its they m a y all give rise to a c u t e glau- o u t e r end w i t h a bistoury, t h u s l a y i n g coma in a p r e d i s p o s e d subject. the sac wide open. T h e a n t e r i o r a n d DISCUSSION.— Lagrange, B o r d e a u x . internal walls are then excised. T h e then r e m a r k e d : "I would like to say r e t r a c t o r is then removed and the treto our colleague that 1 consider it very pan placed in the lower p a r t of the exceptional that g l a u c o m a m a y be cavity in such a w a y that the h a n d l e rests on t h e middle of the s u p e r i o r caused by a m y d r i a t i c , and I base m y opinion on the fact t h a t in the clinic arch. I n this position t h e os u n g u i s is of B o r d e a u x we used h o m a t r o p i n even perforated with r o t a t o r y m o v e m e n t s of to excess in the courses on o p h t h a l - the t r e p a n . T h e g a u z e p a c k i n g is then nioscopy, in spite of which ] have r e m o v e d from the nose. T h e e n s u i n g never seen a case of g l a u c o m a super- h e m o r r h a g e is stilled by p a s s i n g a s t r i p vene. Before me Badal used atropiu of g a u z e in a P e a n forceps which is freely t o dilate t h e p u p i l ; d u r i n g the passed t h r u the o p e n i n g m a d e in the t w e n t y - s e v e n y e a r s I w a s in his ser- <>s u n g u i s u n d e r the g u i d a n c e of a pair vice not a single case of g l a u c o m a oc- of dissecting forceps passed from above curred. ' T h e real reason for the out- t h r u the o p e n i n g . W h e n the bleeding
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has been stopped a rubber drain four or five millimeters in diameter with a flaring upper end is attached to the gauze strip with a silken thread and the strip is drawn into the nose by an assistant. The drain is in place when its end is visible in the aperture. The silken thread is then cut, the gauze strip cut thru as it enters the sac, and what remains is drawn thru the nose. To prevent further hemorrhage the nose is plugged with gauze strips. The drain is shortened in the sac, the wound closed by endermic suture, and a pressure bandage applied. On the following day the bandage is renewed and the gauze removed from the nose. The patient is warned against touching the drain. After the fourth day the dressing is omitted. On the eighth day physiologic serum is injected thru the lacriinal point, and the drain is withdrawn on the tenth to fifteenth day. For several weeks, the lacrimal injection should be continued every week thru the newly formed lacrimal passages. New Observations of the Occupational Nystagmus of Miners. RUTTEN, Liege, in explanation of the lilin shown by Coppez of four miners with generalised nystagmus, stated that this condition represents a disturbance of the equilibrium, and is not due to insufficient illumination nor the abnormal position of the eye during work. Nystagmus of the body may even exist without ocular nystagmus, and may be accompanied by motor troubles of the eyelids, of the muscles of the face, the neck, the trunk, the limbs, sometimes even by a hypoesthesia of the skin and mucous membranes, hemeralopia, photophobia, amblyopia, functional depression of the other organs of sense, and, lastly, trophic disturbances. CHICAGO OPHTHALMOLOGICAL SOCIETY. November 17, 1919. Compensation for Loss of Vision. DR. HARRY S. GRADLE, on behalf of a committee submitted a temporary scheme, as a basis of compensation for
partial or total loss of vision; which could be utilized until such time as the committee of the Ophthalmological Section of the American Medical Association made its report. There were several fundamental things that were to be decided on as absolutely essential, before formulating a basis for compensation. First, all vision is to be measured at a distance of twenty feet, using the illiterate E chart of Snellcn. The committee was making up a series of charts recording vision of 20/20 up to 20/200. Second, at least two months shall elapse between the disappearance of the last visible trace of inflammation and the time of examination upon which the report is to be based. In other words, an injury to the eye is to have as much chance as possible to quiet down. Third, the best possible vision, with or without correcting glasses, shall be used; provided there be not a difference of more than 4 D. spherical refraction between the two eyes. If the difference is more than 4 D. spherical refraction, the best vision of the injured eye without glasses shall be the basis of compensation. Fourth, normal vision is considered as 100. Industrial blindness is 20/200 or less, and shall count as 10. Loss of an eyeball shall count as zero. In other words, the committee decided that 20/200 be the least possible vision with which the average individual can carry on his occupation; that industrial blindness does not entitle an individual to the same compensation as complete loss of an eyeball. The individual gets 10 per cent for losing an eyeball in addition to loss of industrial vision. The vision is recorded by the Snellen test, corresponding to visual efficiency in terms of 100, and the inverse of that or the visual loss in terms of 100. The State law fixes the amount of compensation approximately to oneyear's salary. If a man has been injured in one eye and his vision is 20/40 for that one eye, he has a visual efficiency of 89 and is entitled to 11 per cent compensation.