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Bilateral Vossius Ring Opacity
NOTES, CASES, INSTRUMENTS C A T A R A C T O P E R A T I O N IN T H E PRESENCE OF ACTIVE DIABETES. CLARENCE LOEB, A. M.,
M.
D.
CHICAGO, ILL.
T h e occasion for this report is a pa per by Dr. W . R . Parker, published in the April number of the JOURNAL. He says: " I f patients are made as nearly sugar free as possible before the operation, I have noted no difference in the healing process of the corneal wound in the diabetic cataract, from that seen in cases of uncomplicated senile cataract." In this connection, the following case may be of interest: Mrs. L. D., colored, consulted me Nov. 24, 1924, for bilateral cataract, right mature, left almost mature. V. O. U. = hand movements; projec tion, good. Externally, there was a mild chronic conjunctivitis. She stated that she had been under the care of Dr. T . for diabetes, but had recently been discharged as cured. A telephonic conversation with Dr. T . confirmed this, so the patient was put on treatment to clear up the conjuncti vitis. T h e right eye was operated Dec. 5, 1924, without untoward incidents. Thru some mistake, the urinalysis was not available before the operation, and I did not get to see it until the patient was back in bed. T o my dismay, I then saw a record of 2 % sugar in the urine. She was immediately put on antidiabetic treatment, including the use of insulin. T h e corneal wound was slow in healing, and this was compli cated by the fact that the patient ac cidentally struck her eye one night, which was followed by a prolapse of the iris. I t was subsequently neces sary to excise this, after which the wound normally progressed to healing. There was at no time any indication of iritis. Owing to an incarceration of the edges of the iridectomy wound, the lower margin of the pupil is slight ly higher than normal. However, with + 9 . 0 C + 1 . 0 cyl. ax. 180, V . = 6/6—2, and with -f4.0 sph. added to the above, she reads Jager L 561
This case would seem to show that the presence of glycosuria is not neces sarily a contraindication against cata ract operation, provided the patient is in good condition otherwise, and is treated for the diabetes during the after treatment for the cataract. B I L A T E R A L V O S S I U S RING OPACITY. W I L L I A M C. F I N N O F F , M . D .
and DONALD H . O'ROURKE, M . D . DENVER, COLORADO.
In the September number, 1924, of the American Journal of Ophthal mology, Dr. William Zentmayer re ported a case in which a typical Vossius ring was seen on the anterior capsule of the lens following an oper ative hemorrhage into the anterior chamber. He concluded that Vossius rings may be due to staining of the an terior lens capsule by blood pigments, the explanation advanced by Hesse. The following case history substan tiates Hesse's hypothesis: E . E., male, age 9 years, was play ing with a dynamite cap, which ex ploded and inflicted multiple wounds of the face, head and upper extremities. One hour later ocular examination re vealed a minute perforating injury in the sclera of the right eye, just above the cornea. T h e sclera of the left eye was penetrated 4 mm. above the limbus. Both wounds were 2 mm. to the right of the vertical meridian, and the anterior chambers were filled with blood. At the second examination, 24 hours later, the right eye was un changed. In the left the blood had ab sorbed considerably, and the upper part of the iris and pupil was visible. A distinct Vossius ring was seen on the anterior capsule of the lens. Seventy-two hours after the injury the right anterior chamber had cleared and a similar Vossius ring was present. T h e rings were symmetric and about 3 mm. in diameter, the only difference being that the right was more dense; and
NOTES, OASES AND INSTRUMENTS
562
it is interesting to note that in this eye the hemorrhage was greater and persisted for a longer period of time. With the point of light and corneal microscope, the following details were noted: A disc consisting of minute reddish-brown granules so distributed that a distinct circular band formed an outer bound ary, which enclosed a thinner deposit of similar granules. T h e uveal pig ment at the pupillary margin of the iris was intact. With the ophthalmo scope the ring was distinctly seen and the central disc was hardly visible. Nine days after the injury the pig ment had disappeared from the an terior capsule of the left eye; and on the eleventh d^y from the right. In a series of experiments on twelve we produced rabbits (24 eyes), hemorrhages into the anterior chamber by traumatizing the base of the iris ;md ciliary body with a Ziegler knife needle. Pigmentation of the anterior capsule of the lens occurred in but one eye, and only formed an incomplete ring in the pupillary area. However, in our experiments, even with severe trauma, we were unable to produce as extensive hemorrhages into the an terior chamber as were observed in the case above reported. 217 Imperial Bldg. F O R E I G N B O D Y IN T H E I R I S . A. A. BURKE, .NORFOLK,
M.D. \A.
History: 8/14/24. H. H., aet 26. Seven days ago, while driving a chisel, a piece of steel flew off, which struck him in the left eye, causing only a moment's pain. Nothing more was thought about the piece of steel strik ing him in the eye until that night, when the eye began to pain. T h e next morning he consulted a specialist who, after examining the eye, told him he had iritis. T w o days after the eye was injured, an X-ray picture was taken and reported negative. Physical Findings. Left eye vision equaled 20/40. Lids healthy, conjunc tiva slightly injected, cornea clear save for a very small opacity. T h e iris is
dilated, which dilatation is due to atropin having previously been in stilled into the eye. T h e lens and vitreous are clear. Choroid, retina and optic nerve healthy. At the lower quadrant of the anterior chamber of the left eye, a minute elevation of the iris can be seen. This elevation is about half the size of the head of a small, straight pin. Notwithstanding the fact that the X-ray was negative (the picture was taken by a competent Roentgenologist), I felt confident that there was a small foreign body in the iris, covered over by exudation. My next procedure was to place the eye immediately in front of the giant mag-
Fig. L — S i z e of foreign dime ( 1 ) and pinhead
body (3).
(2)
as
compared
with
net, and when I did so, the patient complained of some pain in the eye, and the iris was seen to bulge slightly forward. Having confirmed my sus picion, I then made an incision in the cornea, similar to the one that is made for extraction of a cataract, only much smaller, and the piece of steel was withdrawn by the magnet. 8/15/24. Patient returned, and the eye was in fair condition. 8/25/24. Patient returned, after having remained away for about ten days without instruction to do so. T h e eye was in first class condition. Vision equaled 20/40. It was my intention to follow this case closely, to see whether there was any refractive error, causing impair ment of vision, but the patient has failed to return for an examination. The interesting points about this case are: First, the piece of steel pene trated the interior of the eye, causing practically no inconvenience, and no thought to the patient that anything was in it. This particular point is nothing new to those of us who have had opportunities to observe this class of injuries, but it is especially brought
M.
D.
CHICAGO, ILL.
T h e occasion for this report is a pa per by Dr. W . R . Parker, published in the April number of the JOURNAL. He says: " I f patients are made as nearly sugar free as possible before the operation, I have noted no difference in the healing process of the corneal wound in the diabetic cataract, from that seen in cases of uncomplicated senile cataract." In this connection, the following case may be of interest: Mrs. L. D., colored, consulted me Nov. 24, 1924, for bilateral cataract, right mature, left almost mature. V. O. U. = hand movements; projec tion, good. Externally, there was a mild chronic conjunctivitis. She stated that she had been under the care of Dr. T . for diabetes, but had recently been discharged as cured. A telephonic conversation with Dr. T . confirmed this, so the patient was put on treatment to clear up the conjuncti vitis. T h e right eye was operated Dec. 5, 1924, without untoward incidents. Thru some mistake, the urinalysis was not available before the operation, and I did not get to see it until the patient was back in bed. T o my dismay, I then saw a record of 2 % sugar in the urine. She was immediately put on antidiabetic treatment, including the use of insulin. T h e corneal wound was slow in healing, and this was compli cated by the fact that the patient ac cidentally struck her eye one night, which was followed by a prolapse of the iris. I t was subsequently neces sary to excise this, after which the wound normally progressed to healing. There was at no time any indication of iritis. Owing to an incarceration of the edges of the iridectomy wound, the lower margin of the pupil is slight ly higher than normal. However, with + 9 . 0 C + 1 . 0 cyl. ax. 180, V . = 6/6—2, and with -f4.0 sph. added to the above, she reads Jager L 561
This case would seem to show that the presence of glycosuria is not neces sarily a contraindication against cata ract operation, provided the patient is in good condition otherwise, and is treated for the diabetes during the after treatment for the cataract. B I L A T E R A L V O S S I U S RING OPACITY. W I L L I A M C. F I N N O F F , M . D .
and DONALD H . O'ROURKE, M . D . DENVER, COLORADO.
In the September number, 1924, of the American Journal of Ophthal mology, Dr. William Zentmayer re ported a case in which a typical Vossius ring was seen on the anterior capsule of the lens following an oper ative hemorrhage into the anterior chamber. He concluded that Vossius rings may be due to staining of the an terior lens capsule by blood pigments, the explanation advanced by Hesse. The following case history substan tiates Hesse's hypothesis: E . E., male, age 9 years, was play ing with a dynamite cap, which ex ploded and inflicted multiple wounds of the face, head and upper extremities. One hour later ocular examination re vealed a minute perforating injury in the sclera of the right eye, just above the cornea. T h e sclera of the left eye was penetrated 4 mm. above the limbus. Both wounds were 2 mm. to the right of the vertical meridian, and the anterior chambers were filled with blood. At the second examination, 24 hours later, the right eye was un changed. In the left the blood had ab sorbed considerably, and the upper part of the iris and pupil was visible. A distinct Vossius ring was seen on the anterior capsule of the lens. Seventy-two hours after the injury the right anterior chamber had cleared and a similar Vossius ring was present. T h e rings were symmetric and about 3 mm. in diameter, the only difference being that the right was more dense; and
NOTES, OASES AND INSTRUMENTS
562
it is interesting to note that in this eye the hemorrhage was greater and persisted for a longer period of time. With the point of light and corneal microscope, the following details were noted: A disc consisting of minute reddish-brown granules so distributed that a distinct circular band formed an outer bound ary, which enclosed a thinner deposit of similar granules. T h e uveal pig ment at the pupillary margin of the iris was intact. With the ophthalmo scope the ring was distinctly seen and the central disc was hardly visible. Nine days after the injury the pig ment had disappeared from the an terior capsule of the left eye; and on the eleventh d^y from the right. In a series of experiments on twelve we produced rabbits (24 eyes), hemorrhages into the anterior chamber by traumatizing the base of the iris ;md ciliary body with a Ziegler knife needle. Pigmentation of the anterior capsule of the lens occurred in but one eye, and only formed an incomplete ring in the pupillary area. However, in our experiments, even with severe trauma, we were unable to produce as extensive hemorrhages into the an terior chamber as were observed in the case above reported. 217 Imperial Bldg. F O R E I G N B O D Y IN T H E I R I S . A. A. BURKE, .NORFOLK,
M.D. \A.
History: 8/14/24. H. H., aet 26. Seven days ago, while driving a chisel, a piece of steel flew off, which struck him in the left eye, causing only a moment's pain. Nothing more was thought about the piece of steel strik ing him in the eye until that night, when the eye began to pain. T h e next morning he consulted a specialist who, after examining the eye, told him he had iritis. T w o days after the eye was injured, an X-ray picture was taken and reported negative. Physical Findings. Left eye vision equaled 20/40. Lids healthy, conjunc tiva slightly injected, cornea clear save for a very small opacity. T h e iris is
dilated, which dilatation is due to atropin having previously been in stilled into the eye. T h e lens and vitreous are clear. Choroid, retina and optic nerve healthy. At the lower quadrant of the anterior chamber of the left eye, a minute elevation of the iris can be seen. This elevation is about half the size of the head of a small, straight pin. Notwithstanding the fact that the X-ray was negative (the picture was taken by a competent Roentgenologist), I felt confident that there was a small foreign body in the iris, covered over by exudation. My next procedure was to place the eye immediately in front of the giant mag-
Fig. L — S i z e of foreign dime ( 1 ) and pinhead
body (3).
(2)
as
compared
with
net, and when I did so, the patient complained of some pain in the eye, and the iris was seen to bulge slightly forward. Having confirmed my sus picion, I then made an incision in the cornea, similar to the one that is made for extraction of a cataract, only much smaller, and the piece of steel was withdrawn by the magnet. 8/15/24. Patient returned, and the eye was in fair condition. 8/25/24. Patient returned, after having remained away for about ten days without instruction to do so. T h e eye was in first class condition. Vision equaled 20/40. It was my intention to follow this case closely, to see whether there was any refractive error, causing impair ment of vision, but the patient has failed to return for an examination. The interesting points about this case are: First, the piece of steel pene trated the interior of the eye, causing practically no inconvenience, and no thought to the patient that anything was in it. This particular point is nothing new to those of us who have had opportunities to observe this class of injuries, but it is especially brought