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Chemically Caused Striate Keratitis*
NOTES, CASES, INSTRUMENTS
712 SUMMARY
T h e literature was reviewed and the eighth case of metastatic carcinoma limited to the iris is reported. The site of the primary lesion was local ized to the lungs by radiographic studies and scalene lymph node biopsy. T h e histologic findings of the metastatic lesion are described and its limitation to the iris is shown.
A general discussion on the incidence, symptomatology, origin, and differential di agnosis is given. Veterans
Administration
Center.
We wish to thank the Armed Forces Institute of Pathology for their co-operation, and the Pho tography Department at this Veterans Hospital, headed by Mr. Willi;im Fox.
REFERENCES
1. 2. 3. 4. 5.
Sanders, T. E.: Am. J. Ophth., 21:646, 1938. Asbury, M. K., and Vail, D.: Am. J. Ophth., 23:402, 1940. Proctor, F. I., and Verhoeff, F. H.: Arch. Ophth., 36:47, 1907. Reese, A. B.: Tumors of the Eye. New York, Hoeber, 1951, p. SO;!. Finkelman, I., and Mayer, L. L.: Arch. Ophth., 10:83, 1933.
CHEMICALLY CAUSED STRIATE KERATITIS* D U E TO T H E INTRODUCTION OF A W E T T I N G AGENT I N T O T H E ANTERIOR CHAMBER DURING CATARACT SURGERY N.
E.
CHRISTY,
M.D.
Taxila In., Pakistan
meridian at the time of the initial incision when an intentional capsulotomy was to be done, so that in :he capsulotomy technique the only instruments entering the anterior chamber were the knife and the iris forceps. In the intracapsul.ir technique either the cap sule forceps or an erisophake was introduced into the anterior chamber in addition to the knife and iris forceps.
In the technique employed in the 1,000 cases reported previously the anterior lens capsule was intentionally incised with the von Graefe knife in the 12- to 6-o'clock
During the peri 3d in which the 1,000 cases reported in the previous article were per formed it was our standard technique to disinfect cutting instruments and capsule forceps by soaking them in a 1:1,000 aqueous solution of Zephiran (alkylbenzyldimethyl ammonium chloride) containing sodium ni trite, four parts per thousand. I n the latter part of the series a similar British drug, Cetavlon (Cetrimide B . P . ) , a quaternary ammonium compound, in a one-percent aque ous solution, also containing sodium nitrite, was used for disinfecting the cutting instru ments and capsule forceps. This solution was shaken from the instruments before they were introduced into the operative field —in the case of the von Graefe knives and capsule forceps into the anterior chamber.
* From the Taxila Hospital, American United Presbyterian Mission.
I n view of the fact that wetting agents are known to cause damage to the corneal
In a series of cataract extractions previ ously reported from this hospital ( A m . J. Ophth., 44:649 [Nov.] 1957), a disturb ingly high incidence of postoperative striate keratitis was noted. In an effort to discover and remove the cause of this keratitis, the routines and techniques employed were re viewed. It was noted that the incidence was higher in the intracapsular extractions than in the capsulotomies, suggesting that the in troduction of one more instrument into the anterior chamber might have had some effect on the incidence of the keratitis.
NOTES, CASES, INSTRUMENTS
713
TABLE 1 INCIDENCE OF STRIATE KERATITIS IN TWO REPORTED SERIES OF CATARACT EXTRACTIONS
1955-56 Series
1957 Series
All Cases Number
+
++ +++
Total
Number
1, 000
Number of Cases Keratitis
Percent
Percent 1, 000
317 79 9
31.7 7.9 0.9
142 40 11
14.2 4.0 1.1
405
40.5
193
19.3
Capsulotomies Number of Cases Keratitis
+
++ +++
Total
365
290
95 22 5
26.0 6.0 1.3
44 12 6
15.2 4.1 2.1
122
33.3
62
21.4
Intracapsular Extractions Number of Cases Keratitis
Total
+
++ +++
610
672
218 55 4
35.8 9.0 0.6
90 17 6
13.7 2.5 0.9
277
45.4
113
17.1
endothelium, it was thought that the small amount of solution remaining on the knives and capsule forceps might be a factor in the high incidence of striate keratitis noted. Consequently, in the cases which form the basis of this report, instruments which had been soaked in Zephiran or Cetavlon were thoroughly rinsed in sterile water and then allowed to soak in sterile water for five to 10 minutes before they were introduced into the eye. Techniques were not significantly changed in any other way during this series; the patients were of the same type as de scribed in the previous series; the distribu tion of cataract types was almost identical; and the surgeon was the same. T h e present report is based on results of 1,000 cataract operations performed at the American Mission Hospital, Taxila, Pakis tan, during the spring eye season, F e b r u a r y to April, 1957.
Table 1 compares the incidence of striate keratitis in the series previously reported (performed in 1955-56) with the incidence of postoperative keratitis in the present series performed in 1957. In the cases in which capsulotomy was performed, the incidence dropped from 33.3 to 21.4 percent. In the cases in which intracapsular extraction was performed, the incidence dropped from 45.4 to 17.1 percent. A s in the previous series the striate keratitis in almost every case cleared entirely within six to eight days but, in a small number of the more severe cases, some corneal opacity persisted. It becomes apparent that even the small amount of wetting agent which clings to knives or other instruments which have been soaked in such agents can be the cause of a considerable amount of postoperative keratitis when these instruments are intro duced into the anterior chamber and that
NOTES, CASES, INSTRUMENTS
714
great care should be used in removing all traces of such agents from instruments be fore they are used in the eye. It should be noted that the manufacturers of Cetavlon, T h e Imperial Chemical Industries, Limited ( L o n d o n ) , recommend in their literature that instruments immersed in Cetavlon be rinsed "thoroughly with sterile water to remove all traces of Cetavlon" before use. I am now trying to find the cause of the remaining postoperative keratitis and, since a 0.1-percent aqueous solution of Cetavlon is used in the preoperative irrigation of the conjunctival sac this is being investigated as a possible cause.
Fig. 1 (Pritikin). Appearance of child.
SUMMARY
Data are presented from two series of cataract extractions of 1,000 cases each illus trating and re-emphasizing the fact that the introduction into the anterior chamber of even minute amounts of detergents or wet ting agents, such as may be introduced on instruments which have been soaked in such agents, may be the cause of striate keratitis following intraocular surgery. I n the series reported a marked reduction in the incidence of postoperative striate kera titis was effected by exercising greater care in the removal of wetting agents from all instruments before they were introduced into the eye. American Mission Hospital.
ANOPHTHALMOS* R O L A N D I.
PRITIKIN,
M.D.
Rockford, Illinois This case of anophthalmos, the name ap plied to the absence of an eyeball, was seen in an infant who was born with the complete absence of both eyes. In addition, this child had some fusion of upper and lower lids (ankyloblepharon) except at the center where some portion of the lid margin was * From the Rockford Memorial Hospital.
Fig. 2 (Prit.kin). Sutures in place. present and a few cilia were seen. There were also a few filamentous adhesions be tween the upper and lower lids (ankyloble pharon fili forme adnatum). C A S E REPORT
Baby J. K., a white girl, was born at term on May 31, 1957. Birth weight was 8 lb., IS oz. No consanguinity was involved. Both parents are healthy. The mother was not ill during the entire period of gestation. There was no history or indica tion of intrauterine infection. Two brothers, aged seven and three years, are living and well. The pa tient was first examined by me when she was six days of age (fig. 1). On July 1, 1957, tie following operation was per formed on the left eye under general anesthesia using rectal pentotlal. The upper and lower lids were separated by incision. The socket was ex plored. No vestige of an eye was found. Three doubled-armed suturss were placed through the skin and conjunctiva abcve and below the incision.
712 SUMMARY
T h e literature was reviewed and the eighth case of metastatic carcinoma limited to the iris is reported. The site of the primary lesion was local ized to the lungs by radiographic studies and scalene lymph node biopsy. T h e histologic findings of the metastatic lesion are described and its limitation to the iris is shown.
A general discussion on the incidence, symptomatology, origin, and differential di agnosis is given. Veterans
Administration
Center.
We wish to thank the Armed Forces Institute of Pathology for their co-operation, and the Pho tography Department at this Veterans Hospital, headed by Mr. Willi;im Fox.
REFERENCES
1. 2. 3. 4. 5.
Sanders, T. E.: Am. J. Ophth., 21:646, 1938. Asbury, M. K., and Vail, D.: Am. J. Ophth., 23:402, 1940. Proctor, F. I., and Verhoeff, F. H.: Arch. Ophth., 36:47, 1907. Reese, A. B.: Tumors of the Eye. New York, Hoeber, 1951, p. SO;!. Finkelman, I., and Mayer, L. L.: Arch. Ophth., 10:83, 1933.
CHEMICALLY CAUSED STRIATE KERATITIS* D U E TO T H E INTRODUCTION OF A W E T T I N G AGENT I N T O T H E ANTERIOR CHAMBER DURING CATARACT SURGERY N.
E.
CHRISTY,
M.D.
Taxila In., Pakistan
meridian at the time of the initial incision when an intentional capsulotomy was to be done, so that in :he capsulotomy technique the only instruments entering the anterior chamber were the knife and the iris forceps. In the intracapsul.ir technique either the cap sule forceps or an erisophake was introduced into the anterior chamber in addition to the knife and iris forceps.
In the technique employed in the 1,000 cases reported previously the anterior lens capsule was intentionally incised with the von Graefe knife in the 12- to 6-o'clock
During the peri 3d in which the 1,000 cases reported in the previous article were per formed it was our standard technique to disinfect cutting instruments and capsule forceps by soaking them in a 1:1,000 aqueous solution of Zephiran (alkylbenzyldimethyl ammonium chloride) containing sodium ni trite, four parts per thousand. I n the latter part of the series a similar British drug, Cetavlon (Cetrimide B . P . ) , a quaternary ammonium compound, in a one-percent aque ous solution, also containing sodium nitrite, was used for disinfecting the cutting instru ments and capsule forceps. This solution was shaken from the instruments before they were introduced into the operative field —in the case of the von Graefe knives and capsule forceps into the anterior chamber.
* From the Taxila Hospital, American United Presbyterian Mission.
I n view of the fact that wetting agents are known to cause damage to the corneal
In a series of cataract extractions previ ously reported from this hospital ( A m . J. Ophth., 44:649 [Nov.] 1957), a disturb ingly high incidence of postoperative striate keratitis was noted. In an effort to discover and remove the cause of this keratitis, the routines and techniques employed were re viewed. It was noted that the incidence was higher in the intracapsular extractions than in the capsulotomies, suggesting that the in troduction of one more instrument into the anterior chamber might have had some effect on the incidence of the keratitis.
NOTES, CASES, INSTRUMENTS
713
TABLE 1 INCIDENCE OF STRIATE KERATITIS IN TWO REPORTED SERIES OF CATARACT EXTRACTIONS
1955-56 Series
1957 Series
All Cases Number
+
++ +++
Total
Number
1, 000
Number of Cases Keratitis
Percent
Percent 1, 000
317 79 9
31.7 7.9 0.9
142 40 11
14.2 4.0 1.1
405
40.5
193
19.3
Capsulotomies Number of Cases Keratitis
+
++ +++
Total
365
290
95 22 5
26.0 6.0 1.3
44 12 6
15.2 4.1 2.1
122
33.3
62
21.4
Intracapsular Extractions Number of Cases Keratitis
Total
+
++ +++
610
672
218 55 4
35.8 9.0 0.6
90 17 6
13.7 2.5 0.9
277
45.4
113
17.1
endothelium, it was thought that the small amount of solution remaining on the knives and capsule forceps might be a factor in the high incidence of striate keratitis noted. Consequently, in the cases which form the basis of this report, instruments which had been soaked in Zephiran or Cetavlon were thoroughly rinsed in sterile water and then allowed to soak in sterile water for five to 10 minutes before they were introduced into the eye. Techniques were not significantly changed in any other way during this series; the patients were of the same type as de scribed in the previous series; the distribu tion of cataract types was almost identical; and the surgeon was the same. T h e present report is based on results of 1,000 cataract operations performed at the American Mission Hospital, Taxila, Pakis tan, during the spring eye season, F e b r u a r y to April, 1957.
Table 1 compares the incidence of striate keratitis in the series previously reported (performed in 1955-56) with the incidence of postoperative keratitis in the present series performed in 1957. In the cases in which capsulotomy was performed, the incidence dropped from 33.3 to 21.4 percent. In the cases in which intracapsular extraction was performed, the incidence dropped from 45.4 to 17.1 percent. A s in the previous series the striate keratitis in almost every case cleared entirely within six to eight days but, in a small number of the more severe cases, some corneal opacity persisted. It becomes apparent that even the small amount of wetting agent which clings to knives or other instruments which have been soaked in such agents can be the cause of a considerable amount of postoperative keratitis when these instruments are intro duced into the anterior chamber and that
NOTES, CASES, INSTRUMENTS
714
great care should be used in removing all traces of such agents from instruments be fore they are used in the eye. It should be noted that the manufacturers of Cetavlon, T h e Imperial Chemical Industries, Limited ( L o n d o n ) , recommend in their literature that instruments immersed in Cetavlon be rinsed "thoroughly with sterile water to remove all traces of Cetavlon" before use. I am now trying to find the cause of the remaining postoperative keratitis and, since a 0.1-percent aqueous solution of Cetavlon is used in the preoperative irrigation of the conjunctival sac this is being investigated as a possible cause.
Fig. 1 (Pritikin). Appearance of child.
SUMMARY
Data are presented from two series of cataract extractions of 1,000 cases each illus trating and re-emphasizing the fact that the introduction into the anterior chamber of even minute amounts of detergents or wet ting agents, such as may be introduced on instruments which have been soaked in such agents, may be the cause of striate keratitis following intraocular surgery. I n the series reported a marked reduction in the incidence of postoperative striate kera titis was effected by exercising greater care in the removal of wetting agents from all instruments before they were introduced into the eye. American Mission Hospital.
ANOPHTHALMOS* R O L A N D I.
PRITIKIN,
M.D.
Rockford, Illinois This case of anophthalmos, the name ap plied to the absence of an eyeball, was seen in an infant who was born with the complete absence of both eyes. In addition, this child had some fusion of upper and lower lids (ankyloblepharon) except at the center where some portion of the lid margin was * From the Rockford Memorial Hospital.
Fig. 2 (Prit.kin). Sutures in place. present and a few cilia were seen. There were also a few filamentous adhesions be tween the upper and lower lids (ankyloble pharon fili forme adnatum). C A S E REPORT
Baby J. K., a white girl, was born at term on May 31, 1957. Birth weight was 8 lb., IS oz. No consanguinity was involved. Both parents are healthy. The mother was not ill during the entire period of gestation. There was no history or indica tion of intrauterine infection. Two brothers, aged seven and three years, are living and well. The pa tient was first examined by me when she was six days of age (fig. 1). On July 1, 1957, tie following operation was per formed on the left eye under general anesthesia using rectal pentotlal. The upper and lower lids were separated by incision. The socket was ex plored. No vestige of an eye was found. Three doubled-armed suturss were placed through the skin and conjunctiva abcve and below the incision.