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Chicago Ophthalmological Society
996
SOCIETY
PROCEEDINGS
iridotasis, cyclodialysis and sclerotomy, with a filtration channel into the suprachoroidal space; the operation was per formed on a patient with chronic glau coma. He said that the technique was simple and the operation was satisfactory. Trachoma The description is as follows: In a D R . A I . V I N J . R A E R read a paper on this deeply set eye one operates on the ex subject. ternal canthal side, about ten or Discussion. D R . A . N . L E M O I N E agreed fifteen degrees from the perpendicular with Dr. Baer, in that certainly not all meridian, making a conjunctival flap as cases of trachoma were infections, as for ordinary trephining or cyclodialy he had seen a number of cases that were sis; about four mm. back of the limbus tuberculous in origin. Some were one cuts through the sclera to the allergic, and some luetic. Dr. Lemoine choroid with a cataract knife or kera felt that the reason for the considerable tome. Then with a cyclodialysis amount of trachoma seen in this lo spatula (the operator used one with a cality was due to different diseases and perfectly straight blade, semi-sharp, but endocrine imbalance. Both of these bent for about 1.5 cm. at an angle of would naturally be found among a class about forty-five degrees) pointed al that live under very poor surroundings ways toward the sclera, the choroid is with lack of proper food. gently separated from the sclera and the Some of these cases were monocular, anterior chamber entered; the spatula and in several instances only one mem is now swung to the right and left so ber of a family was affected though all that the iris is separated from the lived under very unsanitary conditions. scleral spur for about one-half centi The cases he mentioned had all the meter on either side, as in cyclodialysis. characteristic findings of a fully de With a moderately curved but-very veloped trachoma, including pannus. The large percentage of advanced cases fine iris forceps one enters the channel that Dr. Baer had seen in proportion and grasps the pupillary edge of the to the total number of trachomas in this iris, withdrawing it up into this supralocality might be due to the fact that choroidal channel until it appears at the there was very little incipient trachoma incision in the sclera; the forceps are thereabouts, most of the patients com twisted to bring the iridoretinal layers of the iris uppermost. This forms a ing with the disease well developed. tract or channel and leaves the edge DR. E . E . P I C K E N S thought that tra of the iris perfectly free, though en choma was a definite clinical entity and capsulated in the channel. The con that those that were tuberculous were junctiva is closed with a mattress not trachoma. He felt that trachoma suture. As a matter of routine atropin was not as infectious as was usually is dropped in, though this is not always assumed. necessary. The wound is touched with A L B E R T N. LEMOINE, five percent iodin solution and a band Recorder age is applied. The patient is kept in bed for two or three days, and the CHICAGO OPHTHALMO suture removed on the fourth day. LOGICAL SOCIETY The advantages of the operation are manifold. Iridotasis is theoretically a April 21, 1930 perfect operation, but practically it is DR. C H A R L E S G. D A R L I N G , president not, because it does not furnish the ex act mechanical details for filtration. Intraocular iridencleisis That is the objection to incarcerating DR. G. F . S U K E R gave an operative demonstraton of a new operation for the iris anywhere except in a supraglaucoma, which was a combination of choroidal channel. By the Mauksch KANSAS CITY SOCIETY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY April 17, 1930 D R . L . R . F O R G R A V E presiding
SOCIETY
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997
operation there is a drainage into a mm. The entrance at the sclera is a suprachoroidal space, which remains trifle longer than the width of the permanent. It gives a small coloboma spatula itself. upward, remains fixed, and the iris In doing any of these operations it motility is not overly interfered with. is advisable to have a deep orbital in The other additional advantage noted is jection of two percent novocain with that in ascertain percentage of glau adrenalin, waiting four or five minutes coma cases, with such surgical inter to have complete anesthesia and fair im ference as trephining, cyclodialysis or mobility of the globe. The novocain iridotasis, a cataract frequently de and adrenalin will give sufficient dilata velops. With this operation there is no tion of the iris and give a good view of interference fora future corneal section, the anterior chamber, so that the while an iridotasis or trephined area pupillary border may easily be grasped makes a good corneal section almost with the forceps. impossible. Anyone who has done one or the In this operation the iris is held in other operation many times should have the scleral wound, 4 to 6 mm. back of no trouble in combining them and hav the limbus. Hence, when one reaches ing a mechanically perfect operation the limbus in corneal section for without any loss of iris tissue and with cataract extraction, the conjunctiva is out incarcerating the iris at an angle still attached, not bound down by ad where it is hazardous for any further hesions, and a good flap can therefore operative procedure. be obtained. Furthermore, the iri The suitable cases are the chronic dectomy has practically been made, and subacute forms of glaucoma. As which is not true in an iridotasis and yet the speaker had not tried it in acute often not in trephining. In the latter, glaucoma, believing that a deep root very frequently the iris or its pillars iridectomy is preferable in that condi fall back into the hole, greatly compli tion. The reactions following opera cating the corneal section, giving rise tion are not marked; no more than in to more or less iris mutilation. any of the other glaucoma operations. From the mechanical standpoint the Two patients upon whom this operation intraocular tension is immediately re was performed several weeks ago were duced from fifteen to twenty points. shown; each had normal tension. For several days there is a fluctuation Discussion. D R . H . J. S M I T H said that in tension within safe limits, and finally this presentation was of great interest it remains stationary. About ten cases to him because he had used a similar had been operated on in this service, operation for five years, and had records and in none had a permanent subnormal of twenty or more cases operated on by tension followed, which frequently is this method. Instead of pulling the iris the case in cyclodialysis, trephining or in and leaving it in the wound, he cut Lagrange operation. As stated, it is a off the tip of the iris, giving a button combination of the Lagrange, minus the hole opening near the root, but leaving iridectomy, with a cyclodialysis and some in between the choroid and the iridotasis. sclera. He had never had to operate The reason the spatula is bent to on a case a second time, and had never forty-five degrees is to avoid splitting had hypotonus. One case lost an eye the choroid in the attempt to push the with iridocyclitis after some years. Dr. spatula into the anterior chamber. In Francis Lane, shortly before his death, passing a spatula having any other had seen the operation and had thought angle, there is danger of not separating it an excellent procedure for glaucoma. the choroid and thus entering the an DR. ROBERT VON D E R H E T O T said that terior chamber by piercing the root of in doing an iridotasis operation there the iris. The object is to keep the point was always great danger of wounding of the spatula firmly against the sclera the lens capsule. When examining until the point is seen in the entrance eyes after this operation, he could usu of the anterior chamber for about 3 ally tell whether an acute-angled or
998
SOCIETY
PROCEEDINGS
more blunt-angled keratome had been used. The outline of the keratome edges was usually imprinted on the lens capsule and easily seen with the slitlamp. He thought the combined cyclo dialysis and iridotasis a good operation. DR. PETKR K R O N F E L D said the opera tion described by Dr. Suker was re ported first by Mauksch (Zeitschrift für Augenheilkunde, volume 61, p. 278). The surgical procedure was rather simple and the results excellent. As Dr. Suker said, most of the eyes operated on after this method had normal ten sion, not subnormal as after a trephine or a sclerectomy. The operation had been called intraocular iridencleisis, which seemed to be the best name. There was usually no filtration under the conjunctiva, therefore practically no danger of secondary infection. This was an important factor. DR. C. P . S M A L L asked whether any one present had had experience with the Curran operation of peripheral iridotomy. DR. H A R R Y G R A D L E had had some ex perience with the Curran operation and had given it up entirely. It produced a temporary decrease in tension in certain types of cases. The type particularly suited was the one which could not be held with the simpler miotics, but in which immediate operation was not urgently indicated. It apparently re sulted in nothing more than an anterior sclerotomy; incising the iris, as per formed by Curran, was an additional frill which meant nothing. Ignipuncture DR. G E O R G E F . S U K E R discussed a case in which he had performed this opera tion that afternoon. Discussion. DR. ROBERT VON DER H E Y D T called attention to an article by Vogt in the March number of the Klinische Monatsblätter, which showed no less than thirty-seven very beautifully colored pictures of holes in the retina. Vogt contends that the operation is not successful unless the hole is found. The idea of the operation is to cause the scar to form first at the distal end of the hole and
thus protect the retina toward the macula. He uses no fixation forceps. In order to avoid loss of vitreous and pressure on the eye, the patient holds the eye in the direction most favorable for operation. It used to be thought that once detached the retiqa loses its physiological function and remains blind. A certain amount of vision is regained, however, when the ends of the cones again come in contact with pig ment epithelium ; hence the spectacular results in certain cases treated by igni puncture. DR. HARRY GRADLE was enthusiastic about the operation, but wished to speak of one case under his observation. A young woman suflfered detachment of the retina about three years ago. She was hospitalized and given the usual treatment, sweating, etc., for several months without result. Since then she had had no treatment what soever. Vision was light perception only. About a month ago it was noted that there was a spontaneous complete reattachment of the retina, with com plete restoration of the field, although central visual function was still im paired. One should hesitate in ascrib ing attachment to the benefits of modern surgery. He believed the opera tion should be tried because it offered a greater chance for reattachment than anything else. If only twenty to twenty-five percent results were ob tained, it was that much more than could be accomplished before this operation was devised. DR. D . C . O R C U T T had started doing ignipuncture about three years ago; since then he had had three fair suc cesses and one absolutely perfect result, this one having been operated on nearly a year ago. There had been a cataract extraction some six or eight years ago in which detachment had become com plete in the upper portion, and igni puncture was made. The reattachment was successful and vision returned to 20/20 and was still so. In the other cases vision was from 20/l(X) to 20/40. On several others on which the opera tion had been tried, no success had been obtained. The detachment had been for
SOCIETY
PROCEEDINGS
a longer period, whereas in two of those which were successful, the de tachment occurred on the day prior to operation. Strabismus operations D R . W . F . M O N C R E I F F , speaking of the cases shown which had been operated on for squint, said that while he did not advocate any special type of operation, there were two considerations to be emphasized. The first was the princi ple of recession, of suturing the tenotomized muscle to the sclera in stead of allowing its reattachment to the sclera to take place in a haphazard manner. This principle was of greater importance as a rule in dealing with the internal rectus than with the external rectus, for it was usually assumed that in divergent squint, the external rectus could be tenotomized with impunity. Nevertheless, on his service it had re cently been necessary to do secondary advancement of the externus in two cases, in one of which the externus had not even become reattached to the sclera. In both cases the primary opera tion of tenotomy of the externus and advancement of the internus for divergent squint had been done less than five years ago. The second principle was that in the surgery of convergent squint the in ternal rectus should be left untouched whenever possible, and in any event interference with this muscle should be minimal. In other words, the internus should be included in the operative pro cedure only when it was impracticable to secure sufficient correction by means of bilateral advancement or resection of the external recti. Particularly when the operation was confined to one eye, should interference with the functions of divergence and convergence be avoided. Discussion. D R . H A K R V G R A D L E ob jected to the classification by Dr. Suker of lower intelligence as a contributing factor in squint. There was one phase brought out by Dr. Suker which was important; the education of the squint ing eye in concomitant squint. There were two major types of deficient
999
vision; the first, a vision below 20/100 associated with a demonstrable rather large central scotoma, the type that we could not hope to educate in the matter of vision. This type comprised a rather small percentage. The second and larger group had deficient vision, 4/10, 5/10, in which one could not demon strate a definite central scotoma, but rather a generalized deficiency of visual function, probably due to failure of differentiation of the macula. This was probably the same condition described in the albinotic eye, i.e., absolute failure of the macular development, an extra uterine developmental phase. This could be developed in a large percentage of cases if taken early, pro vided there was cooperation on the part of the parents. The method of develop ing not only the deficient eye but also the function of fusion was well known. It could be done also provided it was started early enough. Fusion was present at birth'in normal individuals. It continued to develop for about six years, it was believed; after that age it was extremely diflficult, if not im possible, to develop fusion in a child in whom fusion had not been present be fore. Therefore, in a case of con comitant squint with deficient vision, but no demonstrable scotoma, it be hooved one to confine one's efforts to increasing the vision and developing fusion. It was difficult and painstaking. The average parent had neither the in telligence nor the patience to cooperate. In London, Worth had developed a non medical technician whose time was not so valuable as that of a medical man, who had been educated in developing fusion in children and who could work in harmony with physicians. An oculist could send a child to this technician with directions as to what was to be done toward development of fusion. This training was done for half an hour or so three or four times a week, with a charge within the reach of the individual. Such a technician must be an intelligent young woman who could be trained for the work, and such a service would be very welcome to oculists.
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If it were possible to develop func tion and fusion in a child before the age of six or seven, concomitant squint would disa])pear s])ontaneously, but it could not rest at that. There was a tendency for one eye to i)redominate, and failure to keep on with exercises would result in a gradual slumi). It was necessary to continue the exercises until ten or twelve years of age, to keep the vision in that eye on the same i)Iane as the predominant eye. Probably eightyfive i)ercent of children with concomi tant squint, with vision better than 3/10, if taken sufficiently early and given proper educational measures, would develop not only parallelism but fusion, which they would retain for the rest of their lives Λvithout operative in terference. ROBERT \ Ό Ν
DER H E Y D T ,
Secretary
T H E COLORADO OPHTHAL MOLOGICAL SOCIETY January 18, 1930 D R . W I L L I . \ M C. B A N E presiding Retinoblastoma (bilateral) DR. W I L L I A M M . B A N E showed a child, K. M., aged seventeen months, who had been examined on March 1, 1929 on account of an obstruction of his right tear duct. This trouble was reme died by passing a probe into his nose. No examination of the interior of his eyes was made at that time. On September 12, 1929, the pupils were dilated with homatropin and co cain for the purpose of doing a retinos copy because a squint of the right eye was at that time noticeable. This ex amination showed a complete retinal detachment in the right eye, suggestive of a tumor. A plus 19.00 sphere was at that time needed to get a clear view of the left fundus. This examination was repeated for confirmation October 8, 1929. December 16, 1929, it was noted that the detachment of the left retina had increased and the picture was practi cally the same as that of the right eye. Transillumination seemed to be less dis
tinct from below. A diagnosis of bi lateral retinoblastoma was made. (Since the case was shown before the Society, both eyeballs have been enu cleated, and the diagnosis has been con firmed microscopically.) Discussion. D R S . C R I S P , F I N N O F F and O ' R O U R K E agreed that the clinical picture was unmistakably that of retinoblas toma, and said that immediate enuclea tion was the i)roper j)rocedurc. Rathke pouch cyst (pituitary) DR. W I L L I A M F I N N O F F presented R. I., male, nineteen years old, who had con sulted him on F-ebruary 16, 1929. He was one of twins. He had weighed four pounds at birth. His brother had weighed nine i)Ounds and had died at three months, cause unknown. The chief complaint was diminished vision of the right eye of three weeks dura tion. The left eye had been blind for three years. He had had frontal and occipital headaches, and vomiting for the past four months. He attributed his loss of vision to a fall from a lumber pile five years ago. Following the fall he had had several headaches and had vomited intermittently for about a year. He was poorly developed i)hysically, but was normal mentally. On oi)hthalmoscopic examination the .right eye showed the nasal side of the disk to be pale, but the vessels in the retina normal. In the left eye the disk was white and the vessels in the retina were normal (simple optic atrophy). The vision in the right eye with a small correction equalled 0.4 plus. The x-ray report stated erosion in pituitary re gion, posterior clinoid processes not seen, opacities about an inch posterior to sella turcica. The x-ray diagnosis was tumor in pituitary region about the size of a plum. Laboratory findings were negative, including the Wasser mann reaction. He was referred to Dr. A. W. .Adson, Mayo Clinic, for operation. On March 23, 1929, a Rathke pouch cyst (pitui tary) was enucleated in its capsule. Convalescence was slow but satis factory and when seen again on Sep tember 6, 1929, the fields had increased
SOCIETY
PROCEEDINGS
iridotasis, cyclodialysis and sclerotomy, with a filtration channel into the suprachoroidal space; the operation was per formed on a patient with chronic glau coma. He said that the technique was simple and the operation was satisfactory. Trachoma The description is as follows: In a D R . A I . V I N J . R A E R read a paper on this deeply set eye one operates on the ex subject. ternal canthal side, about ten or Discussion. D R . A . N . L E M O I N E agreed fifteen degrees from the perpendicular with Dr. Baer, in that certainly not all meridian, making a conjunctival flap as cases of trachoma were infections, as for ordinary trephining or cyclodialy he had seen a number of cases that were sis; about four mm. back of the limbus tuberculous in origin. Some were one cuts through the sclera to the allergic, and some luetic. Dr. Lemoine choroid with a cataract knife or kera felt that the reason for the considerable tome. Then with a cyclodialysis amount of trachoma seen in this lo spatula (the operator used one with a cality was due to different diseases and perfectly straight blade, semi-sharp, but endocrine imbalance. Both of these bent for about 1.5 cm. at an angle of would naturally be found among a class about forty-five degrees) pointed al that live under very poor surroundings ways toward the sclera, the choroid is with lack of proper food. gently separated from the sclera and the Some of these cases were monocular, anterior chamber entered; the spatula and in several instances only one mem is now swung to the right and left so ber of a family was affected though all that the iris is separated from the lived under very unsanitary conditions. scleral spur for about one-half centi The cases he mentioned had all the meter on either side, as in cyclodialysis. characteristic findings of a fully de With a moderately curved but-very veloped trachoma, including pannus. The large percentage of advanced cases fine iris forceps one enters the channel that Dr. Baer had seen in proportion and grasps the pupillary edge of the to the total number of trachomas in this iris, withdrawing it up into this supralocality might be due to the fact that choroidal channel until it appears at the there was very little incipient trachoma incision in the sclera; the forceps are thereabouts, most of the patients com twisted to bring the iridoretinal layers of the iris uppermost. This forms a ing with the disease well developed. tract or channel and leaves the edge DR. E . E . P I C K E N S thought that tra of the iris perfectly free, though en choma was a definite clinical entity and capsulated in the channel. The con that those that were tuberculous were junctiva is closed with a mattress not trachoma. He felt that trachoma suture. As a matter of routine atropin was not as infectious as was usually is dropped in, though this is not always assumed. necessary. The wound is touched with A L B E R T N. LEMOINE, five percent iodin solution and a band Recorder age is applied. The patient is kept in bed for two or three days, and the CHICAGO OPHTHALMO suture removed on the fourth day. LOGICAL SOCIETY The advantages of the operation are manifold. Iridotasis is theoretically a April 21, 1930 perfect operation, but practically it is DR. C H A R L E S G. D A R L I N G , president not, because it does not furnish the ex act mechanical details for filtration. Intraocular iridencleisis That is the objection to incarcerating DR. G. F . S U K E R gave an operative demonstraton of a new operation for the iris anywhere except in a supraglaucoma, which was a combination of choroidal channel. By the Mauksch KANSAS CITY SOCIETY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY April 17, 1930 D R . L . R . F O R G R A V E presiding
SOCIETY
PROCEEDINGS
997
operation there is a drainage into a mm. The entrance at the sclera is a suprachoroidal space, which remains trifle longer than the width of the permanent. It gives a small coloboma spatula itself. upward, remains fixed, and the iris In doing any of these operations it motility is not overly interfered with. is advisable to have a deep orbital in The other additional advantage noted is jection of two percent novocain with that in ascertain percentage of glau adrenalin, waiting four or five minutes coma cases, with such surgical inter to have complete anesthesia and fair im ference as trephining, cyclodialysis or mobility of the globe. The novocain iridotasis, a cataract frequently de and adrenalin will give sufficient dilata velops. With this operation there is no tion of the iris and give a good view of interference fora future corneal section, the anterior chamber, so that the while an iridotasis or trephined area pupillary border may easily be grasped makes a good corneal section almost with the forceps. impossible. Anyone who has done one or the In this operation the iris is held in other operation many times should have the scleral wound, 4 to 6 mm. back of no trouble in combining them and hav the limbus. Hence, when one reaches ing a mechanically perfect operation the limbus in corneal section for without any loss of iris tissue and with cataract extraction, the conjunctiva is out incarcerating the iris at an angle still attached, not bound down by ad where it is hazardous for any further hesions, and a good flap can therefore operative procedure. be obtained. Furthermore, the iri The suitable cases are the chronic dectomy has practically been made, and subacute forms of glaucoma. As which is not true in an iridotasis and yet the speaker had not tried it in acute often not in trephining. In the latter, glaucoma, believing that a deep root very frequently the iris or its pillars iridectomy is preferable in that condi fall back into the hole, greatly compli tion. The reactions following opera cating the corneal section, giving rise tion are not marked; no more than in to more or less iris mutilation. any of the other glaucoma operations. From the mechanical standpoint the Two patients upon whom this operation intraocular tension is immediately re was performed several weeks ago were duced from fifteen to twenty points. shown; each had normal tension. For several days there is a fluctuation Discussion. D R . H . J. S M I T H said that in tension within safe limits, and finally this presentation was of great interest it remains stationary. About ten cases to him because he had used a similar had been operated on in this service, operation for five years, and had records and in none had a permanent subnormal of twenty or more cases operated on by tension followed, which frequently is this method. Instead of pulling the iris the case in cyclodialysis, trephining or in and leaving it in the wound, he cut Lagrange operation. As stated, it is a off the tip of the iris, giving a button combination of the Lagrange, minus the hole opening near the root, but leaving iridectomy, with a cyclodialysis and some in between the choroid and the iridotasis. sclera. He had never had to operate The reason the spatula is bent to on a case a second time, and had never forty-five degrees is to avoid splitting had hypotonus. One case lost an eye the choroid in the attempt to push the with iridocyclitis after some years. Dr. spatula into the anterior chamber. In Francis Lane, shortly before his death, passing a spatula having any other had seen the operation and had thought angle, there is danger of not separating it an excellent procedure for glaucoma. the choroid and thus entering the an DR. ROBERT VON D E R H E T O T said that terior chamber by piercing the root of in doing an iridotasis operation there the iris. The object is to keep the point was always great danger of wounding of the spatula firmly against the sclera the lens capsule. When examining until the point is seen in the entrance eyes after this operation, he could usu of the anterior chamber for about 3 ally tell whether an acute-angled or
998
SOCIETY
PROCEEDINGS
more blunt-angled keratome had been used. The outline of the keratome edges was usually imprinted on the lens capsule and easily seen with the slitlamp. He thought the combined cyclo dialysis and iridotasis a good operation. DR. PETKR K R O N F E L D said the opera tion described by Dr. Suker was re ported first by Mauksch (Zeitschrift für Augenheilkunde, volume 61, p. 278). The surgical procedure was rather simple and the results excellent. As Dr. Suker said, most of the eyes operated on after this method had normal ten sion, not subnormal as after a trephine or a sclerectomy. The operation had been called intraocular iridencleisis, which seemed to be the best name. There was usually no filtration under the conjunctiva, therefore practically no danger of secondary infection. This was an important factor. DR. C. P . S M A L L asked whether any one present had had experience with the Curran operation of peripheral iridotomy. DR. H A R R Y G R A D L E had had some ex perience with the Curran operation and had given it up entirely. It produced a temporary decrease in tension in certain types of cases. The type particularly suited was the one which could not be held with the simpler miotics, but in which immediate operation was not urgently indicated. It apparently re sulted in nothing more than an anterior sclerotomy; incising the iris, as per formed by Curran, was an additional frill which meant nothing. Ignipuncture DR. G E O R G E F . S U K E R discussed a case in which he had performed this opera tion that afternoon. Discussion. DR. ROBERT VON DER H E Y D T called attention to an article by Vogt in the March number of the Klinische Monatsblätter, which showed no less than thirty-seven very beautifully colored pictures of holes in the retina. Vogt contends that the operation is not successful unless the hole is found. The idea of the operation is to cause the scar to form first at the distal end of the hole and
thus protect the retina toward the macula. He uses no fixation forceps. In order to avoid loss of vitreous and pressure on the eye, the patient holds the eye in the direction most favorable for operation. It used to be thought that once detached the retiqa loses its physiological function and remains blind. A certain amount of vision is regained, however, when the ends of the cones again come in contact with pig ment epithelium ; hence the spectacular results in certain cases treated by igni puncture. DR. HARRY GRADLE was enthusiastic about the operation, but wished to speak of one case under his observation. A young woman suflfered detachment of the retina about three years ago. She was hospitalized and given the usual treatment, sweating, etc., for several months without result. Since then she had had no treatment what soever. Vision was light perception only. About a month ago it was noted that there was a spontaneous complete reattachment of the retina, with com plete restoration of the field, although central visual function was still im paired. One should hesitate in ascrib ing attachment to the benefits of modern surgery. He believed the opera tion should be tried because it offered a greater chance for reattachment than anything else. If only twenty to twenty-five percent results were ob tained, it was that much more than could be accomplished before this operation was devised. DR. D . C . O R C U T T had started doing ignipuncture about three years ago; since then he had had three fair suc cesses and one absolutely perfect result, this one having been operated on nearly a year ago. There had been a cataract extraction some six or eight years ago in which detachment had become com plete in the upper portion, and igni puncture was made. The reattachment was successful and vision returned to 20/20 and was still so. In the other cases vision was from 20/l(X) to 20/40. On several others on which the opera tion had been tried, no success had been obtained. The detachment had been for
SOCIETY
PROCEEDINGS
a longer period, whereas in two of those which were successful, the de tachment occurred on the day prior to operation. Strabismus operations D R . W . F . M O N C R E I F F , speaking of the cases shown which had been operated on for squint, said that while he did not advocate any special type of operation, there were two considerations to be emphasized. The first was the princi ple of recession, of suturing the tenotomized muscle to the sclera in stead of allowing its reattachment to the sclera to take place in a haphazard manner. This principle was of greater importance as a rule in dealing with the internal rectus than with the external rectus, for it was usually assumed that in divergent squint, the external rectus could be tenotomized with impunity. Nevertheless, on his service it had re cently been necessary to do secondary advancement of the externus in two cases, in one of which the externus had not even become reattached to the sclera. In both cases the primary opera tion of tenotomy of the externus and advancement of the internus for divergent squint had been done less than five years ago. The second principle was that in the surgery of convergent squint the in ternal rectus should be left untouched whenever possible, and in any event interference with this muscle should be minimal. In other words, the internus should be included in the operative pro cedure only when it was impracticable to secure sufficient correction by means of bilateral advancement or resection of the external recti. Particularly when the operation was confined to one eye, should interference with the functions of divergence and convergence be avoided. Discussion. D R . H A K R V G R A D L E ob jected to the classification by Dr. Suker of lower intelligence as a contributing factor in squint. There was one phase brought out by Dr. Suker which was important; the education of the squint ing eye in concomitant squint. There were two major types of deficient
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vision; the first, a vision below 20/100 associated with a demonstrable rather large central scotoma, the type that we could not hope to educate in the matter of vision. This type comprised a rather small percentage. The second and larger group had deficient vision, 4/10, 5/10, in which one could not demon strate a definite central scotoma, but rather a generalized deficiency of visual function, probably due to failure of differentiation of the macula. This was probably the same condition described in the albinotic eye, i.e., absolute failure of the macular development, an extra uterine developmental phase. This could be developed in a large percentage of cases if taken early, pro vided there was cooperation on the part of the parents. The method of develop ing not only the deficient eye but also the function of fusion was well known. It could be done also provided it was started early enough. Fusion was present at birth'in normal individuals. It continued to develop for about six years, it was believed; after that age it was extremely diflficult, if not im possible, to develop fusion in a child in whom fusion had not been present be fore. Therefore, in a case of con comitant squint with deficient vision, but no demonstrable scotoma, it be hooved one to confine one's efforts to increasing the vision and developing fusion. It was difficult and painstaking. The average parent had neither the in telligence nor the patience to cooperate. In London, Worth had developed a non medical technician whose time was not so valuable as that of a medical man, who had been educated in developing fusion in children and who could work in harmony with physicians. An oculist could send a child to this technician with directions as to what was to be done toward development of fusion. This training was done for half an hour or so three or four times a week, with a charge within the reach of the individual. Such a technician must be an intelligent young woman who could be trained for the work, and such a service would be very welcome to oculists.
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SOCIETY
PROCEEDINGS
If it were possible to develop func tion and fusion in a child before the age of six or seven, concomitant squint would disa])pear s])ontaneously, but it could not rest at that. There was a tendency for one eye to i)redominate, and failure to keep on with exercises would result in a gradual slumi). It was necessary to continue the exercises until ten or twelve years of age, to keep the vision in that eye on the same i)Iane as the predominant eye. Probably eightyfive i)ercent of children with concomi tant squint, with vision better than 3/10, if taken sufficiently early and given proper educational measures, would develop not only parallelism but fusion, which they would retain for the rest of their lives Λvithout operative in terference. ROBERT \ Ό Ν
DER H E Y D T ,
Secretary
T H E COLORADO OPHTHAL MOLOGICAL SOCIETY January 18, 1930 D R . W I L L I . \ M C. B A N E presiding Retinoblastoma (bilateral) DR. W I L L I A M M . B A N E showed a child, K. M., aged seventeen months, who had been examined on March 1, 1929 on account of an obstruction of his right tear duct. This trouble was reme died by passing a probe into his nose. No examination of the interior of his eyes was made at that time. On September 12, 1929, the pupils were dilated with homatropin and co cain for the purpose of doing a retinos copy because a squint of the right eye was at that time noticeable. This ex amination showed a complete retinal detachment in the right eye, suggestive of a tumor. A plus 19.00 sphere was at that time needed to get a clear view of the left fundus. This examination was repeated for confirmation October 8, 1929. December 16, 1929, it was noted that the detachment of the left retina had increased and the picture was practi cally the same as that of the right eye. Transillumination seemed to be less dis
tinct from below. A diagnosis of bi lateral retinoblastoma was made. (Since the case was shown before the Society, both eyeballs have been enu cleated, and the diagnosis has been con firmed microscopically.) Discussion. D R S . C R I S P , F I N N O F F and O ' R O U R K E agreed that the clinical picture was unmistakably that of retinoblas toma, and said that immediate enuclea tion was the i)roper j)rocedurc. Rathke pouch cyst (pituitary) DR. W I L L I A M F I N N O F F presented R. I., male, nineteen years old, who had con sulted him on F-ebruary 16, 1929. He was one of twins. He had weighed four pounds at birth. His brother had weighed nine i)Ounds and had died at three months, cause unknown. The chief complaint was diminished vision of the right eye of three weeks dura tion. The left eye had been blind for three years. He had had frontal and occipital headaches, and vomiting for the past four months. He attributed his loss of vision to a fall from a lumber pile five years ago. Following the fall he had had several headaches and had vomited intermittently for about a year. He was poorly developed i)hysically, but was normal mentally. On oi)hthalmoscopic examination the .right eye showed the nasal side of the disk to be pale, but the vessels in the retina normal. In the left eye the disk was white and the vessels in the retina were normal (simple optic atrophy). The vision in the right eye with a small correction equalled 0.4 plus. The x-ray report stated erosion in pituitary re gion, posterior clinoid processes not seen, opacities about an inch posterior to sella turcica. The x-ray diagnosis was tumor in pituitary region about the size of a plum. Laboratory findings were negative, including the Wasser mann reaction. He was referred to Dr. A. W. .Adson, Mayo Clinic, for operation. On March 23, 1929, a Rathke pouch cyst (pitui tary) was enucleated in its capsule. Convalescence was slow but satis factory and when seen again on Sep tember 6, 1929, the fields had increased