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Chicago Ophthalmological Society
50
HOUSTON SOCIETY
THE HOUSTON OPHTHALMOLOGICAL A N D OTO-LARYNGOLOGICAL SOCIETY. October. D R . H E N R Y C. H A D E N
presiding.
D R . C. P . HARRIS read a p a p e r on Roentgentological Considerations for the eye. ear, nose a n d t h r o a t s u r g e o n s . Corneal Sequels of Trachoma. D R . E . L . GOAR presented a m a n 25
years of age. T h e history is that of a chronic inflammatory condition of t h e eyes of several years duration. T h e lids were typical of a chronic, severe type of trachoma, with much scarring and dis tortion. Each cornea was thin and ectatic on the upper half, protruding for ward to such an extent that t h e upper third was even with the apex. T h e tem poral side bulged slightly more than the nasal. Each cornea was vascularized from every p o r t i o n of t h e limbus, t h e attentuated vessels meeting in the center of the cornea. Vision fingers at 15 feet both eyes. Treatment has consisted in resection of both upper tarsi and instil lation of powdered dionin for the past several months. Because of the irregu lar astigmatism and the marked vascularization of t h e cornea, no lens improves the vision. D r . Goar remarked in dis cussing the case, that if it were possible to use a contact glass constantly in this case, the vision might be somewhat improved. A s the keratectasia has not advanced in t h e past year, no operative interference is indicated at present. Iritis and Secondary Glaucoma. DR. W M . L A P A T reported a case of subluxated lens. J. T., age 35 years, col ored, injured August 2nd, 1922, by being struck in right eye by a truck handle. Patient was seen twelve days after in jury, at which time there was much cili ary injection, much pain, cornea slightly hazy, pupil somewhat wide but irregular. T h e iris was muddy, a n d it appeared as if there was subluxation of t h e lens. Tension was 25 m m . H g . , and vision counting fingers at 10 feet. Gradually the cornea began to clear, a n d it was seen the lens had many small spots, such as a r e found after posterior synechia.
There was a gap between t h e outer border of t h e lens and t h e iris. T h e lens appeared to be notched, and t h e iris was slightly tremulous. It was difficult to make out whether it was a subluxated lens with a slight coloboma or a cyst of the iris, the edge of the lens being seen partly in t h e anterior chamber. T h e whole lens w a s clear except for iritic spots. T h e patient complained of much pain, tension was u p to 70. Eserin did n o t r e l i e v e ; iridectomy w a s done. T e n sion came down to 30, and vision at pres ent 20/70. Iridocyclitis from Diseased Tonsils. D R . E . M . ARNOLD reported on F . N .
J., age 32 years, who came J u n e 30th, complaining of pain in right eye, exces sive tearing a n d sensitiveness to light. This condition had existed for three days. Vision was not much impaired. A diagnosis of iritis was made—the pu pil was small, reacted slowly and re sponded poorly to atropin. U n d e r atropin, mercury and hot applications t h e con dition did not improve. T h e teeth were in good condition and the tonsils looked harmless and were not large, neverthe less, it was suggested that the tonsils be removed, and this was done on July 8th. Since the operation there has been no more pain, and the iritis cleared u p promptly. Patient had been using atropin t.i.d. for several days, but the pupil was only partially dilated. B u t t w o days after the operation the pupil became widely dilated with no increase in the atropin. E . M. ARNOLD,
Secretary. CHICAGO O P H T H A L M O L O G I CAL SOCIETY. October 16, 1922. Vice-President, D R . F R A N K BRAWLEY, in
the Chair. Basal Cell Epithelioma of Lids. DR.
LOWRY
(for
Dr.
George
F.
S u k e r ) reported t h e case of a man, 46 vears old, who six months ago had an ulceration of the upper lid of t h e right eye, which extended from the inner canthus to one-half inch beyond the outer
51
SOCIETY PROCEEDINGS
rim. Rodent ulcer of the eyelid was diagnosed. An exenteration of the or bit was performed to extirpate malig nancy. Two pedunculated flaps were brought down from the forehead and at tached to the normal conjunctiva. Cicatricial tissue had since made several outer canthotomies necessary. The patient had received some X-ray therapy since the operation. There was no limitation in the ocular movements, no diplopia or re duction in visual acuity; nor was there an involvement of the cornea. Cavernous Hemangioma of Ophthal mic Vein. DR. COTTLE (for Dr. George F. Suker)
reported the case of a male baby, four weeks old, brought to the hospital 10 days after birth, with a markedly proptosed right eye, which showed corneal abscess with threatened perforation. Tlie equator of the eye was beyond the lid margins and pushed somewhat down ward. The eye could not be replaced. There was no palpable pulsation, and no audible bruit. Above the eye could be felt a soft, compressible mass, which pushed the eye downward and outward. Because of the absolute loss of function, and potential danger to the other eye, the eye was enucleated. The diagnosis was that of hemangioma, probably of the cavernous type. The tumor was still present, but had not in creased in size since the time of opera tion. In this case there was a suspicion of a history of trauma. The child was delivered by a midwife. X-ray exam ination showed no evidence of fracture which might produce a laceration in the orbital region. Examination of the eye and adnexa showed no evidence of extra- or intrabulbar tumor formation. The soft tissues about the optic nerve had the appearance of loose epibulbar tissue, soaked or in filtrated with blood. The central fourfifths of the expanse of the cornea had suffered what appeared to have been an incompletely perforating ulceration. The lens was in its normal position and what could be seen of the iris did not appear to have been displaced forward, as would be the case had the cornea been perfor ated.
Nephritic Retinitis. DR. ROBERTSON (for Dr. George F. Suker) reported the case of a boy, 14 years old, who was admitted one week ago, complaining of periodic attacks of vomiting associated with headache. The attacks started about a year and a half ago, the interval between attacks becom ing shorter and shorter, so that they now occurred every two or three days. There was no history of the disturbances of childhood. The essential positive findings were a systolic pressure of 224, diastolic 170, giving a pulse pressure of 54. The urinalysis showed a large amount of albumin, and a specific gravity of 1011. The blood Wassermann reaction was negative. Examination of the eyes showed R. V. 20/13; L. V. 20/13. Both disc surfaces were edematous, the margins distinctly blurred. The veins were engorged, the arteries small and there were numerous plaques of hyalin degeneration arranged around the macular region. The diagnosis was made of chronic diffuse nephritis and nephritic retinitis. The case was interesting because of the extreme youth of the patient with such high blood pressure and the good vision present in the eyes. Chorioretinitis Pigmentosa.
DR. F I N K (for Dr. George F. Suker)
presented a case of chorioretinitis pig mentosa. Pigment on Caruncle. DR.
OLIVER
TYDINGS
presented
a
young lady, who showed a pigmented spot on the caruncle, which had existed for a year. Microscopic examination had not been attempted. Sarcoma of Orbit.
DR. MICHAEL GOLDENBURG presented
the case of a man, 42 years old. He first noticed a swelling the size of a pea over the left lacrimal sac one year ago, which disappeared after about six weeks, recur ring two months later, and had gradu ally increased in size. The growth had been much more rapid during the past six or seven weeks. It had broken open at two points during the past week and was discharging slightly at present.
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CHICAGO OPHTHALMOLOGICAL SOCIETY
T h e r e w a s a reddish, a n g r y swelling a b o u t t w o b y t h r e e inches, which pro jected a b o u t an inch a n d a half. T h e eye w a s p r o p t o s e d a n d p u s h e d o u t w a r d from t h e midline v e r y m a r k e d l y . O v e r t h e lacrimal area t h e r e w e r e t w o smaller rounded swellings. T o t h e t e m p o r a l side of t h e s e swellings w a s a crevice w h e r e t h e skin w a s b r o k e n open. T e m p o r a l l y a n d 3 / 4 inch b e low this w a s a 3 / 8 inch o p e n i n g in t h e skin which discharged a small a m o u n t of yellowish serous fluid. Large b r a n c h i n g veins could be seen plainly u n d e r t h e skin surface. T h e r i g h t a n d left consensual reactions w e r e good ; t h e left eye reacted slightly t o l i g h t ; t h e left eye w a s blind except for light. T h r e e weeks a g o h e could c o u n t fingers at 18 inches, t o t h e nasal side.
r e s t o r e vision b y an iridectomy o n t h e r i g h t eye. T h e p a t i e n t w a s blind from the a g e of eleven until he w a s t h i r t y . A n i r i d e c t o m y performed a t t h a t time g a v e h i m 20/200 vision. H e t h e n learned t h e brick l a y i n g trade, a n d for t h e last five y e a r s h a d been d r a w i n g full p a y as a brick layer. T h e i n t e r e s t i n g t h i n g w a s t h a t h e w a s n o w a useful man, drawing the same wages as t h o u g h he h a d 2 0 / 2 0 vision. H e would be classed as industrially blind on ac c o u n t of t h e 20/200 vision.
L e n s Extraction b y Barraquer Technic. D R . W . A . F I S H E R p r e s e n t e d a lady to s h o w t h a t t h e lens could b e r e m o v e d by t h e complete B a r r a q u e r technic, car ried o u t as B a r r a q u e r w a s d o i n g it a t this time. H e w a s not o p e r a t i n g a c F u n d u s : T h e disc could n o t be lo c o r d i n g to a n y p a p e r t h a t h e h a d ever cated. M a n y h e m o r r h a g e s w e r e p r e s w r i t t e n . H i s latest paper, n o t y e t p u b ent, retinal a n d subhyaloid. T h e ves lished, would b e s o m e t h i n g quite dif sels w e r e t o r t u o u s . M a n y w h i t e areas ferent. B a r r a q u e r in t h a t p a p e r w o u l d were present. O n the nasal side, it p r e s e n t 112 original pictures, g i v i n g h i s looked as if some d e t a c h m e n t of t h e technic in full. I n this case t h e technic retina w e r e t a k i n g place, w i t h a possi w a s t h a t w h i c h B a r r a q u e r used in bility of a neoplasm b r e a k i n g into t h e Richmond and Philadelphia in April, eyeball. T h e blood W a s s e r m a n n r e 1922. All t h e p a t i e n t s w e r e left with action w a s negative. nice round pupils. In the first place, T h e diagnosis w a s t h a t of s a r c o m a , he dilated t h e pupil w i t h eucain a n d p r o b a b l y o r i g i n a t i n g in t h e e t h m o i d s . cocain, u s i n g it every fifteen m i n u t e s for a n h o u r a n d a half, o r until t h e p u Discussion. — DR. ELBERT CLARK stated: R a d i u m w a s applied exter pil w a s fully dilated. H e t h e n m a d e an nally on J u l y 18 for 4200 milligram injection of novocain across u n d e r t h e hours, screened with 0.6 m m . gold, 1 lower lid, o n e d o w n w a r d a n d o n e u p w a r d . I n every operation h e t u r n e d mm. silver, and 1 1/2 cm. rubber. This the lens upside d o w n , b r i n g i n g t h e application was changed every six h o u r s for forty-eight h o u r s . O n J u l y lower edge up first, and no pressure was 25, 2712 milligram h o u r s w e r e used, used. T h e operation w a s d o n e w i t h a five pieces of r a d i u m b e i n g e m b e d d e d dilated pupil w i t h a very small peri in different p a r t s of t h e t u m o r , a n d so pheral iridectomy, as in this case. I n a r r a n g e d a s to be n o t over o n e centi several cases t h e novocain produced m e t e r apart. N o other t r e a t m e n t h a d a paralysis of t h e orbicularis, a n d been employed. There was a rather stitches w e r e p u t into t h e skin of t h e violent reaction, w i t h a little m o r e lids to keep t h e eye closed. T h e pa tient w a s in t h e hospital nine days, did swelling a n d edema. not h a v e a n y postoperative inflamma Industrial Efficiency with Poor Vision. tion a n d h a d 2 0 / 2 0 vision. D R . W . A. F I S H E R presented a m a n
to show what could be done with 20/200 vision. H e w a s 38 y e a r s old. A t t h e a g e of 11, w h e n in t h e fifth g r a d e a t school, h e c o n t r a c t e d small pox. T h e left eye w a s r e m o v e d b y t h e late D r . Beard, a n d h e a t t e m p t e d t o
Mydriatics and Cycloplegics. D R . G. H E N R Y M U N D T r e a d a p a p e r
on this subject, in which h e stated t h a t one of t h e v e r y i m p o r t a n t w o r k s of the ophthalmologists was refraction, and a vast m a j o r i t y of c o m p e t e n t m e n
SOCIETY PROCEEDINGS
considered a cycloplegic one of the prime essentials of good refraction. He considered the isomeric substances hyoscin hydrobromid and scopolamin hydrobromid identical, since Merck labeled them so; also this was a prac tical settlement of their difference which had been extensively discussed. He was thoroly convinced that in refraction every patient under forty years of age should have a cycloplegic; that nearly all those between forty and fifty should, excepting those who had normal vision and apparently did not need distance lenses; in other words, excepting only those presbyopes who needed reading lenses and had no symptoms other than poor vision for close work. Practically all patifents under fifty years of age should be re fracted with a cycloplegic. In myopia it was as essential to use a mydriatic as in any other class of cases. He could not subscribe to the view that hyperopia was the indication for re fraction with a cycloplegic. If one was to determine with accuracy the total error of any patient, the one right method was to use a cycloplegic, and before any one was really competent to prescribe lenses, he should know the total error of refraction. As to the comparative value of the three common cycloplegics, homatro pin hydrobromid, hyoscin hydrobromid and atropin sulphat, for refraction up to the age of fifteen or sixteen years, homatropin hydrobromid was proba bly the poorest drug for use in these cases; because while its mydriatic ac tion might be complete, the essayist thought it was a failure as a cycloplegic at this age. Atropin sulphat was probably the best drug when used properly, because of its certainty of action and its relatively low toxicity when compared with hyoscin hydro bromid. Hyoscin hydrobromid was a drug of first value; and in selected cases with proper precautions in its administration, it was very reliable, nearly as reliable as atropin sulphat. As to the method of administering homatropin hydrobromid, he used a fresh solution ("made fresh at least once a week) of 2 per cent, homatropin
53
hydrobromid and 1 per cent, cocain hydrochlorid. This was dropped in the conjunctival sac every five to ten minutes a varying number of times, dependent upon the age of the patient: from 15 to 20 years, 8 times; 20 to 30, 6 times; 30 to 40, 4 times; 40 to 50, 3 times, and beyond 50 once or twice only. As to the use of atropin for refraction, a one per cent, aqueous solution was used four times a day for three or four days, in patients beyond six years of age; 3 to 6 years a one-half per cent. solution, and a weaker solution below three years of age. The hyoscin hydrobromid was used in a solution, the maximum dose in adults being two drops of one-half per cent. solution, with the excess mopped up at once and pressure made over the sac. This meant that one drop might be used in each eye, or two drops with an inter val in one eye. This was the maximum dose and must be used with great caution. He more frequently used a one-fourth per cent, solution, but in iritis the onehalf percent, solution was much more ac tive. The one-fourth per cent, solution might be used twice with care as young as twelve years; from 12 to 8 about onesixth or one-eighth per cent., from eight down, much weaker. Discussion. — D R . OLIVER
TYDINGS
fully concurred in the opinion that hy oscin and scopolamin were the most important of the cycloplegics. He did not agree with the essayist as to the strength of scopolamin he used. Dr. Mundt spoke of a 1/2 of 1 per cent., Dr. Tydings used it in about 1/5 of 1 per cent. He did not hesitate to send a patient out with scopolamin any more than with atropin. He did not believe that in the last fifteen to twen ty years he had used atropin in one case out of a hundred. The cycloplegic action that was obtained from scopol amin, in one-half or three-fourths hour. could only be obtained from atropin in three days, or sometimes longer. He did not agree with Dr. Mundt when he advised atropin or scopolamin as a cycloplegic in all cases. He thought one could refract many cases without any cycloplegic at all,
CHICAGO OPHTHALMOLOGICAL SOCIETY
54
D R . T H O M A S F A I T H referred
to
two
points not mentioned in connection with h o m a t r o p i n a n d scopolamin. O n e w a s t h a t m u c h of t h e h o m a t r o p i n h a d been v e r y faulty for a y e a r o r so. T h e r e h a d been m a n y instances in which t h e effects h a d lasted for d a y s . A peculiar t h i n g h e h a d noticed in connection w i t h h o m a t r o p i n w a s t h a t frequently h e could g e t 1/2 t o 1/4 m o r e plus s p h e r e w i t h o u t h o m a t r o p i n , t h a n h e could g e t with it. A n o t h e r t h i n g in connection w i t h the use of scopolamin was, that he had used it in a s t r e n g t h of o n e g r a i n t o the ounce a n d found it d e t e r i o r a t e d very rapidly. I n a v e r y s h o r t time scopolamin would n o t be of a n y value, even at t h e e n d of a week s o m e t i m e s . H e h a d n o t used 1/2 of 1 p e r cent, of gcopolamin, b u t a l w a y s h a d adhered to t h e w e a k e r solutions. H e h a d given (scopolamin t o u s e a t h o m e , g i v i n g them 1/4 grain to the half ounce, and had it applied once o r twice a d a y for several days, a n d t h e n followed with t w o o r t h r e e instillations of scopolamin in t h e office, u s u a l l y two, a t one s i t t i n g with a 15 t o 20 m i n u t e interval. T h e advantage of this was, that instead of h a v i n g t w o weeks m y d r i a s i s h e h a d t w o or t h r e e days. T h e r e w a s a tend ency t o g e t a w a y from h o m a t r o p i n and scopolamin a n d all cycloplegics, b u t h e felt t h a t t h e refraction w a s n o t as good w h e n d o n e w i t h o u t t h e m . H e prefers all his patients to use homa tropin o r scopolamin u p t o f o r t y ; after t h a t h e used h o m a t r o p i n occasionally, b u t n o t as a rule. H e did n o t rely o n h o m a t r o p i n as h e did a few y e a r s a g o , b u t h e did u s e scopolamin r i g h t along. DR. MUNDT.
A S to t h e s t r e n g t h of
hyoscin, t h e m a x i m u m w a s 1/2 of 1 per cent. H e said h e m o r e frequently used 1/4 of 1 p e r cent, b u t o n e could
use 1/2 of 1 p e r cent., a n d it w a s v e r y active. H e d i d n o t prescribe it a s a cycloplegic, because he thought it was too active t o p u t into t h e h a n d s of a patient. H e t h o u g h t scopolamin w a s about like p u t t i n g a can of e t h e r in t h e .hands of a patient. A s t o t h e activity of hyoscin, t h e r e w e r e t h r e e isomeric s u b s t a n c e s . O n e diverted light to t h e right, o n e t o t h e left, a n d o n e w a s n o n l i g h t d i v e r t i n g . T h e nonlightdiverting was absolutely nondilating. H e t h o u g h t t h e r e w a s n o question t h a t h o m a t r o p i n w a s n o t con stant. Results of Col. Smith's Cataract Op erations. D R . W . A . F I S H E R read a paper cor r e c t i n g earlier r e p o r t s ( S e e F e b . N o . ) , which will be published in full in this journal. Discussion.
— DR.
THOMAS
FAITH
s t a t e d t h a t t h e i n t r a c a p s u l a r operation m u s t stand on its o w n m e r i t s , a n d it should b e given this o p p o r t u n i t y . A t the D e c e m b e r m e e t i n g he m a d e t h e s t a t e m e n t t h a t h e could n o t u n d e r s t a n d t h e g r e a t difference in t h e r e sults a t t h e Illinois C h a r i t a b l e E y e a n d E a r I n f i r m a r y a n d t h e Chicago E y e , Ear, Nose a n d T h r o a t Hospital, be cause h e h a d w a t c h e d t h e S m i t h method for several years, and the free d o m from p o s t o p e r a t i v e inflammation w a s striking, a n d h a d been well set forth b y S m i t h in h i s v a r i o u s w r i t i n g s . H e s a w t h e four cases m e n t i o n e d by D r Fisher and was able to obtain 2 0 / 2 0 vision w i t h o u t a n y difficulty in t h r e e , b u t t h e fourth b e i n g a fundus lesion could n o t b e expected t o h a v e n o r m a l vision. H o w e v e r , t h e surgical result in this case w a s excellent. ROBERT V O N D E R H E Y D T ,
C o r r e s p o n d i n g Secretary.
HOUSTON SOCIETY
THE HOUSTON OPHTHALMOLOGICAL A N D OTO-LARYNGOLOGICAL SOCIETY. October. D R . H E N R Y C. H A D E N
presiding.
D R . C. P . HARRIS read a p a p e r on Roentgentological Considerations for the eye. ear, nose a n d t h r o a t s u r g e o n s . Corneal Sequels of Trachoma. D R . E . L . GOAR presented a m a n 25
years of age. T h e history is that of a chronic inflammatory condition of t h e eyes of several years duration. T h e lids were typical of a chronic, severe type of trachoma, with much scarring and dis tortion. Each cornea was thin and ectatic on the upper half, protruding for ward to such an extent that t h e upper third was even with the apex. T h e tem poral side bulged slightly more than the nasal. Each cornea was vascularized from every p o r t i o n of t h e limbus, t h e attentuated vessels meeting in the center of the cornea. Vision fingers at 15 feet both eyes. Treatment has consisted in resection of both upper tarsi and instil lation of powdered dionin for the past several months. Because of the irregu lar astigmatism and the marked vascularization of t h e cornea, no lens improves the vision. D r . Goar remarked in dis cussing the case, that if it were possible to use a contact glass constantly in this case, the vision might be somewhat improved. A s the keratectasia has not advanced in t h e past year, no operative interference is indicated at present. Iritis and Secondary Glaucoma. DR. W M . L A P A T reported a case of subluxated lens. J. T., age 35 years, col ored, injured August 2nd, 1922, by being struck in right eye by a truck handle. Patient was seen twelve days after in jury, at which time there was much cili ary injection, much pain, cornea slightly hazy, pupil somewhat wide but irregular. T h e iris was muddy, a n d it appeared as if there was subluxation of t h e lens. Tension was 25 m m . H g . , and vision counting fingers at 10 feet. Gradually the cornea began to clear, a n d it was seen the lens had many small spots, such as a r e found after posterior synechia.
There was a gap between t h e outer border of t h e lens and t h e iris. T h e lens appeared to be notched, and t h e iris was slightly tremulous. It was difficult to make out whether it was a subluxated lens with a slight coloboma or a cyst of the iris, the edge of the lens being seen partly in t h e anterior chamber. T h e whole lens w a s clear except for iritic spots. T h e patient complained of much pain, tension was u p to 70. Eserin did n o t r e l i e v e ; iridectomy w a s done. T e n sion came down to 30, and vision at pres ent 20/70. Iridocyclitis from Diseased Tonsils. D R . E . M . ARNOLD reported on F . N .
J., age 32 years, who came J u n e 30th, complaining of pain in right eye, exces sive tearing a n d sensitiveness to light. This condition had existed for three days. Vision was not much impaired. A diagnosis of iritis was made—the pu pil was small, reacted slowly and re sponded poorly to atropin. U n d e r atropin, mercury and hot applications t h e con dition did not improve. T h e teeth were in good condition and the tonsils looked harmless and were not large, neverthe less, it was suggested that the tonsils be removed, and this was done on July 8th. Since the operation there has been no more pain, and the iritis cleared u p promptly. Patient had been using atropin t.i.d. for several days, but the pupil was only partially dilated. B u t t w o days after the operation the pupil became widely dilated with no increase in the atropin. E . M. ARNOLD,
Secretary. CHICAGO O P H T H A L M O L O G I CAL SOCIETY. October 16, 1922. Vice-President, D R . F R A N K BRAWLEY, in
the Chair. Basal Cell Epithelioma of Lids. DR.
LOWRY
(for
Dr.
George
F.
S u k e r ) reported t h e case of a man, 46 vears old, who six months ago had an ulceration of the upper lid of t h e right eye, which extended from the inner canthus to one-half inch beyond the outer
51
SOCIETY PROCEEDINGS
rim. Rodent ulcer of the eyelid was diagnosed. An exenteration of the or bit was performed to extirpate malig nancy. Two pedunculated flaps were brought down from the forehead and at tached to the normal conjunctiva. Cicatricial tissue had since made several outer canthotomies necessary. The patient had received some X-ray therapy since the operation. There was no limitation in the ocular movements, no diplopia or re duction in visual acuity; nor was there an involvement of the cornea. Cavernous Hemangioma of Ophthal mic Vein. DR. COTTLE (for Dr. George F. Suker)
reported the case of a male baby, four weeks old, brought to the hospital 10 days after birth, with a markedly proptosed right eye, which showed corneal abscess with threatened perforation. Tlie equator of the eye was beyond the lid margins and pushed somewhat down ward. The eye could not be replaced. There was no palpable pulsation, and no audible bruit. Above the eye could be felt a soft, compressible mass, which pushed the eye downward and outward. Because of the absolute loss of function, and potential danger to the other eye, the eye was enucleated. The diagnosis was that of hemangioma, probably of the cavernous type. The tumor was still present, but had not in creased in size since the time of opera tion. In this case there was a suspicion of a history of trauma. The child was delivered by a midwife. X-ray exam ination showed no evidence of fracture which might produce a laceration in the orbital region. Examination of the eye and adnexa showed no evidence of extra- or intrabulbar tumor formation. The soft tissues about the optic nerve had the appearance of loose epibulbar tissue, soaked or in filtrated with blood. The central fourfifths of the expanse of the cornea had suffered what appeared to have been an incompletely perforating ulceration. The lens was in its normal position and what could be seen of the iris did not appear to have been displaced forward, as would be the case had the cornea been perfor ated.
Nephritic Retinitis. DR. ROBERTSON (for Dr. George F. Suker) reported the case of a boy, 14 years old, who was admitted one week ago, complaining of periodic attacks of vomiting associated with headache. The attacks started about a year and a half ago, the interval between attacks becom ing shorter and shorter, so that they now occurred every two or three days. There was no history of the disturbances of childhood. The essential positive findings were a systolic pressure of 224, diastolic 170, giving a pulse pressure of 54. The urinalysis showed a large amount of albumin, and a specific gravity of 1011. The blood Wassermann reaction was negative. Examination of the eyes showed R. V. 20/13; L. V. 20/13. Both disc surfaces were edematous, the margins distinctly blurred. The veins were engorged, the arteries small and there were numerous plaques of hyalin degeneration arranged around the macular region. The diagnosis was made of chronic diffuse nephritis and nephritic retinitis. The case was interesting because of the extreme youth of the patient with such high blood pressure and the good vision present in the eyes. Chorioretinitis Pigmentosa.
DR. F I N K (for Dr. George F. Suker)
presented a case of chorioretinitis pig mentosa. Pigment on Caruncle. DR.
OLIVER
TYDINGS
presented
a
young lady, who showed a pigmented spot on the caruncle, which had existed for a year. Microscopic examination had not been attempted. Sarcoma of Orbit.
DR. MICHAEL GOLDENBURG presented
the case of a man, 42 years old. He first noticed a swelling the size of a pea over the left lacrimal sac one year ago, which disappeared after about six weeks, recur ring two months later, and had gradu ally increased in size. The growth had been much more rapid during the past six or seven weeks. It had broken open at two points during the past week and was discharging slightly at present.
52
CHICAGO OPHTHALMOLOGICAL SOCIETY
T h e r e w a s a reddish, a n g r y swelling a b o u t t w o b y t h r e e inches, which pro jected a b o u t an inch a n d a half. T h e eye w a s p r o p t o s e d a n d p u s h e d o u t w a r d from t h e midline v e r y m a r k e d l y . O v e r t h e lacrimal area t h e r e w e r e t w o smaller rounded swellings. T o t h e t e m p o r a l side of t h e s e swellings w a s a crevice w h e r e t h e skin w a s b r o k e n open. T e m p o r a l l y a n d 3 / 4 inch b e low this w a s a 3 / 8 inch o p e n i n g in t h e skin which discharged a small a m o u n t of yellowish serous fluid. Large b r a n c h i n g veins could be seen plainly u n d e r t h e skin surface. T h e r i g h t a n d left consensual reactions w e r e good ; t h e left eye reacted slightly t o l i g h t ; t h e left eye w a s blind except for light. T h r e e weeks a g o h e could c o u n t fingers at 18 inches, t o t h e nasal side.
r e s t o r e vision b y an iridectomy o n t h e r i g h t eye. T h e p a t i e n t w a s blind from the a g e of eleven until he w a s t h i r t y . A n i r i d e c t o m y performed a t t h a t time g a v e h i m 20/200 vision. H e t h e n learned t h e brick l a y i n g trade, a n d for t h e last five y e a r s h a d been d r a w i n g full p a y as a brick layer. T h e i n t e r e s t i n g t h i n g w a s t h a t h e w a s n o w a useful man, drawing the same wages as t h o u g h he h a d 2 0 / 2 0 vision. H e would be classed as industrially blind on ac c o u n t of t h e 20/200 vision.
L e n s Extraction b y Barraquer Technic. D R . W . A . F I S H E R p r e s e n t e d a lady to s h o w t h a t t h e lens could b e r e m o v e d by t h e complete B a r r a q u e r technic, car ried o u t as B a r r a q u e r w a s d o i n g it a t this time. H e w a s not o p e r a t i n g a c F u n d u s : T h e disc could n o t be lo c o r d i n g to a n y p a p e r t h a t h e h a d ever cated. M a n y h e m o r r h a g e s w e r e p r e s w r i t t e n . H i s latest paper, n o t y e t p u b ent, retinal a n d subhyaloid. T h e ves lished, would b e s o m e t h i n g quite dif sels w e r e t o r t u o u s . M a n y w h i t e areas ferent. B a r r a q u e r in t h a t p a p e r w o u l d were present. O n the nasal side, it p r e s e n t 112 original pictures, g i v i n g h i s looked as if some d e t a c h m e n t of t h e technic in full. I n this case t h e technic retina w e r e t a k i n g place, w i t h a possi w a s t h a t w h i c h B a r r a q u e r used in bility of a neoplasm b r e a k i n g into t h e Richmond and Philadelphia in April, eyeball. T h e blood W a s s e r m a n n r e 1922. All t h e p a t i e n t s w e r e left with action w a s negative. nice round pupils. In the first place, T h e diagnosis w a s t h a t of s a r c o m a , he dilated t h e pupil w i t h eucain a n d p r o b a b l y o r i g i n a t i n g in t h e e t h m o i d s . cocain, u s i n g it every fifteen m i n u t e s for a n h o u r a n d a half, o r until t h e p u Discussion. — DR. ELBERT CLARK stated: R a d i u m w a s applied exter pil w a s fully dilated. H e t h e n m a d e an nally on J u l y 18 for 4200 milligram injection of novocain across u n d e r t h e hours, screened with 0.6 m m . gold, 1 lower lid, o n e d o w n w a r d a n d o n e u p w a r d . I n every operation h e t u r n e d mm. silver, and 1 1/2 cm. rubber. This the lens upside d o w n , b r i n g i n g t h e application was changed every six h o u r s for forty-eight h o u r s . O n J u l y lower edge up first, and no pressure was 25, 2712 milligram h o u r s w e r e used, used. T h e operation w a s d o n e w i t h a five pieces of r a d i u m b e i n g e m b e d d e d dilated pupil w i t h a very small peri in different p a r t s of t h e t u m o r , a n d so pheral iridectomy, as in this case. I n a r r a n g e d a s to be n o t over o n e centi several cases t h e novocain produced m e t e r apart. N o other t r e a t m e n t h a d a paralysis of t h e orbicularis, a n d been employed. There was a rather stitches w e r e p u t into t h e skin of t h e violent reaction, w i t h a little m o r e lids to keep t h e eye closed. T h e pa tient w a s in t h e hospital nine days, did swelling a n d edema. not h a v e a n y postoperative inflamma Industrial Efficiency with Poor Vision. tion a n d h a d 2 0 / 2 0 vision. D R . W . A. F I S H E R presented a m a n
to show what could be done with 20/200 vision. H e w a s 38 y e a r s old. A t t h e a g e of 11, w h e n in t h e fifth g r a d e a t school, h e c o n t r a c t e d small pox. T h e left eye w a s r e m o v e d b y t h e late D r . Beard, a n d h e a t t e m p t e d t o
Mydriatics and Cycloplegics. D R . G. H E N R Y M U N D T r e a d a p a p e r
on this subject, in which h e stated t h a t one of t h e v e r y i m p o r t a n t w o r k s of the ophthalmologists was refraction, and a vast m a j o r i t y of c o m p e t e n t m e n
SOCIETY PROCEEDINGS
considered a cycloplegic one of the prime essentials of good refraction. He considered the isomeric substances hyoscin hydrobromid and scopolamin hydrobromid identical, since Merck labeled them so; also this was a prac tical settlement of their difference which had been extensively discussed. He was thoroly convinced that in refraction every patient under forty years of age should have a cycloplegic; that nearly all those between forty and fifty should, excepting those who had normal vision and apparently did not need distance lenses; in other words, excepting only those presbyopes who needed reading lenses and had no symptoms other than poor vision for close work. Practically all patifents under fifty years of age should be re fracted with a cycloplegic. In myopia it was as essential to use a mydriatic as in any other class of cases. He could not subscribe to the view that hyperopia was the indication for re fraction with a cycloplegic. If one was to determine with accuracy the total error of any patient, the one right method was to use a cycloplegic, and before any one was really competent to prescribe lenses, he should know the total error of refraction. As to the comparative value of the three common cycloplegics, homatro pin hydrobromid, hyoscin hydrobromid and atropin sulphat, for refraction up to the age of fifteen or sixteen years, homatropin hydrobromid was proba bly the poorest drug for use in these cases; because while its mydriatic ac tion might be complete, the essayist thought it was a failure as a cycloplegic at this age. Atropin sulphat was probably the best drug when used properly, because of its certainty of action and its relatively low toxicity when compared with hyoscin hydro bromid. Hyoscin hydrobromid was a drug of first value; and in selected cases with proper precautions in its administration, it was very reliable, nearly as reliable as atropin sulphat. As to the method of administering homatropin hydrobromid, he used a fresh solution ("made fresh at least once a week) of 2 per cent, homatropin
53
hydrobromid and 1 per cent, cocain hydrochlorid. This was dropped in the conjunctival sac every five to ten minutes a varying number of times, dependent upon the age of the patient: from 15 to 20 years, 8 times; 20 to 30, 6 times; 30 to 40, 4 times; 40 to 50, 3 times, and beyond 50 once or twice only. As to the use of atropin for refraction, a one per cent, aqueous solution was used four times a day for three or four days, in patients beyond six years of age; 3 to 6 years a one-half per cent. solution, and a weaker solution below three years of age. The hyoscin hydrobromid was used in a solution, the maximum dose in adults being two drops of one-half per cent. solution, with the excess mopped up at once and pressure made over the sac. This meant that one drop might be used in each eye, or two drops with an inter val in one eye. This was the maximum dose and must be used with great caution. He more frequently used a one-fourth per cent, solution, but in iritis the onehalf percent, solution was much more ac tive. The one-fourth per cent, solution might be used twice with care as young as twelve years; from 12 to 8 about onesixth or one-eighth per cent., from eight down, much weaker. Discussion. — D R . OLIVER
TYDINGS
fully concurred in the opinion that hy oscin and scopolamin were the most important of the cycloplegics. He did not agree with the essayist as to the strength of scopolamin he used. Dr. Mundt spoke of a 1/2 of 1 per cent., Dr. Tydings used it in about 1/5 of 1 per cent. He did not hesitate to send a patient out with scopolamin any more than with atropin. He did not believe that in the last fifteen to twen ty years he had used atropin in one case out of a hundred. The cycloplegic action that was obtained from scopol amin, in one-half or three-fourths hour. could only be obtained from atropin in three days, or sometimes longer. He did not agree with Dr. Mundt when he advised atropin or scopolamin as a cycloplegic in all cases. He thought one could refract many cases without any cycloplegic at all,
CHICAGO OPHTHALMOLOGICAL SOCIETY
54
D R . T H O M A S F A I T H referred
to
two
points not mentioned in connection with h o m a t r o p i n a n d scopolamin. O n e w a s t h a t m u c h of t h e h o m a t r o p i n h a d been v e r y faulty for a y e a r o r so. T h e r e h a d been m a n y instances in which t h e effects h a d lasted for d a y s . A peculiar t h i n g h e h a d noticed in connection w i t h h o m a t r o p i n w a s t h a t frequently h e could g e t 1/2 t o 1/4 m o r e plus s p h e r e w i t h o u t h o m a t r o p i n , t h a n h e could g e t with it. A n o t h e r t h i n g in connection w i t h the use of scopolamin was, that he had used it in a s t r e n g t h of o n e g r a i n t o the ounce a n d found it d e t e r i o r a t e d very rapidly. I n a v e r y s h o r t time scopolamin would n o t be of a n y value, even at t h e e n d of a week s o m e t i m e s . H e h a d n o t used 1/2 of 1 p e r cent, of gcopolamin, b u t a l w a y s h a d adhered to t h e w e a k e r solutions. H e h a d given (scopolamin t o u s e a t h o m e , g i v i n g them 1/4 grain to the half ounce, and had it applied once o r twice a d a y for several days, a n d t h e n followed with t w o o r t h r e e instillations of scopolamin in t h e office, u s u a l l y two, a t one s i t t i n g with a 15 t o 20 m i n u t e interval. T h e advantage of this was, that instead of h a v i n g t w o weeks m y d r i a s i s h e h a d t w o or t h r e e days. T h e r e w a s a tend ency t o g e t a w a y from h o m a t r o p i n and scopolamin a n d all cycloplegics, b u t h e felt t h a t t h e refraction w a s n o t as good w h e n d o n e w i t h o u t t h e m . H e prefers all his patients to use homa tropin o r scopolamin u p t o f o r t y ; after t h a t h e used h o m a t r o p i n occasionally, b u t n o t as a rule. H e did n o t rely o n h o m a t r o p i n as h e did a few y e a r s a g o , b u t h e did u s e scopolamin r i g h t along. DR. MUNDT.
A S to t h e s t r e n g t h of
hyoscin, t h e m a x i m u m w a s 1/2 of 1 per cent. H e said h e m o r e frequently used 1/4 of 1 p e r cent, b u t o n e could
use 1/2 of 1 p e r cent., a n d it w a s v e r y active. H e d i d n o t prescribe it a s a cycloplegic, because he thought it was too active t o p u t into t h e h a n d s of a patient. H e t h o u g h t scopolamin w a s about like p u t t i n g a can of e t h e r in t h e .hands of a patient. A s t o t h e activity of hyoscin, t h e r e w e r e t h r e e isomeric s u b s t a n c e s . O n e diverted light to t h e right, o n e t o t h e left, a n d o n e w a s n o n l i g h t d i v e r t i n g . T h e nonlightdiverting was absolutely nondilating. H e t h o u g h t t h e r e w a s n o question t h a t h o m a t r o p i n w a s n o t con stant. Results of Col. Smith's Cataract Op erations. D R . W . A . F I S H E R read a paper cor r e c t i n g earlier r e p o r t s ( S e e F e b . N o . ) , which will be published in full in this journal. Discussion.
— DR.
THOMAS
FAITH
s t a t e d t h a t t h e i n t r a c a p s u l a r operation m u s t stand on its o w n m e r i t s , a n d it should b e given this o p p o r t u n i t y . A t the D e c e m b e r m e e t i n g he m a d e t h e s t a t e m e n t t h a t h e could n o t u n d e r s t a n d t h e g r e a t difference in t h e r e sults a t t h e Illinois C h a r i t a b l e E y e a n d E a r I n f i r m a r y a n d t h e Chicago E y e , Ear, Nose a n d T h r o a t Hospital, be cause h e h a d w a t c h e d t h e S m i t h method for several years, and the free d o m from p o s t o p e r a t i v e inflammation w a s striking, a n d h a d been well set forth b y S m i t h in h i s v a r i o u s w r i t i n g s . H e s a w t h e four cases m e n t i o n e d by D r Fisher and was able to obtain 2 0 / 2 0 vision w i t h o u t a n y difficulty in t h r e e , b u t t h e fourth b e i n g a fundus lesion could n o t b e expected t o h a v e n o r m a l vision. H o w e v e r , t h e surgical result in this case w a s excellent. ROBERT V O N D E R H E Y D T ,
C o r r e s p o n d i n g Secretary.