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Chicago Ophthalmological Society
SOCIETY PROCEEDINGS Edited by DON; CHICAGO OPHTHALMOLOGICAL SOCIETY February 20, 1950 DR. DERRICK VAIL,
president
CLINICAL PROGRAM
Presented by the Department of Ophthal mology, University of Illinois Medical School, Research Hospital, Illinois Eye and Ear Infirmary MALIGNANT
(THYROTROPIC)
EXOPHTHAL-
MOS
DR. EDWARD JONES presented R. B., a
Negress aged 62 years, who was first seen at the Illinois Eye and Ear Infirmary on April 14, 1949. For the previous four months she had noticed failing vision, bulging of the right eye and later the left eye, nervous ness, intolerance to heat, excessive perspira tion, a weight loss of 40 pounds and, more recently, fatigability, anorexia, and dysphagia. Her previous health had always been good and there was no history of any eye trouble. Examination revealed an uncorrected vi sion: R.E., 20/70; L.E., 20/50. The lids were somewhat puffy and the eyes appeared abnormally prominent. Both discs showed mild papilledema. The pulse was 80. Two months later, corrected vision was: R.E., 20/50; L.E., 2 0 / 2 0 - 4 . At this time both lids had become markedly edematous, with chemosis and hyperemia of the conjunctiva. Proptosis was so marked that she was unable to close the lids voluntarily over the right cornea, and with difficulty in the left eye. With the Hertel exophthalmometer, the proptosis measured: R.E., 32 mm.; L.E., 28 mm. The tension of the orbital tissues appeared markedly increased, making it diffi-
D J. LYLE,
M.D.
cult to force the globes into orbits. The right cornea showed a superficial infiltration above. Ocular motility was greatly limited, particularly on the right where the globe was almost fixed in the primary position. Ophthalmoscopic examination indicated that the disc margins were more blurred than on the previous visit. Visual fields revealed slight peripheral constriction to 3/330 white on the right, with constriction on down to 20 degrees and baring of the blindspot to 4/1,000 white. The fields of the left eye were normal. She was admitted to Research Hospital for study. The examination revealed a moist skin, pretibial edema, diffuse moderate enlargement of the thyroid; pulse rate, 86; blood pressure, 166/94 mm. Hg. Laboratory studies were normal except for elevation of the sedimentation rate; W.B.C, 7,700, with 50 percent lymphocytes and 50 percent polymorphonuclears; blood sugar, 138 mg. percent; cholesterol, 183 mg. percent. Skull and chest X-ray studies were negative. A tracer dose of radioactive iodine indicated increased thyroid activity. Eleven oxysteroid determinations and the Thorne test suggested increased adrenal cortical function. Basal metabolism rate was plus 78 percent. Bilateral lateral tarsorrhaphies were per formed which afforded adequate protection to both corneas, although during the next few months some difficulty was experienced by prolapse of the conjunctiva nasally. The papilledema did not seem to increase sig nificantly, attaining a maximum of 2 to 3 diopters in the right eye and 1 to 2 diopters in the left. Visual fields showed no evidence of deterioration until the last two weeks, about nine months after onset of papil ledema. Because the eyes seemed to tolerate the marked proptosis, treatment was directed
SOCIETY PROCEEDINGS
297
along medical lines. Ammonium chloride and effective method of slowly reducing the mercurhydrin were used at intervals to re toxicity of Graves's disease without unduly duce tissue edema. Stilbestrol (one mg. per accentuating the thyrotropic manifestations day) was given for two weeks without of malignant exophthalmos. change in the condition of the eyes. TWO CASES OF IRIDOSCHISIS The general thyrotoxic status remained DR. EDWARD G. PANTER said that serious, and various methods to reduce the production of thyroxin were considered. iridoschisis (iris splitting) is quite rare. Being aware of the potential danger to the Linn and Linn (AMERICAN JOURNAL OF eyes by surgical thyroidectomy, propyl- OPHTHALMOLOGY, December, 1949) re thiouracil was instituted (100 mg., three viewed the literature and found 10 cases reported, to which they added one of their times a day) for the next four months. The basal metabolism rate was reduced own; this report adds two more cases. Case 1. R. S., a 62-year-old white woman, from plus 78 percent to plus 43 percent after was first seen at the infirmary in April, 1939, one month, to plus 23 percent in three months, where it has remained until the because of failing vision in each eye for the present time, four and one-half months after past two years. Vision was: 20/100, O.U. ; tension: R.E., 35 mm. H g ; L.E., 32 mm. beginning the use of propylthiouracil. During this therapy the incompressibility Hg (Schio'tz). Gonioscopically the anterior of the globes became slightly less, ocular chambers were shallow but the angles were motility very slightly greater, the exophthal open. The discs revealed bilateral moderate mos remained the same so far as could be physiologic excavation. Both blindspots determined, and the corneas did not suffer were enlarged. She was placed on pilocarpine further damage. The papilledema of the and the tension dropped to normal and right eye almost disappeared, although the vision improved to 20/20 O.U. left disc remained edematous. Both vision and tension remained normal Vision was reduced to: R.E., 20/80; L.E., under miotics until 1946. In January of that 20/50. Visual fields showed further con year the vision was found to be: R.E., striction peripherally of: R.E., about 30 de 2 0 / 4 0 - 3 ; L.E., 2 0 / 2 5 - 3 . Tension was: grees with the 3/330 white test object; L.E., R.E., 30 mm. H g ; L.E., 49 mm. Hg baring of the blindspot to a 2/1,000 white. (SchijzStz). The right eye revealed sectorAlthough the general toxic status of the shaped atrophy of the iris between the patient has improved remarkably and the 3- and 7-o'clock positions. degree of proptosis has not increased sig About two years later marked rupture of nificantly during propylthiouracil therapy, the iris stroma in this area became manifest. the definite signs of optic-nerve damage A year later the whole surface of the iris indicate that decompression of the orbit of the right eye became scattered from the must be done as soon as possible. It is 2- to approximately the 7-o'clock positions, planned to do this by the Kronlein approach the loose ends resembling shredded wheat. to the lateral wall of the orbit and, if neces Under the gonioscope, the angle at the sary, a subsequent Naffziger operation to 6:30-o'clock position was visible to the remove the roof of the orbit. This case scleral spur, with moderate pigmentation of corroborates the report of Beierwalter in the the trabeculum. The angle details were not Archives of Internal Medicine, 1948, in seen elsewhere, due to bulging of the iris. which the use of propylthiouracil in 12 cases Rupture of the iris stroma in the left eye of malignant exophthalmos produced an at the 6-o'clock position began soon after average increase in the exophthalmos of that in the right eye. Gonioscopically no only 1.8 mm. The drug appears to be an details were visible below. The shredded iris
298
SOCIETY PROCEEDINGS
seemed to lie against the posterior corneal surface. At the sides, the scleral spur was seen, and the trabeculum revealed moderate pigmentation. In April, 1949, vision was: R.E., 20/250; L.E., 20/25. In December, 1949, the patient suddenly lost the vision of the right eye, associated with lightninglike flashes on two occasions. Vision had dropped to hand move ments at three feet. Tension was 19 mm. Hg (Schio'tz). An attempt was made to dilate the pupil, but because of poor dilatation plus marked lenticular opacity, the fundus could not be seen. The presumptive diagnosis of thrombosis of the central retinal vein was entertained. In January, 1950, tension was 37 mm. Hg (Schi^tz) in both eyes and has remained at this high level despite intensive miotic ther apy. At this time visual acuity of the right eye is light perception only (good projec tion), and in the left eye 20/20—3. The corneas reveal moderate guttate changes. The anterior chambers are shallow and the aqueous ray is negative. The right iris shows generalized atrophy. The anterior surface between the 2- and 8-o'clock posi tions is fragmented, some strands being free, but most attached to the sphincter or ciliary zone. These fragments are brown and re semble shredded wheat or seaweed. The underlying pigmented layer of the iris seems to be less involved. The left iris is also atrophic and many freckles are present. The anterior surface is frayed from about the 5- to 7-o'clock posi tion. The pupils are small. The lenses, especially the right, are quite opaque, obscuring observation of the fundi. Tension in both eyes is 39 mm. Hg. The right eye transilluminates well. Associated general findings are advanced arteriosclerosis and mild thyrotoxicosis. On February 9, 1950, a cyclodialysis followed by air injection was done on the left eye. This was complicated by a moderate an terior-chamber hemorrhage. Tactile tension
is normal. Tension in the right eye has re mained at 39 mm. Hg (Schi$?ftz). A lens extraction on the right eye is contemplated. Case 2. R. B., aged 81 years, came to the infirmary in October, 1946, for glasses. Corrected vision was: R.E., 20/40; L.E., 20/40—3. The iris of the left eye revealed an unusual and interesting discontinuity of the normal architecture from the 5- to 7o'clock positions. Under the slitlamp, the iris at this point had a shredded-wheat ap pearance with some strands floating in the anterior chamber. There were also asteroid bodies of the vitreous. In October, 1949, corrected vision was 20/40 in both eyes; tension, 24 mm. Hg (Schio'tz). In the left eye from the 5- to 7-o'clock positions and from the 11- to 12o'clock positions, the iris seemed to be ripped up peripherally and anterior stromal shreds were floating free in the anterior chamber, attached only near the sphincter. A similar process was starting at the 6-o'clock position in the right eye. The patient gave no history of uveitis or glaucoma. The discs revealed nasal displacement of vessels and pallor of the temporal aspect. Comment. Two more cases of iridoschisis are presented. One had the associated ocular findings of chronic glaucoma and cataracts. In the other case there were no associated ocular findings. In the 11 previously re ported cases," the findings were: Six had otherwise normal eyes or senile cataract; three had primary glaucoma; one had iridocyclitis; one had secondary glaucoma. Even though four out of a total of 13 cases had primary glaucoma, no relation be tween that and the disease could be found. Loewenstein and Foster suggested that the mechanism of the changes of iridoschisis is merely the exaggeration of the physiologic aging process of the iris, in which the middle layers become atrophic. Subsequently the two layers are separated, and finally the threads of the anterior layer which remain, rupture and float freely at one end.
SOCIETY PROCEEDINGS UVEOPAROTID FEVER: HEERFORDT'S DISEASE
DR. MAURICE D.
PEARLMAN presented
Mrs. H. K., a 54-year-old white woman, whose history stated that during the spring of 1948 generalized aching of muscles and joints developed and recurred periodically since that time. In midsummer, 1948, she developed swelling of the left parotid gland which lasted about two months and was diag nosed as mumps. Paralysis of the left facial region ensued and still remains. Soon after the parotitis began, first the left and then both eyes became reddened and teared excessively; there was no or little associated ocular pain. This persisted in spite of local and general therapy, but gradually subsided after about 12 months of steady visual deterioration to the level of light per ception only in each eye. Red-brownish circinate skin lesions ap peared on the right thigh about five months after the ocular symptoms started, and have remained to date. She was referred to the Beta Therapy Clinic for possible iradiation to the corneal vessels, but such treatment was deemed in advisable because of their inaccessible depth. Past history is irrelevant. She had eight siblings, three of whom died of tuberculosis and one of multiple sclerosis. Her husband is now hospitalized with a lung abscess. Examination of the right eye revealed light perception with good projection. The cornea showed epithelial edema and bullae, deep stratified stromal scarring with a mod erate amount of vascularization intermingled below, and a moderate number of old, large keratic precipitates. The anterior chamber was of average depth with a two-plus aqueous ray present. The aqueous cells could not be seen nor cer tainly excluded because of poor corneal lucency. The iris showed mild erasure of markings only, no nodules were noted. The lens and posterior segment details could not be viewed. A good red reflex was present.
299
In the left eye, the vision was light per ception with faulty projection nasally and superiorly. The corneal involvement re sembled that of the other eye, but to a much greater degree and extent. The corneal scarring and vascularization obscured any proper view of the anterior or posterior segments. Laboratory studies disclosed a normal urinalysis, leukopenia of 2,750 cells per cu. mm., a disproportionate elevation of monocytes in the peripheral blood (10 percent), increased sedimentation rate of 39 mm. per hour. Blood serology for syphilis, comple ment fixation for gonorrhea, and agglutina tions for Brucella were all negative. Intracutaneous sensitivity tests were negative to brucellergin and first strength purified pro tein derivative, and 2-plus (10 by 10 mm. induration) to second strength purified pro tein derivative. Blood globulin level was 3.8 mg. percent. A / G ratio was 1.3-1. X-ray studies indicated minimal increase in pulmonary markings and evidence of old fibrotic scars in the bases, but no evidence of active infection. Biopsy of the skin lesion of the right thigh showed subcutaneous tuberclelike formations made up of epithelioid cells and giant cells; no caseation. These changes are considered consistent with sarcoidosis. Guinea-pig inoculation of the biopsy material produced no obvious change in .the animal after almost two months. Biopsy of the right iris (performed as an optical iridectomy) showed only non specific chronic inflammatory changes. This case conforms well to the usual fea tures of Heerfordt's disease—"a chronic parotitis and uveitis, associated with paresis of cranial nerves and other general symp toms, and having a tendency toward spon taneous resolution." The family background of tuberculosis also concurs with many other case reports suggesting some special rela tionship with tuberculosis, perhaps of atypical or modified form. Since this condi tion is probably a manifestation of sar-
300
SOCIETY PROCEEDINGS
coidosis the problem of etiology resolves it self to the fundamental cause of sarcoid granulomas, which is unknown. The fact that the patient had only uni lateral parotitis and homolateral facial pa ralysis favors the opinion that the facial nerve was compromised locally in the gland substance, yet it is interesting to note that Duke-Elder insists that the cranial nerve in volvement is of central origin, and part of a generalized polyneuritis. The prevalence of keratitis in cases of ocular sarcoidosis, ac cording to the literature, is from 20 to 50 percent and, as in this case, is usually deep in character. The treatment results are dis couraging. Calciferol in large doses (100,000 units per day) is under trial. The sequelae in this case, corneal scarring, permitted only an optical iridectomy.
several spells of vomiting and ocular pain. The next morning, examination showed mild edema of the flap over the nasal suture, a flat anterior chamber, and fair red reflex. The following night she had severe pain in the eye with much nausea and vomiting. On the second postoperative morning, vision in the eye was reduced to poor light perception and faulty projection, and blood was ob served on the anterior surface of the vitreous. The next day, with clearing of the media, a large reddish-brown mass was seen, pro jecting from the temporal side completely across the pupillary space, meeting two smaller masses above and nasally. The ap pearance was similar to that of a marked combined choroidal detachment, except that the temporal mass completely dominated the picture and transillumination was nil. SUBCHOROIDAL HEMORRHAGE Diagnosis of a delayed subchoroidal hemorrhage was made, limited in extent by DR. JAMES E. MCDONALD presented a 63-year-old white woman, first seen at the the two corneoscleral sutures. Both pillars infirmary in November, 1949, with the com of the iris were seen to be shortened, but no plaint of painless and progressive loss of definite prolapse could be noted. vision in the left eye for 18 months. On On the seventh postoperative day, at the examination the right eye was normal, with suggestion of Dr. Peter C. Kronfeld, a 20/20 corrected vision, mild nuclear haze in scleral trephination was performed in the in the lens, and normal fundus. In the left eye, ferior temporal quadrant about seven mm. vision was limited to perception of hand behind the limbus. Dark-red blood and some movements at one foot, with good central fresh blood burst forth under considerable fixation, color perception, and light projec pressure, a total of about four cc. being tion. A large intumescent cataract was pres evacuated. The patient was immediately re ent. Tension measured 16 mm. Hg lieved of the low-grade headache which had (Schijzftz). The patient gave a history of been present during the preceding week. high blood pressure and two previous left- The collapsed globe was restored to normal sided strokes from which she had recovered. shape by injection of air anteriorly. Blood pressure on admission was 180/90. The postoperative course was uneventful Otherwise physical and laboratory findings and the patient was discharged with cor were normal. rected vision of 20/200. A white streak in On November 12, 1949, a left intracapsu- terpreted as a retinal fold could be made out lar cataract extraction with complete in the superior temporal area. Three months after operation, corrected iridectomy and two McLean corneoscleral sutures was performed without complica vision in the left eye was 20/100. Visual tions. The patient volunteered the informa fields were somewhat constricted especially tion that she could see the operator quite nasally, with a relative central scotoma. A clearly soon after delivery of the lens. Dur small knuckle of iris was seen in the area of ing the first postoperative night she had the shortened nasal pillar, which was well
SOCIETY PROCEEDINGS covered by flap. The cornea was thickened in its upper half. The anterior chamber was well formed, especially below. The media were more clear than previously but still contained some curtainlike opacities. The fundus was somewhat pale temporally and the retinal fold could be seen well in this area. The macular details were not well made out due to haze in the media. This patient is presented as another case of massive subchoroidal hemorrhage treated successfully by evacuation of blood, in this instance by trephination. The first such case was reported by Verhoeff in 1915, three more by Vail in 1938 and 1949, and one by Duehr and Hogensen in 1947. The present case represents the delayed type of sub choroidal hemorrhage, like Vail's first case, but without extrusion of vitreous. This might well be due to closure of the wound by corneoscleral sutures, as in the case re ported by Duehr and Hogensen. The differ entiation from simple choroidal detachment includes firm eye, more massive size, severe ocular pain, and absence of transillumination. If prolapse of the retina does not oc cur, removal of the blood is feasible and the eye may be saved from an otherwise hopeless prognosis. Richard C. Gamble, Secretary.
NEW YORK SOCIETY FOR CLINICAL OPHTHALMOLOGY February 6, 1950 DR. SIDNEY A. Fox, president SOME ASPECTS OF OCULAR THERAPY DR. ARTHUR LINKSZ discussed this topic during the instruction period. USE OF ETHER IN HERPETIC KERATITIS DR. BERNARD KRONENBERG said that in August, 1941, he reported on the use of
301
ether in the treatment of herpetic keratitis in the Archives of Ophthalmology. Since that time, he has had ample opportunity to re-evaluate the method and confirm its suc cessful use. The discrepancy between his continued successful results with this treat ment and the number of unfavorable reports from reliable sources made Dr. Kronenberg feel that it would be wise to reexamine the reason for the success obtained in his series in contrast with the lack of success reported by others. With this in mind, Dr. Kronenberg sug gested to Dr. Fenn T. Ralph, resident at the New York Eye and Ear Infirmary, that he treat a series of 12 cases of herpetic keratitis following exactly the technique outlined. Dr. Kronenberg also included in this survey 10 cases from his private practice. As a result of this investigation and conversations with others who have used the technique, Dr. Kronenberg concluded that the technique must be followed faithfully if it is to be successful. The following method of application has proved effective. The patient's eye is anesthetized with pontocaine (0.5 percent) and the lesion is outlined with fluorescein. The patient's head is made comfortable in a headrest. Good illumination is necessary. An assistant holds the container of fresh ether; into this container a tightly woven small cotton applicator, previously prepared, is dipped. The excess is quickly shaken off and the lesion is rubbed with the still-wet ap plicator, removing the corneal epithelium of the lesion and a small amount of the epithe lium surrounding the lesion. The mere appli cation of ether to the lesion is not sufficient; it must be rubbed in. If one application is not sufficient because the ether may have evaporated, a fresh applicator is dipped into the ether and the rest of the lesion treated in a similar manner. Metaphen ophthalmic oint ment is then instilled and the eye bandaged. The eye must be examined 24 hours later. Again the cornea is stained with fluorescein. Any small particles of the lesions which may
president
CLINICAL PROGRAM
Presented by the Department of Ophthal mology, University of Illinois Medical School, Research Hospital, Illinois Eye and Ear Infirmary MALIGNANT
(THYROTROPIC)
EXOPHTHAL-
MOS
DR. EDWARD JONES presented R. B., a
Negress aged 62 years, who was first seen at the Illinois Eye and Ear Infirmary on April 14, 1949. For the previous four months she had noticed failing vision, bulging of the right eye and later the left eye, nervous ness, intolerance to heat, excessive perspira tion, a weight loss of 40 pounds and, more recently, fatigability, anorexia, and dysphagia. Her previous health had always been good and there was no history of any eye trouble. Examination revealed an uncorrected vi sion: R.E., 20/70; L.E., 20/50. The lids were somewhat puffy and the eyes appeared abnormally prominent. Both discs showed mild papilledema. The pulse was 80. Two months later, corrected vision was: R.E., 20/50; L.E., 2 0 / 2 0 - 4 . At this time both lids had become markedly edematous, with chemosis and hyperemia of the conjunctiva. Proptosis was so marked that she was unable to close the lids voluntarily over the right cornea, and with difficulty in the left eye. With the Hertel exophthalmometer, the proptosis measured: R.E., 32 mm.; L.E., 28 mm. The tension of the orbital tissues appeared markedly increased, making it diffi-
D J. LYLE,
M.D.
cult to force the globes into orbits. The right cornea showed a superficial infiltration above. Ocular motility was greatly limited, particularly on the right where the globe was almost fixed in the primary position. Ophthalmoscopic examination indicated that the disc margins were more blurred than on the previous visit. Visual fields revealed slight peripheral constriction to 3/330 white on the right, with constriction on down to 20 degrees and baring of the blindspot to 4/1,000 white. The fields of the left eye were normal. She was admitted to Research Hospital for study. The examination revealed a moist skin, pretibial edema, diffuse moderate enlargement of the thyroid; pulse rate, 86; blood pressure, 166/94 mm. Hg. Laboratory studies were normal except for elevation of the sedimentation rate; W.B.C, 7,700, with 50 percent lymphocytes and 50 percent polymorphonuclears; blood sugar, 138 mg. percent; cholesterol, 183 mg. percent. Skull and chest X-ray studies were negative. A tracer dose of radioactive iodine indicated increased thyroid activity. Eleven oxysteroid determinations and the Thorne test suggested increased adrenal cortical function. Basal metabolism rate was plus 78 percent. Bilateral lateral tarsorrhaphies were per formed which afforded adequate protection to both corneas, although during the next few months some difficulty was experienced by prolapse of the conjunctiva nasally. The papilledema did not seem to increase sig nificantly, attaining a maximum of 2 to 3 diopters in the right eye and 1 to 2 diopters in the left. Visual fields showed no evidence of deterioration until the last two weeks, about nine months after onset of papil ledema. Because the eyes seemed to tolerate the marked proptosis, treatment was directed
SOCIETY PROCEEDINGS
297
along medical lines. Ammonium chloride and effective method of slowly reducing the mercurhydrin were used at intervals to re toxicity of Graves's disease without unduly duce tissue edema. Stilbestrol (one mg. per accentuating the thyrotropic manifestations day) was given for two weeks without of malignant exophthalmos. change in the condition of the eyes. TWO CASES OF IRIDOSCHISIS The general thyrotoxic status remained DR. EDWARD G. PANTER said that serious, and various methods to reduce the production of thyroxin were considered. iridoschisis (iris splitting) is quite rare. Being aware of the potential danger to the Linn and Linn (AMERICAN JOURNAL OF eyes by surgical thyroidectomy, propyl- OPHTHALMOLOGY, December, 1949) re thiouracil was instituted (100 mg., three viewed the literature and found 10 cases reported, to which they added one of their times a day) for the next four months. The basal metabolism rate was reduced own; this report adds two more cases. Case 1. R. S., a 62-year-old white woman, from plus 78 percent to plus 43 percent after was first seen at the infirmary in April, 1939, one month, to plus 23 percent in three months, where it has remained until the because of failing vision in each eye for the present time, four and one-half months after past two years. Vision was: 20/100, O.U. ; tension: R.E., 35 mm. H g ; L.E., 32 mm. beginning the use of propylthiouracil. During this therapy the incompressibility Hg (Schio'tz). Gonioscopically the anterior of the globes became slightly less, ocular chambers were shallow but the angles were motility very slightly greater, the exophthal open. The discs revealed bilateral moderate mos remained the same so far as could be physiologic excavation. Both blindspots determined, and the corneas did not suffer were enlarged. She was placed on pilocarpine further damage. The papilledema of the and the tension dropped to normal and right eye almost disappeared, although the vision improved to 20/20 O.U. left disc remained edematous. Both vision and tension remained normal Vision was reduced to: R.E., 20/80; L.E., under miotics until 1946. In January of that 20/50. Visual fields showed further con year the vision was found to be: R.E., striction peripherally of: R.E., about 30 de 2 0 / 4 0 - 3 ; L.E., 2 0 / 2 5 - 3 . Tension was: grees with the 3/330 white test object; L.E., R.E., 30 mm. H g ; L.E., 49 mm. Hg baring of the blindspot to a 2/1,000 white. (SchijzStz). The right eye revealed sectorAlthough the general toxic status of the shaped atrophy of the iris between the patient has improved remarkably and the 3- and 7-o'clock positions. degree of proptosis has not increased sig About two years later marked rupture of nificantly during propylthiouracil therapy, the iris stroma in this area became manifest. the definite signs of optic-nerve damage A year later the whole surface of the iris indicate that decompression of the orbit of the right eye became scattered from the must be done as soon as possible. It is 2- to approximately the 7-o'clock positions, planned to do this by the Kronlein approach the loose ends resembling shredded wheat. to the lateral wall of the orbit and, if neces Under the gonioscope, the angle at the sary, a subsequent Naffziger operation to 6:30-o'clock position was visible to the remove the roof of the orbit. This case scleral spur, with moderate pigmentation of corroborates the report of Beierwalter in the the trabeculum. The angle details were not Archives of Internal Medicine, 1948, in seen elsewhere, due to bulging of the iris. which the use of propylthiouracil in 12 cases Rupture of the iris stroma in the left eye of malignant exophthalmos produced an at the 6-o'clock position began soon after average increase in the exophthalmos of that in the right eye. Gonioscopically no only 1.8 mm. The drug appears to be an details were visible below. The shredded iris
298
SOCIETY PROCEEDINGS
seemed to lie against the posterior corneal surface. At the sides, the scleral spur was seen, and the trabeculum revealed moderate pigmentation. In April, 1949, vision was: R.E., 20/250; L.E., 20/25. In December, 1949, the patient suddenly lost the vision of the right eye, associated with lightninglike flashes on two occasions. Vision had dropped to hand move ments at three feet. Tension was 19 mm. Hg (Schio'tz). An attempt was made to dilate the pupil, but because of poor dilatation plus marked lenticular opacity, the fundus could not be seen. The presumptive diagnosis of thrombosis of the central retinal vein was entertained. In January, 1950, tension was 37 mm. Hg (Schi^tz) in both eyes and has remained at this high level despite intensive miotic ther apy. At this time visual acuity of the right eye is light perception only (good projec tion), and in the left eye 20/20—3. The corneas reveal moderate guttate changes. The anterior chambers are shallow and the aqueous ray is negative. The right iris shows generalized atrophy. The anterior surface between the 2- and 8-o'clock posi tions is fragmented, some strands being free, but most attached to the sphincter or ciliary zone. These fragments are brown and re semble shredded wheat or seaweed. The underlying pigmented layer of the iris seems to be less involved. The left iris is also atrophic and many freckles are present. The anterior surface is frayed from about the 5- to 7-o'clock posi tion. The pupils are small. The lenses, especially the right, are quite opaque, obscuring observation of the fundi. Tension in both eyes is 39 mm. Hg. The right eye transilluminates well. Associated general findings are advanced arteriosclerosis and mild thyrotoxicosis. On February 9, 1950, a cyclodialysis followed by air injection was done on the left eye. This was complicated by a moderate an terior-chamber hemorrhage. Tactile tension
is normal. Tension in the right eye has re mained at 39 mm. Hg (Schi$?ftz). A lens extraction on the right eye is contemplated. Case 2. R. B., aged 81 years, came to the infirmary in October, 1946, for glasses. Corrected vision was: R.E., 20/40; L.E., 20/40—3. The iris of the left eye revealed an unusual and interesting discontinuity of the normal architecture from the 5- to 7o'clock positions. Under the slitlamp, the iris at this point had a shredded-wheat ap pearance with some strands floating in the anterior chamber. There were also asteroid bodies of the vitreous. In October, 1949, corrected vision was 20/40 in both eyes; tension, 24 mm. Hg (Schio'tz). In the left eye from the 5- to 7-o'clock positions and from the 11- to 12o'clock positions, the iris seemed to be ripped up peripherally and anterior stromal shreds were floating free in the anterior chamber, attached only near the sphincter. A similar process was starting at the 6-o'clock position in the right eye. The patient gave no history of uveitis or glaucoma. The discs revealed nasal displacement of vessels and pallor of the temporal aspect. Comment. Two more cases of iridoschisis are presented. One had the associated ocular findings of chronic glaucoma and cataracts. In the other case there were no associated ocular findings. In the 11 previously re ported cases," the findings were: Six had otherwise normal eyes or senile cataract; three had primary glaucoma; one had iridocyclitis; one had secondary glaucoma. Even though four out of a total of 13 cases had primary glaucoma, no relation be tween that and the disease could be found. Loewenstein and Foster suggested that the mechanism of the changes of iridoschisis is merely the exaggeration of the physiologic aging process of the iris, in which the middle layers become atrophic. Subsequently the two layers are separated, and finally the threads of the anterior layer which remain, rupture and float freely at one end.
SOCIETY PROCEEDINGS UVEOPAROTID FEVER: HEERFORDT'S DISEASE
DR. MAURICE D.
PEARLMAN presented
Mrs. H. K., a 54-year-old white woman, whose history stated that during the spring of 1948 generalized aching of muscles and joints developed and recurred periodically since that time. In midsummer, 1948, she developed swelling of the left parotid gland which lasted about two months and was diag nosed as mumps. Paralysis of the left facial region ensued and still remains. Soon after the parotitis began, first the left and then both eyes became reddened and teared excessively; there was no or little associated ocular pain. This persisted in spite of local and general therapy, but gradually subsided after about 12 months of steady visual deterioration to the level of light per ception only in each eye. Red-brownish circinate skin lesions ap peared on the right thigh about five months after the ocular symptoms started, and have remained to date. She was referred to the Beta Therapy Clinic for possible iradiation to the corneal vessels, but such treatment was deemed in advisable because of their inaccessible depth. Past history is irrelevant. She had eight siblings, three of whom died of tuberculosis and one of multiple sclerosis. Her husband is now hospitalized with a lung abscess. Examination of the right eye revealed light perception with good projection. The cornea showed epithelial edema and bullae, deep stratified stromal scarring with a mod erate amount of vascularization intermingled below, and a moderate number of old, large keratic precipitates. The anterior chamber was of average depth with a two-plus aqueous ray present. The aqueous cells could not be seen nor cer tainly excluded because of poor corneal lucency. The iris showed mild erasure of markings only, no nodules were noted. The lens and posterior segment details could not be viewed. A good red reflex was present.
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In the left eye, the vision was light per ception with faulty projection nasally and superiorly. The corneal involvement re sembled that of the other eye, but to a much greater degree and extent. The corneal scarring and vascularization obscured any proper view of the anterior or posterior segments. Laboratory studies disclosed a normal urinalysis, leukopenia of 2,750 cells per cu. mm., a disproportionate elevation of monocytes in the peripheral blood (10 percent), increased sedimentation rate of 39 mm. per hour. Blood serology for syphilis, comple ment fixation for gonorrhea, and agglutina tions for Brucella were all negative. Intracutaneous sensitivity tests were negative to brucellergin and first strength purified pro tein derivative, and 2-plus (10 by 10 mm. induration) to second strength purified pro tein derivative. Blood globulin level was 3.8 mg. percent. A / G ratio was 1.3-1. X-ray studies indicated minimal increase in pulmonary markings and evidence of old fibrotic scars in the bases, but no evidence of active infection. Biopsy of the skin lesion of the right thigh showed subcutaneous tuberclelike formations made up of epithelioid cells and giant cells; no caseation. These changes are considered consistent with sarcoidosis. Guinea-pig inoculation of the biopsy material produced no obvious change in .the animal after almost two months. Biopsy of the right iris (performed as an optical iridectomy) showed only non specific chronic inflammatory changes. This case conforms well to the usual fea tures of Heerfordt's disease—"a chronic parotitis and uveitis, associated with paresis of cranial nerves and other general symp toms, and having a tendency toward spon taneous resolution." The family background of tuberculosis also concurs with many other case reports suggesting some special rela tionship with tuberculosis, perhaps of atypical or modified form. Since this condi tion is probably a manifestation of sar-
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SOCIETY PROCEEDINGS
coidosis the problem of etiology resolves it self to the fundamental cause of sarcoid granulomas, which is unknown. The fact that the patient had only uni lateral parotitis and homolateral facial pa ralysis favors the opinion that the facial nerve was compromised locally in the gland substance, yet it is interesting to note that Duke-Elder insists that the cranial nerve in volvement is of central origin, and part of a generalized polyneuritis. The prevalence of keratitis in cases of ocular sarcoidosis, ac cording to the literature, is from 20 to 50 percent and, as in this case, is usually deep in character. The treatment results are dis couraging. Calciferol in large doses (100,000 units per day) is under trial. The sequelae in this case, corneal scarring, permitted only an optical iridectomy.
several spells of vomiting and ocular pain. The next morning, examination showed mild edema of the flap over the nasal suture, a flat anterior chamber, and fair red reflex. The following night she had severe pain in the eye with much nausea and vomiting. On the second postoperative morning, vision in the eye was reduced to poor light perception and faulty projection, and blood was ob served on the anterior surface of the vitreous. The next day, with clearing of the media, a large reddish-brown mass was seen, pro jecting from the temporal side completely across the pupillary space, meeting two smaller masses above and nasally. The ap pearance was similar to that of a marked combined choroidal detachment, except that the temporal mass completely dominated the picture and transillumination was nil. SUBCHOROIDAL HEMORRHAGE Diagnosis of a delayed subchoroidal hemorrhage was made, limited in extent by DR. JAMES E. MCDONALD presented a 63-year-old white woman, first seen at the the two corneoscleral sutures. Both pillars infirmary in November, 1949, with the com of the iris were seen to be shortened, but no plaint of painless and progressive loss of definite prolapse could be noted. vision in the left eye for 18 months. On On the seventh postoperative day, at the examination the right eye was normal, with suggestion of Dr. Peter C. Kronfeld, a 20/20 corrected vision, mild nuclear haze in scleral trephination was performed in the in the lens, and normal fundus. In the left eye, ferior temporal quadrant about seven mm. vision was limited to perception of hand behind the limbus. Dark-red blood and some movements at one foot, with good central fresh blood burst forth under considerable fixation, color perception, and light projec pressure, a total of about four cc. being tion. A large intumescent cataract was pres evacuated. The patient was immediately re ent. Tension measured 16 mm. Hg lieved of the low-grade headache which had (Schijzftz). The patient gave a history of been present during the preceding week. high blood pressure and two previous left- The collapsed globe was restored to normal sided strokes from which she had recovered. shape by injection of air anteriorly. Blood pressure on admission was 180/90. The postoperative course was uneventful Otherwise physical and laboratory findings and the patient was discharged with cor were normal. rected vision of 20/200. A white streak in On November 12, 1949, a left intracapsu- terpreted as a retinal fold could be made out lar cataract extraction with complete in the superior temporal area. Three months after operation, corrected iridectomy and two McLean corneoscleral sutures was performed without complica vision in the left eye was 20/100. Visual tions. The patient volunteered the informa fields were somewhat constricted especially tion that she could see the operator quite nasally, with a relative central scotoma. A clearly soon after delivery of the lens. Dur small knuckle of iris was seen in the area of ing the first postoperative night she had the shortened nasal pillar, which was well
SOCIETY PROCEEDINGS covered by flap. The cornea was thickened in its upper half. The anterior chamber was well formed, especially below. The media were more clear than previously but still contained some curtainlike opacities. The fundus was somewhat pale temporally and the retinal fold could be seen well in this area. The macular details were not well made out due to haze in the media. This patient is presented as another case of massive subchoroidal hemorrhage treated successfully by evacuation of blood, in this instance by trephination. The first such case was reported by Verhoeff in 1915, three more by Vail in 1938 and 1949, and one by Duehr and Hogensen in 1947. The present case represents the delayed type of sub choroidal hemorrhage, like Vail's first case, but without extrusion of vitreous. This might well be due to closure of the wound by corneoscleral sutures, as in the case re ported by Duehr and Hogensen. The differ entiation from simple choroidal detachment includes firm eye, more massive size, severe ocular pain, and absence of transillumination. If prolapse of the retina does not oc cur, removal of the blood is feasible and the eye may be saved from an otherwise hopeless prognosis. Richard C. Gamble, Secretary.
NEW YORK SOCIETY FOR CLINICAL OPHTHALMOLOGY February 6, 1950 DR. SIDNEY A. Fox, president SOME ASPECTS OF OCULAR THERAPY DR. ARTHUR LINKSZ discussed this topic during the instruction period. USE OF ETHER IN HERPETIC KERATITIS DR. BERNARD KRONENBERG said that in August, 1941, he reported on the use of
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ether in the treatment of herpetic keratitis in the Archives of Ophthalmology. Since that time, he has had ample opportunity to re-evaluate the method and confirm its suc cessful use. The discrepancy between his continued successful results with this treat ment and the number of unfavorable reports from reliable sources made Dr. Kronenberg feel that it would be wise to reexamine the reason for the success obtained in his series in contrast with the lack of success reported by others. With this in mind, Dr. Kronenberg sug gested to Dr. Fenn T. Ralph, resident at the New York Eye and Ear Infirmary, that he treat a series of 12 cases of herpetic keratitis following exactly the technique outlined. Dr. Kronenberg also included in this survey 10 cases from his private practice. As a result of this investigation and conversations with others who have used the technique, Dr. Kronenberg concluded that the technique must be followed faithfully if it is to be successful. The following method of application has proved effective. The patient's eye is anesthetized with pontocaine (0.5 percent) and the lesion is outlined with fluorescein. The patient's head is made comfortable in a headrest. Good illumination is necessary. An assistant holds the container of fresh ether; into this container a tightly woven small cotton applicator, previously prepared, is dipped. The excess is quickly shaken off and the lesion is rubbed with the still-wet ap plicator, removing the corneal epithelium of the lesion and a small amount of the epithe lium surrounding the lesion. The mere appli cation of ether to the lesion is not sufficient; it must be rubbed in. If one application is not sufficient because the ether may have evaporated, a fresh applicator is dipped into the ether and the rest of the lesion treated in a similar manner. Metaphen ophthalmic oint ment is then instilled and the eye bandaged. The eye must be examined 24 hours later. Again the cornea is stained with fluorescein. Any small particles of the lesions which may