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Contact Lenses for an Infant
NOTES, CASES, INSTRUMENTS allows the technician to watch the tonometric pulsations on both the meter and the recorder. If either instrument malfunctions the source of difficulty is readily apparent. As mentioned previously, a large interval between tonometer scale divisions is neces sary (fig. 2). The Speedomax G recorder has an interval of 15 to 17 mm. between each scale division. This desirable feature has been incorporated in the new recorder modification (Speedomax H ) , which has a scale interval of 14 mm., whereas the Muel ler Tonographer has intervals of only seven to eight mm. Demonstrative tonographic tracings taken from normal patients are shown in Figure 4, allowing comparison of the three recorders here discussed. For pur poses of direct comparison between the Speedomax H and the Mueller Tonographer (Esterline Angus), the second and third tracings were obtained from the same eye of the same patient. The amplifier of the modified Speedomax H includes a Zener diode constant voltage supply and automatic standardization which does not require an external voltage regu lator. The response time is one second for full scale compared to two seconds for full scale of the Mueller Tonographer. Several modifications have been made to adapt the Speedomax H for tonography. A
305
plug-in range card of 0.9689 mv. to 5.0 mv. matches the recorder with the output of the Mueller electric tonometer. Mechanical zeroright has been changed to the conventional zero-left and the chart speed has been in creased to 120 inches per hour exact, to equal that of the Speedomax G. A 500 ohm voltage divider across the circuit allows easy adjustment of the zero-set with that of the tonometer. Other additions include a chart tear-off strip with an indicator for scale reading four, a remote foot switch for acti vation of the chart motor, and a carrying handle which makes the recorder portable and enables it to be used with several to nometers. The total scale span of the modi fied Speedomax H is from tonometer-scale minus one to slightly over tonometer-scale 12, which encompasses the majority of tonograms seen clinically, and especially those with suspected or overt glaucoma. The modified Speedomax H is quiet and dependable. The moderate cost and other advantages of this instrument make it de sirable for use in clinical and research to nography. University of California at Los Angeles. ACKNOWLEDGMENT
I wish to thank Mr. Phillip Myers and Mr. Robert Irish for technical assistance.
REFERENCES
1. Ballintine, E. J. : Personal communication. 2. Roberts, W.: Clinical tonography with and without a recording galvanometer. Am. J. Ophth., 49:80, 1960.
CONTACT LENSES FOR AN I N F A N T AFTER BILATERAL CATARACT SURGERY J O H N R. CASSADY,
M.D.
South Bend, Indiana The surgery of congenital cataract has, generally, become quite successful in recent years. With such modern techniques as lin-
ear extraction, extracapsular lens extrac tion with or without iridectomy, or with the more recently publicized aspiration of cer tain congenital cataracts, such complications as secondary glaucoma, corneal opacifications and vitreous loss can generally be avoided and a good anatomic result can be obtained, in most instances, by the experi enced operator.
306
NOTES, CASES, INSTRUMENTS
Unfortunately, the adequate pupillary opening in an eye with normal intraocular pressure, a clear cornea and a normal-ap pearing retina does not always assure good vision. There is frequently nystagmus asso ciated with congenital cataract and persist ing after surgery to reduce markedly the visual result. In the infant with unilateral congenital cataract, the removal of the cata ract barely prevents the development of amblyopia. It is probable that subnormal vision results in these successfully operated con genital cataract patients because of failure to provide them with an optical correction for their aphakia during a critical period in their visual development. It would seem logical that the utilization of contact lenses shortly after surgery at an early age would permit the more complete rehabilitation of individuals with dense cata racts present at birth. It was with this idea in mind that an at tempt was made to fit a 14-month-old in fant with corneal contact lenses following cataract surgery. Little information was available on the subject, so a technique was devised for my patient combining some features of methods used in two previous re ports : Sato and Saito1 reported the fitting of two infants with contact lenses for aphakia in 1959; in their cases the infants wore the lenses continuously and were fitted with trial lenses while under general anesthesia. In 1961, Girard2 mentioned the fitting of some infants with corneal contact lenses and de termined the fit with keratometric readings taken without the use of general anesthesia. The lenses were inserted and removed by the parent. The lens specifications for my patient were determined by the use of the keratometer while the patient was under general anesthe sia. The lenses were inserted and removed by the parents. The patient was wearing the lenses all day within 10 days with no ap parent difficulty to date.
C A S E REPORT
The patient, a three-month-old white boy with congenital cataracts, was seen August 31, 1961. The father had had surgery for bilateral congenital cataracts when he was six years of age. The pa tient's pupils dilated poorly with atropine. The lenses were milky white, having the appearance of mature cortical cataracts. On November 29, 1961, when the child was six months of age, an extracapsular cataract extraction with full iridectomy was per formed under general anesthesia, using three preplaced 6-0 catgut corneo-scleral sutures. This sur gery was without incident and left a clear pupillary area. On February 7, 1962, when the child was eight months of age, an identical procedure was performed on the other eye without complication, leaving a clear pupillary area and a good view of a normal-appearing fundus. From the time of the first examination, the child had demonstrated a slow, searching-type horizontal nystagmus which persisted after the lens extraction. On August 20, with the patient under general anes thesia, keratometer readings were obtained. The patient was anesthetized and then held in the keratometer with his eye directed in the straightahead position and his lid elevated. Several readings were taken on each eye. These were slightly difficult to obtain because of the tendency for the cornea to dry off and because of the awkwardness of holding the patient securely in the keratometer. The keratometer readings were averaged and the base-curve of the lenses ordered from these read ings. The lenses were made 9.2 mm. in size and had an arbitrary power of +14.SD. in each lens. They were made in lenticular form. An attempt was made to confirm the keratometer readings by the use of trial lenses while the patient was under anesthesia but this was not particularly helpful be cause of the lack of normal tearing while under anesthesia. On September 7, when the child was 14 months of age, the lenses were inserted for the first time. The child was restrained and, with the use of topical anesthesia, a lens was inserted in each eye. He wore the lenses for four hours in the office with out difficulty. Surprisingly enough he made no at tempt to touch his eyes and showed no symptoms of discomfort or irritation. It was most gratifying to see a sudden arrest of the nystagmus and the onset of steady central fixation shortly after the lenses were inserted. He showed an alternating exotropia with or without the contact lenses but the nystagmus was eliminated with the lenses in place. The parents were instructed on how to insert and remove the lenses. It was necessary for them to restrain the child in a sheet to remove and insert them ; however, once the lenses were in place on the cornea, there was no apparent irritation and within two weeks the patient was wearing the lenses all day without difficulty. The parents were instructed to bring the patient in immediately if there was any exudate or inflammation and were given Neosporin ophthalmic ointment to use at bedtime if
NOTES, CASES, INSTRUMENTS there was any sign of irritation prior to bringing the patient in. The child has been wearing the lenses for three months without difficulty and with marked improvement in his nystagmus and, presumably, in his vision. COMMENT
Although it is dangerous to draw any con clusions from a single case, the ease with which an apparently adequate set of lenses was selected, the apparent visual improve ment immediately produced, as evidenced by the arrest of the nystagmus, the lack of dif ficulty which the parents experience on in serting and removing lenses and the ab
307
sence of irritation to the patient, all have been most encouraging. I am anxious to attempt this same method on other infants as the occasion arises and would hope that others would be encour aged to attempt to use contact lenses on in fants for whom there is such a definite op tical indication. A development of a satisfactory technique would permit the rehabilitation of many eyes which are otherwise optically badly handi capped in later life due to inability to cor rect, at an early critical age, high anisometropia and unilateral or bilateral aphakia. 105 East Jefferson Boulevard (1).
REFERENCES
1. Sato, T., and Saito, N.: Contact lenses for babies and children. Contacto, 3:419-424 (Dec), 1959. 2. Girard, L.: Personal interview: Corneal contact lenses. Highlights of Ophthal., 4:228-241, 1961.
cance at this time was a faint dotlike opacity of the central area of the posterior subcapsular zone in both lenses. The tension with a Schi^tz tonom eter was 18 mm. Hg in each eye. With a —0.75D. cyl. ax. 165°, the vision, R.E., was 20/30 ; L.E. could R E P O R T OF A CASE AT T H E AGE O F FORTY not be corrected. The diagnostic impression at this time was early bilateral complicated cataracts. Since YEARS I N A M A N UNDER PROLONGED STEROID there was a possibility of a very low-grade cyclitic THERAPY FOR M A R I E - S T R Ü M P E L L DISEASE process, Cortone ophthalmic solution was pre scribed. C. V. CRANE, M.D. The patient was seen one week later and there St. Petersburg, Florida were no objective changes. The corrected vision at this time with a —1.0D. cyl. ax. 180° was The patient to be reported had been under 20/20-2, R.E.; with a -0.5D. cyl. ax. 30° 20/20, corticosteroid medication for approximately L.E. When seen one week later, the corrected vision was the same; however, at this time, on seven years when he was first seen. transillumination, there was a very definite central posterior cortical and subcapsular lens opacity in C A S E REPORT each eye, more dense in the right eye than in the Mr. T. S. was first seen on April 20, 1959. At left. The patient was next seen on November 2, 1960, that time he complained of blurred vision in both at which time there was a dense large central pos eyes of one week's duration. He gave a history of having had an attack of iritis in the right eye four terior cortical and subcapsular opacity in each lens, years earlier which lasted about two weeks. This more dense in the right eye. The corrected vision was not confirmed by the record or by the objective in the right eye with a —2.0D. cyl. ax. 180° was findings. The visual acuity in the right eye was 20/50—1 ; in the left eye with a —0.5D. cyl. ax. 30° 20/40, J l at 7.5 inches; in the left eye 20/30, Jl the vision was 20/30 with difficulty. When seen on at 8.0 inches. The only findings of clinical signifi- February 15, 1961, there was very little objective change and the corrected vision in the right eye * From the Veterans Administration Regional Of was 20/30 and in the left eye 20/30. When seen on November 7, 1962, the patient fice.
POSTERIOR SUBCAPSULAR CATARACTS*
305
plug-in range card of 0.9689 mv. to 5.0 mv. matches the recorder with the output of the Mueller electric tonometer. Mechanical zeroright has been changed to the conventional zero-left and the chart speed has been in creased to 120 inches per hour exact, to equal that of the Speedomax G. A 500 ohm voltage divider across the circuit allows easy adjustment of the zero-set with that of the tonometer. Other additions include a chart tear-off strip with an indicator for scale reading four, a remote foot switch for acti vation of the chart motor, and a carrying handle which makes the recorder portable and enables it to be used with several to nometers. The total scale span of the modi fied Speedomax H is from tonometer-scale minus one to slightly over tonometer-scale 12, which encompasses the majority of tonograms seen clinically, and especially those with suspected or overt glaucoma. The modified Speedomax H is quiet and dependable. The moderate cost and other advantages of this instrument make it de sirable for use in clinical and research to nography. University of California at Los Angeles. ACKNOWLEDGMENT
I wish to thank Mr. Phillip Myers and Mr. Robert Irish for technical assistance.
REFERENCES
1. Ballintine, E. J. : Personal communication. 2. Roberts, W.: Clinical tonography with and without a recording galvanometer. Am. J. Ophth., 49:80, 1960.
CONTACT LENSES FOR AN I N F A N T AFTER BILATERAL CATARACT SURGERY J O H N R. CASSADY,
M.D.
South Bend, Indiana The surgery of congenital cataract has, generally, become quite successful in recent years. With such modern techniques as lin-
ear extraction, extracapsular lens extrac tion with or without iridectomy, or with the more recently publicized aspiration of cer tain congenital cataracts, such complications as secondary glaucoma, corneal opacifications and vitreous loss can generally be avoided and a good anatomic result can be obtained, in most instances, by the experi enced operator.
306
NOTES, CASES, INSTRUMENTS
Unfortunately, the adequate pupillary opening in an eye with normal intraocular pressure, a clear cornea and a normal-ap pearing retina does not always assure good vision. There is frequently nystagmus asso ciated with congenital cataract and persist ing after surgery to reduce markedly the visual result. In the infant with unilateral congenital cataract, the removal of the cata ract barely prevents the development of amblyopia. It is probable that subnormal vision results in these successfully operated con genital cataract patients because of failure to provide them with an optical correction for their aphakia during a critical period in their visual development. It would seem logical that the utilization of contact lenses shortly after surgery at an early age would permit the more complete rehabilitation of individuals with dense cata racts present at birth. It was with this idea in mind that an at tempt was made to fit a 14-month-old in fant with corneal contact lenses following cataract surgery. Little information was available on the subject, so a technique was devised for my patient combining some features of methods used in two previous re ports : Sato and Saito1 reported the fitting of two infants with contact lenses for aphakia in 1959; in their cases the infants wore the lenses continuously and were fitted with trial lenses while under general anesthesia. In 1961, Girard2 mentioned the fitting of some infants with corneal contact lenses and de termined the fit with keratometric readings taken without the use of general anesthesia. The lenses were inserted and removed by the parent. The lens specifications for my patient were determined by the use of the keratometer while the patient was under general anesthe sia. The lenses were inserted and removed by the parents. The patient was wearing the lenses all day within 10 days with no ap parent difficulty to date.
C A S E REPORT
The patient, a three-month-old white boy with congenital cataracts, was seen August 31, 1961. The father had had surgery for bilateral congenital cataracts when he was six years of age. The pa tient's pupils dilated poorly with atropine. The lenses were milky white, having the appearance of mature cortical cataracts. On November 29, 1961, when the child was six months of age, an extracapsular cataract extraction with full iridectomy was per formed under general anesthesia, using three preplaced 6-0 catgut corneo-scleral sutures. This sur gery was without incident and left a clear pupillary area. On February 7, 1962, when the child was eight months of age, an identical procedure was performed on the other eye without complication, leaving a clear pupillary area and a good view of a normal-appearing fundus. From the time of the first examination, the child had demonstrated a slow, searching-type horizontal nystagmus which persisted after the lens extraction. On August 20, with the patient under general anes thesia, keratometer readings were obtained. The patient was anesthetized and then held in the keratometer with his eye directed in the straightahead position and his lid elevated. Several readings were taken on each eye. These were slightly difficult to obtain because of the tendency for the cornea to dry off and because of the awkwardness of holding the patient securely in the keratometer. The keratometer readings were averaged and the base-curve of the lenses ordered from these read ings. The lenses were made 9.2 mm. in size and had an arbitrary power of +14.SD. in each lens. They were made in lenticular form. An attempt was made to confirm the keratometer readings by the use of trial lenses while the patient was under anesthesia but this was not particularly helpful be cause of the lack of normal tearing while under anesthesia. On September 7, when the child was 14 months of age, the lenses were inserted for the first time. The child was restrained and, with the use of topical anesthesia, a lens was inserted in each eye. He wore the lenses for four hours in the office with out difficulty. Surprisingly enough he made no at tempt to touch his eyes and showed no symptoms of discomfort or irritation. It was most gratifying to see a sudden arrest of the nystagmus and the onset of steady central fixation shortly after the lenses were inserted. He showed an alternating exotropia with or without the contact lenses but the nystagmus was eliminated with the lenses in place. The parents were instructed on how to insert and remove the lenses. It was necessary for them to restrain the child in a sheet to remove and insert them ; however, once the lenses were in place on the cornea, there was no apparent irritation and within two weeks the patient was wearing the lenses all day without difficulty. The parents were instructed to bring the patient in immediately if there was any exudate or inflammation and were given Neosporin ophthalmic ointment to use at bedtime if
NOTES, CASES, INSTRUMENTS there was any sign of irritation prior to bringing the patient in. The child has been wearing the lenses for three months without difficulty and with marked improvement in his nystagmus and, presumably, in his vision. COMMENT
Although it is dangerous to draw any con clusions from a single case, the ease with which an apparently adequate set of lenses was selected, the apparent visual improve ment immediately produced, as evidenced by the arrest of the nystagmus, the lack of dif ficulty which the parents experience on in serting and removing lenses and the ab
307
sence of irritation to the patient, all have been most encouraging. I am anxious to attempt this same method on other infants as the occasion arises and would hope that others would be encour aged to attempt to use contact lenses on in fants for whom there is such a definite op tical indication. A development of a satisfactory technique would permit the rehabilitation of many eyes which are otherwise optically badly handi capped in later life due to inability to cor rect, at an early critical age, high anisometropia and unilateral or bilateral aphakia. 105 East Jefferson Boulevard (1).
REFERENCES
1. Sato, T., and Saito, N.: Contact lenses for babies and children. Contacto, 3:419-424 (Dec), 1959. 2. Girard, L.: Personal interview: Corneal contact lenses. Highlights of Ophthal., 4:228-241, 1961.
cance at this time was a faint dotlike opacity of the central area of the posterior subcapsular zone in both lenses. The tension with a Schi^tz tonom eter was 18 mm. Hg in each eye. With a —0.75D. cyl. ax. 165°, the vision, R.E., was 20/30 ; L.E. could R E P O R T OF A CASE AT T H E AGE O F FORTY not be corrected. The diagnostic impression at this time was early bilateral complicated cataracts. Since YEARS I N A M A N UNDER PROLONGED STEROID there was a possibility of a very low-grade cyclitic THERAPY FOR M A R I E - S T R Ü M P E L L DISEASE process, Cortone ophthalmic solution was pre scribed. C. V. CRANE, M.D. The patient was seen one week later and there St. Petersburg, Florida were no objective changes. The corrected vision at this time with a —1.0D. cyl. ax. 180° was The patient to be reported had been under 20/20-2, R.E.; with a -0.5D. cyl. ax. 30° 20/20, corticosteroid medication for approximately L.E. When seen one week later, the corrected vision was the same; however, at this time, on seven years when he was first seen. transillumination, there was a very definite central posterior cortical and subcapsular lens opacity in C A S E REPORT each eye, more dense in the right eye than in the Mr. T. S. was first seen on April 20, 1959. At left. The patient was next seen on November 2, 1960, that time he complained of blurred vision in both at which time there was a dense large central pos eyes of one week's duration. He gave a history of having had an attack of iritis in the right eye four terior cortical and subcapsular opacity in each lens, years earlier which lasted about two weeks. This more dense in the right eye. The corrected vision was not confirmed by the record or by the objective in the right eye with a —2.0D. cyl. ax. 180° was findings. The visual acuity in the right eye was 20/50—1 ; in the left eye with a —0.5D. cyl. ax. 30° 20/40, J l at 7.5 inches; in the left eye 20/30, Jl the vision was 20/30 with difficulty. When seen on at 8.0 inches. The only findings of clinical signifi- February 15, 1961, there was very little objective change and the corrected vision in the right eye * From the Veterans Administration Regional Of was 20/30 and in the left eye 20/30. When seen on November 7, 1962, the patient fice.
POSTERIOR SUBCAPSULAR CATARACTS*