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Diabetes Mellitus with Relative Hyperopia
NOTES, CASES, INSTRUMENTS DeSchweinitz3 mentioned that myopia was commonly seen in diabetes after the age of 40 years but mentioned eight cases on record in which a transitory increase in hyperopia was observed.
DIABETES MELLITUS W I T H RELATIVE HYPEROPIA A
CASE REPORT
MORRIS ROSEN,
M.D.
Philadelphia, Pennsylvania
That diabetes can affect the eye is well known. One of the poorly understood effects is on the refraction of the eye. Duke-Elder 1 reports that he investigated 43 references on the subject and myopia followed a rise in the blood sugar with a rare tendency to hyperopia. After discarding such explanations as change in the size of the eyeball, change in refractive index of the eye media, and change in accommodation, he cites a case of Elschnig's in which a patient with unilateral aphakia showed changes in refraction only in the phakic eye when the blood sugar changed. This indicated that, in this case at least, the lens was the site of the change in refraction. Duke-Elder suggested that, because of the diuresis and loss of solids in the urine asso ciated with an elevation in the blood sugar, the osmotic pressure of the aqueous de creased, causing imbibition of fluid by the lens cortex. By consequent increase in the curvature of the lens, myopia is encouraged. By decreasing the density of the cortex in relation to the nucleus of the lens, which does not partake in the absorption of fluid because of its sclerosis, the change at the zone of discontinuity between the two parts of the lens is greater and a ray of light passing through the lens will be deviated to a greater degree. This also tends to result in myopia. Walsh 2 found that 21 percent of diabetics showed accommodative weakness. DukeElder states that accommodative changes are not important because most of the refractive changes in diabetes occur after the age of 40 years, when accommodation is decreasing, that atropine does not affect the refraction, and that astigmatic changes are common.
CASE REPORT
This is a brief report of one of the unusual results of diabetes, a relative hyperopia fol lowing an increase in blood sugar. The pa tient, a 42-year-old white man, had been myopic since childhood. He had had a coro nary occlusion for which he had been hospi talized about two years before he consulted me. At that time, no diabetes was discovered. His glasses were about five years old and were satisfactory until a week or two before his first visit when he noted that his distant vision was poor. He was taking 14 units of insulin daily and his blood sugar (four days ago) was 150 mm. per cc. The vision was: O.D., 6/60 corrected to 6/60 with a -5.25D. sph. C - 0 . 5 D . cyl. ax. 140° ; O.S., 6/60 corrected to 6 / 6 0 + 1 with a - 5 . 5 D . sph. C - 0 . 5 D . cyl. ax. 90°. On be ing refracted, he was found to take O.D. : - 3 . 0 D . sph. C - 0 . 5 D . cyl. ax. 180° = 6/5 ; O.S., - 3 . 0 D . sph. C - 0 . 5 D . cyl. ax. 45° = 6/5. Despite the fact that he understood that change in blood sugar would affect his re fraction, he insisted on getting the new cor rection because part of his duties was driving a truck and his vision with his present glasses was too poor for safety. He promised to co-operate with his family doctor in re ducing his blood sugar. His next visit was six months later, at which time he stated that his blood sugar was now normal and that he did not see well with his new glasses. A check showed that he had 6/21 vision in each eye with his new glasses, whereas he saw 6/6 or better with each eye with his old glasses.
680
NOTES, CASES, INSTRUMENTS DISCUSSION
If we agree that the seat of the refractive change in diabetes is in the lens, one explana tion for the occasional hyperopic result with rise in the blood sugar may be that the nu cleus engages in hydration as well as the cortex of the lens in these cases. This would make the entire lens more uniform in density and there would be less refraction of a ray of light at the zone of discontinuity between and cortex and the nucleus. Another explanation may be that the hy-
681
peropic changes may be due to the accommo dative weakness which Walsh stated oc curred in 21 percent of diabetics. While ac commodation decreases with age, at 40 years a person would expect to have about 4.5 diopters of accommodation to be decreased by accommodative weakness, causing a hy peropic change. These changes are not the usual conditions one finds in diabetes, and therefore myopia occurs much more fre quently than hyperopia. 744 Ritner Street
(48).
REFERENCES
1. Duke-Elder, W. S. : Textbook of Ophthalmology. St. Louis, Mosby. v. 4, 1950, p. 4364. 2. Walsh, F. B. : Clinical Neuro-Ophthalmology. Baltimore, Williams & Wilkins, 1948, p. 835. 3. deSchweinitz, G. E. : Diseases of the Eye. Philadelphia, Saunders, 1913 ed. 7, p. 166.
FORCEPS FOR CORNEOSCLERAL SUTURES* ANTHONY AMBROSE,
M.D.
Newark, New Jersey
This new forceps (fig. 1) is designed for inserting the corneal side of the postplaced corneoscleral suture. The lower blade is smooth and without teeth. The upper blade has an U-shaped tip, each arm being one-mm. wide and the open space one-mm. wide. Under each arm is a single sharp tooth which fixes the corneal lip. Since the under blade is smooth, the corneal endothelium is not subjected to trauma. This solid blade flattens out the cornea and the needle is passed through easily without the cornea buckling up.
Fig. 1 (Ambrose). Forceps for corneoscleral sutures. * Made by the Storz Instrument Company, Saint Louis, Missouri.
My technique is as follows : Leaving the needle in place, the forceps is handed to my assistant who is ready with a Castroviejo forceps or other commonly used bipronged instrument. With this I grasp the scierai edge of the wound through which I pass the needle without first pulling it en tirely out of the cornea. 15 Washington Street (2)
A DEVICE FOR OBTAINING A D E Q U A T E AIRWAY I N E Y E SURGERY* MAX M. KULVIN,
M.D.t
Miami, Florida
The problem of proper ventilation for the patient during surgery seems to have been given very little thought in the eagerness of the surgeon to carry out a meticulous and carefully planned surgical technique. Recent ly, one of our operating room nurses picked up a wire basket, the kind used in labora* From the Veterans Administration Hospital, Coral Gables, Florida. t Chief, Ophthalmology and Otolaryngology Sec tion.
DIABETES MELLITUS W I T H RELATIVE HYPEROPIA A
CASE REPORT
MORRIS ROSEN,
M.D.
Philadelphia, Pennsylvania
That diabetes can affect the eye is well known. One of the poorly understood effects is on the refraction of the eye. Duke-Elder 1 reports that he investigated 43 references on the subject and myopia followed a rise in the blood sugar with a rare tendency to hyperopia. After discarding such explanations as change in the size of the eyeball, change in refractive index of the eye media, and change in accommodation, he cites a case of Elschnig's in which a patient with unilateral aphakia showed changes in refraction only in the phakic eye when the blood sugar changed. This indicated that, in this case at least, the lens was the site of the change in refraction. Duke-Elder suggested that, because of the diuresis and loss of solids in the urine asso ciated with an elevation in the blood sugar, the osmotic pressure of the aqueous de creased, causing imbibition of fluid by the lens cortex. By consequent increase in the curvature of the lens, myopia is encouraged. By decreasing the density of the cortex in relation to the nucleus of the lens, which does not partake in the absorption of fluid because of its sclerosis, the change at the zone of discontinuity between the two parts of the lens is greater and a ray of light passing through the lens will be deviated to a greater degree. This also tends to result in myopia. Walsh 2 found that 21 percent of diabetics showed accommodative weakness. DukeElder states that accommodative changes are not important because most of the refractive changes in diabetes occur after the age of 40 years, when accommodation is decreasing, that atropine does not affect the refraction, and that astigmatic changes are common.
CASE REPORT
This is a brief report of one of the unusual results of diabetes, a relative hyperopia fol lowing an increase in blood sugar. The pa tient, a 42-year-old white man, had been myopic since childhood. He had had a coro nary occlusion for which he had been hospi talized about two years before he consulted me. At that time, no diabetes was discovered. His glasses were about five years old and were satisfactory until a week or two before his first visit when he noted that his distant vision was poor. He was taking 14 units of insulin daily and his blood sugar (four days ago) was 150 mm. per cc. The vision was: O.D., 6/60 corrected to 6/60 with a -5.25D. sph. C - 0 . 5 D . cyl. ax. 140° ; O.S., 6/60 corrected to 6 / 6 0 + 1 with a - 5 . 5 D . sph. C - 0 . 5 D . cyl. ax. 90°. On be ing refracted, he was found to take O.D. : - 3 . 0 D . sph. C - 0 . 5 D . cyl. ax. 180° = 6/5 ; O.S., - 3 . 0 D . sph. C - 0 . 5 D . cyl. ax. 45° = 6/5. Despite the fact that he understood that change in blood sugar would affect his re fraction, he insisted on getting the new cor rection because part of his duties was driving a truck and his vision with his present glasses was too poor for safety. He promised to co-operate with his family doctor in re ducing his blood sugar. His next visit was six months later, at which time he stated that his blood sugar was now normal and that he did not see well with his new glasses. A check showed that he had 6/21 vision in each eye with his new glasses, whereas he saw 6/6 or better with each eye with his old glasses.
680
NOTES, CASES, INSTRUMENTS DISCUSSION
If we agree that the seat of the refractive change in diabetes is in the lens, one explana tion for the occasional hyperopic result with rise in the blood sugar may be that the nu cleus engages in hydration as well as the cortex of the lens in these cases. This would make the entire lens more uniform in density and there would be less refraction of a ray of light at the zone of discontinuity between and cortex and the nucleus. Another explanation may be that the hy-
681
peropic changes may be due to the accommo dative weakness which Walsh stated oc curred in 21 percent of diabetics. While ac commodation decreases with age, at 40 years a person would expect to have about 4.5 diopters of accommodation to be decreased by accommodative weakness, causing a hy peropic change. These changes are not the usual conditions one finds in diabetes, and therefore myopia occurs much more fre quently than hyperopia. 744 Ritner Street
(48).
REFERENCES
1. Duke-Elder, W. S. : Textbook of Ophthalmology. St. Louis, Mosby. v. 4, 1950, p. 4364. 2. Walsh, F. B. : Clinical Neuro-Ophthalmology. Baltimore, Williams & Wilkins, 1948, p. 835. 3. deSchweinitz, G. E. : Diseases of the Eye. Philadelphia, Saunders, 1913 ed. 7, p. 166.
FORCEPS FOR CORNEOSCLERAL SUTURES* ANTHONY AMBROSE,
M.D.
Newark, New Jersey
This new forceps (fig. 1) is designed for inserting the corneal side of the postplaced corneoscleral suture. The lower blade is smooth and without teeth. The upper blade has an U-shaped tip, each arm being one-mm. wide and the open space one-mm. wide. Under each arm is a single sharp tooth which fixes the corneal lip. Since the under blade is smooth, the corneal endothelium is not subjected to trauma. This solid blade flattens out the cornea and the needle is passed through easily without the cornea buckling up.
Fig. 1 (Ambrose). Forceps for corneoscleral sutures. * Made by the Storz Instrument Company, Saint Louis, Missouri.
My technique is as follows : Leaving the needle in place, the forceps is handed to my assistant who is ready with a Castroviejo forceps or other commonly used bipronged instrument. With this I grasp the scierai edge of the wound through which I pass the needle without first pulling it en tirely out of the cornea. 15 Washington Street (2)
A DEVICE FOR OBTAINING A D E Q U A T E AIRWAY I N E Y E SURGERY* MAX M. KULVIN,
M.D.t
Miami, Florida
The problem of proper ventilation for the patient during surgery seems to have been given very little thought in the eagerness of the surgeon to carry out a meticulous and carefully planned surgical technique. Recent ly, one of our operating room nurses picked up a wire basket, the kind used in labora* From the Veterans Administration Hospital, Coral Gables, Florida. t Chief, Ophthalmology and Otolaryngology Sec tion.