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Diplopia with Lens Opacity
NOTES, CASES AND INSTRUMENTS LOCATION OF EXCAVATION.
The point at which the excavation most nearly approaches the margin of the disc is to be recorded in terms of axes (American Astigmatic Axis Notation). Examples of records employing this method of notation would be as follows: METHODS OF U S E .
Ex. II-B would indicate a moderately deep centrally located excavation 'with sloping sides but not overhanging, occu pying more than one-third of the area of the entire disc. Ex. III-D-30 would indicate a deep excavation with the tips of the Lamina Cribrosa visible, an excavation with one side overhanging and the remainder slop ing, located excentrically and approach ing the disc most nearly at axis 30. (In the left eye, for example, this would mean 30 degrees above the external hori zontal meridian). V O L U N T A R Y U N I L A T E R A L NY STAGMUS. JAMES
MOORES BALL,
M.D.
ST. LOUIS, MO.
The following brief account of a rare condition is submitted for publi cation for the purpose of securing priority. So far as the writer knows, only one like case (that of Pyle) has been recorded. J. L., male, aged 21 years, consulted me on March 15, 1921, complaining of headache over the left eye—a symptom which had been present for six months. H e also is troubled with after images. The globes, adnexae, and pupillary reactions are normal. Stevenson's muscle test shows insufficiency of convergence varying from 1° to 14°. Kagenaar's ophthalmometer shows as tigmatism with the rule: 0.75 D. in the right eye; 1 D. in the left. Vision in the right eye = 20/20; in left eye, 20/20. At this point in the examina tion the patient mentioned his ability to produce nystagmus at will, and at once gave a demonstration, as fol lows :— Seated at one meter, fixing with his right eye, Mr. L., at will, could move
673
his left eye inward and outward for about 2 millimetres from the vertical line. Meanwhile the right eye re mained immobile. Under cycloplegia (atropin) vision w a s : R. E . = 2 0 / 5 0 ; L. E.=20/40. R. E. with + . 5 0 + .50 axis 9 0 ° = 20/13. L. E. with + . 7 5 axis 90°=20/13. A Wassermann test was negative. The writer expects to make a full report of this case at a later date. Pyle: Jour. Am. Med. Assn., Dec. 5, 1908.
DIPLOPIA W I T H L E N S OPACITY EDWARD JACKSON,
M.D.
DENVER, COLO.
Mr. F., aged 59, lost useful sight of the right eye from being struck by an automobile, 8 years ago. The loss was noticed when he regained con sciousness 26 days after the injury. The upper two-thirds of the optic disc is atrophic; but some vision remains in the nasal periphery of the field. The left eye has corrected vision of 1.1 and a full field; but it has been
Fig. 1.—Diagram of pupil showing spicule of opacity of lens, and clotted lines to indicate axes of convex correcting cylinders in parts of the pupil above and below the opacities.
failing in the last year. The chief com plaint is of diplopia, a bright image seen above, and a fainter image below to the left. These images have slowly become more widely separated. The ophthalmoscope shows a single definite spicule of lens opacity situated in the anterior cortex, extending from "two o'clock" toward "nine o'clock," as shown in Fig. 1. Otherwise the media are clear. In both eyes the vessels are irregularly constricted and the veins "kinked" where they cross the arteries. Skiascopy shows entirely different refraction in the areas above and below
674
NOTES, CASES AND INSTRUMENTS
the spicule of opacity. Both are hyper- Circumscribed ectasia is an appanage opic; but the upper one seems to need of old age, rarely occurring before 60 a plus cyl. ax. 30°, and is irregular. years; this patient was 72 years. It is The lower one is more regular and of very slow development, transparent, seems to require a plus O. 75 cyl. ax. and usually accompanied by very high 130°, which gives the eye its best dis astigmatism, 7 to 13 diopters with tant vision. The separation of the myopia, which accounts for the poor images is about as great as would be vision following it. produced by a 4° prism. This patient has always done very On bringing a card before the eye fine needlework with the aid of a minus so that it covered the upper area, the 4 diopter lens. She consulted me be lower and fainter image disappeared. cause her vision was reduced to count On bringing the card from below so ing fingers at three feet. Besides not that it covered the lower area of the ing the ectasia, I found an almost com pupil, the upper and brighter im plete opacification of the lens, the an age disappeared. The ophthalmometer terior chamber very deep, the iris fun showed no corresponding defect or nel shaped, the tension and the light perception normal. The ectasia occu flattening of the cornea. pies the upper margin of the cornea It was concluded that the diplopia for about 3 mm. and is opaque, the rest was due to a slight relative flattening of the cornea is clear. The opacity is of the anterior surface of the crystal concentric with the limbus, from which line lens, along the line of the spicule it is separated by a narrow strip of of opacity; that this flattening had transparent cornea. been increasing. T h a t this indicated Fuchs believes that ectasia is a de a condition of shrinking rather than swelling in the region of the opacity. generative process intimately related And that this shrinking in conjunction to an exaggerated development of the with the definite boundaries of the arcus senilis; while Terrien believes in opacity and absence of haze in other the theory of dystrophy; and Lauber parts of the lens, indicated that the thinks it due to an inflammatory lens opacity was likely not to increase. cause. I advised removing the lens, since her previous vision had been so good. CIRCUMSCRIBED ECTASIA OF The poor vision that usually accom panies ectasia of the cornea, constitut T H E CORNEA. ing its principal symptom, tho present G; N. BRAZEAU, M.D., F.A.C.S. now, is not due to any corneal irregu larity but rather to the defective condi MILWAUKEE, WIS. tion of the lens. Had the poor vision It is not unusual for thinning of the existing been due to any great amount cornea, from either traumatic or in of astigmatism the removal of the lens fectious inflammatory causes, to end would again complicate the situation in a keratocele, but in cases such as by adding to the already existing this one the cause remains unknown. astigmatism, that, incident to a corneal In this latter variety, the ectasia is section. more or less symmetrically developed The usual treatment of ectasia of in both eyes, tho its bilaterality could the cornea consists in correcting all not be determined here as the right the errors of refraction as well as pos eye had been removed many years ago. sible. At best, the vision remains low.
The point at which the excavation most nearly approaches the margin of the disc is to be recorded in terms of axes (American Astigmatic Axis Notation). Examples of records employing this method of notation would be as follows: METHODS OF U S E .
Ex. II-B would indicate a moderately deep centrally located excavation 'with sloping sides but not overhanging, occu pying more than one-third of the area of the entire disc. Ex. III-D-30 would indicate a deep excavation with the tips of the Lamina Cribrosa visible, an excavation with one side overhanging and the remainder slop ing, located excentrically and approach ing the disc most nearly at axis 30. (In the left eye, for example, this would mean 30 degrees above the external hori zontal meridian). V O L U N T A R Y U N I L A T E R A L NY STAGMUS. JAMES
MOORES BALL,
M.D.
ST. LOUIS, MO.
The following brief account of a rare condition is submitted for publi cation for the purpose of securing priority. So far as the writer knows, only one like case (that of Pyle) has been recorded. J. L., male, aged 21 years, consulted me on March 15, 1921, complaining of headache over the left eye—a symptom which had been present for six months. H e also is troubled with after images. The globes, adnexae, and pupillary reactions are normal. Stevenson's muscle test shows insufficiency of convergence varying from 1° to 14°. Kagenaar's ophthalmometer shows as tigmatism with the rule: 0.75 D. in the right eye; 1 D. in the left. Vision in the right eye = 20/20; in left eye, 20/20. At this point in the examina tion the patient mentioned his ability to produce nystagmus at will, and at once gave a demonstration, as fol lows :— Seated at one meter, fixing with his right eye, Mr. L., at will, could move
673
his left eye inward and outward for about 2 millimetres from the vertical line. Meanwhile the right eye re mained immobile. Under cycloplegia (atropin) vision w a s : R. E . = 2 0 / 5 0 ; L. E.=20/40. R. E. with + . 5 0 + .50 axis 9 0 ° = 20/13. L. E. with + . 7 5 axis 90°=20/13. A Wassermann test was negative. The writer expects to make a full report of this case at a later date. Pyle: Jour. Am. Med. Assn., Dec. 5, 1908.
DIPLOPIA W I T H L E N S OPACITY EDWARD JACKSON,
M.D.
DENVER, COLO.
Mr. F., aged 59, lost useful sight of the right eye from being struck by an automobile, 8 years ago. The loss was noticed when he regained con sciousness 26 days after the injury. The upper two-thirds of the optic disc is atrophic; but some vision remains in the nasal periphery of the field. The left eye has corrected vision of 1.1 and a full field; but it has been
Fig. 1.—Diagram of pupil showing spicule of opacity of lens, and clotted lines to indicate axes of convex correcting cylinders in parts of the pupil above and below the opacities.
failing in the last year. The chief com plaint is of diplopia, a bright image seen above, and a fainter image below to the left. These images have slowly become more widely separated. The ophthalmoscope shows a single definite spicule of lens opacity situated in the anterior cortex, extending from "two o'clock" toward "nine o'clock," as shown in Fig. 1. Otherwise the media are clear. In both eyes the vessels are irregularly constricted and the veins "kinked" where they cross the arteries. Skiascopy shows entirely different refraction in the areas above and below
674
NOTES, CASES AND INSTRUMENTS
the spicule of opacity. Both are hyper- Circumscribed ectasia is an appanage opic; but the upper one seems to need of old age, rarely occurring before 60 a plus cyl. ax. 30°, and is irregular. years; this patient was 72 years. It is The lower one is more regular and of very slow development, transparent, seems to require a plus O. 75 cyl. ax. and usually accompanied by very high 130°, which gives the eye its best dis astigmatism, 7 to 13 diopters with tant vision. The separation of the myopia, which accounts for the poor images is about as great as would be vision following it. produced by a 4° prism. This patient has always done very On bringing a card before the eye fine needlework with the aid of a minus so that it covered the upper area, the 4 diopter lens. She consulted me be lower and fainter image disappeared. cause her vision was reduced to count On bringing the card from below so ing fingers at three feet. Besides not that it covered the lower area of the ing the ectasia, I found an almost com pupil, the upper and brighter im plete opacification of the lens, the an age disappeared. The ophthalmometer terior chamber very deep, the iris fun showed no corresponding defect or nel shaped, the tension and the light perception normal. The ectasia occu flattening of the cornea. pies the upper margin of the cornea It was concluded that the diplopia for about 3 mm. and is opaque, the rest was due to a slight relative flattening of the cornea is clear. The opacity is of the anterior surface of the crystal concentric with the limbus, from which line lens, along the line of the spicule it is separated by a narrow strip of of opacity; that this flattening had transparent cornea. been increasing. T h a t this indicated Fuchs believes that ectasia is a de a condition of shrinking rather than swelling in the region of the opacity. generative process intimately related And that this shrinking in conjunction to an exaggerated development of the with the definite boundaries of the arcus senilis; while Terrien believes in opacity and absence of haze in other the theory of dystrophy; and Lauber parts of the lens, indicated that the thinks it due to an inflammatory lens opacity was likely not to increase. cause. I advised removing the lens, since her previous vision had been so good. CIRCUMSCRIBED ECTASIA OF The poor vision that usually accom panies ectasia of the cornea, constitut T H E CORNEA. ing its principal symptom, tho present G; N. BRAZEAU, M.D., F.A.C.S. now, is not due to any corneal irregu larity but rather to the defective condi MILWAUKEE, WIS. tion of the lens. Had the poor vision It is not unusual for thinning of the existing been due to any great amount cornea, from either traumatic or in of astigmatism the removal of the lens fectious inflammatory causes, to end would again complicate the situation in a keratocele, but in cases such as by adding to the already existing this one the cause remains unknown. astigmatism, that, incident to a corneal In this latter variety, the ectasia is section. more or less symmetrically developed The usual treatment of ectasia of in both eyes, tho its bilaterality could the cornea consists in correcting all not be determined here as the right the errors of refraction as well as pos eye had been removed many years ago. sible. At best, the vision remains low.