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Effect of Subconjunctival Cortisone Upon the Immediate Union of Experimental Corneal Grafts⋆
E F F E C T O F SUBCONJUNCTIVAL CORTISONE U P O N T H E IMMEDIATE U N I O N O F E X P E R I M E N T A L CORNEAL GRAFTS* FRANK W.
NEWELL,
M.D.
Chicago, Illinois AND J O S E P H M. D I X O N , *
M.D.
Birmingham, Alabama
It has been recognized for many years that hyperadrenalism (Cushing) is associated with disturbances in the connective tissues with delayed and defective healing of wounds. Clinical observations with ACTH and cortisone have demonstrated this same tendency. This depression of the mesenchymal activity has occurred with such regularity that it has been postulated, at least as far as the collagen diseases are concerned, that the beneficial effects are related to this activ A number of reports 2 during the past year ity rather than to the more widely investigated have directed attention to the value of the changes which occur in the electrolyte bal adrenocorticotropic hormone (ACTH) and ance and in carbohydrate metabolism. cortisone in the treatment of inflammatory The hyperadrenalism and its effects on diseases of the eye. Both of the compounds wound healing occur following the use have a marked action in blocking the char of ACTH and cortisone have been demon acteristic signs of inflammation due to infec strated in a number of different animals. tion without, however, exerting any effect Ragan et al.3 were the first to demonstrate upon the progress of the infectious process delayed wound healing in man. They also itself. showed a similar inhibition of standardized Similarly, the compounds, in a large de wounds in the ears of rabbits. A comparable gree, suppress the vascular and tissue re dosage in the rat (1 mg./lOO gm.), how sponses which usually occur in the course of ever, did not affect the healing, which may an antigen-antibody reaction in the hyper be in accord with the general resistance of sensitive animal. the species to most drugs rather than to an The effective application of ACTH neces absence of activity of the hormone. sitates the functional integrity of the adrenal Baker and Whitaker 7 showed that the glands and therefore it is effective only when local application of cortisone and compound used parenterally in the presence of adrenal F interfered with wound healing, indicating glands capable of stimulation. the likelihood of the action being peripheral Cortisone, at least as far as the anterior on the cells themselves, and not due to a segment of the eye is concerned, produces generalized disturbance of protein metabo comparable results whether it be used topi lism. cally or parenterally. Maumenee4 and Klima5 indicated experi mentally that the loss of transparency, which * From the Department of Ophthalmology, Northwestern Medical School. This study was sup may occur following corneal grafting, arises ported in part by a grant from the Kramer Fund. because of differences in the tissue types of t Heed Fellow in Ophthalmology. the donor and recipient. Because of the anti977
Cortisone or compound E is one of a number of steroids secreted by the adrenal cortex in response to the stimulation by the adrenocorticotropic hormone of the anterior pituitary gland. Hench, Kendall, Slocumb, and Polley1 initially showed it to be of value in ameliorating the symptoms and signs of rheumatoid arthritis. Subsequent studies demonstrated the usefulness of cortisone in the treatment of several conditions character ized by collagen degeneration.
978
FRANK W. NEWELL AND JOSEPH M. DIXON
allergic properties of cortisone, it seemed logical to assume that its use would minimize this reaction. Jones and Meyer 6 showed that the use of cortisone subconjunctivally inhibited the vascularization which occurs in the cornea of the rabbit following chemical burns. Their ob servations were made in the course of a much larger study demonstrating the depression of mesenchyme proliferation in skin wounds following the use of A C T H and cortisone. The desirability of suppressing new blood vessel formation in corneal grafts requires no comment. E X P E R I M E N T A L PROCEDURE
Mongrel male rabbits weighing between 2,500 and 4,000 gm. were used. Homologous, 4.5-mm. round corneal grafts with overlying sutures were done centrally in each eye. T h e right eye was used as a control while the left eye was treated with cortisone injected sub conjunctivally. Only those rabbits with bi lateral technically satisfactory operations, having deep anterior chambers, and without anterior synechias were included in the ex periment. Animals were killed for pathologic study on the following postoperative d a y s : 1 , 2 , 3 , 4 , 6 , 8 , 11, and 14. The pupils were dilated preoperatively with atropine and a 10-percent emulsion of neosynephrin was instilled into the conjunctival sac. Cortisone (Cortone acetate Merck Lot # 4 7 8 ) (1.25 mg.) was injected subcon junctivally in the left eye immediately after surgery and thereafter every 48 hours until the animal was killed. At the time of surgery 100,000 units of crystalline penicillin-G procaine, 33,000 units of buffered crystalline penicillin-G sodium, and 0.3 gm. dihydrostreptomycin were injected intramuscularly to reduce the possibility of wound infection. T h e lids were not closed with sutures. W h e n required, the pupils were dilated with two-percent homatropine and a 10-percent neosynephrin emul sion. T h e animals were killed with intravenous
sodium pentobarbital, decapitated, and the entire head placed in 10-percent formalin without disturbing the ocular wound. After fixation for three to five days, the anterior segments of the eyes were excised, paraffin sections prepared and stained with hematoxylin and eosin. POSTOPERATIVE COURSE
T h e postoperative course was uneventful. In one eye, a small amount of fibrin was seen grossly around the wound and sutures. H o w ever, fibrin was found microscopically on the anterior surface of the corneas of all animals. Five eyes had small anterior synechias on the first or second postoperative day which separated easily and permanently with topical application of mydriatics. T h e postoperative appearance of the treated and control eyes was similar the first three or four days of the experiment. There after, however, the eyes receiving the corti sone did not do so well as the control eyes. There was more bulging of the grafts, and the graft and adjacent cornea were not as clear. MICROSCOPIC
FINDINGS
There was no evidence that cortisone had any significant influence on the normal rapid proliferation of the corneal epithelium which covered the anterior border of the wounds within 24 hours and was found proliferating along all of the suture tracts of the control and treated eyes after 48 hours (fig. 1 ) . During the first 96 hours, there was very little difference in the microscopic appearance of the wounds in the treated and untreated eyes. T h e epithelium was absent in some areas over the grafts and in other areas con sisted only of small islands, one or two cells in thickness. During this period the grafts were edematous. Polymorphonuclear neutrophils and eosinophils infiltrated the wound margins and were abundant in the fibrinous exudate on the corneal surface. Endothelial cells in the grafts were absent in many areas and frag-
CORTISONE AND UNION OF CORNEAL GRAFTS
979
Fig. 1 (Newell and Dixon). Proliferation of epithelium in suture tract 48 hours after corneal transplant. mented in others. Fibrin filled the posterior edges of the wounds. Differences between the treated and con trol eyes became evident after the third day. In the normal untreated control wounds, the neutrophils and eosinophils began to dis appear and proliferating keratoblasts mi grated between the wound margins, displac ing the epithelium and forming cellular con nective tissue. In some instances, • small islands of epithelial cells persisted5".deep in the con nective-tissue meshwork :as reported by Col lins,8 and Theobald and Haas. 9 In the eyes receiving cortisone, there was persistence of the leukocytes in the wound and very little displacement of epithelium by proliferating keratoblasts. The number of leukocytes infiltrating the wound was in constant and one of the treated eyes had a few more on the eighth day than another treated eye on the sixth day. Keratoblastic proliferation was minimal and, as late as the
11th day, the wounds were filled only by epithelium and fibrin (fig. 2). The healing process was not uniformly depressed in the same graft and some wounds showed a thin cicatrix on one side with the opposite side open. In this early stage, there was no significant difference in the behavior of the fibrin and endothelium in the treated and the control eyes. COMMENT
The failure of mesenchyme proliferation observed in these animals is similar to that which is noted in wounds in man, rats, and rabbits and which is seen after the experi mental production of a fracture of the femur in the rabbit. The mechanism of this response is not clear but, since it follows the regional administration of cortisone, the activity is not due to the antianabolic effect of the hormone on protein metabolism. Ragan,30 suggests that, in the hyperadrenal state, connective tissue loses its
980
FRANK W. NEWELL AND JOSEPH M. DIXON
Depression of neovasculogenesis is not a fundamental part of the inhibition of heal ing since the retardation, which is observed in the healing of the nonvascular cornea, is similar to that which is seen in experimental wounds of the skin. From the observations made in this limited series, it appears that corneal wound healing is delayed because of a failure of the kerato blasts to proliferate without any apparent marked effect on the proliferation of the epithelium. A downgrowth of the surface epithelium into the anterior chamber may occur because-' of the delay in the keratoblastic displacement of the more rapidly growing epithelium. This was. not, however, observed in this small series of cases. It must be emphasized that only a delay in the normal rate of heal ing was observed with no other sign of any
Fig. 2 (Newell and Dixon). Well-healed corneal wound 11 days after corneal transplant. The epithelial plug from the anterior surface has been displaced by actively proliferating keratoblasts with an island of epithelium isolated below. There is still evidence of the fibrin plug on the posterior surface.
ability to respond to trauma. If this hy pothesis is correct, then the fundamental disturbance is not a depression of mesenchyme proliferation, but rather a failure of the mesenchymal tissue to respond to the stimulus of the injury. Quantitative studies have shown that there is a decrease in the amount of ground substance in wounds which parallels the de pression of the fibroblastic proliferation. The administration of hyaluronidase in experi mental wounds of the skin results in a "pseudohealing" with complete epithelization, but with a minimum amount of con nective-tissue regeneration. The findings are not unlike those which are observed in the wound healing associated with ascorbic-acid deficiency.
Fig. 3 (Newell and Dixon). Poorly healed wound in eye treated with cortisone, 11 days after corneal transplant. The epithelium extends deep into the wound and there is minimal evidence of keratoblastic. proliferation.
981
CORTISONE AND UNION OF CORNEAL GRAFTS pathologic process being evident. The actions of cortisone on corneal grafts after the keratoblastic proliferation has been well initiated, its effects on the loss of corneal clarity occurring several months following surgery, and its effect on new blood vessel formation after wound healing is advanced have not been investigated. These subjects offer fruitful fields for further experimental study. On the basis of these limited observations, however, it appears to be unwise to use cortisone either locally or systemically immediately following surgical procedures in-
volving the cornea, if rapid healing is desired. CONCLUSIONS
Subconjunctival administration of cortisone in rabbits following homologous corneal grafts was associated with a delay in wound healing with a failure of keratoblastic proliferation. No inhibition of epithelial proliferation was observed in this study. 30 North Michigan Avenue 903 South 21st Street.
(2).
REFERENCES
1. Hench, P. S., Kendall, E. C, Slocumb; C. H., and Polley, H. F . : Effect of a hormone of the adrenal cortex (17-hydroxy-ll-dehydrocorticosterone—compound E) and of pituitary adrenocorticotropic-hor mone on rheumatoid arthritis: Preliminary report. Proc. Staff Meet., Mayo Clin., 24:181, 1949. 2. Woods, A. C.: ACTH and cortisone in ocular disease. Am. J. Ophth., 33 :132S, 1950. 2a. Gordon, D. M., and McLean, J. M.: Effects of pituitary adrenocorticotropic hormone (ACTH) therapy in ophthalmologic conditions. J.A.M.A., 142:1271, 1950. 2b. Steffensen, E. H., Olson, J. A., Margulis, R. R., Smith, R. W., and Whitney, E. L.: The experi mental use of cortisone in inflammatory eye disease. Am. J. Ophth., 33:1033, 1950. 2c. Olson, J. A., Steffensen, E. H., Margulis, R. R., Smith, R. W., and Whitney, E. L.: The effect of ACTH on certain inflammatory diseases of the eye: A preliminary report. J.A.M.A., 142 :1276-1279, 1950. 2d. Theodore, F. H . : Use of cortisone in severe bilateral uveitis. E.E.N.T. Monthly, 29:314, 1950. 2e. Posner, A.: Cortisone in the treatment of recurrent iritis associated with Marie-Struempell spondylitis. E.E.N.T. Monthly, 29:316,1950. 2f. Henderson, J. W., and Hollenhorst, Ti. W.: Effects of cortisone on certain ophthalmic diseases. Proc. Staff Meet. Mayo Clin., 24:491, 1950. 2g. Lippman, O.: Use of adrenal cortical hormone in inflammatory eye diseases. Texas State M. J., 46:708,1950. 2h. Present status of cortisone and ACTH: A symposium. Bull. N. Y. Acad. Med., 26:206-259, 1950. 2i. Mann, W. A., and Markson, D. E.: A case of recurrent iritis and episcleritis on a rheumatic basis treated with ACTH. Am. J. Ophth., 33:459,1950. 2j. Harvey, H., J. E., and Kattus, A. A.: Effect of adrenocorticotropic hormone (ACTH) and corti sone on certain diseases of eye in which hypersensitivity plays a role. Bull. Johns Hopkins Hosp., 87: 461,1950. 2k. Woods, A. C, and Wood, R. M.: Action of ACTH and cortisone on experimental ocular inflam mation. Bull. Johns Hopkins Hosp., 87 :482, 1950. 3. Ragan, C , Grokoest, A. W., and Boots, R. H.: Effect of adrenocorticotropic hormone (ACTH) on rheumatoid arthritis. Am. J. Med., 7:741,1949. 3a. Ragan, C, Howes, F. L., Plotz, C. M., Meyer, K., and Blunt, J. W.: Effect of cortisone on pro duction of granulation tissue in the rabbit. Proc. Soc. Exper. Biol. & Med., 72:718,1949. 3b. Creditor, M. C, Bevans, M., Mundy, W. L., and Ragan, C.: Effect of ACTH on wound healing in humans. Proc. Soc. Exper. Biol. & Med., 74:245, 1950. 3c. Ragan, C , Howes, E. L., Plotz, C. M., Meyer, K., Blunt, J. W., and Lattes, R. S..: The effect of ACTH and cortisone on connective tissue. Bull. N. Y. Acad. Med., 26:251, 1950. 4. Maumenee, A. E.: Influence of donor-recipient sensitization on corneal grafts. Am. J. Ophth., 34:142 (May, Pt. 2) 1951. 5. Klima, M.: Antigenic properties of corneal protein. Shornik Lekarsky 51:1, 1949. Abstract in Excerpta Medica: Ophthalmology, 4:280,1950. 6. Jones, T. S., and Meyer, K.: Inhibition of vascularization of the rabbit cornea by local application of cortisone. Proc. Soc. Exper. Biol. & Med., 74:102,1950. 7. Baker, B. L., and Whitaker, W. L.: Interference with wound healing by the local action of adrenocortical steroids. Endocrinology, 46:544, 1950.
982
ARTHUR M. CULLER AND SAMUEL G. CLARK
Castor, C. W., and Baker, B. L.: The local action of adrenocortical steroids on epidermis and connective tissue. Endocrinology, 47:234, 1950. 8. Collins, E. T.: Discussion of postoperative complications of cataract extraction. Tr. Ophth. Soc. U. Kingdom, 34:18, 1914. 9. Theobald, G. D., and Haas, J. S.: Epithelial invasion of the anterior chamber. Tr. Am. Acad. Ophth., 57:470,1948.
AUREOMYCIN AS PROPHYLAXIS AGAINST
OPHTHALMIA
NEONATORUM: SECOND SERIES* A R T H U R M.
CULLER, M.D.,
AND S A M U E L G.
CLARK,
M.D.
Columbus, Ohio Observation of aureomycin as prophylaxis against ophthalmia neonatorum has been ex tended to include 1,957 additional newborn babies. The experiment was continued in the interest of acquiring sufficient data to be statistically significant on the efficiency of the method as a preventative of gonococcal and virus infections of the newborn.
In this series, discharge was seen in only 12 infants after the second day. Table 1 reviews the bacteriologic studies of these 12 patients. T h e occurrence of examples of both gon ococcal ophthalmia and inclusion blennorrhea in this series is fortuitous and noteworthy. T h e Neisserian infection occurred in a pre-
TABLE 1 BACTERIOLOGIC STUDIES IN 12 PATIENTS SHOWING DISCHARGE AFTER THE SECOND DAY
Smears and Cultures
Treatment
Result Cleared spontaneously 24 hr. Cleared 48 hr.
No growth
4
Streptococcus -alpha -beta
1 1
2 none 2 aureomycin Aureomycin Aureomycin
N. gonorrheae
1
Penicillin
Cleared 24 hr. Recurrence 21 days later
Diphtheroids Staphylococcus Inclusion bodies
2 2 1
Aureomycin Aureomycin Aureomycin q | h
Cleared 48 hr. Cleared 48 hr. Cleared 5 days
Total
Cleared 48 hr. Cleared 48 hr.
12
In order to make this study comparable with studies of other antibiotics, slight de grees of swelling and redness of the lids and slight discharge during the first two days only were noted. Some slight evidence of inflammation, probably infectious, was seen in approximately 20 percent of the infants. In nearly all of them, the condition cleared spontaneously within 48 hours without any treatment. * Read before the second annual meeting of the East Central Section of the Association for Re search in Ophthalmology, Cincinnati, January, 1951.
mature Negro infant. This male baby had a birth weight of four pounds and three ounces, and was transferred to the premature ward at Children's Hospital without post natal contact with the mother. On the third day of life a moderate puru lent discharge appeared in both eyes. Smears showed Gram-negative intracellular diplococci and cultures later identified the organ ism as Neisseria gonorrheae. T h e purulent discharge and injection had disappeared 24 hours later and cultures taken at this time were negative. Treatment with penicillin was discontinued after three days.
NEWELL,
M.D.
Chicago, Illinois AND J O S E P H M. D I X O N , *
M.D.
Birmingham, Alabama
It has been recognized for many years that hyperadrenalism (Cushing) is associated with disturbances in the connective tissues with delayed and defective healing of wounds. Clinical observations with ACTH and cortisone have demonstrated this same tendency. This depression of the mesenchymal activity has occurred with such regularity that it has been postulated, at least as far as the collagen diseases are concerned, that the beneficial effects are related to this activ A number of reports 2 during the past year ity rather than to the more widely investigated have directed attention to the value of the changes which occur in the electrolyte bal adrenocorticotropic hormone (ACTH) and ance and in carbohydrate metabolism. cortisone in the treatment of inflammatory The hyperadrenalism and its effects on diseases of the eye. Both of the compounds wound healing occur following the use have a marked action in blocking the char of ACTH and cortisone have been demon acteristic signs of inflammation due to infec strated in a number of different animals. tion without, however, exerting any effect Ragan et al.3 were the first to demonstrate upon the progress of the infectious process delayed wound healing in man. They also itself. showed a similar inhibition of standardized Similarly, the compounds, in a large de wounds in the ears of rabbits. A comparable gree, suppress the vascular and tissue re dosage in the rat (1 mg./lOO gm.), how sponses which usually occur in the course of ever, did not affect the healing, which may an antigen-antibody reaction in the hyper be in accord with the general resistance of sensitive animal. the species to most drugs rather than to an The effective application of ACTH neces absence of activity of the hormone. sitates the functional integrity of the adrenal Baker and Whitaker 7 showed that the glands and therefore it is effective only when local application of cortisone and compound used parenterally in the presence of adrenal F interfered with wound healing, indicating glands capable of stimulation. the likelihood of the action being peripheral Cortisone, at least as far as the anterior on the cells themselves, and not due to a segment of the eye is concerned, produces generalized disturbance of protein metabo comparable results whether it be used topi lism. cally or parenterally. Maumenee4 and Klima5 indicated experi mentally that the loss of transparency, which * From the Department of Ophthalmology, Northwestern Medical School. This study was sup may occur following corneal grafting, arises ported in part by a grant from the Kramer Fund. because of differences in the tissue types of t Heed Fellow in Ophthalmology. the donor and recipient. Because of the anti977
Cortisone or compound E is one of a number of steroids secreted by the adrenal cortex in response to the stimulation by the adrenocorticotropic hormone of the anterior pituitary gland. Hench, Kendall, Slocumb, and Polley1 initially showed it to be of value in ameliorating the symptoms and signs of rheumatoid arthritis. Subsequent studies demonstrated the usefulness of cortisone in the treatment of several conditions character ized by collagen degeneration.
978
FRANK W. NEWELL AND JOSEPH M. DIXON
allergic properties of cortisone, it seemed logical to assume that its use would minimize this reaction. Jones and Meyer 6 showed that the use of cortisone subconjunctivally inhibited the vascularization which occurs in the cornea of the rabbit following chemical burns. Their ob servations were made in the course of a much larger study demonstrating the depression of mesenchyme proliferation in skin wounds following the use of A C T H and cortisone. The desirability of suppressing new blood vessel formation in corneal grafts requires no comment. E X P E R I M E N T A L PROCEDURE
Mongrel male rabbits weighing between 2,500 and 4,000 gm. were used. Homologous, 4.5-mm. round corneal grafts with overlying sutures were done centrally in each eye. T h e right eye was used as a control while the left eye was treated with cortisone injected sub conjunctivally. Only those rabbits with bi lateral technically satisfactory operations, having deep anterior chambers, and without anterior synechias were included in the ex periment. Animals were killed for pathologic study on the following postoperative d a y s : 1 , 2 , 3 , 4 , 6 , 8 , 11, and 14. The pupils were dilated preoperatively with atropine and a 10-percent emulsion of neosynephrin was instilled into the conjunctival sac. Cortisone (Cortone acetate Merck Lot # 4 7 8 ) (1.25 mg.) was injected subcon junctivally in the left eye immediately after surgery and thereafter every 48 hours until the animal was killed. At the time of surgery 100,000 units of crystalline penicillin-G procaine, 33,000 units of buffered crystalline penicillin-G sodium, and 0.3 gm. dihydrostreptomycin were injected intramuscularly to reduce the possibility of wound infection. T h e lids were not closed with sutures. W h e n required, the pupils were dilated with two-percent homatropine and a 10-percent neosynephrin emul sion. T h e animals were killed with intravenous
sodium pentobarbital, decapitated, and the entire head placed in 10-percent formalin without disturbing the ocular wound. After fixation for three to five days, the anterior segments of the eyes were excised, paraffin sections prepared and stained with hematoxylin and eosin. POSTOPERATIVE COURSE
T h e postoperative course was uneventful. In one eye, a small amount of fibrin was seen grossly around the wound and sutures. H o w ever, fibrin was found microscopically on the anterior surface of the corneas of all animals. Five eyes had small anterior synechias on the first or second postoperative day which separated easily and permanently with topical application of mydriatics. T h e postoperative appearance of the treated and control eyes was similar the first three or four days of the experiment. There after, however, the eyes receiving the corti sone did not do so well as the control eyes. There was more bulging of the grafts, and the graft and adjacent cornea were not as clear. MICROSCOPIC
FINDINGS
There was no evidence that cortisone had any significant influence on the normal rapid proliferation of the corneal epithelium which covered the anterior border of the wounds within 24 hours and was found proliferating along all of the suture tracts of the control and treated eyes after 48 hours (fig. 1 ) . During the first 96 hours, there was very little difference in the microscopic appearance of the wounds in the treated and untreated eyes. T h e epithelium was absent in some areas over the grafts and in other areas con sisted only of small islands, one or two cells in thickness. During this period the grafts were edematous. Polymorphonuclear neutrophils and eosinophils infiltrated the wound margins and were abundant in the fibrinous exudate on the corneal surface. Endothelial cells in the grafts were absent in many areas and frag-
CORTISONE AND UNION OF CORNEAL GRAFTS
979
Fig. 1 (Newell and Dixon). Proliferation of epithelium in suture tract 48 hours after corneal transplant. mented in others. Fibrin filled the posterior edges of the wounds. Differences between the treated and con trol eyes became evident after the third day. In the normal untreated control wounds, the neutrophils and eosinophils began to dis appear and proliferating keratoblasts mi grated between the wound margins, displac ing the epithelium and forming cellular con nective tissue. In some instances, • small islands of epithelial cells persisted5".deep in the con nective-tissue meshwork :as reported by Col lins,8 and Theobald and Haas. 9 In the eyes receiving cortisone, there was persistence of the leukocytes in the wound and very little displacement of epithelium by proliferating keratoblasts. The number of leukocytes infiltrating the wound was in constant and one of the treated eyes had a few more on the eighth day than another treated eye on the sixth day. Keratoblastic proliferation was minimal and, as late as the
11th day, the wounds were filled only by epithelium and fibrin (fig. 2). The healing process was not uniformly depressed in the same graft and some wounds showed a thin cicatrix on one side with the opposite side open. In this early stage, there was no significant difference in the behavior of the fibrin and endothelium in the treated and the control eyes. COMMENT
The failure of mesenchyme proliferation observed in these animals is similar to that which is noted in wounds in man, rats, and rabbits and which is seen after the experi mental production of a fracture of the femur in the rabbit. The mechanism of this response is not clear but, since it follows the regional administration of cortisone, the activity is not due to the antianabolic effect of the hormone on protein metabolism. Ragan,30 suggests that, in the hyperadrenal state, connective tissue loses its
980
FRANK W. NEWELL AND JOSEPH M. DIXON
Depression of neovasculogenesis is not a fundamental part of the inhibition of heal ing since the retardation, which is observed in the healing of the nonvascular cornea, is similar to that which is seen in experimental wounds of the skin. From the observations made in this limited series, it appears that corneal wound healing is delayed because of a failure of the kerato blasts to proliferate without any apparent marked effect on the proliferation of the epithelium. A downgrowth of the surface epithelium into the anterior chamber may occur because-' of the delay in the keratoblastic displacement of the more rapidly growing epithelium. This was. not, however, observed in this small series of cases. It must be emphasized that only a delay in the normal rate of heal ing was observed with no other sign of any
Fig. 2 (Newell and Dixon). Well-healed corneal wound 11 days after corneal transplant. The epithelial plug from the anterior surface has been displaced by actively proliferating keratoblasts with an island of epithelium isolated below. There is still evidence of the fibrin plug on the posterior surface.
ability to respond to trauma. If this hy pothesis is correct, then the fundamental disturbance is not a depression of mesenchyme proliferation, but rather a failure of the mesenchymal tissue to respond to the stimulus of the injury. Quantitative studies have shown that there is a decrease in the amount of ground substance in wounds which parallels the de pression of the fibroblastic proliferation. The administration of hyaluronidase in experi mental wounds of the skin results in a "pseudohealing" with complete epithelization, but with a minimum amount of con nective-tissue regeneration. The findings are not unlike those which are observed in the wound healing associated with ascorbic-acid deficiency.
Fig. 3 (Newell and Dixon). Poorly healed wound in eye treated with cortisone, 11 days after corneal transplant. The epithelium extends deep into the wound and there is minimal evidence of keratoblastic. proliferation.
981
CORTISONE AND UNION OF CORNEAL GRAFTS pathologic process being evident. The actions of cortisone on corneal grafts after the keratoblastic proliferation has been well initiated, its effects on the loss of corneal clarity occurring several months following surgery, and its effect on new blood vessel formation after wound healing is advanced have not been investigated. These subjects offer fruitful fields for further experimental study. On the basis of these limited observations, however, it appears to be unwise to use cortisone either locally or systemically immediately following surgical procedures in-
volving the cornea, if rapid healing is desired. CONCLUSIONS
Subconjunctival administration of cortisone in rabbits following homologous corneal grafts was associated with a delay in wound healing with a failure of keratoblastic proliferation. No inhibition of epithelial proliferation was observed in this study. 30 North Michigan Avenue 903 South 21st Street.
(2).
REFERENCES
1. Hench, P. S., Kendall, E. C, Slocumb; C. H., and Polley, H. F . : Effect of a hormone of the adrenal cortex (17-hydroxy-ll-dehydrocorticosterone—compound E) and of pituitary adrenocorticotropic-hor mone on rheumatoid arthritis: Preliminary report. Proc. Staff Meet., Mayo Clin., 24:181, 1949. 2. Woods, A. C.: ACTH and cortisone in ocular disease. Am. J. Ophth., 33 :132S, 1950. 2a. Gordon, D. M., and McLean, J. M.: Effects of pituitary adrenocorticotropic hormone (ACTH) therapy in ophthalmologic conditions. J.A.M.A., 142:1271, 1950. 2b. Steffensen, E. H., Olson, J. A., Margulis, R. R., Smith, R. W., and Whitney, E. L.: The experi mental use of cortisone in inflammatory eye disease. Am. J. Ophth., 33:1033, 1950. 2c. Olson, J. A., Steffensen, E. H., Margulis, R. R., Smith, R. W., and Whitney, E. L.: The effect of ACTH on certain inflammatory diseases of the eye: A preliminary report. J.A.M.A., 142 :1276-1279, 1950. 2d. Theodore, F. H . : Use of cortisone in severe bilateral uveitis. E.E.N.T. Monthly, 29:314, 1950. 2e. Posner, A.: Cortisone in the treatment of recurrent iritis associated with Marie-Struempell spondylitis. E.E.N.T. Monthly, 29:316,1950. 2f. Henderson, J. W., and Hollenhorst, Ti. W.: Effects of cortisone on certain ophthalmic diseases. Proc. Staff Meet. Mayo Clin., 24:491, 1950. 2g. Lippman, O.: Use of adrenal cortical hormone in inflammatory eye diseases. Texas State M. J., 46:708,1950. 2h. Present status of cortisone and ACTH: A symposium. Bull. N. Y. Acad. Med., 26:206-259, 1950. 2i. Mann, W. A., and Markson, D. E.: A case of recurrent iritis and episcleritis on a rheumatic basis treated with ACTH. Am. J. Ophth., 33:459,1950. 2j. Harvey, H., J. E., and Kattus, A. A.: Effect of adrenocorticotropic hormone (ACTH) and corti sone on certain diseases of eye in which hypersensitivity plays a role. Bull. Johns Hopkins Hosp., 87: 461,1950. 2k. Woods, A. C, and Wood, R. M.: Action of ACTH and cortisone on experimental ocular inflam mation. Bull. Johns Hopkins Hosp., 87 :482, 1950. 3. Ragan, C , Grokoest, A. W., and Boots, R. H.: Effect of adrenocorticotropic hormone (ACTH) on rheumatoid arthritis. Am. J. Med., 7:741,1949. 3a. Ragan, C, Howes, F. L., Plotz, C. M., Meyer, K., and Blunt, J. W.: Effect of cortisone on pro duction of granulation tissue in the rabbit. Proc. Soc. Exper. Biol. & Med., 72:718,1949. 3b. Creditor, M. C, Bevans, M., Mundy, W. L., and Ragan, C.: Effect of ACTH on wound healing in humans. Proc. Soc. Exper. Biol. & Med., 74:245, 1950. 3c. Ragan, C , Howes, E. L., Plotz, C. M., Meyer, K., Blunt, J. W., and Lattes, R. S..: The effect of ACTH and cortisone on connective tissue. Bull. N. Y. Acad. Med., 26:251, 1950. 4. Maumenee, A. E.: Influence of donor-recipient sensitization on corneal grafts. Am. J. Ophth., 34:142 (May, Pt. 2) 1951. 5. Klima, M.: Antigenic properties of corneal protein. Shornik Lekarsky 51:1, 1949. Abstract in Excerpta Medica: Ophthalmology, 4:280,1950. 6. Jones, T. S., and Meyer, K.: Inhibition of vascularization of the rabbit cornea by local application of cortisone. Proc. Soc. Exper. Biol. & Med., 74:102,1950. 7. Baker, B. L., and Whitaker, W. L.: Interference with wound healing by the local action of adrenocortical steroids. Endocrinology, 46:544, 1950.
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Castor, C. W., and Baker, B. L.: The local action of adrenocortical steroids on epidermis and connective tissue. Endocrinology, 47:234, 1950. 8. Collins, E. T.: Discussion of postoperative complications of cataract extraction. Tr. Ophth. Soc. U. Kingdom, 34:18, 1914. 9. Theobald, G. D., and Haas, J. S.: Epithelial invasion of the anterior chamber. Tr. Am. Acad. Ophth., 57:470,1948.
AUREOMYCIN AS PROPHYLAXIS AGAINST
OPHTHALMIA
NEONATORUM: SECOND SERIES* A R T H U R M.
CULLER, M.D.,
AND S A M U E L G.
CLARK,
M.D.
Columbus, Ohio Observation of aureomycin as prophylaxis against ophthalmia neonatorum has been ex tended to include 1,957 additional newborn babies. The experiment was continued in the interest of acquiring sufficient data to be statistically significant on the efficiency of the method as a preventative of gonococcal and virus infections of the newborn.
In this series, discharge was seen in only 12 infants after the second day. Table 1 reviews the bacteriologic studies of these 12 patients. T h e occurrence of examples of both gon ococcal ophthalmia and inclusion blennorrhea in this series is fortuitous and noteworthy. T h e Neisserian infection occurred in a pre-
TABLE 1 BACTERIOLOGIC STUDIES IN 12 PATIENTS SHOWING DISCHARGE AFTER THE SECOND DAY
Smears and Cultures
Treatment
Result Cleared spontaneously 24 hr. Cleared 48 hr.
No growth
4
Streptococcus -alpha -beta
1 1
2 none 2 aureomycin Aureomycin Aureomycin
N. gonorrheae
1
Penicillin
Cleared 24 hr. Recurrence 21 days later
Diphtheroids Staphylococcus Inclusion bodies
2 2 1
Aureomycin Aureomycin Aureomycin q | h
Cleared 48 hr. Cleared 48 hr. Cleared 5 days
Total
Cleared 48 hr. Cleared 48 hr.
12
In order to make this study comparable with studies of other antibiotics, slight de grees of swelling and redness of the lids and slight discharge during the first two days only were noted. Some slight evidence of inflammation, probably infectious, was seen in approximately 20 percent of the infants. In nearly all of them, the condition cleared spontaneously within 48 hours without any treatment. * Read before the second annual meeting of the East Central Section of the Association for Re search in Ophthalmology, Cincinnati, January, 1951.
mature Negro infant. This male baby had a birth weight of four pounds and three ounces, and was transferred to the premature ward at Children's Hospital without post natal contact with the mother. On the third day of life a moderate puru lent discharge appeared in both eyes. Smears showed Gram-negative intracellular diplococci and cultures later identified the organ ism as Neisseria gonorrheae. T h e purulent discharge and injection had disappeared 24 hours later and cultures taken at this time were negative. Treatment with penicillin was discontinued after three days.