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Eye Findings in Strangulation of the Optic Nerve*
NOTES, CASES, INSTRUMENTS
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right eye with the lens removed. With such a lens over each eye', thereby negating accommodation bi laterally, no constriction occurred in either eye with position change but there was a constriction in convergence response to prisms in each eye. This supports the theory that the efferent path ways for accommodation and convergence are not the same.' Of course in this case only the afferent pathway for accommodation might have been harmed. From the pupillary responses this latter supposition seems unlikely. Either way is sugges tive of a neural rather than muscular involvement. After orbital injuries the convergence mechanism recovers first even before the light response and long before accommodation recovery, but here the light response recovered first which again tends to support a neural rather than muscular involve ment.* Some pupillary responses to drugs were noted. Those of the normal left eye were usual. Neostigmine (5.0 and 2.5 percent) and five-percent methacholine hydrochloride (Mecholyl) and carbachol (0.75 percent) had little or no action on the right pupil. Such lack of reactions proved no help in differentiating the lesion as neural or muscular. One year later the pupil of the right eye was
still slightly dilated and all reactions were normal, including drug responses. Accommodation was not quite the same as in the uninvolved eye (on refrac tion +0.75D. sph., O.D., for near was needed to balance accommodation) but no near lens was necessary for daily function and comfort. Manifest and cycloplegic refractions remained the same for distance. SUMMARY
A case of internal ophthalmoplegia follow ing a limbal papule during varicella is pre sented. Some tests and the nature of the re covery suggest the lesion was neural and not muscular. There remain a slight pupillary dilatation and some slight depression of ac commodation in this eye over a year later but the patient is comfortable and requires only a distance correction. Since the neurotoxicity of the varicella virus is well known, such a reaction is not too surprising. 321 East Front Street.
REFERENCES
1. Duke-Elder, S.: Textbook of Ophthalmology. St. Louis, Mosby, 1954, v. 4, p. 6948. 2. Suie, T.: Microbiolgy of the Eye. Manual Am. Acad. Ophth., chap. VI, p. 42. 3. Monod, M. F.: Concerning a case of tonic pupil in the course of varicella. Bull. Soc. ophtal. Franc;, 1958, No. 11, pp. 754-756. 4. Gavel, M. A.: Unilateral partial mydriasis as the result of varicella. Bull. Soc. ophtal. Fran?, 1958, No. 11, pp. 756-57, Nov. 1958. 5. Adler, F. H.: Gifford's Textbook of Ophthalmology. Philadelphia, Saunders, 1949, ed. 4, p. 448. 6. Berens, C.: The Eye and Its Diseases. Philadelphia, Saunders, 1936, p. 289. 7. Duke-Elder, S.: Textbook of Ophthalmology. St. Louis, Mosby Co., 1954, v. 4, p. 3747. 8. : Textbook of Ophthalmology. St. Louis, Mosby, 1954, v. 4, p. 3795. 9. : Textbook of Ophthalmology. St. Louis, Mosby, 1954, v. 4, p. 3734-3735.
EYE FINDINGS IN STRANGULATION O F T H E OPTIC NERVE* PAUL LEVATIN,
M.D.
Oakland, California Perimetry in acute retrobulbar neuritis usually reveals a central or cecocentral scotoma (axial neuritis), and more rarely a peripheral contraction (perineuritis), or a generalized depression of the entire visual field without a central scotoma (total trans* From the Department of Ophthalmology, the Permanente Medical Group, Kaiser Foundation Hospital.
verse neuritis). That these three field defects may also be produced by pressure of tumor upon an optic nerve is not surprising, for in the central nervous system lesions of differ ent etiology often produce the same neuro logic signs. In the Foster Kennedy syn drome, a central scotoma occurs on the sidi of a basofrontal tumor presumably due to hypersensitivity to pressure of the macular fibers. But the view that direct compression of an optic nerve manifests itself most com monly by a central scotoma has been chal lenged in recent years. Mooney and McConnell1 stated, "In the most common type of pituitary tumor the
NOTES, CASES, I N S T R U M E N T S
optic nerve appears to be whiter than nor mal, to be flattened and to curve round the tumor tightly embracing it. The expanded tumor must have exerted a considerable amount of pressure to produce such a dis tortion yet a central scotoma in such a case is a rarity." Chamlin2 reported 23 verified cases of mass compression of the optic nerve (chiefly due to meningiomas of the sphenoid ridge or olfactory groove), all with some involve ment of the peripheral fields and none with a discrete central scotoma unrelated to a more peripheral defect. In this paper is described a tumor which produced neither a central scotoma nor a pe ripheral contraction but a generalized depres sion of the entire visual field, as in total trans verse neuritis. The unusual manner of com pression revealed at operation was sufficient to explain the eye signs. REPORT OF A CASE A 51-year-old housewife consulted an ophthal mologist in March, 1955, because of frontal head ache and blurred vision in the left eye of three months' duration. The vision of the left eye, which was 20/40, dropped in the next six weeks for no apparent reason to 8/200. The fundi were normal and no cecocentral or nerve-fiber bundle defect could be found in the amblyopic eye. A diagnosis of retrobulbar neuritis was made and the pa tient was given typhoid vaccine intravenously and A C T H , with improvement in vision to 20/30. However, by September the vision of the left eye had decreased to 20/70. Fortunately, X-ray films of the sinuses were ordered by an otolaryngologist and, when these revealed enlargement and destruc tion of the sella turcica, the patient was sent to this hospital for the neurosurgical treatment of a pituitary tumor. No evidence of pituitary dysfunction was found on admission. The only neurologic finding was hyperactive deep tendon reflexes. Pneumo-encephalography revealed normal ventricles and a rather pointed soft tissue mass within the sella, pro truding upward beyond the diaphragm. The sella was markedly enlarged, with a depressed floor, and there was considerable thinning of the posterior clinoids (fig. 1). Ophthalmologic consultation revealed that the visual acuity of the right eye was 20/20; that of the left eye was reduced to 2/200. The pupils were equal. The left pupil reacted to light through a narrower arc than did the right, and redilated promptly (a positive Marcus Gunn pupillary sign).
1309
Fig. 1 (Levatin). Pneumoencephalogram show ing a pointed intrasellar soft tissue mass. The sella turcica is enlarged with erosion of the floor and posterior clinoids.
The pupillary escape in this eye was strikingly demonstrated when a flashlight was passed back and forth between the two eyes, the right pupil be coming small when illuminated and the left pupil becoming large when the flashlight was transferred to it. The optic discs were flat and pink but the right had eight capillaries on its surface and the left only four. The peripheral field of the right eye for 3/330 white was full, but for 1/330 white showed a generalized contraction to 32 degrees from fixation. However, a definite superior temporal contraction with a hemianopic character was present in the field for 2/330 white. The peripheral field of the left eye for 20/330 white (smaller targets allegedly not visible) revealed only a slight temporal con traction. The central field of the right eye for 1/1000 white was uniformly contracted to 13 de grees from fixation; that of the left eye was ir regularly contracted to approximately 15 degrees for 20/1000 white (fig. 2 ) . The large white test object appeared "beige" everywhere within the visible field of the left eye, as did the white fixation object. With this eye the 20-mm. white target ap peared most bright in the nasal quadrants, and least bright in the temporal quadrants; while with a large red test object a temporal hemianopia was present. On the Harrington-Flocks multiple pattern field screener, four targets were missing in the upper temporal quadrant of the right eye and all the targets were invisible to the left eye. When the test was repeated a few minutes later all the targets were visible to the right eye. Two days later, when the test was made more sensitive by
1310
NOTES, CASES, INSTRUMENTS Two months postoperatively the vision of the left eye was 20/30-2 and the peripheral fields of both eyes for 2/330 white were normal. Eight months later visual acuity and fields of both eyes were normal but for the next three years it was possible to demonstrate pupillary escape in the left eye by means of the swinging flashlight test.3 When last seen, in January, 1960, the patient was symp tom free, with vision of 20/20 in each eye, full fields, and no pupillary escape. The left optic disc was slightly paler than the right with fewer capillaries on its surface. COMMENT
Fig. 2 (Levatin). A pituitary adenoma com pletely surrounding the left optic nerve produced minimal contraction of the peripheral field and a generalized depression of the left central field, con verting the entire central field to a giant relative scotoma for white. The same tumor, exerting pres sure on the inferomedial aspect of the right optic nerve, produced a superior temporal defect with a hemianopic character in the zone between 30 and 50 degrees of the right peripheral field (2/330 white). The 1/330 field was too small and the 3/330 field too large to show this defect.
performing it with the room in full illumination, the patient missed two targets in the upper tem poral quadrant of the right central field and all of the targets in the left central field. On December 1, 1955, a transfrontal craniotomy was performed by Dr. Ching T. Liu, and a large, fleshy, rounded, well-encapsulated tumor was found just medial to the right optic nerve. The tumor extended above the sella and completely surrounded the left optic nerve so that only three mm. of the nerve was visible under the anterior clinoid process. The growth (a chromophobe adenoma) was re moved as completely as possible and at the end of the operation the chiasm and both optic nerves were clearlv visualized.
It is apparent from this case that pressure by a mass lesion when applied about the pe riphery of an optic nerve may decrease the conductivity of the entire cross section of the nerve. Examples of perimetric studies on tumors strangling the optic nerve are rare. Dandy4 described a girl, aged 13 years, with extraocular muscle palsies and slow bilateral pro gressive loss of vision. The right eye was totally blind; the left had a vision of 8/200 with complete loss of color perception. The visual field in this eye was preserved for form but somewhat contracted (only a small superior contraction was present with no central scotoma). At operation, surrounding each optic nerve was a small collarlike tumor "which in its slow fibrous growth had gradu ally constricted and strangled the optic nerve." The tumors were dural endotheliomas arising from the dural sheaths at the optic foramen. Another example of extensive involvement of both optic nerves without a central scotoma and with minimal changes in the peripheral fields was given in a previous paper.5 The patient was a 12-year-old boy with bilateral primary optic atrophy. The peripheral field of his amblyopic left eye (vision 20/400) was normal and that of his right eye (vision 20/30) had a temporal contraction of approximately 10 degrees. Op eration disclosed a large glioma at the chiasm completely surrounding the left optic nerve and almost completely the right nerve, with extension into the third ventricle. According to Traquair, 6 the field changes
NOTES, CASES, INSTRUMENTS
1311
in glioma of the optic nerve consist of "a that a positive Marcus Gunn sign was read slowly progressing depression and constric ily obtained in the left eye with the swing tion and are not in any way specially charac ing flashlight test. teristic." Others describe the visual fields in 4. The severe amblyopia was due to the glioma of the chiasm as bizarre, peculiar, or impaired conductivity of both the central as showing atypical or incongruous bitem- and peripheral fibers of the left optic nerve; poral defects. Gradual throttling of the optic that is, the conductivity of all the fibers in nerves may well be responsible for these the nerve was decreased. The absence of a unusual field changes, since these gliomas, as relative or absolute central scotoma in this in the 12-year-old boy just cited, tend to eye was not surprising, for a central scotoma surround as well as to invade the optic in chiasmal interference is so rare that, nerves. among their 156 verified cases of pituitary Four facets of the case reported in this adenoma and craniopharyngioma, Chamlin, Davidoff, and Feiring 8 found none with a paper merit emphasis: 1. Chamlin7 has pointed out that the visual purely central defect surrounded by com field defect produced by a prechiasmal lesion pletely normal field. may lie in a zone between 30 and 50 degrees SUMMARY which lies outside the normal central field and inside the inner limits of the usual periph In a patient with a pituitary tumor which eral field. To study this "intermediate field completely enveloped the left optic nerve, of vision" more carefully, he has devised a the left eye showed amblyopia, mild contrac special bowl-shaped perimeter of 750-mm. tion of the peripheral field for white, and radius and has predicted that some prechias generalized depression of the entire visible mal lesions would show the most marked field without a central scotoma. In addition, visual field defect in this intermediate field. pupillary escape (the only objective one My case, which was both chiasmal and pre of these eye signs) was present and persisted chiasmal, confirms this prediction as far as for three years after visual acuity and fields the right eye was concerned. had returned to normal following excision of 2. The Harrington-Flocks multiple pat the chromophobe adenoma. tern field screener with remarkable sensitiv Reference is made to two other cases in ity rapidly detected the small superior tem which tumors (a dural endothelioma and a poral field cut, which was difficult to plot chiasmal glioma), acting like constricting by ordinary perimetry even though it was rings about the optic nerves, caused similar sought assiduously in view of the abnormal eye signs. sella turcica. CONCLUSION 3. Pupillary escape should be demonstra A mass lesion that encircles and strangles ble whenever the light sense of one eye is the intracranial part of an optic nerve may, reduced by disease of the retina or optic by decreasing the conductivity of the entire nerve or by mass compression of an optic cross section of the optic nerve, produce the nerve. In this case, although both optic nerves eye findings characteristic of total trans were compressed, the difference in light verse neuritis. sense of the two eyes was so great (because 280 West MacArthur Boulevard (11). of the greater involvement of the left nerve) REFERENCES
1. Mooney, A. J., and McConnell, A. A.: Visual scotomata with intracranial lesions affecting the optic nerve. J. Neurol. Neurosurg. & Psychiat., 12:205, 1949. 2. Chamlin, M.: Visual field defects due to optic nerve compression by mass lesions. AMA Arch. Ophth., 58:37, 1957.
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NOTES, CASES, INSTRUMENTS
3. Levatin, P.: Pupillary escape in disease of the retina or optic nerve. AM A Arch. Ophth., 62:768, 1959. 4. Dandy, W. E.: Prechiasmal intracranial tumors of the optic nerves. Am. J. Ophth., 5:169, 1922. 5. Levatin, P.: Increased intracranial pressure without papilledema. AMA Arch. Ophth., 58:683, 1957. 6. Traquair, H. M.: An Introduction to Clinical Perimetry. St. Louis, Mosby, 1949, p. 197. 7. Chamlin, M.: An isopter in the intermediate field of vision. AMA Arch. Ophth., 61:608, 1959. 8. Chamlin, M., Davidoff, L. M., and Feiring, E. H.: Ophthalmologic changes produced by pituitary tumors. Am. I. Ophth, 40:353, 1955.
NONCICATRICIAL E N T R O P I O N O F LOWER LID* T R E A T E D BY T H E P A I V A GoNgALVES F I L H O SUTURE L. B O T E L H O F E R R E I R A ,
M.D.
Rio de Janeiro, Brazil
This is a new method for palpebral ptoses based on the Friedenwald-Guyton suture. The technique, as described by Paiva Goncalves Filho, is as follows: A 30.7 or 30.6 needle mounted on a syr inge filled with four-percent Novocaine is introduced from the outer canthus one or two mm. below the lid margin, entering horizontally and deeply to emerge parallel with the lacrimal punctum. The anesthetic is injected as the needle advances. The syringe is removed and the needle is left in place. A 5-0 mononylon suture is threaded through the needle which is removed, the thread being left in its place. Now the needle is introduced deep from down upward, verti cally about 30 mm. below the first point of exit where it must now emerge; the suture is left and the needle removed. Again, the needle is introduced deeply and vertically, 30 mm. below where the operation began and the suture is placed. Finally, the needle is again introduced from the temporal to the nasal side and the suture is placed. The ends of the sutures are not tied now because local edema due to the infiltration anesthetic obscures landmarks; however, a loop is tied over a piece of gauze or rubber to get an overcorrection. After the edema * From the Hospital dos Servidores do Estado.
has subsided (generally a week), the ends are tied. It is advisable to obtain a slight overcorrection. If general anesthesia is used an incision can be made to bury the sutures deep. This technique has been used in several cases with good results. The one failure was due to the vertical nasal step being shorter than the temporal one. CASE REPORTS
CASE 1
R. M. M. (H.S.E. Reg. No. 230237), a white woman, aged 72 years, was operated for senile entropion of the left lower lid four years ago without success. We performed this technique on the same lid on January 8, 1959, with good results. CASE 2
W. L. B. (F.F. Clinic Reg. No. 12013), a white woman, on June 6, 1958, had a Gaillart suture placed in the right lid without any results. On Jan uary 24, 1959, another operation was performed, using the present suture, with success. On April 9, 1959 the left lower lid was operated with good re sults.
Fig. 1 (Ferreira). Diagram showing the four steps in placing the Paiva Gongalves Filho suture.
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right eye with the lens removed. With such a lens over each eye', thereby negating accommodation bi laterally, no constriction occurred in either eye with position change but there was a constriction in convergence response to prisms in each eye. This supports the theory that the efferent path ways for accommodation and convergence are not the same.' Of course in this case only the afferent pathway for accommodation might have been harmed. From the pupillary responses this latter supposition seems unlikely. Either way is sugges tive of a neural rather than muscular involvement. After orbital injuries the convergence mechanism recovers first even before the light response and long before accommodation recovery, but here the light response recovered first which again tends to support a neural rather than muscular involve ment.* Some pupillary responses to drugs were noted. Those of the normal left eye were usual. Neostigmine (5.0 and 2.5 percent) and five-percent methacholine hydrochloride (Mecholyl) and carbachol (0.75 percent) had little or no action on the right pupil. Such lack of reactions proved no help in differentiating the lesion as neural or muscular. One year later the pupil of the right eye was
still slightly dilated and all reactions were normal, including drug responses. Accommodation was not quite the same as in the uninvolved eye (on refrac tion +0.75D. sph., O.D., for near was needed to balance accommodation) but no near lens was necessary for daily function and comfort. Manifest and cycloplegic refractions remained the same for distance. SUMMARY
A case of internal ophthalmoplegia follow ing a limbal papule during varicella is pre sented. Some tests and the nature of the re covery suggest the lesion was neural and not muscular. There remain a slight pupillary dilatation and some slight depression of ac commodation in this eye over a year later but the patient is comfortable and requires only a distance correction. Since the neurotoxicity of the varicella virus is well known, such a reaction is not too surprising. 321 East Front Street.
REFERENCES
1. Duke-Elder, S.: Textbook of Ophthalmology. St. Louis, Mosby, 1954, v. 4, p. 6948. 2. Suie, T.: Microbiolgy of the Eye. Manual Am. Acad. Ophth., chap. VI, p. 42. 3. Monod, M. F.: Concerning a case of tonic pupil in the course of varicella. Bull. Soc. ophtal. Franc;, 1958, No. 11, pp. 754-756. 4. Gavel, M. A.: Unilateral partial mydriasis as the result of varicella. Bull. Soc. ophtal. Fran?, 1958, No. 11, pp. 756-57, Nov. 1958. 5. Adler, F. H.: Gifford's Textbook of Ophthalmology. Philadelphia, Saunders, 1949, ed. 4, p. 448. 6. Berens, C.: The Eye and Its Diseases. Philadelphia, Saunders, 1936, p. 289. 7. Duke-Elder, S.: Textbook of Ophthalmology. St. Louis, Mosby Co., 1954, v. 4, p. 3747. 8. : Textbook of Ophthalmology. St. Louis, Mosby, 1954, v. 4, p. 3795. 9. : Textbook of Ophthalmology. St. Louis, Mosby, 1954, v. 4, p. 3734-3735.
EYE FINDINGS IN STRANGULATION O F T H E OPTIC NERVE* PAUL LEVATIN,
M.D.
Oakland, California Perimetry in acute retrobulbar neuritis usually reveals a central or cecocentral scotoma (axial neuritis), and more rarely a peripheral contraction (perineuritis), or a generalized depression of the entire visual field without a central scotoma (total trans* From the Department of Ophthalmology, the Permanente Medical Group, Kaiser Foundation Hospital.
verse neuritis). That these three field defects may also be produced by pressure of tumor upon an optic nerve is not surprising, for in the central nervous system lesions of differ ent etiology often produce the same neuro logic signs. In the Foster Kennedy syn drome, a central scotoma occurs on the sidi of a basofrontal tumor presumably due to hypersensitivity to pressure of the macular fibers. But the view that direct compression of an optic nerve manifests itself most com monly by a central scotoma has been chal lenged in recent years. Mooney and McConnell1 stated, "In the most common type of pituitary tumor the
NOTES, CASES, I N S T R U M E N T S
optic nerve appears to be whiter than nor mal, to be flattened and to curve round the tumor tightly embracing it. The expanded tumor must have exerted a considerable amount of pressure to produce such a dis tortion yet a central scotoma in such a case is a rarity." Chamlin2 reported 23 verified cases of mass compression of the optic nerve (chiefly due to meningiomas of the sphenoid ridge or olfactory groove), all with some involve ment of the peripheral fields and none with a discrete central scotoma unrelated to a more peripheral defect. In this paper is described a tumor which produced neither a central scotoma nor a pe ripheral contraction but a generalized depres sion of the entire visual field, as in total trans verse neuritis. The unusual manner of com pression revealed at operation was sufficient to explain the eye signs. REPORT OF A CASE A 51-year-old housewife consulted an ophthal mologist in March, 1955, because of frontal head ache and blurred vision in the left eye of three months' duration. The vision of the left eye, which was 20/40, dropped in the next six weeks for no apparent reason to 8/200. The fundi were normal and no cecocentral or nerve-fiber bundle defect could be found in the amblyopic eye. A diagnosis of retrobulbar neuritis was made and the pa tient was given typhoid vaccine intravenously and A C T H , with improvement in vision to 20/30. However, by September the vision of the left eye had decreased to 20/70. Fortunately, X-ray films of the sinuses were ordered by an otolaryngologist and, when these revealed enlargement and destruc tion of the sella turcica, the patient was sent to this hospital for the neurosurgical treatment of a pituitary tumor. No evidence of pituitary dysfunction was found on admission. The only neurologic finding was hyperactive deep tendon reflexes. Pneumo-encephalography revealed normal ventricles and a rather pointed soft tissue mass within the sella, pro truding upward beyond the diaphragm. The sella was markedly enlarged, with a depressed floor, and there was considerable thinning of the posterior clinoids (fig. 1). Ophthalmologic consultation revealed that the visual acuity of the right eye was 20/20; that of the left eye was reduced to 2/200. The pupils were equal. The left pupil reacted to light through a narrower arc than did the right, and redilated promptly (a positive Marcus Gunn pupillary sign).
1309
Fig. 1 (Levatin). Pneumoencephalogram show ing a pointed intrasellar soft tissue mass. The sella turcica is enlarged with erosion of the floor and posterior clinoids.
The pupillary escape in this eye was strikingly demonstrated when a flashlight was passed back and forth between the two eyes, the right pupil be coming small when illuminated and the left pupil becoming large when the flashlight was transferred to it. The optic discs were flat and pink but the right had eight capillaries on its surface and the left only four. The peripheral field of the right eye for 3/330 white was full, but for 1/330 white showed a generalized contraction to 32 degrees from fixation. However, a definite superior temporal contraction with a hemianopic character was present in the field for 2/330 white. The peripheral field of the left eye for 20/330 white (smaller targets allegedly not visible) revealed only a slight temporal con traction. The central field of the right eye for 1/1000 white was uniformly contracted to 13 de grees from fixation; that of the left eye was ir regularly contracted to approximately 15 degrees for 20/1000 white (fig. 2 ) . The large white test object appeared "beige" everywhere within the visible field of the left eye, as did the white fixation object. With this eye the 20-mm. white target ap peared most bright in the nasal quadrants, and least bright in the temporal quadrants; while with a large red test object a temporal hemianopia was present. On the Harrington-Flocks multiple pattern field screener, four targets were missing in the upper temporal quadrant of the right eye and all the targets were invisible to the left eye. When the test was repeated a few minutes later all the targets were visible to the right eye. Two days later, when the test was made more sensitive by
1310
NOTES, CASES, INSTRUMENTS Two months postoperatively the vision of the left eye was 20/30-2 and the peripheral fields of both eyes for 2/330 white were normal. Eight months later visual acuity and fields of both eyes were normal but for the next three years it was possible to demonstrate pupillary escape in the left eye by means of the swinging flashlight test.3 When last seen, in January, 1960, the patient was symp tom free, with vision of 20/20 in each eye, full fields, and no pupillary escape. The left optic disc was slightly paler than the right with fewer capillaries on its surface. COMMENT
Fig. 2 (Levatin). A pituitary adenoma com pletely surrounding the left optic nerve produced minimal contraction of the peripheral field and a generalized depression of the left central field, con verting the entire central field to a giant relative scotoma for white. The same tumor, exerting pres sure on the inferomedial aspect of the right optic nerve, produced a superior temporal defect with a hemianopic character in the zone between 30 and 50 degrees of the right peripheral field (2/330 white). The 1/330 field was too small and the 3/330 field too large to show this defect.
performing it with the room in full illumination, the patient missed two targets in the upper tem poral quadrant of the right central field and all of the targets in the left central field. On December 1, 1955, a transfrontal craniotomy was performed by Dr. Ching T. Liu, and a large, fleshy, rounded, well-encapsulated tumor was found just medial to the right optic nerve. The tumor extended above the sella and completely surrounded the left optic nerve so that only three mm. of the nerve was visible under the anterior clinoid process. The growth (a chromophobe adenoma) was re moved as completely as possible and at the end of the operation the chiasm and both optic nerves were clearlv visualized.
It is apparent from this case that pressure by a mass lesion when applied about the pe riphery of an optic nerve may decrease the conductivity of the entire cross section of the nerve. Examples of perimetric studies on tumors strangling the optic nerve are rare. Dandy4 described a girl, aged 13 years, with extraocular muscle palsies and slow bilateral pro gressive loss of vision. The right eye was totally blind; the left had a vision of 8/200 with complete loss of color perception. The visual field in this eye was preserved for form but somewhat contracted (only a small superior contraction was present with no central scotoma). At operation, surrounding each optic nerve was a small collarlike tumor "which in its slow fibrous growth had gradu ally constricted and strangled the optic nerve." The tumors were dural endotheliomas arising from the dural sheaths at the optic foramen. Another example of extensive involvement of both optic nerves without a central scotoma and with minimal changes in the peripheral fields was given in a previous paper.5 The patient was a 12-year-old boy with bilateral primary optic atrophy. The peripheral field of his amblyopic left eye (vision 20/400) was normal and that of his right eye (vision 20/30) had a temporal contraction of approximately 10 degrees. Op eration disclosed a large glioma at the chiasm completely surrounding the left optic nerve and almost completely the right nerve, with extension into the third ventricle. According to Traquair, 6 the field changes
NOTES, CASES, INSTRUMENTS
1311
in glioma of the optic nerve consist of "a that a positive Marcus Gunn sign was read slowly progressing depression and constric ily obtained in the left eye with the swing tion and are not in any way specially charac ing flashlight test. teristic." Others describe the visual fields in 4. The severe amblyopia was due to the glioma of the chiasm as bizarre, peculiar, or impaired conductivity of both the central as showing atypical or incongruous bitem- and peripheral fibers of the left optic nerve; poral defects. Gradual throttling of the optic that is, the conductivity of all the fibers in nerves may well be responsible for these the nerve was decreased. The absence of a unusual field changes, since these gliomas, as relative or absolute central scotoma in this in the 12-year-old boy just cited, tend to eye was not surprising, for a central scotoma surround as well as to invade the optic in chiasmal interference is so rare that, nerves. among their 156 verified cases of pituitary Four facets of the case reported in this adenoma and craniopharyngioma, Chamlin, Davidoff, and Feiring 8 found none with a paper merit emphasis: 1. Chamlin7 has pointed out that the visual purely central defect surrounded by com field defect produced by a prechiasmal lesion pletely normal field. may lie in a zone between 30 and 50 degrees SUMMARY which lies outside the normal central field and inside the inner limits of the usual periph In a patient with a pituitary tumor which eral field. To study this "intermediate field completely enveloped the left optic nerve, of vision" more carefully, he has devised a the left eye showed amblyopia, mild contrac special bowl-shaped perimeter of 750-mm. tion of the peripheral field for white, and radius and has predicted that some prechias generalized depression of the entire visible mal lesions would show the most marked field without a central scotoma. In addition, visual field defect in this intermediate field. pupillary escape (the only objective one My case, which was both chiasmal and pre of these eye signs) was present and persisted chiasmal, confirms this prediction as far as for three years after visual acuity and fields the right eye was concerned. had returned to normal following excision of 2. The Harrington-Flocks multiple pat the chromophobe adenoma. tern field screener with remarkable sensitiv Reference is made to two other cases in ity rapidly detected the small superior tem which tumors (a dural endothelioma and a poral field cut, which was difficult to plot chiasmal glioma), acting like constricting by ordinary perimetry even though it was rings about the optic nerves, caused similar sought assiduously in view of the abnormal eye signs. sella turcica. CONCLUSION 3. Pupillary escape should be demonstra A mass lesion that encircles and strangles ble whenever the light sense of one eye is the intracranial part of an optic nerve may, reduced by disease of the retina or optic by decreasing the conductivity of the entire nerve or by mass compression of an optic cross section of the optic nerve, produce the nerve. In this case, although both optic nerves eye findings characteristic of total trans were compressed, the difference in light verse neuritis. sense of the two eyes was so great (because 280 West MacArthur Boulevard (11). of the greater involvement of the left nerve) REFERENCES
1. Mooney, A. J., and McConnell, A. A.: Visual scotomata with intracranial lesions affecting the optic nerve. J. Neurol. Neurosurg. & Psychiat., 12:205, 1949. 2. Chamlin, M.: Visual field defects due to optic nerve compression by mass lesions. AMA Arch. Ophth., 58:37, 1957.
1312
NOTES, CASES, INSTRUMENTS
3. Levatin, P.: Pupillary escape in disease of the retina or optic nerve. AM A Arch. Ophth., 62:768, 1959. 4. Dandy, W. E.: Prechiasmal intracranial tumors of the optic nerves. Am. J. Ophth., 5:169, 1922. 5. Levatin, P.: Increased intracranial pressure without papilledema. AMA Arch. Ophth., 58:683, 1957. 6. Traquair, H. M.: An Introduction to Clinical Perimetry. St. Louis, Mosby, 1949, p. 197. 7. Chamlin, M.: An isopter in the intermediate field of vision. AMA Arch. Ophth., 61:608, 1959. 8. Chamlin, M., Davidoff, L. M., and Feiring, E. H.: Ophthalmologic changes produced by pituitary tumors. Am. I. Ophth, 40:353, 1955.
NONCICATRICIAL E N T R O P I O N O F LOWER LID* T R E A T E D BY T H E P A I V A GoNgALVES F I L H O SUTURE L. B O T E L H O F E R R E I R A ,
M.D.
Rio de Janeiro, Brazil
This is a new method for palpebral ptoses based on the Friedenwald-Guyton suture. The technique, as described by Paiva Goncalves Filho, is as follows: A 30.7 or 30.6 needle mounted on a syr inge filled with four-percent Novocaine is introduced from the outer canthus one or two mm. below the lid margin, entering horizontally and deeply to emerge parallel with the lacrimal punctum. The anesthetic is injected as the needle advances. The syringe is removed and the needle is left in place. A 5-0 mononylon suture is threaded through the needle which is removed, the thread being left in its place. Now the needle is introduced deep from down upward, verti cally about 30 mm. below the first point of exit where it must now emerge; the suture is left and the needle removed. Again, the needle is introduced deeply and vertically, 30 mm. below where the operation began and the suture is placed. Finally, the needle is again introduced from the temporal to the nasal side and the suture is placed. The ends of the sutures are not tied now because local edema due to the infiltration anesthetic obscures landmarks; however, a loop is tied over a piece of gauze or rubber to get an overcorrection. After the edema * From the Hospital dos Servidores do Estado.
has subsided (generally a week), the ends are tied. It is advisable to obtain a slight overcorrection. If general anesthesia is used an incision can be made to bury the sutures deep. This technique has been used in several cases with good results. The one failure was due to the vertical nasal step being shorter than the temporal one. CASE REPORTS
CASE 1
R. M. M. (H.S.E. Reg. No. 230237), a white woman, aged 72 years, was operated for senile entropion of the left lower lid four years ago without success. We performed this technique on the same lid on January 8, 1959, with good results. CASE 2
W. L. B. (F.F. Clinic Reg. No. 12013), a white woman, on June 6, 1958, had a Gaillart suture placed in the right lid without any results. On Jan uary 24, 1959, another operation was performed, using the present suture, with success. On April 9, 1959 the left lower lid was operated with good re sults.
Fig. 1 (Ferreira). Diagram showing the four steps in placing the Paiva Gongalves Filho suture.