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Filamentary Keratitis*
NOTES, CASES, INSTRUMENTS
1292
the left nostril and left in place for approximately six weeks. However, the watering eventually re curred and, in April, 1959, a Jameson procedure was done, with insertion of a strip of Gelfilm. The postoperative course was not remarkable except for the slightly prolonged inflammatory reaction and slow healing. The patient has been comfortable since. The Schirmer test at the time of her last visit in September was 10 mm. CASE 3
A 63-year-old white man was seen in Decem ber, 1958, with watering of both eyes, of about 15 years' duration. This was much worse on the right. He gave a history of repeated nasolacrimal duct probings which at first had afforded slight relief but eventually none. There was a slight mucopurulent discharge. The right duct system was totally obstructed, the left incompletely so. He refused to have a dacryocystorhinostomy and would submit only to a "simple procedure." In
February, 1959, the Jameson procedure with Gelfilm insert was done. Surgery and postoperative course proceeded satisfactorily and he has been very much improved since. SUMMARY
The original procedure of subconjunctival sectioning of the lacrimal gland ductules as described by Jameson has been modified by insertion of a strip of Gelfilm. It is felt that this modification enhances the probability of obtaining a favorable result in chronic epiphora from obstructed lacrimal passages. Three case reports are included. The opera tion is contraindicated in cases of deficient lacrimal secretion. 117 East Eighth Street (13).
REFERENCES
1. Iliff, C. E.: A simplified dacryocystorhinostomy. Tr. Am. Acad. Ophth., 58:590-592 (July) 1954. 2. Bietti, G. B., and Boles-Carentini, B.: Tecnica e resultati della intubazione ad imora con cannula di polietilene del dotta naso-lacrimale nella carcriocistite. Boll, ocul., 32:385-400 (July) 1953. 3. Jameson, P. C.: Subconjunctival section of ductules of lacrimal glands as cure for epiphora. Arch. Ophth., 17:207-12 (Feb.) 1937. 4. Callahan, A.: Surgery of the Eye Diseases. Springfield, 111., Thomas, 1956. 5. The Collected Letters of the International Correspondence Society of Ophthalmologists & Otolaryngologists: Series IV, October 30, 1959, pp. 153-160. 6. Laval, J.: Use of Gelfilm in glaucoma filtration surgery. Arch. Ophth., 54:677 (Nov.) 1955. 7. Barsky, D., and Schimek, R. A.: Evaluation of absorbable gelatin film in cyclodialysis of rabbits. Arch. Ophth., 60:1044-1052 (Dec.) 1958. 8. Laval, J.: The use of absorbable gelatin film (Gelfilm) in ophthalmic surgery. New York State J. Med., 58:2399-2401 (July) 1958.
FILAMENTARY KERATITIS* RESPONSE TO BETA RADIATION DAVID M. WINTERS,
M.D.
AND TAYLOR ASBURY,
M.D.
Cincinnati, Ohio Filamentary keratitis is not a specific dis ease entity but a term used to describe a type of corneal abnormality characterized by the presence of epithelial filaments. It is known that the herpes-simplex virus can be a cause of filamentary keratitis. Filaments are also * From the Department of Ophthalmology, Uni versity of Cincinnati, College of Medicine. Pre sented before the Frederick C. Cordes Eye Society San Francisco, May 22, 1960.
seen in keratoconjunctivitis sicca, or asso ciated with recurrent corneal erosion. Fila mentary keratitis must be considered to be idiopathic when these causes can be ruled out. The condition causes marked ocular dis comfort, photophobia, lacrimation and visual impairment. As with any condition that does not respond well to existing treatment, many forms of therapy have been tried, such as tarsorrhaphy, various types of topical medi cations including antibiotics,1 amino acids2 and chemical agents, mechanical denudation, smallpox vaccination, therapeutic scleral contact lens and judicious waiting. A thorough search of the literature re veals little information concerning fila-
NOTES, CASES, INSTRUMENTS
Fig. 1 (Winters and Asbury). Appearance of filamentary keratitis, November, 1959, prior to beta radiation.
mentary keratitis 3-6 and only an occasional suggestion for satisfactory therapy. This short report describes a case in which a persistent, very uncomfortable filamentary keratitis apparently responded to beta ir radiation after a number of other attempts at therapy had failed. Only one reference in the literature can be found which utilized beta irradiation as therapy for filamentary keratitis. Thomas,7 in his excellent review of corneal disease, mentions three cases unsuc cessfully treated with beta radiation. It seemed worthwhile therefore to report on the following case. CASE REPORT
Present illness. B. C, a 38-year-old white man, was first seen by the eye service, Cincinnati Gen eral Hospital on September 14, 1959. His right eye was red and irritated with symptoms of lacrimation, photophobia, and pain which had been present about three weeks. The patient is a known chronic alcoholic of at least 10 years' duration. In May, 1957, he sustained a traumatic right subdural hematoma which was evacuated. He recovered well except for a complete right third-nerve palsy and a spastic bladder. He was followed by the neuro logic department of the U.S. Veterans Administra tion Hospital, Cincinnati, Ohio, until May, 1958, by which time there was definite improvement of the right third-nerve function. The palsy included a partial ptosis of the right upper lid, slightly dilated pupil and a right exotropia with no evi dence of fourth or sixth nerve involvement. Ocular examination revealed considerable bulbar conjunctival injection of the right eye. The palpebral conjunctiva was normal. Visual acuity was 20/200 with correction. Slitlamp examination re vealed multiple epithelial filaments on the cornea, mostly attached near the superior limbus and typi-
1293
Fig. 2 (Winters and Asbury). Appearance of cornea, April, 1960, four months after course of beta radiation. cal of filamentary keratitis. They were about one mm. wide, five mm. thick and hung down over the cornea. The rest of the examination of the right eye and the entire examination of the left eye was normal (visual acuity = 20/20 with cor rection). A right exotropia of 404 for near and distance was also present. Course and treatment. During September, 1959, the patient was placed on a local antibiotic steroid solution every four hours. There may have been some decrease in the number of filaments and the conjunctival injection was less. During October, 1959, while still on local antibiotic steroid com binations, the eye appeared much worse. Many more epithelial filaments appeared, measuring about one mm. in thickness, up to five mm. in length and predominantly present on the superior half of the cornea. Corneal sensation was slightly reduced and the Schirmer test was normal. Bacterial and virus cultures were negative on repeated testing. Later in October, pressure dressings with local antibiotic steroid ointments did not reduce the symptoms nor improve the keratitis. During No vember, 1959, the entire corneal epithelium was mechanically denuded on several occasions. This helped symptomatically until the full-blown fila mentary keratitis returned within seven to 10 days after each scraping. In December, 1959, it was decided to try a short course of beta radiation. Without scraping off the filaments prior to therapy, a strontium applicator was used to deliver 500 rep. from the 9- to 12o'clock positions and 500 rep. from the 12- to 3-o'clock positions. Three days later the 3- to 6-o'clock and the 6- to 9-o'clock quadrants were also treated with 500 rep. each, making a total of 2,000 rep. to the eye. Within two weeks the fila ments had entirely disappeared and the epithelium had returned to a normal appearance. During a 12-month follow-up period there has been complete remission of the keratitis. The eye has remained white, the patient comfortable. The cornea shows no abnormalities under slitlamp examination. Visual acuity returned to 20/30.
1294
NOTES, CASES, INSTRUMENTS DISCUSSION
A s to the etiology in this case, herpes sim plex has been ruled out. T h e normal Schirmer test rules out keratitis sicca. There is no history of trauma or evidence of recur rent erosion. The retention of corneal sensa tion rules out trophic changes as a possible cause. W i t h our present lack of knowledge, this case falls into the idiopathic group of filamentary keratitis. O n the basis of one patient with an ap parently favorable response to beta radia tion, it is impossible to draw definite con clusions, especially since it is well known that spontaneous remission does occur. O n the other hand, some cases of filamentary keratitis have proven to be most refractory to any form of therapy and the case here re ported would appear to be one of these. This apparent response to beta radiation once again focuses our attention on a type of treat ment that hit its zenith 10 or 12 years ago when advocated by some enthusiasts as a panacea for almost any corneal o r scleral disease. With few exceptions beta radiation
is now generally reserved for treating cor neal vascularization in connection with keratoplasty, recurrent pterygium, rosacea kera titis and severe vernal conjunctivitis. 8 I t s further use in the treatment of idiopathic filamentary keratitis unresponsive to other forms of therapy seems warranted. SUMMARY
A case history of a 38-year-old white man w h o developed persistent filamentary keratitis following a traumatic right subdural hematoma is presented. T h e fila mentary keratitis failed to respond to a num ber of therapeutic measures including local antibiotic and steroid ointment, repeated mechanical denudation, pressure dressings and watchful waiting. Following the applica tion of minimum beta radiation therapy, the filamentary keratitis cleared completely. T h e patient has been entirely symptom free for a 12-month follow-up period.
2325 Vera (13). 718 Carew Tozver (2).
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8.
Benner, R.: Is filamentary keratitis infectious? Ann. ocul., 180:140-141, 1947. Schaeffer, A. J.: Amino acids in corneal healing. Am. J. Ophth., 33:741-750, 1950. Thomas, C. I.: The Cornea. Springfield, 111., Thomas, 1955, pp. 467-470. Berliner, M. L.: Biomicroscopy of the Eye. 1949, v. 1, pp. 490-492. Bossalino, G.: Keratitis filamentosa Boll, ocul., 15:1193-1214, 1936. Westkamp, C : Parenchymatous origin of filamentary keratitis. Am. J. Ophth., 42:115-120, 1956. Thomas, C. I.: The Cornea. Springfield, 111., Thomas, 1955, p. 990. Lehey, B. D.: Beta radiation in ophthalmology. Am. T. Ophth., 49 :7-28, 1960.
LYMPHOSARCOMA O F T H E CHOROID HAROLD BEASLEY,
M.D.
Fort Worth, Texas Primary lymphomatous lesions are un common in the eye and the adnexa and pri mary lymphomatous lesions of the choroid, without systemic involvement, are extremely rare. Stout has classified lymphomatous tumors into the lymphocytic cell type, the giant follicle type and the reticulum cell type.
Lymphatic leukemia and possibly Hodgkin's disease may also be considered in this group. T h e giant follicle type is the least malignant and the reticulum cell type the most malig nant. Since the eye does not contain lymphoid tissue or true lymphatics, intraocular lymphosarcoma of the lymphocytic cell type should be found only as a metastatic lesion. Cells of the reticulo-endothelial system a r e found in the eye, therefore we should expect to see primary lesions of the reticulum cell type. Reese reported three cases of intraocular
1292
the left nostril and left in place for approximately six weeks. However, the watering eventually re curred and, in April, 1959, a Jameson procedure was done, with insertion of a strip of Gelfilm. The postoperative course was not remarkable except for the slightly prolonged inflammatory reaction and slow healing. The patient has been comfortable since. The Schirmer test at the time of her last visit in September was 10 mm. CASE 3
A 63-year-old white man was seen in Decem ber, 1958, with watering of both eyes, of about 15 years' duration. This was much worse on the right. He gave a history of repeated nasolacrimal duct probings which at first had afforded slight relief but eventually none. There was a slight mucopurulent discharge. The right duct system was totally obstructed, the left incompletely so. He refused to have a dacryocystorhinostomy and would submit only to a "simple procedure." In
February, 1959, the Jameson procedure with Gelfilm insert was done. Surgery and postoperative course proceeded satisfactorily and he has been very much improved since. SUMMARY
The original procedure of subconjunctival sectioning of the lacrimal gland ductules as described by Jameson has been modified by insertion of a strip of Gelfilm. It is felt that this modification enhances the probability of obtaining a favorable result in chronic epiphora from obstructed lacrimal passages. Three case reports are included. The opera tion is contraindicated in cases of deficient lacrimal secretion. 117 East Eighth Street (13).
REFERENCES
1. Iliff, C. E.: A simplified dacryocystorhinostomy. Tr. Am. Acad. Ophth., 58:590-592 (July) 1954. 2. Bietti, G. B., and Boles-Carentini, B.: Tecnica e resultati della intubazione ad imora con cannula di polietilene del dotta naso-lacrimale nella carcriocistite. Boll, ocul., 32:385-400 (July) 1953. 3. Jameson, P. C.: Subconjunctival section of ductules of lacrimal glands as cure for epiphora. Arch. Ophth., 17:207-12 (Feb.) 1937. 4. Callahan, A.: Surgery of the Eye Diseases. Springfield, 111., Thomas, 1956. 5. The Collected Letters of the International Correspondence Society of Ophthalmologists & Otolaryngologists: Series IV, October 30, 1959, pp. 153-160. 6. Laval, J.: Use of Gelfilm in glaucoma filtration surgery. Arch. Ophth., 54:677 (Nov.) 1955. 7. Barsky, D., and Schimek, R. A.: Evaluation of absorbable gelatin film in cyclodialysis of rabbits. Arch. Ophth., 60:1044-1052 (Dec.) 1958. 8. Laval, J.: The use of absorbable gelatin film (Gelfilm) in ophthalmic surgery. New York State J. Med., 58:2399-2401 (July) 1958.
FILAMENTARY KERATITIS* RESPONSE TO BETA RADIATION DAVID M. WINTERS,
M.D.
AND TAYLOR ASBURY,
M.D.
Cincinnati, Ohio Filamentary keratitis is not a specific dis ease entity but a term used to describe a type of corneal abnormality characterized by the presence of epithelial filaments. It is known that the herpes-simplex virus can be a cause of filamentary keratitis. Filaments are also * From the Department of Ophthalmology, Uni versity of Cincinnati, College of Medicine. Pre sented before the Frederick C. Cordes Eye Society San Francisco, May 22, 1960.
seen in keratoconjunctivitis sicca, or asso ciated with recurrent corneal erosion. Fila mentary keratitis must be considered to be idiopathic when these causes can be ruled out. The condition causes marked ocular dis comfort, photophobia, lacrimation and visual impairment. As with any condition that does not respond well to existing treatment, many forms of therapy have been tried, such as tarsorrhaphy, various types of topical medi cations including antibiotics,1 amino acids2 and chemical agents, mechanical denudation, smallpox vaccination, therapeutic scleral contact lens and judicious waiting. A thorough search of the literature re veals little information concerning fila-
NOTES, CASES, INSTRUMENTS
Fig. 1 (Winters and Asbury). Appearance of filamentary keratitis, November, 1959, prior to beta radiation.
mentary keratitis 3-6 and only an occasional suggestion for satisfactory therapy. This short report describes a case in which a persistent, very uncomfortable filamentary keratitis apparently responded to beta ir radiation after a number of other attempts at therapy had failed. Only one reference in the literature can be found which utilized beta irradiation as therapy for filamentary keratitis. Thomas,7 in his excellent review of corneal disease, mentions three cases unsuc cessfully treated with beta radiation. It seemed worthwhile therefore to report on the following case. CASE REPORT
Present illness. B. C, a 38-year-old white man, was first seen by the eye service, Cincinnati Gen eral Hospital on September 14, 1959. His right eye was red and irritated with symptoms of lacrimation, photophobia, and pain which had been present about three weeks. The patient is a known chronic alcoholic of at least 10 years' duration. In May, 1957, he sustained a traumatic right subdural hematoma which was evacuated. He recovered well except for a complete right third-nerve palsy and a spastic bladder. He was followed by the neuro logic department of the U.S. Veterans Administra tion Hospital, Cincinnati, Ohio, until May, 1958, by which time there was definite improvement of the right third-nerve function. The palsy included a partial ptosis of the right upper lid, slightly dilated pupil and a right exotropia with no evi dence of fourth or sixth nerve involvement. Ocular examination revealed considerable bulbar conjunctival injection of the right eye. The palpebral conjunctiva was normal. Visual acuity was 20/200 with correction. Slitlamp examination re vealed multiple epithelial filaments on the cornea, mostly attached near the superior limbus and typi-
1293
Fig. 2 (Winters and Asbury). Appearance of cornea, April, 1960, four months after course of beta radiation. cal of filamentary keratitis. They were about one mm. wide, five mm. thick and hung down over the cornea. The rest of the examination of the right eye and the entire examination of the left eye was normal (visual acuity = 20/20 with cor rection). A right exotropia of 404 for near and distance was also present. Course and treatment. During September, 1959, the patient was placed on a local antibiotic steroid solution every four hours. There may have been some decrease in the number of filaments and the conjunctival injection was less. During October, 1959, while still on local antibiotic steroid com binations, the eye appeared much worse. Many more epithelial filaments appeared, measuring about one mm. in thickness, up to five mm. in length and predominantly present on the superior half of the cornea. Corneal sensation was slightly reduced and the Schirmer test was normal. Bacterial and virus cultures were negative on repeated testing. Later in October, pressure dressings with local antibiotic steroid ointments did not reduce the symptoms nor improve the keratitis. During No vember, 1959, the entire corneal epithelium was mechanically denuded on several occasions. This helped symptomatically until the full-blown fila mentary keratitis returned within seven to 10 days after each scraping. In December, 1959, it was decided to try a short course of beta radiation. Without scraping off the filaments prior to therapy, a strontium applicator was used to deliver 500 rep. from the 9- to 12o'clock positions and 500 rep. from the 12- to 3-o'clock positions. Three days later the 3- to 6-o'clock and the 6- to 9-o'clock quadrants were also treated with 500 rep. each, making a total of 2,000 rep. to the eye. Within two weeks the fila ments had entirely disappeared and the epithelium had returned to a normal appearance. During a 12-month follow-up period there has been complete remission of the keratitis. The eye has remained white, the patient comfortable. The cornea shows no abnormalities under slitlamp examination. Visual acuity returned to 20/30.
1294
NOTES, CASES, INSTRUMENTS DISCUSSION
A s to the etiology in this case, herpes sim plex has been ruled out. T h e normal Schirmer test rules out keratitis sicca. There is no history of trauma or evidence of recur rent erosion. The retention of corneal sensa tion rules out trophic changes as a possible cause. W i t h our present lack of knowledge, this case falls into the idiopathic group of filamentary keratitis. O n the basis of one patient with an ap parently favorable response to beta radia tion, it is impossible to draw definite con clusions, especially since it is well known that spontaneous remission does occur. O n the other hand, some cases of filamentary keratitis have proven to be most refractory to any form of therapy and the case here re ported would appear to be one of these. This apparent response to beta radiation once again focuses our attention on a type of treat ment that hit its zenith 10 or 12 years ago when advocated by some enthusiasts as a panacea for almost any corneal o r scleral disease. With few exceptions beta radiation
is now generally reserved for treating cor neal vascularization in connection with keratoplasty, recurrent pterygium, rosacea kera titis and severe vernal conjunctivitis. 8 I t s further use in the treatment of idiopathic filamentary keratitis unresponsive to other forms of therapy seems warranted. SUMMARY
A case history of a 38-year-old white man w h o developed persistent filamentary keratitis following a traumatic right subdural hematoma is presented. T h e fila mentary keratitis failed to respond to a num ber of therapeutic measures including local antibiotic and steroid ointment, repeated mechanical denudation, pressure dressings and watchful waiting. Following the applica tion of minimum beta radiation therapy, the filamentary keratitis cleared completely. T h e patient has been entirely symptom free for a 12-month follow-up period.
2325 Vera (13). 718 Carew Tozver (2).
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8.
Benner, R.: Is filamentary keratitis infectious? Ann. ocul., 180:140-141, 1947. Schaeffer, A. J.: Amino acids in corneal healing. Am. J. Ophth., 33:741-750, 1950. Thomas, C. I.: The Cornea. Springfield, 111., Thomas, 1955, pp. 467-470. Berliner, M. L.: Biomicroscopy of the Eye. 1949, v. 1, pp. 490-492. Bossalino, G.: Keratitis filamentosa Boll, ocul., 15:1193-1214, 1936. Westkamp, C : Parenchymatous origin of filamentary keratitis. Am. J. Ophth., 42:115-120, 1956. Thomas, C. I.: The Cornea. Springfield, 111., Thomas, 1955, p. 990. Lehey, B. D.: Beta radiation in ophthalmology. Am. T. Ophth., 49 :7-28, 1960.
LYMPHOSARCOMA O F T H E CHOROID HAROLD BEASLEY,
M.D.
Fort Worth, Texas Primary lymphomatous lesions are un common in the eye and the adnexa and pri mary lymphomatous lesions of the choroid, without systemic involvement, are extremely rare. Stout has classified lymphomatous tumors into the lymphocytic cell type, the giant follicle type and the reticulum cell type.
Lymphatic leukemia and possibly Hodgkin's disease may also be considered in this group. T h e giant follicle type is the least malignant and the reticulum cell type the most malig nant. Since the eye does not contain lymphoid tissue or true lymphatics, intraocular lymphosarcoma of the lymphocytic cell type should be found only as a metastatic lesion. Cells of the reticulo-endothelial system a r e found in the eye, therefore we should expect to see primary lesions of the reticulum cell type. Reese reported three cases of intraocular