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Further Studies on the Effect of Agents on Regeneration of Corneal Epithelium*
544
MARR, WOOD AND GRIEVES REFEREKCES
1. Bignell, J. L.: Infection of the cornea with B. pyocyaneus: Clinical study and summary of ten cases personally observed. Brit. J. Ophth., 35 :419-423, 1951. 2. Brown, E. H".: Therapeutic experiences with corneal ulcer due to Bacillus pyocyaneus. Arch. Ophth., 30:221-224,1943. 3. Joy, H. H.: Treatment of experimental Bacillus pyocyaneus ulcer of cornea with sulfapyridine. Arch. Ophth., 27:1135-1164, 1942. 4. Juler, F., and Young, M. Y.: The treatment of septic ulcer of the cornea by local application of penicillin. Brit. J. Ophth., 29 :312-322, 1945. 5. Ainslie, D., and Smith, C.: Polymyxin E., Penetration into the eye and therapeutic value in experi mental infection due to Ps. pyocyanea. Brit. J. Ophth., 36 :352-361, 1952. 6. Wiggins, R. L.: Experimental studies on the eye with polymyxin B. Am. J.Ophth., 35 :83-99, 1952. 7. Eareckson, V. C, Miller, J. M., and Long, P. H.: Infection of the eye due to Pseudomonas aeruginosa treated with polymyxin B and "Varidase." Arch. Ophth., 49:158-160, 1953. 8. Kagan, B. M., Krevsky, D., Milzer, A., and Locke, M.: Polymyxin B and polymyxin E. J. Lab. & Clin. Med., 37:402-414, 1951. 9. Brownlee, G., and Bushby, S. R. M.: Chemotherapy and pharmacology of Aerosporin. Lancet 1: 127-132, 1948. 10. Jawetz, E.: Infections with Pseudomonas aeruginosa treated with polymyxin B. Arch. Int. Med., 89: 90-98, 1952. 11. Searle, D. S.: Personal communication.
F U R T H E R STUDIES ON T H E E F F E C T O F AGENTS ON REGENERATION O F CORNEAL E P I T H E L I U M * WILLIAM G. MARR, M.D.,
RONALD WOOD, P H . D . , AND MARTHA GRIEVES
Baltimore, Maryland
In a previous publication,1 using a tech nique devised by Buschke and Friedenwald, it was shown that the available antibiotic de rivatives of actinomycetes (streptomycin, chloromycetin, aureomycin, and terramycin) in concentrations used clinically and with the pH of the solutions maintained at 7.2 did not delay the healing of epithelial defects in the rat's cornea. Normal healing also took place when the sodium or potassium salt of crystal line penicillin. G was used in a concentration of 2,500 units per cc. Two nonmetallic organic antiseptics, zephiran and phemerol chloride, and two anes thetic solutions, butyn sulfate and tetracaine hydrochloride, prevented healing. This paper presents the results obtained *From the Wilmer Ophthalmological Institute of The Johns Hopkins University and Hospital. This work was supported in part by grants-in-aid from the American Cancer Society through the Committee on Growth of the National Research Council and from the Institute of Neurology and Blindness of the Federal Security Agency.
with some antiseptics not tested previously and with some of the more recently available antibiotics. In addition, experiments were undertaken to discover if, within the limita tions of the technique employed, there was any evidence of stimulation of epithelization by calsulfhydryl (Hydrosulphosol®). METHOD
The experiments were performed in the same manner as was described in the paper 1 published in 1951. For a more thorough dis cussion of the technique the original publica tion of Buschke and Friedenwald2 may be consulted. Briefly, with a fine needle, small circular epithelial defects were produced in the cornea of an anesthetized rat's eye, the eyes were enucleated and placed in test solu tions. The pH of the test solution was main tained at neutrality with a buffer and the solution with the enucleated eyes aerated for ® Hydrosulphosol is the registered trademark of the E. C. Lientz & Co., Inc.
REGENERATION OF CORNEAL EPITHELIUM
three hours at a temperature of 38°C. Follow ing the aeration the eyes were removed and the corneas prepared so that the epithelial defects could be examined under the high power of the microscope. The nuclei of cells around healed defects showed an increased staining and the nuclei of cells, especially of the basal layers, were arranged in a radial pattern and the cells covered the floor of the defect (fig. 1). The nuclei of cells around an unhealed lesion did not show an increased staining and the nuclei were in a tangential pattern rather than in a radial arrangement to the uncovered defect (fig. 2 ) . In lesions showing retarded healing the nuclei were arranged in a radial pattern at the periphery but the defect was still present and uncovered. In earlier experiments it was found that the epithelial defects were practically all healed after three hours in Sorenson's phos phate buffer with a pH of 7.2. Little observa ble change could be seen in the epithelial de fects after one hour but after the second hour the defects changed rapidly. Observations
545
Fig. 2 (Marr, Wood, and Grieves). Photomicro graph, showing unhealed epithelial lesions.
made after two, and two and one-half hours against controls were used to ascertain whether there was any evidence of stimula tion of epithelization by the substance being tested. RESULTS
Table 1 shows the results obtained when the eyes were placed for three hours in Sorensen's phosphate buffer solution at a pH of 7.0 in the presence of the various agents under investigation. The controls were eyes placed for three hours in Sorensen's phosphate buffer solution at a pH of 7.0. Polymyxin B sulfate, a polypeptide anti biotic derived from a bacillus, did not delay healing in a concentration used clinically of 20,000 μ^ per ml. Erythromycin,* a recent derivative from an actinomycete, is mainly active against
Fig. 1 (Marr, Wood, and Grieves). Photomicro graph, showing healed epithelial defects.
* We wish to thank the following companies for generously supplying the indicated material: Eli Lilly & Co., erythromycin; Charles Pfizer & Co., Inc., carbomycin; the Upjohn Co., circulin; Merck & Co., Inc., MK-65.
546
MARR, WOOD AND GRIEVES TABLE 1 R E S U L T S OBTAINED WITH VARIQUS AGENTS
Agent in Buffer Control (Sorensen's phosphate buffer) Polymyxin B sulfate Polymyxin B sulfate Erythromycin Viomycin sulfate Viomycin sulfate Carbomycin (magnamycin hydrochloride) Carbomycin (magnamycin hydrochloride) Neomycin sulfate Neomycin sulfate Circulin Circulin MK-65 MK-65 Nitrofurazone (Furacin) Nitrofurazone (Furacin) Sodium propionate (Propion) Sodium propionate (Propion) Sulfamylon Sulfamylon Phenazoline (Antistine) Phenazoline (Antistine)
Concentration 20,000 Mg./ml. 5,000 Mg./ml. 2 Mg./ml. (ale. 1:100) 2.5mg./ml. 0.1 mg./ml. 500 Mg./ml. 100 Mg./ml. 3.5 mg./ml. 1.0 mg./ml. 3.5 mg./ml. 1.0 mg./ml. 50 mg./ml. 5 mg./ml. 0.2 mg./ml. 0.02 mg./ml. 5% 0.5% 5% 0.5% 0.5% 0.05%
gram-positive organisms. Erythromycin is relatively insoluble and was used in a con centration of 2.0 μg. per ml. This concentra tion was obtained by disolving the powder first in a small amount of alcohol and then in the buffer. In the resultant solution al cohol was present in a dilution of 1:100. Erythromycin is stable at a pH of 7.0 but, at a pH below 6.0, it decomposes in a matter of hours. The erythromycin solution did not delay healing nor did a control solution of the buffer containing alcohol 1:100. Viomycin sulfate,3 a new tuberculostatic antibiotic derived from an actinomycete, was tested. It has antibacterial activity in the pH range from neutrality to 8.5. Viomycin did not inhibit healing in a concentration of 2.5 mg. per ml. Carbomycin* (magnamycin hydrochlo ride), another derivative from an actino mycete, is principally active against grampositive bacteria.4 Carbomycin is fairly solu ble and in the concentration of 500 μg. per ml. did not interfere with healing. Neomycin sulfate, also from an actinoWe wish to acknowledge the technical assistance of Miss Sylvia Sigelman.
Normal^ Healing
Retarded Healing
+ + + + + + + + + + +
+ + +
■
No Healing
+ + +
+
+ + + +
mycete, is readily soluble in water. Neomycin did not delay healing in a therapeutic con centration of 3.5 mg. per ml. Circulin,* an antibiotic obtained from a bacillus, is mainly active against gram-nega tive organisms.5 Circulin prevented healing in a concentration of 3.5 mg. per ml. How ever, in a concentration of 1.0 mg. per ml., normal healing took place. MK-65,* a new broad-range antibiotic obtained from a soil organism, is freely soluble and delayed healing in the high con centration of 50 mg. per ml. but healing oc curred at the normal rate with a concentra tion of 5.0 mg. per ml. This latter concentra tion probably will be closer than the former to the strength used clinically. Nitrofurazone (Furacin) is not very solu ble in water and in the concentration used therapeutically, which is 0.2 mg. per ml., re tarded healing while in a concentration of 0.02 mg. per ml. normal healing took place. Sodium propionate (Propion) prevented healing in a five-percent concentration which is the strength used clinically. Normal heal ing occurred with a 0.5-percent solution. Sulfamylon, a sulfonamide compound,
REGENERATION OF CORNEAL EPITHELIUM
547
TABLE 2 RESULTS OBTAINED WITH CALSULFHYDRYL
Agent in Buffer
Time (hr.)
Control (Sorensen's phosphate buffer) Calsulfhydryl (Hydrosulphosol) Calsulfhydryl (Hydrosulphosol) Control (Sorensen's phosphate buffer) Calsulfhydryl (Hydrosulphosol) Control (Sorensen's phosphate buffer) Calsulfhydryl (Hydrosulphosol)
3 3 3 2* 2i 2 2
prevented healing in both the clinically used five-percent concentration and in a 0.5-per cent concentration. Sulfisoxazole (Gantrisin) is another sulf onamide compound but the powder was not soluble in the phosphate buffer. Gantrisin ophthalmic solution (four percent) was di luted with the phosphate buffer 1:5 and with this dilution normal healing took place. In Table 2 may be seen the findings re sulting from the use of calsulfhydryl (Hy drosulphosol). Hydrosulphosol was not available in the powder form but was ob tained as a solution. This solution was used updiluted and also was diluted 1:40 with the usual phosphate buffer. The solution was di luted 1:40 because this is the strength sug gested in one of the clinical reports. 6 The eyes remaining in the undiluted Hydro sulphosol solution for three hours showed no evidence of healing while the epithelial defects in the eyes in the 1:40 dilution for the same length of time showed retarded healing as compared to the controls. In an effort to determine if there was any evidence for stimulation of epithelization three eyes were placed in 1:40 Hydrosulph osol solution for two and one-half hours and three other eyes were placed in 1:40 Hydrosulphosol solution for two hours. Con trol eyes were placed in Sorensen's phosphate buffer for identical periods of time." In both cases the eyes which were in the diluted Hydrosulphosol solution showed less healing of the epithelial defects than did the control eyes.
Concentra tion Undiluted 1:40 1:40 1:40
Normal Healing
Retarded Healing
+ + +
+ + +
No Healing
+
COMMENT
This method of study eliminates the possi bility of infection influencing the rate of healing of the corneal abrasion as may oc cur when the cornea of a live animal is abraded and the healing observed for several days. This approach cannot be used for some drugs which, because they are also dyes, ob scure the staining and cellular detail of the corneal specimen. In addition this technique is not suitable for some surface-tension re ducing agents because the epithelial layer is frequently separated from the corneal stroma in the fixed and stained specimen. This sepa ration of the epithelial layer occurred in a preliminary test with sodium-potassium cop per chlorophyllin which is prepared by saponification. CONCLUSIONS
Using a technique devised by Buschke and Friedenwald with the pH of the test solu tion maintained at neutrality by Sorensen's phosphate buffer it was found that polymyxin B sulfate, erythromycin, viomycin sulfate, carbomycin, and neomycin sulfate in the concentrations described did not delay the healing of epithelial defects in the rat's cornea. The effect of several other compounds was also determined. Calsulfhydryl in the concentrations employed showed no evidence of stimulation of epithelization. The Johns Hopkins Hospital (5).
548
WALTER H. FINK REFERENCES
1. Marr, W. G., Wood, R., and Storck, M.: Effect of some agents on regeneration of corneal epithelium. Am. J. Ophth., 34:609, 1951. 2. Friedenwald, J. S., and Buschke, W.: The influence of some experimental variables on the epithelial movements in the healing of corneal wounds. J. Cell. & Comp. Physiol., 23:95, 1944. 3. Bartz, Q. R., Ehrlich, ]., Mold, J. D., Penner, M. A., and Smith, R. M.: Viomycin, a new tuberculostatic antibiotic. Am. Rev. Tuberc, 63:4, 1951. 4. Tanner, F. W., Jr., English, A. R., Lees, T. M., and Routien, J. B.: Some properties of Magnamycin, a new antibiotic. Antibiot. and Chemotherap. 2:441, 1952. 5. Murray, F. J., Tetrault, P. A., Kaufmann, O. W., Koffler, H., Peterson, D. H., and Colingsworth, D. R.: Circulin, an antibiotic from an organism resembling bacillus circulans. J. Bact., 57:305, 1949. 6. Cruthirds, A. E.: Use of sulfhydryl in the treatment of corneal scars following chemical eye burns and ulcers. Tr. Am. Acad. Ophth., 54:732. 1950.
P R E S E N T CONCEPT O F SUPERIOR OBLIQUE SURGERY* WALTER H.
FINK,
M.D.
Minneapolis, Minnesota
Previous to 1942, the literature is prac tically devoid of references to the surgical correction of superior oblique defects. Oper ative measures were not considered feasible, and the general attitude was well expressed by Jackson,1 in 1903, when he stated that, because of its deep insertion, operative steps upon the tendon of the superior oblique near its insertion are not practical. This feeling was confirmed by Banister,2 in 1928, when he said that, owing to the anatomic relations of the superior oblique muscle to the eyeball, its deep location in the orbit, and it attachments to the globe in the neighborhood of the equator, surgical pro cedures are out of the question. In attempting to relieve the distressing diplopia in such in stances of paralysis, he believed that the ophthalmic surgeon must make use of the recti muscles. In 1934, Wheeler 3 introduced an opera tion for underaction of the superior oblique. Apparently the procedure was not widely ac cepted, judging from the absence of reports in the literature. The majority of attempts to correct a superior oblique defect continued to deal with yoke or direct antagonist muscles and, as far as can be detremined, only in * Presented before -the New England thalmological Society, October, 1951.
Oph-
rare instances was the tendon of the superior oblique operated upon. The belief of most ophthalmologists that it is dangerous to operate upon the superior oblique was deeply ingrained. As accurately as can be determined, no further operations on the superior oblique were reported until 1940, when Meesman4 described overaction of the superior oblique and its successful treatment by resection of the trochlea. In 1942, Malbran 5 made a similar report. In the same year, Hughes and Bogart6 described a method of recession of the trochlea in cases of overaction of the superior oblique. In 1946, Berke7 reported a series of cases in which a tenotomy of the superior oblique tendon was performed to relieve hypertropia in patients with overaction of this muscle. In 1946, McGuire 8 reported a series of cases of underaction of the superior oblique for which he resected the tendon. The present trend in surgery of the su perior oblique muscle was expressed by White 9 when he wrote, "I have found no occasion to keep 'hands off the obliques' when by tests such surgery is indicated." And the increase in the number of papers on this sub ject in recent years reveals, more than any thing else, the change in attitude. There seems to be developing a tendency
MARR, WOOD AND GRIEVES REFEREKCES
1. Bignell, J. L.: Infection of the cornea with B. pyocyaneus: Clinical study and summary of ten cases personally observed. Brit. J. Ophth., 35 :419-423, 1951. 2. Brown, E. H".: Therapeutic experiences with corneal ulcer due to Bacillus pyocyaneus. Arch. Ophth., 30:221-224,1943. 3. Joy, H. H.: Treatment of experimental Bacillus pyocyaneus ulcer of cornea with sulfapyridine. Arch. Ophth., 27:1135-1164, 1942. 4. Juler, F., and Young, M. Y.: The treatment of septic ulcer of the cornea by local application of penicillin. Brit. J. Ophth., 29 :312-322, 1945. 5. Ainslie, D., and Smith, C.: Polymyxin E., Penetration into the eye and therapeutic value in experi mental infection due to Ps. pyocyanea. Brit. J. Ophth., 36 :352-361, 1952. 6. Wiggins, R. L.: Experimental studies on the eye with polymyxin B. Am. J.Ophth., 35 :83-99, 1952. 7. Eareckson, V. C, Miller, J. M., and Long, P. H.: Infection of the eye due to Pseudomonas aeruginosa treated with polymyxin B and "Varidase." Arch. Ophth., 49:158-160, 1953. 8. Kagan, B. M., Krevsky, D., Milzer, A., and Locke, M.: Polymyxin B and polymyxin E. J. Lab. & Clin. Med., 37:402-414, 1951. 9. Brownlee, G., and Bushby, S. R. M.: Chemotherapy and pharmacology of Aerosporin. Lancet 1: 127-132, 1948. 10. Jawetz, E.: Infections with Pseudomonas aeruginosa treated with polymyxin B. Arch. Int. Med., 89: 90-98, 1952. 11. Searle, D. S.: Personal communication.
F U R T H E R STUDIES ON T H E E F F E C T O F AGENTS ON REGENERATION O F CORNEAL E P I T H E L I U M * WILLIAM G. MARR, M.D.,
RONALD WOOD, P H . D . , AND MARTHA GRIEVES
Baltimore, Maryland
In a previous publication,1 using a tech nique devised by Buschke and Friedenwald, it was shown that the available antibiotic de rivatives of actinomycetes (streptomycin, chloromycetin, aureomycin, and terramycin) in concentrations used clinically and with the pH of the solutions maintained at 7.2 did not delay the healing of epithelial defects in the rat's cornea. Normal healing also took place when the sodium or potassium salt of crystal line penicillin. G was used in a concentration of 2,500 units per cc. Two nonmetallic organic antiseptics, zephiran and phemerol chloride, and two anes thetic solutions, butyn sulfate and tetracaine hydrochloride, prevented healing. This paper presents the results obtained *From the Wilmer Ophthalmological Institute of The Johns Hopkins University and Hospital. This work was supported in part by grants-in-aid from the American Cancer Society through the Committee on Growth of the National Research Council and from the Institute of Neurology and Blindness of the Federal Security Agency.
with some antiseptics not tested previously and with some of the more recently available antibiotics. In addition, experiments were undertaken to discover if, within the limita tions of the technique employed, there was any evidence of stimulation of epithelization by calsulfhydryl (Hydrosulphosol®). METHOD
The experiments were performed in the same manner as was described in the paper 1 published in 1951. For a more thorough dis cussion of the technique the original publica tion of Buschke and Friedenwald2 may be consulted. Briefly, with a fine needle, small circular epithelial defects were produced in the cornea of an anesthetized rat's eye, the eyes were enucleated and placed in test solu tions. The pH of the test solution was main tained at neutrality with a buffer and the solution with the enucleated eyes aerated for ® Hydrosulphosol is the registered trademark of the E. C. Lientz & Co., Inc.
REGENERATION OF CORNEAL EPITHELIUM
three hours at a temperature of 38°C. Follow ing the aeration the eyes were removed and the corneas prepared so that the epithelial defects could be examined under the high power of the microscope. The nuclei of cells around healed defects showed an increased staining and the nuclei of cells, especially of the basal layers, were arranged in a radial pattern and the cells covered the floor of the defect (fig. 1). The nuclei of cells around an unhealed lesion did not show an increased staining and the nuclei were in a tangential pattern rather than in a radial arrangement to the uncovered defect (fig. 2 ) . In lesions showing retarded healing the nuclei were arranged in a radial pattern at the periphery but the defect was still present and uncovered. In earlier experiments it was found that the epithelial defects were practically all healed after three hours in Sorenson's phos phate buffer with a pH of 7.2. Little observa ble change could be seen in the epithelial de fects after one hour but after the second hour the defects changed rapidly. Observations
545
Fig. 2 (Marr, Wood, and Grieves). Photomicro graph, showing unhealed epithelial lesions.
made after two, and two and one-half hours against controls were used to ascertain whether there was any evidence of stimula tion of epithelization by the substance being tested. RESULTS
Table 1 shows the results obtained when the eyes were placed for three hours in Sorensen's phosphate buffer solution at a pH of 7.0 in the presence of the various agents under investigation. The controls were eyes placed for three hours in Sorensen's phosphate buffer solution at a pH of 7.0. Polymyxin B sulfate, a polypeptide anti biotic derived from a bacillus, did not delay healing in a concentration used clinically of 20,000 μ^ per ml. Erythromycin,* a recent derivative from an actinomycete, is mainly active against
Fig. 1 (Marr, Wood, and Grieves). Photomicro graph, showing healed epithelial defects.
* We wish to thank the following companies for generously supplying the indicated material: Eli Lilly & Co., erythromycin; Charles Pfizer & Co., Inc., carbomycin; the Upjohn Co., circulin; Merck & Co., Inc., MK-65.
546
MARR, WOOD AND GRIEVES TABLE 1 R E S U L T S OBTAINED WITH VARIQUS AGENTS
Agent in Buffer Control (Sorensen's phosphate buffer) Polymyxin B sulfate Polymyxin B sulfate Erythromycin Viomycin sulfate Viomycin sulfate Carbomycin (magnamycin hydrochloride) Carbomycin (magnamycin hydrochloride) Neomycin sulfate Neomycin sulfate Circulin Circulin MK-65 MK-65 Nitrofurazone (Furacin) Nitrofurazone (Furacin) Sodium propionate (Propion) Sodium propionate (Propion) Sulfamylon Sulfamylon Phenazoline (Antistine) Phenazoline (Antistine)
Concentration 20,000 Mg./ml. 5,000 Mg./ml. 2 Mg./ml. (ale. 1:100) 2.5mg./ml. 0.1 mg./ml. 500 Mg./ml. 100 Mg./ml. 3.5 mg./ml. 1.0 mg./ml. 3.5 mg./ml. 1.0 mg./ml. 50 mg./ml. 5 mg./ml. 0.2 mg./ml. 0.02 mg./ml. 5% 0.5% 5% 0.5% 0.5% 0.05%
gram-positive organisms. Erythromycin is relatively insoluble and was used in a con centration of 2.0 μg. per ml. This concentra tion was obtained by disolving the powder first in a small amount of alcohol and then in the buffer. In the resultant solution al cohol was present in a dilution of 1:100. Erythromycin is stable at a pH of 7.0 but, at a pH below 6.0, it decomposes in a matter of hours. The erythromycin solution did not delay healing nor did a control solution of the buffer containing alcohol 1:100. Viomycin sulfate,3 a new tuberculostatic antibiotic derived from an actinomycete, was tested. It has antibacterial activity in the pH range from neutrality to 8.5. Viomycin did not inhibit healing in a concentration of 2.5 mg. per ml. Carbomycin* (magnamycin hydrochlo ride), another derivative from an actino mycete, is principally active against grampositive bacteria.4 Carbomycin is fairly solu ble and in the concentration of 500 μg. per ml. did not interfere with healing. Neomycin sulfate, also from an actinoWe wish to acknowledge the technical assistance of Miss Sylvia Sigelman.
Normal^ Healing
Retarded Healing
+ + + + + + + + + + +
+ + +
■
No Healing
+ + +
+
+ + + +
mycete, is readily soluble in water. Neomycin did not delay healing in a therapeutic con centration of 3.5 mg. per ml. Circulin,* an antibiotic obtained from a bacillus, is mainly active against gram-nega tive organisms.5 Circulin prevented healing in a concentration of 3.5 mg. per ml. How ever, in a concentration of 1.0 mg. per ml., normal healing took place. MK-65,* a new broad-range antibiotic obtained from a soil organism, is freely soluble and delayed healing in the high con centration of 50 mg. per ml. but healing oc curred at the normal rate with a concentra tion of 5.0 mg. per ml. This latter concentra tion probably will be closer than the former to the strength used clinically. Nitrofurazone (Furacin) is not very solu ble in water and in the concentration used therapeutically, which is 0.2 mg. per ml., re tarded healing while in a concentration of 0.02 mg. per ml. normal healing took place. Sodium propionate (Propion) prevented healing in a five-percent concentration which is the strength used clinically. Normal heal ing occurred with a 0.5-percent solution. Sulfamylon, a sulfonamide compound,
REGENERATION OF CORNEAL EPITHELIUM
547
TABLE 2 RESULTS OBTAINED WITH CALSULFHYDRYL
Agent in Buffer
Time (hr.)
Control (Sorensen's phosphate buffer) Calsulfhydryl (Hydrosulphosol) Calsulfhydryl (Hydrosulphosol) Control (Sorensen's phosphate buffer) Calsulfhydryl (Hydrosulphosol) Control (Sorensen's phosphate buffer) Calsulfhydryl (Hydrosulphosol)
3 3 3 2* 2i 2 2
prevented healing in both the clinically used five-percent concentration and in a 0.5-per cent concentration. Sulfisoxazole (Gantrisin) is another sulf onamide compound but the powder was not soluble in the phosphate buffer. Gantrisin ophthalmic solution (four percent) was di luted with the phosphate buffer 1:5 and with this dilution normal healing took place. In Table 2 may be seen the findings re sulting from the use of calsulfhydryl (Hy drosulphosol). Hydrosulphosol was not available in the powder form but was ob tained as a solution. This solution was used updiluted and also was diluted 1:40 with the usual phosphate buffer. The solution was di luted 1:40 because this is the strength sug gested in one of the clinical reports. 6 The eyes remaining in the undiluted Hydro sulphosol solution for three hours showed no evidence of healing while the epithelial defects in the eyes in the 1:40 dilution for the same length of time showed retarded healing as compared to the controls. In an effort to determine if there was any evidence for stimulation of epithelization three eyes were placed in 1:40 Hydrosulph osol solution for two and one-half hours and three other eyes were placed in 1:40 Hydrosulphosol solution for two hours. Con trol eyes were placed in Sorensen's phosphate buffer for identical periods of time." In both cases the eyes which were in the diluted Hydrosulphosol solution showed less healing of the epithelial defects than did the control eyes.
Concentra tion Undiluted 1:40 1:40 1:40
Normal Healing
Retarded Healing
+ + +
+ + +
No Healing
+
COMMENT
This method of study eliminates the possi bility of infection influencing the rate of healing of the corneal abrasion as may oc cur when the cornea of a live animal is abraded and the healing observed for several days. This approach cannot be used for some drugs which, because they are also dyes, ob scure the staining and cellular detail of the corneal specimen. In addition this technique is not suitable for some surface-tension re ducing agents because the epithelial layer is frequently separated from the corneal stroma in the fixed and stained specimen. This sepa ration of the epithelial layer occurred in a preliminary test with sodium-potassium cop per chlorophyllin which is prepared by saponification. CONCLUSIONS
Using a technique devised by Buschke and Friedenwald with the pH of the test solu tion maintained at neutrality by Sorensen's phosphate buffer it was found that polymyxin B sulfate, erythromycin, viomycin sulfate, carbomycin, and neomycin sulfate in the concentrations described did not delay the healing of epithelial defects in the rat's cornea. The effect of several other compounds was also determined. Calsulfhydryl in the concentrations employed showed no evidence of stimulation of epithelization. The Johns Hopkins Hospital (5).
548
WALTER H. FINK REFERENCES
1. Marr, W. G., Wood, R., and Storck, M.: Effect of some agents on regeneration of corneal epithelium. Am. J. Ophth., 34:609, 1951. 2. Friedenwald, J. S., and Buschke, W.: The influence of some experimental variables on the epithelial movements in the healing of corneal wounds. J. Cell. & Comp. Physiol., 23:95, 1944. 3. Bartz, Q. R., Ehrlich, ]., Mold, J. D., Penner, M. A., and Smith, R. M.: Viomycin, a new tuberculostatic antibiotic. Am. Rev. Tuberc, 63:4, 1951. 4. Tanner, F. W., Jr., English, A. R., Lees, T. M., and Routien, J. B.: Some properties of Magnamycin, a new antibiotic. Antibiot. and Chemotherap. 2:441, 1952. 5. Murray, F. J., Tetrault, P. A., Kaufmann, O. W., Koffler, H., Peterson, D. H., and Colingsworth, D. R.: Circulin, an antibiotic from an organism resembling bacillus circulans. J. Bact., 57:305, 1949. 6. Cruthirds, A. E.: Use of sulfhydryl in the treatment of corneal scars following chemical eye burns and ulcers. Tr. Am. Acad. Ophth., 54:732. 1950.
P R E S E N T CONCEPT O F SUPERIOR OBLIQUE SURGERY* WALTER H.
FINK,
M.D.
Minneapolis, Minnesota
Previous to 1942, the literature is prac tically devoid of references to the surgical correction of superior oblique defects. Oper ative measures were not considered feasible, and the general attitude was well expressed by Jackson,1 in 1903, when he stated that, because of its deep insertion, operative steps upon the tendon of the superior oblique near its insertion are not practical. This feeling was confirmed by Banister,2 in 1928, when he said that, owing to the anatomic relations of the superior oblique muscle to the eyeball, its deep location in the orbit, and it attachments to the globe in the neighborhood of the equator, surgical pro cedures are out of the question. In attempting to relieve the distressing diplopia in such in stances of paralysis, he believed that the ophthalmic surgeon must make use of the recti muscles. In 1934, Wheeler 3 introduced an opera tion for underaction of the superior oblique. Apparently the procedure was not widely ac cepted, judging from the absence of reports in the literature. The majority of attempts to correct a superior oblique defect continued to deal with yoke or direct antagonist muscles and, as far as can be detremined, only in * Presented before -the New England thalmological Society, October, 1951.
Oph-
rare instances was the tendon of the superior oblique operated upon. The belief of most ophthalmologists that it is dangerous to operate upon the superior oblique was deeply ingrained. As accurately as can be determined, no further operations on the superior oblique were reported until 1940, when Meesman4 described overaction of the superior oblique and its successful treatment by resection of the trochlea. In 1942, Malbran 5 made a similar report. In the same year, Hughes and Bogart6 described a method of recession of the trochlea in cases of overaction of the superior oblique. In 1946, Berke7 reported a series of cases in which a tenotomy of the superior oblique tendon was performed to relieve hypertropia in patients with overaction of this muscle. In 1946, McGuire 8 reported a series of cases of underaction of the superior oblique for which he resected the tendon. The present trend in surgery of the su perior oblique muscle was expressed by White 9 when he wrote, "I have found no occasion to keep 'hands off the obliques' when by tests such surgery is indicated." And the increase in the number of papers on this sub ject in recent years reveals, more than any thing else, the change in attitude. There seems to be developing a tendency