- Email: [email protected]
Gonioscopy Ointment
was normal. Examination with a contact lens of the fundus disclosed no evidence of inflammatory cells in the vitreous, no vitreous body detachment pos teriorly, and no vitreous strands to the macula. Central fields were normal to 1/1,000 white and red test objects. Fluorescein angiography revealed a nor mal pattern without evidence of abnormal posterior pole fluorescence. The diagnosis at this time was contracture of the internal surface of the retina, left eye. DISCUSSION 2,3
419
NOTES, CASES, INSTRUMENTS
VOL. 67, NO. 3
The patient was the youngest thus far re ported to have this condition without appar ent abnormal vitreoretinal adherence. SUMMARY
A macular lesion with typical symptoms and signs of contracture of the internal sur face of the retina, without vitreoretinal adherence, occurred in a 22-year-old man, the youngest person thus far reported with this condition. U.S. Naval Hospital (20014)
Jaffe reported macular retinopathy as sociated with vitreoretinal adherence fol lowing detachment of the posterior vitreous ACKNOWLEDGMENT body. Maumenee4 also has stressed the fore We wish to thank Frances H. Atkinson, R.R.L., going condition as Category 4 in his classifi for technical editing. cation of maculopathies. Both authors have REFERENCES described the symptoms of the syndrome as 1. Lyle, D. J. : Detachment of the internal limit acute onset of blurred vision, micropsia, ing membrane of the retina. Tr. Am. Acad. Ophth. metamorphopsia, and scotomas. Otolaryng. 39:201, 1934. An increased incidence of this condition is 2. Jaffe, N. S. : Macular retinopathy after sepa observed in phakic eyes. On ophthalmoscopic ration of vitreoretinal adherence. Arch. Ophth. 1967. and contact lens examinations there was evi 78:585, 3. Jaffe, N. S. : Vitreous traction at the posterior dence of separation of the posterior vitreous pole of the fundus due to alterations in the vitreous body, increased macular shagreen, increased posterior. Tr. Am. Acad. Ophth. Otolaryng. 71 : 1967. tortuosity of the macular vessels, folds ra 642, 4. Maumenee, A. E. : Further advances in the diating from the macular area, and no leak study of the macula. Arch. Ophth. 78:151, 1967. age of fluorescein into the macular area on fluorescein angiography. Maumenee4 also de scribed contraction of the internal surface of the retina as a separate type of lesion (Cate gory 5) with findings identical to those of the vitreous traction syndrome, but without GONIOSCOPY O I N T M E N T evidence of vitreous body traction. In his cases, however, other intraocular pathologic DAVID MILLER, M.D., MARIO V. AQUINO, conditions were present. Maumenee postu M.D. AND ALFRED S. FIORE, M.S. lated, in addition to vitreous traction as an Boston, Massachusetts etiology of the aforementioned maculopathy, An optically clear, nontoxic ointment was that contractions of the internal surface of prepared to simplify gonioscopy in the up the retina may result from a splitting of the right and recumbent positions by eliminating internal limiting membrane with a prolifera fluid spillage and helping maintain a tighter tion of vitreous cells on the vitreous part of lens fit. This report details the composition of the membrane. the ointment and describes our experiences This case was an instance of contracture with its use. of the internal surface of the retina with ab From the Massachusetts Eye and Ear Infirmary, sence of vitreoretinal adherence or other de monstrable intraocular pathologic processes. Harvard University Medical School. This work was supported by USPHS Grant NB-05691 from The condition may best be classified in the National Institute of Neurological Diseases and Maumenee's Category 5 of maculopathies. Blindness.
420
AMERICAN JOURNAL OF OPHTHALMOLOGY MATERIAL AND
TABLE 1
METHOD
The ointment was composed of the fol lowing : Methylcellulose powder 4,000 c.p.s. Methylparaben Propylparaben Sodium chloride U.S.P. Distilled water q.s. ad
MARCH, 1969
2.5 gm 0.023 gm 0.01 gm 1.20 gm 100.00 ml
Seven patients between the ages of 46 and 68 years, with absolute glaucoma in one eye, volunteered for the study. Their anterior segments were essentially normal by slitlamp examination. Preliminary staining with 1% rose bengal was done in both eyes of each patient (base line). The ointment was placed in the conjunctival sac of the eye with abso lute glaucoma three times a day for a period of one week. The fellow eyes were un treated. At the end of seven days the eyes were again examined by slitlamp for any ab normalities and again stained with rose ben gal 1%. The treated and untreated eyes were compared. Fifty-eight patients had gonioscopy with the Koeppe lens with the ointment in one eye and the usual gonioscopic fluid in the other eye (0.9% saline or 1% methylcellulose). Both eyes were examined initially with the slitlamp for any anterior segment abnormali ties. The gonioscopic lenses were placed si multaneously on both eyes for a period of 15 to 20 minutes, longer than the time usually required for a gonioscopic examination. Subjective symptoms as well as clarity were noted during the procedure. At the end of this period, the lenses were removed, both eyes were tested with rose bengal 1%, and the staining compared. RESULTS
All seven patients who used the ointment for one week were asymptomatic. There was slight superficial congestion in two eyes but the corneas were grossly normal. Rose ben gal staining showed no difference in the treated and untreated eyes. Of the 58 patients in whom the ointment was used for gonioscopy, 51 showed no sig-
CORNEAL PATHOLOGY AFTER GONIOSCOPY
No. Patients
OintmentAdministered Eye
Control SolutionAdministered Eye
51 5 1 1
Trace-staining 1 -f- staining No pathology 2+staining
Trace staining No pathology 1 + staining No pathology
nificant difference in staining in the treated and untreated eyes (table 1). In fact, one treated eye showed even less staining than the untreated eye. Seven eyes showed more staining but subjectively these patients did not differ from the rest of the subjects. Practi cally all patients noted temporary hazy vision in the ointment-treated eye after gonioscopy. There was no significant difference in the an terior segment findings by slitlamp after the procedure. Bactériologie cultures of the contents of the ointment tubes upon opening and after three weeks of use, failed to demonstrate any growth. In the 58 patients in whom a Koeppe lens and the ointment were used on one eye and the standard solution and a Koeppe lens on the other eye simultaneously, clarity of gonio scopic detail was similar in each eye. DISCUSSION
The high viscosity of this ointment ensured ease of application to the lens and little or no movement of the lens during eye or head movements. This property is of great help in slitlamp examination when the Hruby lens and the Goldmann three-mirror lens was used. The elastic property of this polymer as sured a tight fit and maintained a negative pressure between lens and eye during dislodgement, forcing the lens to snap back in place when the external force was withdrawn. The preservatives in the ointment main tained sterility, yet did not produce corneal toxicity. There was less manipulation of the patient's eye and the gonioscopy lens, as well as less equipment, and thus a smaller possi-
VOL. 67, NO. 3
NOTES, CASES, INSTRUMENTS
421
bility of introducing infective agents into the eye. Finally, the ointment displayed optical properties comparable to currently used gonioscopic solutions ; however, care must be taken that the ointment is prepared free of
used in gonioscopic examination of 58 patients proved to be of low toxicity, easy to use, and to have good optical qualities. 243 Charles Street (02114) ______
bubbles.
We thank the Cornea Service of the Massachu setts Eye and Ear Infirmary, and the Pharmacy Manufacturing Research and Development Depart ment of the Massachusetts General Hospital, Bos-
SUMMARY
A viscous 2.5% methylcellulose ointment
ACKNOWLEDGMENT
ton, for their help in this study.
OPHTHALMIC MINIATURE
The astronomer Galileo shared with the great poet in the calamity of blindness. The following circumstances are related by Sir D. Brewster. "Although his right eye had for some years lost its power, yet his gen eral vision was sufficiently perfect to enable him to carry on his usual researches. "In 1636, however, this affection of his eye became more serious, and in 1637 his left eye was attacked with the same disease. His medical friends at first supposed that cataracts were formed in the crystalline lens, and anticipated a cure from the operation of couching. These hopes were fallacious. The disease turned out to be in the cornea, and every attempt to restore its transparency was fruitless. In a few months the white cloud covered the whole aperture of the pupil, and Galileo became totally blind. This sudden and unexpected calamity had almost over whelmed Galileo and his friends. In writing to a correspondent he ex claims, 'Alas! your dear friend and servant has become totally and ir reparably blind. These heavens, this earth, this universe which by won derful observation, I had enlarged a thousand times beyond the belief of past ages, are henceforth shrunk into the narrow space which I myself occupy. So it pleases God, it shall therefore please me also.' " His friend, Father Castelli, deplores the calamity in the same tone of pathetic sublimity: "The noblest eye," says he, "which ever nature made, is darkened— an eye so privileged, and gifted with such rare powers, that it may truly be said to have seen more than the eyes of all that are gone, and to have opened the eyes of all that are to come !" Cooper, William White: Practical Remarks on New Sight, Aged Sight, and Impaired Vision. London, John Churchill, 1847.
419
NOTES, CASES, INSTRUMENTS
VOL. 67, NO. 3
The patient was the youngest thus far re ported to have this condition without appar ent abnormal vitreoretinal adherence. SUMMARY
A macular lesion with typical symptoms and signs of contracture of the internal sur face of the retina, without vitreoretinal adherence, occurred in a 22-year-old man, the youngest person thus far reported with this condition. U.S. Naval Hospital (20014)
Jaffe reported macular retinopathy as sociated with vitreoretinal adherence fol lowing detachment of the posterior vitreous ACKNOWLEDGMENT body. Maumenee4 also has stressed the fore We wish to thank Frances H. Atkinson, R.R.L., going condition as Category 4 in his classifi for technical editing. cation of maculopathies. Both authors have REFERENCES described the symptoms of the syndrome as 1. Lyle, D. J. : Detachment of the internal limit acute onset of blurred vision, micropsia, ing membrane of the retina. Tr. Am. Acad. Ophth. metamorphopsia, and scotomas. Otolaryng. 39:201, 1934. An increased incidence of this condition is 2. Jaffe, N. S. : Macular retinopathy after sepa observed in phakic eyes. On ophthalmoscopic ration of vitreoretinal adherence. Arch. Ophth. 1967. and contact lens examinations there was evi 78:585, 3. Jaffe, N. S. : Vitreous traction at the posterior dence of separation of the posterior vitreous pole of the fundus due to alterations in the vitreous body, increased macular shagreen, increased posterior. Tr. Am. Acad. Ophth. Otolaryng. 71 : 1967. tortuosity of the macular vessels, folds ra 642, 4. Maumenee, A. E. : Further advances in the diating from the macular area, and no leak study of the macula. Arch. Ophth. 78:151, 1967. age of fluorescein into the macular area on fluorescein angiography. Maumenee4 also de scribed contraction of the internal surface of the retina as a separate type of lesion (Cate gory 5) with findings identical to those of the vitreous traction syndrome, but without GONIOSCOPY O I N T M E N T evidence of vitreous body traction. In his cases, however, other intraocular pathologic DAVID MILLER, M.D., MARIO V. AQUINO, conditions were present. Maumenee postu M.D. AND ALFRED S. FIORE, M.S. lated, in addition to vitreous traction as an Boston, Massachusetts etiology of the aforementioned maculopathy, An optically clear, nontoxic ointment was that contractions of the internal surface of prepared to simplify gonioscopy in the up the retina may result from a splitting of the right and recumbent positions by eliminating internal limiting membrane with a prolifera fluid spillage and helping maintain a tighter tion of vitreous cells on the vitreous part of lens fit. This report details the composition of the membrane. the ointment and describes our experiences This case was an instance of contracture with its use. of the internal surface of the retina with ab From the Massachusetts Eye and Ear Infirmary, sence of vitreoretinal adherence or other de monstrable intraocular pathologic processes. Harvard University Medical School. This work was supported by USPHS Grant NB-05691 from The condition may best be classified in the National Institute of Neurological Diseases and Maumenee's Category 5 of maculopathies. Blindness.
420
AMERICAN JOURNAL OF OPHTHALMOLOGY MATERIAL AND
TABLE 1
METHOD
The ointment was composed of the fol lowing : Methylcellulose powder 4,000 c.p.s. Methylparaben Propylparaben Sodium chloride U.S.P. Distilled water q.s. ad
MARCH, 1969
2.5 gm 0.023 gm 0.01 gm 1.20 gm 100.00 ml
Seven patients between the ages of 46 and 68 years, with absolute glaucoma in one eye, volunteered for the study. Their anterior segments were essentially normal by slitlamp examination. Preliminary staining with 1% rose bengal was done in both eyes of each patient (base line). The ointment was placed in the conjunctival sac of the eye with abso lute glaucoma three times a day for a period of one week. The fellow eyes were un treated. At the end of seven days the eyes were again examined by slitlamp for any ab normalities and again stained with rose ben gal 1%. The treated and untreated eyes were compared. Fifty-eight patients had gonioscopy with the Koeppe lens with the ointment in one eye and the usual gonioscopic fluid in the other eye (0.9% saline or 1% methylcellulose). Both eyes were examined initially with the slitlamp for any anterior segment abnormali ties. The gonioscopic lenses were placed si multaneously on both eyes for a period of 15 to 20 minutes, longer than the time usually required for a gonioscopic examination. Subjective symptoms as well as clarity were noted during the procedure. At the end of this period, the lenses were removed, both eyes were tested with rose bengal 1%, and the staining compared. RESULTS
All seven patients who used the ointment for one week were asymptomatic. There was slight superficial congestion in two eyes but the corneas were grossly normal. Rose ben gal staining showed no difference in the treated and untreated eyes. Of the 58 patients in whom the ointment was used for gonioscopy, 51 showed no sig-
CORNEAL PATHOLOGY AFTER GONIOSCOPY
No. Patients
OintmentAdministered Eye
Control SolutionAdministered Eye
51 5 1 1
Trace-staining 1 -f- staining No pathology 2+staining
Trace staining No pathology 1 + staining No pathology
nificant difference in staining in the treated and untreated eyes (table 1). In fact, one treated eye showed even less staining than the untreated eye. Seven eyes showed more staining but subjectively these patients did not differ from the rest of the subjects. Practi cally all patients noted temporary hazy vision in the ointment-treated eye after gonioscopy. There was no significant difference in the an terior segment findings by slitlamp after the procedure. Bactériologie cultures of the contents of the ointment tubes upon opening and after three weeks of use, failed to demonstrate any growth. In the 58 patients in whom a Koeppe lens and the ointment were used on one eye and the standard solution and a Koeppe lens on the other eye simultaneously, clarity of gonio scopic detail was similar in each eye. DISCUSSION
The high viscosity of this ointment ensured ease of application to the lens and little or no movement of the lens during eye or head movements. This property is of great help in slitlamp examination when the Hruby lens and the Goldmann three-mirror lens was used. The elastic property of this polymer as sured a tight fit and maintained a negative pressure between lens and eye during dislodgement, forcing the lens to snap back in place when the external force was withdrawn. The preservatives in the ointment main tained sterility, yet did not produce corneal toxicity. There was less manipulation of the patient's eye and the gonioscopy lens, as well as less equipment, and thus a smaller possi-
VOL. 67, NO. 3
NOTES, CASES, INSTRUMENTS
421
bility of introducing infective agents into the eye. Finally, the ointment displayed optical properties comparable to currently used gonioscopic solutions ; however, care must be taken that the ointment is prepared free of
used in gonioscopic examination of 58 patients proved to be of low toxicity, easy to use, and to have good optical qualities. 243 Charles Street (02114) ______
bubbles.
We thank the Cornea Service of the Massachu setts Eye and Ear Infirmary, and the Pharmacy Manufacturing Research and Development Depart ment of the Massachusetts General Hospital, Bos-
SUMMARY
A viscous 2.5% methylcellulose ointment
ACKNOWLEDGMENT
ton, for their help in this study.
OPHTHALMIC MINIATURE
The astronomer Galileo shared with the great poet in the calamity of blindness. The following circumstances are related by Sir D. Brewster. "Although his right eye had for some years lost its power, yet his gen eral vision was sufficiently perfect to enable him to carry on his usual researches. "In 1636, however, this affection of his eye became more serious, and in 1637 his left eye was attacked with the same disease. His medical friends at first supposed that cataracts were formed in the crystalline lens, and anticipated a cure from the operation of couching. These hopes were fallacious. The disease turned out to be in the cornea, and every attempt to restore its transparency was fruitless. In a few months the white cloud covered the whole aperture of the pupil, and Galileo became totally blind. This sudden and unexpected calamity had almost over whelmed Galileo and his friends. In writing to a correspondent he ex claims, 'Alas! your dear friend and servant has become totally and ir reparably blind. These heavens, this earth, this universe which by won derful observation, I had enlarged a thousand times beyond the belief of past ages, are henceforth shrunk into the narrow space which I myself occupy. So it pleases God, it shall therefore please me also.' " His friend, Father Castelli, deplores the calamity in the same tone of pathetic sublimity: "The noblest eye," says he, "which ever nature made, is darkened— an eye so privileged, and gifted with such rare powers, that it may truly be said to have seen more than the eyes of all that are gone, and to have opened the eyes of all that are to come !" Cooper, William White: Practical Remarks on New Sight, Aged Sight, and Impaired Vision. London, John Churchill, 1847.