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Intraocular Foreign Body with Bacillus Welchi Infection
INTRAOCULAR FOREIGN BODY WITH BACILLUS WELCHI INFECTION EDWIN M. BEERY,
M.D.
BROOKLYN
A case of this rare infection is reported and the literature reviewed. The wide distribution and frequent ported in the British Journal of Oph occurrence of gas gangrene in general thalmology, two cases of pan-opthalsurgery would lead one to anticipate a mitis due to B. welchi infection. In greater incidence of this condition in both cases the organism was identified eye surgery than a survey of the litera culturally and the cases terminated in ture indicates. The intraocular con evisceration, one on the third and the tents furnish ideal culture media of the other on the fourth day after onset. anerobic variety in which the Bacillus Report of case: T. V. aged 43 years, welchi flourishes. I have been unable to a robust male, with previous history find any cases reported from this coun irrelevant was admitted to the Brook try, but European observers have re lyn Eye and Ear Hospital, January 20, ported nine cases, all of which followed 1932. He gave a history of having felt penetrating wounds of the globe, and something strike his right eye at ten usually were in cases of retained for o'clock the previous evening while en eign body. gaged in cutting a nut off a motorcycle Chaillous 1 , of Paris, reported a case in the cellar of his home. He went im in 1904, and another in 1905. The or mediately to a general hospital where ganism was cultured and positively he was assured that the eye was only bruised and showed no foreign body. identified as B. welchi in both cases. Darier 2 , in 1906, reported two cases. He returned home and passed a com Identification of the organism was by fortable night, but at 10:00 a.m. the its appearance in conjunctival smears following morning pain was felt in eye. only, and lacking cultures, the diag As this increased in severity, he ap nosis appears somewhat doubtful. Gas plied at the Brooklyn Eye and Ear bubbles, however, were seen adhering Hospital that afternoon. to the foreign body in one of his cases. Examination at 2:00 p.m. revealed All of the above cases were termin temperature of 98°; pulse, 76; respira tion, 18; the lids were slightly edemaated by enucleation. James 3 , in 1910, reported in the Brit tous, conjunctiva moderately chemotic. ish Journal of Ophthalmology, a case A small perforation of conjunctiva and which presented gas bubbles in the an sclera was noted in the horizontal terior chamber. The organism was plane 2 mm. internal to the limbus. A identified by culture. The case termin moderate hematoma had collected un der the conjunctiva below the limbus. ated in evisceration on the fifth day. Heath 4 , in 1929, reported in the Brit The cornea was steamy, pupil 3 mm. ish Journal of Ophthalmology, a case in diameter, iris congested, anterior in which the organism was identified chamber shallow, aqueous slightly by culture. This case also terminated in blood tinged, vision nil and there was no fundus reflex. The globe was stony evisceration. Ridley 5 , of London, in 1929, reported hard and presented the appearance of in the Transactions of the Ophthalmo- an active pan-ophthalmitis. The patient logical Society of the United Kingdom, was suffering agonizing pain, for the a case of gas-gangrene pan-ophthal- relief of which morphine was immedi mitis developing twenty-four hours af ately administered hypodermically. The ter penetrating injury of the globe. The x-ray revealed a foreign body 2 x 4 organism was identified culturally. mm. located 20 mm. behind the anterior Evisceration was performed eight surface of the cornea, 4 mm. below the horizontal plane and 6 mm. nasally to hours after onset of evident infection. Hamilton", of London, in 1930, re the vertical plane. 1022
BACILLUS W E L C H I I N F E C T I O N
The patient was removed to the operating room at 7 p.m. Chemosis had increased by that time until large folds protruded from the palpebral fissure. Separating these, the pupil was found fully dilated and a gas bubble 5 mm. in diameter occupied the anterior cham ber. The giant magnet was applied to the scleral wound but no pull was ob tained. A probe-pointed Bowman knife was then entered in the scleral wound and passed backward without resist ance for a distance of 20 mm. in the di rection of the foreign body. The knife had penetrated no further than 10 mm. when foul smelling gas, blood-tinged fluid, fragments of ciliary body, and later, vitreous, escaped around the shank of the knife. This flow stopped immediately when the knife was with drawn but returned with each entrance of the knife into the wound. Evidently an injured portion of the ciliary body was acting as an effective valve, pre venting the escape of both gas and fluids from the globe when not displaced by the instrument. With the knife in posi tion the magnet was attached and a mild pull was several times detected but the foreign body could not be drawn forward. With the escape of intraocular contents, the tension dropped and pain ceased, but the appearance of the bub ble in the anterior chamber was un changed. The patient refused removal of the eye and was returned to bed. The following morning his tempera ture was 102°; pulse 100; respiration 24. Chemosis was less, the gas bubble had disappeared and the anterior cham ber was filled with blood. The globe was again stony hard, and bulging of the entire limbus extending to the scleral wound was noted. Pain was again intense and the patient con sented to enucleation. During adminis tration of the anesthetic the globe rup tured spontaneously, beginning at the scleral wound and extending into the limbus, which it followed for twothirds of the corneal circumference. The eye was enucleated, bleeding con
1023
trolled with hot tampons, the cavity flushed with hot saline and the incision closed with interrupted sutures. Only moderate reaction followed. The wound healed promptly without swell ing or discharge and the patient was permitted to leave on the sixth day. Conjunctival smears taken on ad mission showed numerous leucocytes and staphylococci, a few Gram posi tive and Gram negative bacilli. Con junctival cultures taken after rupture of the globe and extrusion of ocular contents into conjunctival sac, showed only staphylococci. Intraocular cul tures grown under anerobic conditions showed a few staphylococci and many typical B. welchi. In some of these cultures the growth of the organism and generation of gas was so vigorous that the stoppers and large portions of the media were blown entirely out of the test tubes. Comment. This case presented the classical features in mode of infection, period of incubation and course. Ridley states that, given severe pain, rise of tension and hemorrhage within twentyfour hours following penetrating wound of globe, a diagnosis of B. wel chi infection should be made without further evidence. As will be noted, French surgeons enucleated all such cases, while Eng lishmen resorted to evisceration, some operators taking the precaution to leave a 2 mm. strip of corneal tissue, to avoid grasping the conjunctiva with forceps, and to leave the wound unsutured four or five days to avoid giv ing entrance for the organism to postorbital tissues. In none of the reported cases was there any invasion of ad jacent tissues, whether enucleation or evisceration was practiced. In my case, with ordinary enucleation, irrigation and immediate closure of the wound, healing was as prompt and kindly as is usually seen after removal of an uninfected globe. 118 Gates avenue.
1
References Chaillous, J. Infection traumatiquc du globe oculaire par un microbe anaerobic (Bacillus perfringens). Rec. d'opht. Paris, 1904, v. 24, pp. 678-680.
1024
LEO L. MAYER AND HUGO R. RONY
2
Darier, A. Panophtalmie gaseuse et B. perfringens. Clin. opht. Paris, 1906, v. 12, pp. 227229. James, R. R. Penetrating injury of globe with panophthalmitis due to gas-forming organ ism. Ophth. Review. London, 1910, v. 24, pp. 161-166. 4 Heath, W. E. B. welchi infection of globe following perforating injury. Brit. Jour. Ophthal., 1929, v. 13, pp. 574-575. B Ridley, F. Panophthalmitis. Trans. Ophth. Soc. U. Kingdom. 1929, v. 49, pp. 221-225. 6 Hamilton, J. B. B. welchi infection of optic globe. Brit. Jour. Ophthal., 1930, v. 14, pp. 452-455. a
V I S U A L FIELDS, B L I N D SPOTS, A N D T H E OPTIC DISCS IN E N D O C R I N E DISEASES L E O L. M A Y E R ,
M.D.
and H U G O R. R O N Y , CHICAGO
M.D.
In fifty patients with endocrine disturbances, seen over a period of two years, ocular examination showed no deviation from the normal in respect to visual fields, blind spots, and color of discs, characteristic of the disease. There were no abnormal findings even in cases showing the most evident and serious endocrine disease. Read before the Chicago Ophthalmological Society, March 21, 1932. From the departments of ophthalmology and medicine, Northwestern University Medical School. I n 1929 R o w e 1 a n d his c o l l a b o r a t o r s published a v o l u m e c o n c e r n i n g endo crine studies. A m o n g o t h e r factors re p o r t e d w e r e ocular i n v e s t i g a t i o n s . T h e n u m b e r of visual-field c h a n g e s a p p e a r e d e n o r m o u s . Detailed reference to t h e s e findings will be m a d e l a t e r ; h o w ever, t h e i r r e p o r t s t i m u l a t e d this in v e s t i g a t i o n . W i t h t h e e s t a b l i s h m e n t of a s e p a r a t e e n d o c r i n e clinic a p a r t from t h e u s u a l medical clinic at N o r t h w e s t ern U n i v e r s i t y Medical School in c h a r g e of one of us ( H . R . R . ) , this s t u d y w a s b e g u n a b o u t t w o y e a r s ago. T h e p r e s e n t c o m m u n i c a t i o n deals w i t h fifty e n d o c r i n e p a t i e n t s seen over this pe riod of t i m e in r e g a r d t o visual fields, blind s p o t s , a n d coloration of t h e optic discs. T h e l i t e r a t u r e c o n c e r n i n g this p h a s e of o p h t h a l m o l o g y is indeed scarce a n d confusing. A s h o r t review w o u l d t h e r e fore seem p e r t i n e n t . I t is m o s t n a t u r a l b e c a u s e of its a n a t o m i c a l s i t u a t i o n in relation to t h e visual p a t h w a y s , and b e c a u s e of its physiological connection w i t h t h e g o n a d a l o r g a n s , especially noted d u r i n g p r e g n a n c y , t h a t t h e pitui t a r y gland should be considered of u n u s u a l i m p o r t a n c e for s t u d y . A s e a r l y as 1914 O p p e n h e i m 2 expressed t h e opinion t h a t certain toxic s u b s t a n c e s w h i c h
might produce optic-nerve degenera tion m i g h t be derived from the pitui t a r y g l a n d w h e r e n o a c t u a l enlarge m e n t of t h e g l a n d w a s d e m o n s t r a b l e . F r o m his experience in v i e w i n g t h e discs of p i t u i t a r y d i s o r d e r s w i t h o u t signs of g r o s s e n l a r g e m e n t of t h e gland, Benedict 3 described a w a x y pal lor of t h e disc n o t a c c o m p a n i e d b y loss of s u b s t a n c e . H e explained 4 t h a t t h e color indicated a vitality of t h e n e r v e in w h i c h good r e c o v e r y could be ex pected. T h i s t y p e of disc h a s b e c o m e k n o w n as t h e yellow or w a x y disc. T h e basic w o r k c o n c e r n i n g c h a n g e s in the p i t u i t a r y gland d u r i n g p r e g n a n c y w a s done b y E r d h e i m a n d S t u m m e 5 . T h e y w e r e able t o d e m o n s t r a t e e n l a r g e m e n t of t h e g l a n d p r o p o r t i o n a l t o t h e n u m b e r of p r e g n a n c i e s . R e p o r t s of visualfield s t u d i e s on p r e g n a n t w o m e n are frequently found in t h e l i t e r a t u r e . T h e " b o n e of c o n t e n t i o n " seems t o be the theoretical consideration of w h e t h e r t h e c h a n g e s are caused b y an actual a n a t o m i c a l e n l a r g e m e n t of t h e g l a n d or u p o n toxic influences on t h e optic n e r v e s . T w o s e p a r a t e a u t h o r s h a v e re cently r e v i e w e d t h e entire l i t e r a t u r e c o n c e r n i n g t h e visual fields in p r e g n a n c y . T h e one, J o h n s 6 discusses t h e pros and cons as t o t h e a n a l y s i s of the
M.D.
BROOKLYN
A case of this rare infection is reported and the literature reviewed. The wide distribution and frequent ported in the British Journal of Oph occurrence of gas gangrene in general thalmology, two cases of pan-opthalsurgery would lead one to anticipate a mitis due to B. welchi infection. In greater incidence of this condition in both cases the organism was identified eye surgery than a survey of the litera culturally and the cases terminated in ture indicates. The intraocular con evisceration, one on the third and the tents furnish ideal culture media of the other on the fourth day after onset. anerobic variety in which the Bacillus Report of case: T. V. aged 43 years, welchi flourishes. I have been unable to a robust male, with previous history find any cases reported from this coun irrelevant was admitted to the Brook try, but European observers have re lyn Eye and Ear Hospital, January 20, ported nine cases, all of which followed 1932. He gave a history of having felt penetrating wounds of the globe, and something strike his right eye at ten usually were in cases of retained for o'clock the previous evening while en eign body. gaged in cutting a nut off a motorcycle Chaillous 1 , of Paris, reported a case in the cellar of his home. He went im in 1904, and another in 1905. The or mediately to a general hospital where ganism was cultured and positively he was assured that the eye was only bruised and showed no foreign body. identified as B. welchi in both cases. Darier 2 , in 1906, reported two cases. He returned home and passed a com Identification of the organism was by fortable night, but at 10:00 a.m. the its appearance in conjunctival smears following morning pain was felt in eye. only, and lacking cultures, the diag As this increased in severity, he ap nosis appears somewhat doubtful. Gas plied at the Brooklyn Eye and Ear bubbles, however, were seen adhering Hospital that afternoon. to the foreign body in one of his cases. Examination at 2:00 p.m. revealed All of the above cases were termin temperature of 98°; pulse, 76; respira tion, 18; the lids were slightly edemaated by enucleation. James 3 , in 1910, reported in the Brit tous, conjunctiva moderately chemotic. ish Journal of Ophthalmology, a case A small perforation of conjunctiva and which presented gas bubbles in the an sclera was noted in the horizontal terior chamber. The organism was plane 2 mm. internal to the limbus. A identified by culture. The case termin moderate hematoma had collected un der the conjunctiva below the limbus. ated in evisceration on the fifth day. Heath 4 , in 1929, reported in the Brit The cornea was steamy, pupil 3 mm. ish Journal of Ophthalmology, a case in diameter, iris congested, anterior in which the organism was identified chamber shallow, aqueous slightly by culture. This case also terminated in blood tinged, vision nil and there was no fundus reflex. The globe was stony evisceration. Ridley 5 , of London, in 1929, reported hard and presented the appearance of in the Transactions of the Ophthalmo- an active pan-ophthalmitis. The patient logical Society of the United Kingdom, was suffering agonizing pain, for the a case of gas-gangrene pan-ophthal- relief of which morphine was immedi mitis developing twenty-four hours af ately administered hypodermically. The ter penetrating injury of the globe. The x-ray revealed a foreign body 2 x 4 organism was identified culturally. mm. located 20 mm. behind the anterior Evisceration was performed eight surface of the cornea, 4 mm. below the horizontal plane and 6 mm. nasally to hours after onset of evident infection. Hamilton", of London, in 1930, re the vertical plane. 1022
BACILLUS W E L C H I I N F E C T I O N
The patient was removed to the operating room at 7 p.m. Chemosis had increased by that time until large folds protruded from the palpebral fissure. Separating these, the pupil was found fully dilated and a gas bubble 5 mm. in diameter occupied the anterior cham ber. The giant magnet was applied to the scleral wound but no pull was ob tained. A probe-pointed Bowman knife was then entered in the scleral wound and passed backward without resist ance for a distance of 20 mm. in the di rection of the foreign body. The knife had penetrated no further than 10 mm. when foul smelling gas, blood-tinged fluid, fragments of ciliary body, and later, vitreous, escaped around the shank of the knife. This flow stopped immediately when the knife was with drawn but returned with each entrance of the knife into the wound. Evidently an injured portion of the ciliary body was acting as an effective valve, pre venting the escape of both gas and fluids from the globe when not displaced by the instrument. With the knife in posi tion the magnet was attached and a mild pull was several times detected but the foreign body could not be drawn forward. With the escape of intraocular contents, the tension dropped and pain ceased, but the appearance of the bub ble in the anterior chamber was un changed. The patient refused removal of the eye and was returned to bed. The following morning his tempera ture was 102°; pulse 100; respiration 24. Chemosis was less, the gas bubble had disappeared and the anterior cham ber was filled with blood. The globe was again stony hard, and bulging of the entire limbus extending to the scleral wound was noted. Pain was again intense and the patient con sented to enucleation. During adminis tration of the anesthetic the globe rup tured spontaneously, beginning at the scleral wound and extending into the limbus, which it followed for twothirds of the corneal circumference. The eye was enucleated, bleeding con
1023
trolled with hot tampons, the cavity flushed with hot saline and the incision closed with interrupted sutures. Only moderate reaction followed. The wound healed promptly without swell ing or discharge and the patient was permitted to leave on the sixth day. Conjunctival smears taken on ad mission showed numerous leucocytes and staphylococci, a few Gram posi tive and Gram negative bacilli. Con junctival cultures taken after rupture of the globe and extrusion of ocular contents into conjunctival sac, showed only staphylococci. Intraocular cul tures grown under anerobic conditions showed a few staphylococci and many typical B. welchi. In some of these cultures the growth of the organism and generation of gas was so vigorous that the stoppers and large portions of the media were blown entirely out of the test tubes. Comment. This case presented the classical features in mode of infection, period of incubation and course. Ridley states that, given severe pain, rise of tension and hemorrhage within twentyfour hours following penetrating wound of globe, a diagnosis of B. wel chi infection should be made without further evidence. As will be noted, French surgeons enucleated all such cases, while Eng lishmen resorted to evisceration, some operators taking the precaution to leave a 2 mm. strip of corneal tissue, to avoid grasping the conjunctiva with forceps, and to leave the wound unsutured four or five days to avoid giv ing entrance for the organism to postorbital tissues. In none of the reported cases was there any invasion of ad jacent tissues, whether enucleation or evisceration was practiced. In my case, with ordinary enucleation, irrigation and immediate closure of the wound, healing was as prompt and kindly as is usually seen after removal of an uninfected globe. 118 Gates avenue.
1
References Chaillous, J. Infection traumatiquc du globe oculaire par un microbe anaerobic (Bacillus perfringens). Rec. d'opht. Paris, 1904, v. 24, pp. 678-680.
1024
LEO L. MAYER AND HUGO R. RONY
2
Darier, A. Panophtalmie gaseuse et B. perfringens. Clin. opht. Paris, 1906, v. 12, pp. 227229. James, R. R. Penetrating injury of globe with panophthalmitis due to gas-forming organ ism. Ophth. Review. London, 1910, v. 24, pp. 161-166. 4 Heath, W. E. B. welchi infection of globe following perforating injury. Brit. Jour. Ophthal., 1929, v. 13, pp. 574-575. B Ridley, F. Panophthalmitis. Trans. Ophth. Soc. U. Kingdom. 1929, v. 49, pp. 221-225. 6 Hamilton, J. B. B. welchi infection of optic globe. Brit. Jour. Ophthal., 1930, v. 14, pp. 452-455. a
V I S U A L FIELDS, B L I N D SPOTS, A N D T H E OPTIC DISCS IN E N D O C R I N E DISEASES L E O L. M A Y E R ,
M.D.
and H U G O R. R O N Y , CHICAGO
M.D.
In fifty patients with endocrine disturbances, seen over a period of two years, ocular examination showed no deviation from the normal in respect to visual fields, blind spots, and color of discs, characteristic of the disease. There were no abnormal findings even in cases showing the most evident and serious endocrine disease. Read before the Chicago Ophthalmological Society, March 21, 1932. From the departments of ophthalmology and medicine, Northwestern University Medical School. I n 1929 R o w e 1 a n d his c o l l a b o r a t o r s published a v o l u m e c o n c e r n i n g endo crine studies. A m o n g o t h e r factors re p o r t e d w e r e ocular i n v e s t i g a t i o n s . T h e n u m b e r of visual-field c h a n g e s a p p e a r e d e n o r m o u s . Detailed reference to t h e s e findings will be m a d e l a t e r ; h o w ever, t h e i r r e p o r t s t i m u l a t e d this in v e s t i g a t i o n . W i t h t h e e s t a b l i s h m e n t of a s e p a r a t e e n d o c r i n e clinic a p a r t from t h e u s u a l medical clinic at N o r t h w e s t ern U n i v e r s i t y Medical School in c h a r g e of one of us ( H . R . R . ) , this s t u d y w a s b e g u n a b o u t t w o y e a r s ago. T h e p r e s e n t c o m m u n i c a t i o n deals w i t h fifty e n d o c r i n e p a t i e n t s seen over this pe riod of t i m e in r e g a r d t o visual fields, blind s p o t s , a n d coloration of t h e optic discs. T h e l i t e r a t u r e c o n c e r n i n g this p h a s e of o p h t h a l m o l o g y is indeed scarce a n d confusing. A s h o r t review w o u l d t h e r e fore seem p e r t i n e n t . I t is m o s t n a t u r a l b e c a u s e of its a n a t o m i c a l s i t u a t i o n in relation to t h e visual p a t h w a y s , and b e c a u s e of its physiological connection w i t h t h e g o n a d a l o r g a n s , especially noted d u r i n g p r e g n a n c y , t h a t t h e pitui t a r y gland should be considered of u n u s u a l i m p o r t a n c e for s t u d y . A s e a r l y as 1914 O p p e n h e i m 2 expressed t h e opinion t h a t certain toxic s u b s t a n c e s w h i c h
might produce optic-nerve degenera tion m i g h t be derived from the pitui t a r y g l a n d w h e r e n o a c t u a l enlarge m e n t of t h e g l a n d w a s d e m o n s t r a b l e . F r o m his experience in v i e w i n g t h e discs of p i t u i t a r y d i s o r d e r s w i t h o u t signs of g r o s s e n l a r g e m e n t of t h e gland, Benedict 3 described a w a x y pal lor of t h e disc n o t a c c o m p a n i e d b y loss of s u b s t a n c e . H e explained 4 t h a t t h e color indicated a vitality of t h e n e r v e in w h i c h good r e c o v e r y could be ex pected. T h i s t y p e of disc h a s b e c o m e k n o w n as t h e yellow or w a x y disc. T h e basic w o r k c o n c e r n i n g c h a n g e s in the p i t u i t a r y gland d u r i n g p r e g n a n c y w a s done b y E r d h e i m a n d S t u m m e 5 . T h e y w e r e able t o d e m o n s t r a t e e n l a r g e m e n t of t h e g l a n d p r o p o r t i o n a l t o t h e n u m b e r of p r e g n a n c i e s . R e p o r t s of visualfield s t u d i e s on p r e g n a n t w o m e n are frequently found in t h e l i t e r a t u r e . T h e " b o n e of c o n t e n t i o n " seems t o be the theoretical consideration of w h e t h e r t h e c h a n g e s are caused b y an actual a n a t o m i c a l e n l a r g e m e n t of t h e g l a n d or u p o n toxic influences on t h e optic n e r v e s . T w o s e p a r a t e a u t h o r s h a v e re cently r e v i e w e d t h e entire l i t e r a t u r e c o n c e r n i n g t h e visual fields in p r e g n a n c y . T h e one, J o h n s 6 discusses t h e pros and cons as t o t h e a n a l y s i s of the