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Intravenous Urea in Malignant Glaucoma*
NOTES, CASES,
309
INSTRUMENTS
I N T R A V E N O U S U R E A IN MALIGNANT GLAUCOMA* RKPORT OF Λ JUAN
CASF.
V E R D A G U E R , JR.,
M.D.
AND CARLOS
LIRA,
Santiago,
M.D.
Chile
Our experience with intravenous urea in glaucoma is in close agreement with previous reports. Nevertheless, it is worthwhile mentioning that we have been able to demonstrate a "rebound phenomenon" in several patients not subjected to surgery (the tension was higher than pre-urea levels three to four hours after the infusion). 1-5
6
We wish to report a case of malignant glaucoma treated with urea in which the effect was dramatic and unexpected. W e find no report of a similar case. CASE
REPORT
M r s . E . C , aged 63 years, had a diagnosis of bilateral angle-closure glaucoma. S h e complained of only occasional episodes of headache and blurred vision. O n admission t o the E y e Clinic in M a r c h , 1960, the e x a m i n a t i o n revealed a normal visual a c u ity. T h e r e w a s slight hyperopia ( - | - 1 . 5 D . sph.) and an e x t r e m e shallowness of the anterior c h a m b e r s ; the angle w a s very n a r r o w in both eyes. T h e r e w e r e a f e w peripheral anterior synechias. T h e funduscopic e x a m i n a t i o n revealed a p h y s i o l o g i c e x c a v a t i o n and the visual fields w e r e normal. T h e tension w a s permanently but slightly increased. Pilocarpine w a s g i v e n but had t o be discontinued because the patient presented a paradoxical effect, w i t h increase in tension. S h e developed a slight field d e f e c t in the left eye. F i l t e r i n g surgery w a s performed in M a y , 1961, on the right eye (peripheral iridotomy w i t h incarceration in the w o u n d of the iris flap thus c r e a t e d ) . T h e r e w e r e n o complications a n d the tension and visual field h a v e remained normal. Shortly after operation on the right eye, the same procedure w a s performed o n the left eye. T h i s time air w a s not injected into the anterior chamber at the operation. T h e chamber failed t o r e f o r m and the tension rose ( 3 7 m m . H g ) and remained high. A posterior sclerotomy w a s p e r f o r m e d and air w a s injected into the anterior chamber. T h e chamber w a s f o r m e d o n the fourth day. T e n s i o n w a s normal and remained s o until the last check-up,
* F r o m the Department of Ophthalmology, H o s pital J o s é J. A g u i r r e . U n i v e r s i d a d de Chile.
Iimi|lllll|lllll|lllll| ι ι ι ι ι ι ι ι τ—ι—ι HOURS
I
(24)
OIAMOX
HOURS
7BO mg. / E4
DAYS
ι ι
HOURS
F i g . 1 ( V e r d a g u e r and L i r a ) . T o n o m e t r i c record in the case reported, s h o w i n g the reformation of the chamber and normalization of the intraocular pressure after infusion of urea. five days b e f o r e the n e w crisis of malignant glauc o m a about to be described. T h r e e m o n t h s after the operation, the patient w a s admitted t o hospital w i t h a clinical picture of sudden onset t w o days before. S h e complained of marked pain and loss of vision in the left eye. S h e w a s under strong emotional stress. E x a m i n a t i o n s h o w e d a complete collapse of the anterior chamber w i t h a tension of 60 m m . H g . Administration of D i a m o x lowered the tension to 4 0 mm. H g . but the chamber w a s not reformed after 2 4 hours. R e m o v a l of the clear lens seemed t o be imperative.' A n intravenous infusion of 3 0 percent lyophilized a m m o n i a - f r e e urea in 10-percent d e x t r o s e w a s administered at 4.0 m l . / m i n . ( 0 . 8 g m . per k g . of body w e i g h t ) . T h e r e w a s a dramatic drop in the intraocular pressure and 3 0 minutes after the end of the infusion, the anterior chamber w a s entirely reformed, as seen by the slitlamp. I n the f o l l o w i n g days, the tension remained l o w and D i a m o x could be discontinued. T h r e e months later the tension w a s normal. T h e r e w e r e w i d e and permanent goniosynechias but a g o o d filtering bleb. T h e vision w a s normal and the visual field h a s remained unchanged. COMMENT
W e are not able to explain satisfactorily the mechanism that caused the malignant glaucoma in this eye three months after a filtering operation; nor can we explain the relief of the condition by the use of the urea. Nevertheless, we speculate that ( 1 ) with sudden swelling of vitreous in an anatomically predisposed eye with a very narrow angle and a relatively large lens, the chamber is lost and the tension rises, estab-
310
NOTES, CASES,
lishing a vicious circle; ( 2 ) dehydration and reduction of the vitreous volume following administration of urea permits the lens to
INSTRUMENTS
come back and the drop in the intraocular pressure breaks the vicious circle, Nicaragua 2280.
REFERENCES
1. Galin, M. A , A i z a w a , F , and M c L e a n , J.: U r e a as an osmotic ocular hypotensive agent in g l a u coma. Α Μ Α A r c h . O p h t h , 6 2 : 3 4 7 , 1959. 2. : Intravenous urea in the treatment of acute angle-closure glaucoma. A m . J. O p h t h , 5 0 : 3 7 9 , 1960. 3. Galin, M. A , and N a n o , H . : U r e a endovenosa en oftalmologia. A r c h . Oftal. B u e n o s A i r e s , 3 6 : 4 9 7 , 1961. 4. D a v i s , M , Duehr, P , and Javid, M . : T h e clinical use of urea for reduction of intraocular pressures. Α Μ Α A r c h . O p h t h , 6 5 : 5 2 6 , 1961. 5. Hill, K , W h i t n e y , J , and Trotter, R.: Intravenous hypertonic urea in the ménagement o f acute angle-closure glaucoma. Α Μ Α A r c h . O p h t h , 6 5 : 4 9 7 , 1961. 6. Verdaguer, T , Juan y Lira, C : U r e a endovenosa en el glaucoma. A r c h . Chile. O f t a l , in press. 7. Chandler, P . Α . : Malignant glaucoma. A m . J. O p h t h , 3 4 : 9 9 3 , 1951.
ESSENTIAL XANTHOMATOSIS*
been found in many other organs and tissues. Lesions have been demonstrated on the mucosal surface of the mouth, epiglottis and larynx, on the cornea and sclera, in the pleura, lungs, pituitary gland and the tuber cinerium, in bones, spinal cord, lymph glands and spleen, in the brain, in the liver and on the serous surfaces of the pericardium and peritoneum, the walls of the esophagus, stomach and intestinal mucosa, as well as in such glands as the thymus, pancreas and adrenals. In fact, Thannhausen has indicated that xanthomatous nodules may originate in every organ where reticulum cells and histiocytes are normally present. 3
B.
M.
CHATTERJEE,
Calcutta,
F.R.C.S.
India
Xanthomatosis is a form of lipoidosis, a term which has been applied to a group of diseases in which the lesions, due to a local or generalized disturbance of the lipoid metabolism, contain lipoid substances. Duke-Elder states that in a localized disturbance, as in the skin, owing to deficient local oxidation, there is an accumulation of lipoids in the tissues, an unmasking of the invisibly fine fatty emulsion normally present in the cells and its deposition in visible form, a process which excites a foreignbody reaction involving the mobilization of histiocytic cells, the proliferation of fibrous tissue and the appearance of giant cells. 6
2
A generalized disturbance, on the other hand, may or may not depend upon a hypercholesteremia but there is a derangement of lipoid metabolism whereby lipoids are accumulated in various tissues of the body, particularly the reticulo-endothelial system. Thus in xanthomatosis, in addition to skin involvement, xanthomatous changes have
* F r o m the D e p a r t m e n t o f Ophthalmology, S . S . K . M . Hospital. R e a d before the Ophthalmological Society of Bengal, July, 1961.
7
10
4
11
8
The following case is one of generalized xanthomatosis without hypercholesteremia. CASE
REPORT
U . K. D , a H i n d u man, aged 4 9 years, a goldsmith by occupation, attended the ophthalmic department of S . S . K . M . Hospital, Calcutta, on September 8, I960, w i t h a history that 14 years a g o a s w e l l i n g first appeared in the l o w e r lid of the left eye w h i c h gradually increased. A f t e r a week, the left upper lid also s h o w e d evidence of swelling. W i t h i n a short time, the right lids started to swell, the upper lid f o l l o w i n g the lower. T h e swelling w a s at first slight but, within a period of s i x years, they attained the present dimensions (fig. 1 ) . H e suffered f r o m asthma for the last 10 years and had had gonorrhea at the a g e of 20 years w h i c h w a s cured. Examination. T h e r e w a s m a s s i v e swelling o f both the lids o n both sides, protruding f o r w a r d and
309
INSTRUMENTS
I N T R A V E N O U S U R E A IN MALIGNANT GLAUCOMA* RKPORT OF Λ JUAN
CASF.
V E R D A G U E R , JR.,
M.D.
AND CARLOS
LIRA,
Santiago,
M.D.
Chile
Our experience with intravenous urea in glaucoma is in close agreement with previous reports. Nevertheless, it is worthwhile mentioning that we have been able to demonstrate a "rebound phenomenon" in several patients not subjected to surgery (the tension was higher than pre-urea levels three to four hours after the infusion). 1-5
6
We wish to report a case of malignant glaucoma treated with urea in which the effect was dramatic and unexpected. W e find no report of a similar case. CASE
REPORT
M r s . E . C , aged 63 years, had a diagnosis of bilateral angle-closure glaucoma. S h e complained of only occasional episodes of headache and blurred vision. O n admission t o the E y e Clinic in M a r c h , 1960, the e x a m i n a t i o n revealed a normal visual a c u ity. T h e r e w a s slight hyperopia ( - | - 1 . 5 D . sph.) and an e x t r e m e shallowness of the anterior c h a m b e r s ; the angle w a s very n a r r o w in both eyes. T h e r e w e r e a f e w peripheral anterior synechias. T h e funduscopic e x a m i n a t i o n revealed a p h y s i o l o g i c e x c a v a t i o n and the visual fields w e r e normal. T h e tension w a s permanently but slightly increased. Pilocarpine w a s g i v e n but had t o be discontinued because the patient presented a paradoxical effect, w i t h increase in tension. S h e developed a slight field d e f e c t in the left eye. F i l t e r i n g surgery w a s performed in M a y , 1961, on the right eye (peripheral iridotomy w i t h incarceration in the w o u n d of the iris flap thus c r e a t e d ) . T h e r e w e r e n o complications a n d the tension and visual field h a v e remained normal. Shortly after operation on the right eye, the same procedure w a s performed o n the left eye. T h i s time air w a s not injected into the anterior chamber at the operation. T h e chamber failed t o r e f o r m and the tension rose ( 3 7 m m . H g ) and remained high. A posterior sclerotomy w a s p e r f o r m e d and air w a s injected into the anterior chamber. T h e chamber w a s f o r m e d o n the fourth day. T e n s i o n w a s normal and remained s o until the last check-up,
* F r o m the Department of Ophthalmology, H o s pital J o s é J. A g u i r r e . U n i v e r s i d a d de Chile.
Iimi|lllll|lllll|lllll| ι ι ι ι ι ι ι ι τ—ι—ι HOURS
I
(24)
OIAMOX
HOURS
7BO mg. / E4
DAYS
ι ι
HOURS
F i g . 1 ( V e r d a g u e r and L i r a ) . T o n o m e t r i c record in the case reported, s h o w i n g the reformation of the chamber and normalization of the intraocular pressure after infusion of urea. five days b e f o r e the n e w crisis of malignant glauc o m a about to be described. T h r e e m o n t h s after the operation, the patient w a s admitted t o hospital w i t h a clinical picture of sudden onset t w o days before. S h e complained of marked pain and loss of vision in the left eye. S h e w a s under strong emotional stress. E x a m i n a t i o n s h o w e d a complete collapse of the anterior chamber w i t h a tension of 60 m m . H g . Administration of D i a m o x lowered the tension to 4 0 mm. H g . but the chamber w a s not reformed after 2 4 hours. R e m o v a l of the clear lens seemed t o be imperative.' A n intravenous infusion of 3 0 percent lyophilized a m m o n i a - f r e e urea in 10-percent d e x t r o s e w a s administered at 4.0 m l . / m i n . ( 0 . 8 g m . per k g . of body w e i g h t ) . T h e r e w a s a dramatic drop in the intraocular pressure and 3 0 minutes after the end of the infusion, the anterior chamber w a s entirely reformed, as seen by the slitlamp. I n the f o l l o w i n g days, the tension remained l o w and D i a m o x could be discontinued. T h r e e months later the tension w a s normal. T h e r e w e r e w i d e and permanent goniosynechias but a g o o d filtering bleb. T h e vision w a s normal and the visual field h a s remained unchanged. COMMENT
W e are not able to explain satisfactorily the mechanism that caused the malignant glaucoma in this eye three months after a filtering operation; nor can we explain the relief of the condition by the use of the urea. Nevertheless, we speculate that ( 1 ) with sudden swelling of vitreous in an anatomically predisposed eye with a very narrow angle and a relatively large lens, the chamber is lost and the tension rises, estab-
310
NOTES, CASES,
lishing a vicious circle; ( 2 ) dehydration and reduction of the vitreous volume following administration of urea permits the lens to
INSTRUMENTS
come back and the drop in the intraocular pressure breaks the vicious circle, Nicaragua 2280.
REFERENCES
1. Galin, M. A , A i z a w a , F , and M c L e a n , J.: U r e a as an osmotic ocular hypotensive agent in g l a u coma. Α Μ Α A r c h . O p h t h , 6 2 : 3 4 7 , 1959. 2. : Intravenous urea in the treatment of acute angle-closure glaucoma. A m . J. O p h t h , 5 0 : 3 7 9 , 1960. 3. Galin, M. A , and N a n o , H . : U r e a endovenosa en oftalmologia. A r c h . Oftal. B u e n o s A i r e s , 3 6 : 4 9 7 , 1961. 4. D a v i s , M , Duehr, P , and Javid, M . : T h e clinical use of urea for reduction of intraocular pressures. Α Μ Α A r c h . O p h t h , 6 5 : 5 2 6 , 1961. 5. Hill, K , W h i t n e y , J , and Trotter, R.: Intravenous hypertonic urea in the ménagement o f acute angle-closure glaucoma. Α Μ Α A r c h . O p h t h , 6 5 : 4 9 7 , 1961. 6. Verdaguer, T , Juan y Lira, C : U r e a endovenosa en el glaucoma. A r c h . Chile. O f t a l , in press. 7. Chandler, P . Α . : Malignant glaucoma. A m . J. O p h t h , 3 4 : 9 9 3 , 1951.
ESSENTIAL XANTHOMATOSIS*
been found in many other organs and tissues. Lesions have been demonstrated on the mucosal surface of the mouth, epiglottis and larynx, on the cornea and sclera, in the pleura, lungs, pituitary gland and the tuber cinerium, in bones, spinal cord, lymph glands and spleen, in the brain, in the liver and on the serous surfaces of the pericardium and peritoneum, the walls of the esophagus, stomach and intestinal mucosa, as well as in such glands as the thymus, pancreas and adrenals. In fact, Thannhausen has indicated that xanthomatous nodules may originate in every organ where reticulum cells and histiocytes are normally present. 3
B.
M.
CHATTERJEE,
Calcutta,
F.R.C.S.
India
Xanthomatosis is a form of lipoidosis, a term which has been applied to a group of diseases in which the lesions, due to a local or generalized disturbance of the lipoid metabolism, contain lipoid substances. Duke-Elder states that in a localized disturbance, as in the skin, owing to deficient local oxidation, there is an accumulation of lipoids in the tissues, an unmasking of the invisibly fine fatty emulsion normally present in the cells and its deposition in visible form, a process which excites a foreignbody reaction involving the mobilization of histiocytic cells, the proliferation of fibrous tissue and the appearance of giant cells. 6
2
A generalized disturbance, on the other hand, may or may not depend upon a hypercholesteremia but there is a derangement of lipoid metabolism whereby lipoids are accumulated in various tissues of the body, particularly the reticulo-endothelial system. Thus in xanthomatosis, in addition to skin involvement, xanthomatous changes have
* F r o m the D e p a r t m e n t o f Ophthalmology, S . S . K . M . Hospital. R e a d before the Ophthalmological Society of Bengal, July, 1961.
7
10
4
11
8
The following case is one of generalized xanthomatosis without hypercholesteremia. CASE
REPORT
U . K. D , a H i n d u man, aged 4 9 years, a goldsmith by occupation, attended the ophthalmic department of S . S . K . M . Hospital, Calcutta, on September 8, I960, w i t h a history that 14 years a g o a s w e l l i n g first appeared in the l o w e r lid of the left eye w h i c h gradually increased. A f t e r a week, the left upper lid also s h o w e d evidence of swelling. W i t h i n a short time, the right lids started to swell, the upper lid f o l l o w i n g the lower. T h e swelling w a s at first slight but, within a period of s i x years, they attained the present dimensions (fig. 1 ) . H e suffered f r o m asthma for the last 10 years and had had gonorrhea at the a g e of 20 years w h i c h w a s cured. Examination. T h e r e w a s m a s s i v e swelling o f both the lids o n both sides, protruding f o r w a r d and