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Iritis with Unusual Focus of Infection
NOTES, CASES, INSTRUMENTS I R I T I S W I T H UNUSUAJL F O C U S OF INFECTION. WM.
EVANS BRUNEK, A.M.,
M.D.
CLEVELAND, OHIO.
T h e following case of iritis is of spe cial interest only because of the un usual focus of infection. Mr. C , age 57, consulted me No vember 23, 1921, with the history that the right eye had been inflamed a week. Three days ago he consulted an oculist in Kansas City who put some drops in the eye and told him to continue boric acid solution. T w o days later while in St. Louis, he saw Dr. Wiener who found that he had an iritis with adhesions, but he had no time to study the etiology as the pa tient was leaving the city in a few hours for home. Dr. Wiener accord ingly advised him to consult me at once upon his arrival in Cleveland. I saw him the following morning. Examination show'ed considerable bulbar congestion, cornea slightly hazy with some deposits in the lower portion, iris muddy, pupil semidilated but not perfectly round, a complete circle of brown pigment spots on the anterior capsule of the lens, where pos terior synechiae had evidently started to form—in other words, a typical case of iritis. Ophthalmoscopic examina tion showed the fundus hyperemic and hazy and compression of the veins by the overlying arteries. Tonsils were not enlarged. The teeth looked fair and were later shown by X-ray to be in good condition. He was troubled with chronic constipa tion, but controlled this by salts every morning. He considered himself in good condition except for one thing— he had had a discharge from the bone of the right thigh for years. He had had a fracture of this bone many years ago, as a result of which a sinus de veloped. He had been operated upon first by the late Dr. D. P. Allen of Cleveland, and later twenty years ago, by the late Dr. Nicholas Senn. Each operation helped for a time, then the wound broke down and the discharge continued. F o r years he has noticed that if the wound becomes clogged so it cannot discharge freely, he feels 56
badly and has a slight fever. Exami nation showed a very large scar to the outer side of the lower end of the thigh with some discharge. I suspected at once that absorption from this osteomyelitis might account for t h e iritis and so told him. But he had had such a long period in the hos pital upon the occasion of each former operation without permanent cure, that he was much averse to another operation. To be certain that there might not be some other focus of in fection which would account for the inflammation of the eye, he was sent to the Cleveland Clinic for a complete general examination. They were "un able to find any cause for the iritis un less it could be the old infection of the femur." He was very desirous be cause of business reasons to postpone the operation for several months. Local and general medication were in stituted tho I urged that operation up on the leg offered the best hope of clearing up the eye. As the inflam mation had not improved by the twenty-ninth, the congestion being no less and the cornea even more hazy, he consented to operation. I saw him the following morning at the hospital before the operation, and the eye showed no change. Atropin of course was continued but all other medication stopped. Operation was performed by Dr. Crilc. An incision was made along the old scar and dissection carried down to the femur. T h e medullary cavity was opened and considerable bone removed, though no sequestra were found. T h e bone cavity was packed with iodoform gauze. The following morning the eye was looking better. On the second morn ing the redness was much less and the pupil larger, and on the third morn ing the redness was almost entirely gone with pupil dilated ad maximum the cornea clear, and the eye perfectly comfortable. Recovery was so prompt and complete, following the operation, that it seemed there could be no rea sonable doubt that absorption from the diseased femur had caused the iritis. His recovery was uninterrupted except for one little flare up, due to absorption from a pocket of pus, which
NOTES. CASES AND
was not properly draining; and he left the hospital January 11th. March 30th refraction was tested with the following result: R . + 0.50 C + 0.25 Cy. 90° V = 6 / 5 L . + 0.25 C + 0.25 Cy. 1 2 0 ° V = 6 / 5 He was ordered this, with + 2 . 2 5 bi focals for reading. Since that time he has had no further trouble with the eye. A
RANGE F O R REFRACTION EMBODYING N E W FEATURES. SIDNEY L . OLSHO, M . D . PHILADELPHIA, PA.
Sidelights, shadows, reflections, pic
Fie-
1.—^A Refraction
INSTRUMENTS
57
tures, articles of furniture and irrele vant objects in general, all tend to di vert the patient's attention during a re fraction, and therefore prolong it, hasten retinal fatigue and lessen the accuracy of the result. Figure 1 shows a refraction range in which these objectionable features, present in so many refracting rooms, have been overcome. T o provide this particular range, the wall toward a distally adjoining room was opened from floor to ceiling for a width of five feet. The light from two windows was successfully ob scured without seriously affecting the ventilation. These windows were framed and curtained in a special prac-
Range showing a continuous unbroken, neutral-gray vista, leading to test cabinet and muscle lights.
chart
EVANS BRUNEK, A.M.,
M.D.
CLEVELAND, OHIO.
T h e following case of iritis is of spe cial interest only because of the un usual focus of infection. Mr. C , age 57, consulted me No vember 23, 1921, with the history that the right eye had been inflamed a week. Three days ago he consulted an oculist in Kansas City who put some drops in the eye and told him to continue boric acid solution. T w o days later while in St. Louis, he saw Dr. Wiener who found that he had an iritis with adhesions, but he had no time to study the etiology as the pa tient was leaving the city in a few hours for home. Dr. Wiener accord ingly advised him to consult me at once upon his arrival in Cleveland. I saw him the following morning. Examination show'ed considerable bulbar congestion, cornea slightly hazy with some deposits in the lower portion, iris muddy, pupil semidilated but not perfectly round, a complete circle of brown pigment spots on the anterior capsule of the lens, where pos terior synechiae had evidently started to form—in other words, a typical case of iritis. Ophthalmoscopic examina tion showed the fundus hyperemic and hazy and compression of the veins by the overlying arteries. Tonsils were not enlarged. The teeth looked fair and were later shown by X-ray to be in good condition. He was troubled with chronic constipa tion, but controlled this by salts every morning. He considered himself in good condition except for one thing— he had had a discharge from the bone of the right thigh for years. He had had a fracture of this bone many years ago, as a result of which a sinus de veloped. He had been operated upon first by the late Dr. D. P. Allen of Cleveland, and later twenty years ago, by the late Dr. Nicholas Senn. Each operation helped for a time, then the wound broke down and the discharge continued. F o r years he has noticed that if the wound becomes clogged so it cannot discharge freely, he feels 56
badly and has a slight fever. Exami nation showed a very large scar to the outer side of the lower end of the thigh with some discharge. I suspected at once that absorption from this osteomyelitis might account for t h e iritis and so told him. But he had had such a long period in the hos pital upon the occasion of each former operation without permanent cure, that he was much averse to another operation. To be certain that there might not be some other focus of in fection which would account for the inflammation of the eye, he was sent to the Cleveland Clinic for a complete general examination. They were "un able to find any cause for the iritis un less it could be the old infection of the femur." He was very desirous be cause of business reasons to postpone the operation for several months. Local and general medication were in stituted tho I urged that operation up on the leg offered the best hope of clearing up the eye. As the inflam mation had not improved by the twenty-ninth, the congestion being no less and the cornea even more hazy, he consented to operation. I saw him the following morning at the hospital before the operation, and the eye showed no change. Atropin of course was continued but all other medication stopped. Operation was performed by Dr. Crilc. An incision was made along the old scar and dissection carried down to the femur. T h e medullary cavity was opened and considerable bone removed, though no sequestra were found. T h e bone cavity was packed with iodoform gauze. The following morning the eye was looking better. On the second morn ing the redness was much less and the pupil larger, and on the third morn ing the redness was almost entirely gone with pupil dilated ad maximum the cornea clear, and the eye perfectly comfortable. Recovery was so prompt and complete, following the operation, that it seemed there could be no rea sonable doubt that absorption from the diseased femur had caused the iritis. His recovery was uninterrupted except for one little flare up, due to absorption from a pocket of pus, which
NOTES. CASES AND
was not properly draining; and he left the hospital January 11th. March 30th refraction was tested with the following result: R . + 0.50 C + 0.25 Cy. 90° V = 6 / 5 L . + 0.25 C + 0.25 Cy. 1 2 0 ° V = 6 / 5 He was ordered this, with + 2 . 2 5 bi focals for reading. Since that time he has had no further trouble with the eye. A
RANGE F O R REFRACTION EMBODYING N E W FEATURES. SIDNEY L . OLSHO, M . D . PHILADELPHIA, PA.
Sidelights, shadows, reflections, pic
Fie-
1.—^A Refraction
INSTRUMENTS
57
tures, articles of furniture and irrele vant objects in general, all tend to di vert the patient's attention during a re fraction, and therefore prolong it, hasten retinal fatigue and lessen the accuracy of the result. Figure 1 shows a refraction range in which these objectionable features, present in so many refracting rooms, have been overcome. T o provide this particular range, the wall toward a distally adjoining room was opened from floor to ceiling for a width of five feet. The light from two windows was successfully ob scured without seriously affecting the ventilation. These windows were framed and curtained in a special prac-
Range showing a continuous unbroken, neutral-gray vista, leading to test cabinet and muscle lights.
chart