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Los Angeles Society of Ophthalmology and Otolaryngology
SOCIETY PROCEEDINGS this Journal (November, 1938). Discussion. Dr. H. J. Smith wished to call attention to those patients with a refractive error which may include astig matism. Peter has called attention to the fact that it is often unnecessary to give any vertical correction for hyperphoria: correction of the refractive error will cause the muscle imbalance to correct it self. It is not always necessary to add prisms, base up or base down, when there are lenses of unequal power. The optician may be instructed to raise or lower the optical center to give enough prism effect in the proper direction. He objected to prisms, base in, for exophoria except in older patients, and preferred to use in stead exercises for convergence insuffi ciency arising in early presbyopia. He agreed with the speaker that the best recommendation for any refraction was the satisfied patient, no matter how it is accomplished. Dr. J. E. Lebensohn (closing) said that Dr. Smith had offered objection to the use of prisms, base in, for convergence insufficiency. In the case cited the lenses with prisms were only prescribed for near work. The patient originally had 15 de grees of exophoria for near; after using the lenses ordered for a year, he then had 6.5 degrees of exophoria: the prisms were then reduced one half, and in the following year the exophoria for near was within normal limits, and reading glasses were prescribed without prisms. He was interested in determining the dominant eye, and any vertically acting prism prescribed is for the nondominant eye. It is surprising how much prism can be so prescribed: in one child with head tilting, 7 degrees, base up, right eye was readily accepted and relieved the condi tion. Dr. Halper had objected to overcorrection of myopia at any time. Most of the patients seen were wearing an approxi mately correct refraction. Because of exo
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phoria still present, a little extra minus was given, and the result justified the procedure. Robert von der Heydt. LOS ANGELES SOCIETY O F OPHTHALMOLOGY AND OTOLARYNGOLOGY March 28, 1938 DR. CLIFFORD
B. WALKER, president
EXPERIMENTAL IONTOPHORESIS ON RAB BITS' CORNEAS
DR. S. G. SEECH opened his subject with the statement that ionic medication has been used in ophthalmology since 1900. He stated that the positive ions of zinc, copper, mercury, silver, and quinine were used for their antiseptic properties to promote healing of chronic infections and many kind of ulcers. The negative ions of chlorine, iodine, and salicylic acid were used to soften superficial scars and to promote their absorption. He contended that the theory of ionic medication was rational, failures being due to improper technique. Imperfect penetration of ions, and formation of in soluble compounds with the plasma result in failure. The application of a galvanic current of two or three miliamperes per square centimeter of surface for a dura tion of two to three minutes gives the best results. The current should be gradu ally increased and then gradually de creased. Should the metallic part of the electrode touch any portion of the treated surface, the caustic product formed under the metal electrode will cause tissue dam age. Dr. Seech then proceeded to describe some experimental effects on the corneas of healthy rabbits. He stated that histological methods have shown that the chemical salt solution will enter corneal tissue and be disseminated through it for variable depths, and can even be extended to the posterior pole of the eyeball, in
190
SOCIETY PROCEEDINGS
which case permanent pathological changes result. Naturally from a thera peutic standpoint one should produce only transient changes where the tissues will return to normal after the response to stimulation. The rationale of ionic medi cation is to promote temporary tissue changes; upon its return to a resting state the rehabilitation of the surrounding nor mal tissue will commence regeneration in the adjacent diseased tissue. In the cornea the stimulation causes fluid to be brought and interdispersed in the lamellae. The corneal corpuscles at first respond by becoming mildly edematous, and as this process continues fluid accumulation occurs in the lacunae, and there develops intercellular pressure on the individual fibers and corpuscles of the substantia propria. Repetition of the process periodically produces an al ternating irritation and relaxation, which stimulates the tissues in their reparative function. With zinc sulphate, the healing process is considerably delayed, which makes it necessary to increase the time interval between treatments, allowing sufficient time for return of the inflammatory struc tures to a normal state after each stimula tion. A one-quarter-percent solution with one milliampere current applied for three minutes or less is satisfactory. Stronger solutions consistently induced a tendency to vacuolization in the substantia propria, even to rupture of Descemet's membrane. Zinc chloride always produced patho logical changes even in high dilution, producing marked edema, resulting in bulging of the cornea or ulceration. Hyperplasia of the epithelial elements and in flammatory infiltration of the stroma were found in these cases. On this account the agent was soon discarded. Physiological salt solution resulted in changes so slight as to be of no therapeutic value.
Colloidal sulphur was found to be un satisfactory, because particles of sulphur, tending to polarize, formed minute de posits of highly charged irritants in the tissue. Sections showed such peppered areas in the corneal epithelial layer. Quinine bisulphate was borne by the tissues in concentrations as high as 10 percent for as long as a 10-minute applica tion, with a 2y2 milliampere current. Microchemical tests were used to prove its presence in the tissues. Dr. Seech described the changes occur ring in his experiments as follows: The reparative or therapeutic change was that of a superficial reaction not extending past the anterior lamina elastica, and seen as a haziness of the cornea. This is fol lowed by dissemination of ions in the stratified pavement epithelial layer, clini cally seen as a powdery, sprayed area with hazy margins. Finally, edema of the corneal corpuscles next to Bowman's membrane which are distorted but do not lose their stellate forms. The borderline changes Dr. Seech de scribed as varying from mild vacuoliza tion, tending to crush or displace the lamellae, to distortion and rupture of the corneal corpuscles, to finally marked dis tortion of the fibrillae with edematous fluid. The first stages are probably reclaimable. Pathologic or destructive changes were described as a diffuse inflammatory in filtration composed of granulocytes, plasma cells, and collagenous histiocytes, all of which are later replaced by lympho cytes. Vacuolization occurs, and the cor nea bulges forward. Second, inflamma tory hyperplasia of the epithelium and of the posterior lamina elastica occurs. Third, dehydration and subsequent co agulation and necrosis occurs. Finally, re parative fibrosis completes the destruc tive change. Dr. Seech then proceeded to describe
SOCIETY PROCEEDINGS two cases of corneal dystrophy which he treated with quinine bisulphate iontopho resis. Both cases showed improvement after several treatments of the one-quar ter-percent solution of quinine bisulphate. T h e first improved in vision from 2 0 / 6 0 to 2 0 / 2 0 and the second from 20/100 to 20/20. HAROLD F . W H A L M A N ,
Editor.
M E M P H I S SOCIETY O F OPH THALMOLOGY AND OTOLARYNGOLOGY March 8, 1938 D R . C. H . GLOVER,
presiding
IRIDENCLEISIS FOR GLAUCOMA
D R . E . C. E L L E T T reported a case of simple glaucoma for which an iridenclei sis had been performed on one eye. I n this eye there was very little impairment of the central vision, but the tension was persistently around 40 mm. in spite of miotics, and there was a beginning cata ract. T h e operation was performed a week before, with inclusion of one pillar in the wound. T h e healing was satisfactory and the tension 11 m m . T h e other eye also has glaucoma, but the field and vision are normal, and the tension is kept down with miotics. T h e patient is 66 years old. In answer to a question as to the choice of operation in this case, it was deter mined by the fact that there is a begin ning cataract and that probably some day a cataract operation will be required. IRIDENCLEISIS FOR GLAUCOMA
D R . P H I L M. L E W I S presented a white
man, aged 65 years, upon whom he had operated for glaucoma three days previ ously. This patient was first seen in Au gust, 1935, and in spite of the regular use of miotics the tension continued high, O.D. 35 and O . S . 50 mm. H g ( S c h i o t z ) .
191
T h e visual fields of the right eye were moderately contracted, those of the left eye decidedly narrow. Central vision was 20/100 in each eye, unimproved by lenses. A bilateral iridencleisis had been per formed three days ago. T h e technique w a s that recommended by Constantine and described by him in the American J o u r nal of Ophthalmology for July, 1937. C o m m e n t : T h e reason for presenting this patient was to bring to the attention of the Society the operation of iridenclei sis. T h e writer has performed quite a number of these operations during the past three years and the results have been so satisfactory that he now prefers it to any other procedure. At first he was ex tremely skeptical, because h e w a s opposed to any type of operation in which the iris was drawn into and left in the wound, but to date there have been no untoward complications. D E T A C H M E N T OF RETINA
D R . E . C. E L L E T T presented the case of O. W . , colored, aged 40 years, who had a cataract operation in 1929 on each eye, and failed to regain vision in the left eye. H e had a good visual result in t h e right eye until July, 1937, when it suddenly failed. Examination showed almost total retinal detachment O.D., although the area up and in was barely loose and re tained good color. T h e disc was not visi ble. N o tear was seen. T h e r e was a good upward iris coloboma, with a dense sec ondary membrane, but good opening. T h e outer half of the eye was exposed, the external rectus divided, and about 2 0 diathermy needles applied to the eye. T h e sclera was then trephined down and out. O n November 20th the fundus was clearly seen and the whole retina reattached. T h e macular region shows a white scar be tween it and the disc. O n November 6th, O.D. vision w a s 5/15 with + 1 1 . 0 0 D . sph. =C= + 1 . 0 0 D. cyl. ax. 150°.
189
phoria still present, a little extra minus was given, and the result justified the procedure. Robert von der Heydt. LOS ANGELES SOCIETY O F OPHTHALMOLOGY AND OTOLARYNGOLOGY March 28, 1938 DR. CLIFFORD
B. WALKER, president
EXPERIMENTAL IONTOPHORESIS ON RAB BITS' CORNEAS
DR. S. G. SEECH opened his subject with the statement that ionic medication has been used in ophthalmology since 1900. He stated that the positive ions of zinc, copper, mercury, silver, and quinine were used for their antiseptic properties to promote healing of chronic infections and many kind of ulcers. The negative ions of chlorine, iodine, and salicylic acid were used to soften superficial scars and to promote their absorption. He contended that the theory of ionic medication was rational, failures being due to improper technique. Imperfect penetration of ions, and formation of in soluble compounds with the plasma result in failure. The application of a galvanic current of two or three miliamperes per square centimeter of surface for a dura tion of two to three minutes gives the best results. The current should be gradu ally increased and then gradually de creased. Should the metallic part of the electrode touch any portion of the treated surface, the caustic product formed under the metal electrode will cause tissue dam age. Dr. Seech then proceeded to describe some experimental effects on the corneas of healthy rabbits. He stated that histological methods have shown that the chemical salt solution will enter corneal tissue and be disseminated through it for variable depths, and can even be extended to the posterior pole of the eyeball, in
190
SOCIETY PROCEEDINGS
which case permanent pathological changes result. Naturally from a thera peutic standpoint one should produce only transient changes where the tissues will return to normal after the response to stimulation. The rationale of ionic medi cation is to promote temporary tissue changes; upon its return to a resting state the rehabilitation of the surrounding nor mal tissue will commence regeneration in the adjacent diseased tissue. In the cornea the stimulation causes fluid to be brought and interdispersed in the lamellae. The corneal corpuscles at first respond by becoming mildly edematous, and as this process continues fluid accumulation occurs in the lacunae, and there develops intercellular pressure on the individual fibers and corpuscles of the substantia propria. Repetition of the process periodically produces an al ternating irritation and relaxation, which stimulates the tissues in their reparative function. With zinc sulphate, the healing process is considerably delayed, which makes it necessary to increase the time interval between treatments, allowing sufficient time for return of the inflammatory struc tures to a normal state after each stimula tion. A one-quarter-percent solution with one milliampere current applied for three minutes or less is satisfactory. Stronger solutions consistently induced a tendency to vacuolization in the substantia propria, even to rupture of Descemet's membrane. Zinc chloride always produced patho logical changes even in high dilution, producing marked edema, resulting in bulging of the cornea or ulceration. Hyperplasia of the epithelial elements and in flammatory infiltration of the stroma were found in these cases. On this account the agent was soon discarded. Physiological salt solution resulted in changes so slight as to be of no therapeutic value.
Colloidal sulphur was found to be un satisfactory, because particles of sulphur, tending to polarize, formed minute de posits of highly charged irritants in the tissue. Sections showed such peppered areas in the corneal epithelial layer. Quinine bisulphate was borne by the tissues in concentrations as high as 10 percent for as long as a 10-minute applica tion, with a 2y2 milliampere current. Microchemical tests were used to prove its presence in the tissues. Dr. Seech described the changes occur ring in his experiments as follows: The reparative or therapeutic change was that of a superficial reaction not extending past the anterior lamina elastica, and seen as a haziness of the cornea. This is fol lowed by dissemination of ions in the stratified pavement epithelial layer, clini cally seen as a powdery, sprayed area with hazy margins. Finally, edema of the corneal corpuscles next to Bowman's membrane which are distorted but do not lose their stellate forms. The borderline changes Dr. Seech de scribed as varying from mild vacuoliza tion, tending to crush or displace the lamellae, to distortion and rupture of the corneal corpuscles, to finally marked dis tortion of the fibrillae with edematous fluid. The first stages are probably reclaimable. Pathologic or destructive changes were described as a diffuse inflammatory in filtration composed of granulocytes, plasma cells, and collagenous histiocytes, all of which are later replaced by lympho cytes. Vacuolization occurs, and the cor nea bulges forward. Second, inflamma tory hyperplasia of the epithelium and of the posterior lamina elastica occurs. Third, dehydration and subsequent co agulation and necrosis occurs. Finally, re parative fibrosis completes the destruc tive change. Dr. Seech then proceeded to describe
SOCIETY PROCEEDINGS two cases of corneal dystrophy which he treated with quinine bisulphate iontopho resis. Both cases showed improvement after several treatments of the one-quar ter-percent solution of quinine bisulphate. T h e first improved in vision from 2 0 / 6 0 to 2 0 / 2 0 and the second from 20/100 to 20/20. HAROLD F . W H A L M A N ,
Editor.
M E M P H I S SOCIETY O F OPH THALMOLOGY AND OTOLARYNGOLOGY March 8, 1938 D R . C. H . GLOVER,
presiding
IRIDENCLEISIS FOR GLAUCOMA
D R . E . C. E L L E T T reported a case of simple glaucoma for which an iridenclei sis had been performed on one eye. I n this eye there was very little impairment of the central vision, but the tension was persistently around 40 mm. in spite of miotics, and there was a beginning cata ract. T h e operation was performed a week before, with inclusion of one pillar in the wound. T h e healing was satisfactory and the tension 11 m m . T h e other eye also has glaucoma, but the field and vision are normal, and the tension is kept down with miotics. T h e patient is 66 years old. In answer to a question as to the choice of operation in this case, it was deter mined by the fact that there is a begin ning cataract and that probably some day a cataract operation will be required. IRIDENCLEISIS FOR GLAUCOMA
D R . P H I L M. L E W I S presented a white
man, aged 65 years, upon whom he had operated for glaucoma three days previ ously. This patient was first seen in Au gust, 1935, and in spite of the regular use of miotics the tension continued high, O.D. 35 and O . S . 50 mm. H g ( S c h i o t z ) .
191
T h e visual fields of the right eye were moderately contracted, those of the left eye decidedly narrow. Central vision was 20/100 in each eye, unimproved by lenses. A bilateral iridencleisis had been per formed three days ago. T h e technique w a s that recommended by Constantine and described by him in the American J o u r nal of Ophthalmology for July, 1937. C o m m e n t : T h e reason for presenting this patient was to bring to the attention of the Society the operation of iridenclei sis. T h e writer has performed quite a number of these operations during the past three years and the results have been so satisfactory that he now prefers it to any other procedure. At first he was ex tremely skeptical, because h e w a s opposed to any type of operation in which the iris was drawn into and left in the wound, but to date there have been no untoward complications. D E T A C H M E N T OF RETINA
D R . E . C. E L L E T T presented the case of O. W . , colored, aged 40 years, who had a cataract operation in 1929 on each eye, and failed to regain vision in the left eye. H e had a good visual result in t h e right eye until July, 1937, when it suddenly failed. Examination showed almost total retinal detachment O.D., although the area up and in was barely loose and re tained good color. T h e disc was not visi ble. N o tear was seen. T h e r e was a good upward iris coloboma, with a dense sec ondary membrane, but good opening. T h e outer half of the eye was exposed, the external rectus divided, and about 2 0 diathermy needles applied to the eye. T h e sclera was then trephined down and out. O n November 20th the fundus was clearly seen and the whole retina reattached. T h e macular region shows a white scar be tween it and the disc. O n November 6th, O.D. vision w a s 5/15 with + 1 1 . 0 0 D . sph. =C= + 1 . 0 0 D. cyl. ax. 150°.