Management of Convergence Insufficiency and Diplopia

no

N O T E S , CASES, I N S T R U M E N T S

PERFORATED WILLIAM

BROWN

New

that a defect of the media against persistent

PROSTHESIS DOHERTY,

pressure, whether from congenital (residual

M.D.

weakness at site of the primitive trigeminal

York

vessels) or acquired causes, plays a dominant

A f t e r the fitting of an artificial eye, it has been my observation that in many cases the prosthesis seemed to float, as it were, in a

part in its formation. Congenital intracranial aneurysms are more frequently unilateral. A b o u t half o f all cerebral aneurysms

af­

lake or reservoir o f fluid, limiting its m o ­

fect the internal carotid artery after pierc­

tility and producing a pseudoexophthalmos.

ing the dura mater, or they may occur in the

This has been demonstrated

upon the

re­

moval o f the artificial eye by a gush o f tears. T h e idea occurred to me that, if perfora­ tions were made in the lower part o f the arti­

cavernous sinus. Clinical manifestations

are

due to the presence, trauma, location, pres­ sure, or rupture o f the aneurysm. General ocular symptoms and

signs in­

ficial eye where they would be hidden in the

clude vague headaches on the side o f the

lower cul-de-sac, drainage would be estab-

lesion, gradual or sudden impairment o f vi­ sion mostly on the same side. Field defects, which vary, include central scotoma, nasal hemianopsia, amaurosis on the same side with a temporal defect o f the other eye. I f

the

crossed nasal fibers o f the other retina are under pressure, or if the chiasm is pushed against the contralateral sclerotic carotid or the bony structure, an added nasal defect on the contralateral eye may result in blindness o f the eye opposite to the side o f lesion. Binasal hemianopsia is rare; however, it Fig. 1 (Doherty). The perforated

lished and

the

prosthesis

prosthesis.

would fit more

closely to the underlying conjunctiva. I am enclosing a photograph o f such an eye which was made for me by M r . H u g h W . Laubheimer o f Mager and Gougelman, Inc., N e w Y o r k . T h e patient's motility and tearing seemed to improve. T h e prosthesis was more comfortable.

AND

DIPLOPIA

I N A PATIENT WITH INTRACRANIAL

ANEURYSM WILLIAM T . BROWN, M . D .

New

on the

uncrossed

fibers of the same side, may cause indirect pressure on the uncrossed nerve fibers on the contralateral side by pushing the chiasm to the opposite bony structure or against

the

contralateral sclerotic carotid. The

aneurysm

frequently

involves

the

trigeminal ganglion, causing Raeder's paratrigeminal syndrome o f pain along the eral cornea, and third-nerve

OF CONVERGENCE

INSUFFICIENCY

ercising direct pressure

fifth-

nerve, relative insensitivity o f the homolat­

150 West 55th Street. MANAGEMENT

is conceivable that the carotid aneurysm, e x ­

York

T h e problem o f intracranial aneurysm is not a simple one. Most investigators agree

palsies. Optic

atrophy, with or without pathologic cupping, may occur. Frequently it is more pronounced on the side of the lesion. I f the aneurysm ruptures into the subarachnoidal space, it is often

fatal.

I f single or multiple ruptures

occur into the brain

substance,

symptoms

and signs of increased intracranial pressure may follow. Emotional excitement, alcohol, hypertension, or large pulse pressure

may

thin or stretch the aneurysm, causing low

111

NOTES, CASES, I N S T R U M E N T S

grade or intermittent leakage, before rupture, with meningeal symptoms.

Anatomically there are usually three kinds of carotid aneurysm: saccular, berry-form,

and diffuse fusiform dilatations. CASE REPORT Hutory. H. B., a 38-year-old man, a clerical worker, was referred for ophthalmologic consulta­ tion in November, 1953. He gave the history of a fall on his head in 1943, while in military training. H e was unconscious for a few seconds only. On re­ covery, he had no symptoms; however, some months later he began to have hazy vision in front of his right eye and difficulty in co-ordinating and focusing with his right eye. Later he was found to have high blood pressure, which necessitated his discharge from military service. In July, 1952, he suflered an attack of subarachnoid hemorrhage and an intracranial aneurysm was diagnosed. He survived and had only vague symptoms of ill-defined head­ aches, mostly on the right side. In March, 1953, he was hospitalized and a right carotid angiogram revealed a small aneurysm aris­ ing in the intracranial part of the right internal carotid artery in its supraclinoid portion. A left carotid angiogram (done because of the possibility of multiple aneurysms) revealed no evidence of a left-sided lesion. His case and therapy were dis­ cussed in a joint neurologic-neurosurgical confer­ ence. As a result, a gradual cervical ligation of the internal carotid artery was decided upon. It was felt that an intracranial ligation of the carotid above the aneurysm was too risky, partly because of close vicinity of the posterior communicating artery and the high mortality in intracranial liga­ tion procedures. An hour and a half after the artery has been completely ligated in the neck, the patient had a transient left hemiplegia, which disappeared in a few mmutes before the ligation could be undone. H e recovered uneventfully. On Christmas Day he was involved in an auto­ mobile accident, at which time he was thrown forward, striking his head. His main complaint after this was an inability to focus with his right eye and diplopia worse at near vision. He had to cover his right eye when reading or writing to avoid diplopia and confusion. He also complained of a transient monocular diplopia with either eye. Subsequent eye examination revealed no gross external abnormalities. Visual acuity was: R.E., 20/40-1-; L.E., 20/30-1- ; O.U., 20/20. He was wearing: R.E.,-|-l.OD. sph. Ζ - l.OD. cyl. ax. 180° ; L.E., -f 0.87D. sph. C — 0.87D. cyl ax. 15°. He had better visual acuity for distance without glasses. Motility studies revealed a convergence insuffi­ ciency and diplopia setting in, without correction

Fig. 1 (Brown). Quantitative fields. at 55 cm. measured from the root of the nose. With his correction, diplopia occurred at 40 cm.; 6*, base-in in front of right eye eliminated the diplopia. These readings indicate his average measurements, which varied somewhat on different occasions. Ductions with either eye, did not reveal any ab­ normality. There were no pupillary changes. Intra­ ocular pressure measured: O.U., 26.5 mm. H g (Schiøtz). Fundus examination under paredrine (one percent) mydriasis revealed: R.E., clear media, welldefined disc but considerably hyperemic with dilated capillaries and veins, increased epivascular reflexes, few crossing phenomena including segmentation, serpentine pulsation, no exudates, no hemorrhages; L.E., hyperemic disc. R.E. > L.E., unusual looping of vessels at disc and vicinity. Increased epivascular reflexes-increased venous and arterial pulsation R.E. > L.E., few deflection phenomena, no exudates, no hemorrhages. Quantitative fields were as shown in Figure 1. It is interesting to note, that no monocular diplopia was elicited in either eye with the red glass, while the other eye was covered. The patient, as a clerk with a desk job, was most annoyed by the diplopia and convergence insufficiency, which he could only control by covering his right eye, preferring to use his left eye only for near vision. He was in constant fear of losing his job. With the head erect, without glasses, his diplopia started at 55 cm. from the root of the nose, 45 degrees downward from the horizontal level. His glasses corrected about 15 cm., as his diplopia started at 40 cm. with glasses. Prescription. He was given: O.U., 1", base-in, clipovers to wear with his glasses for close work. This corrected his diplopia to 25 cm., which allowed him fusion without difficulty at ordinary near distance of 30 or 40 cm. He likes his clipovers. H e can use both eyes now while working, which has also considerably allayed his fears in connection with his job.

333 Central Park West

REFERENCES Alfano, J. E . : The Internal Carotid Artery. Amer. Acad. Ophth., Course 1, 1954.

(25J.

112

NOTES, CASES, I N S T R U M E N T S

Duke-Elder, W . S.: Textbook of Ophthalmology. St. Louis, Mosby, 1949, v. 4, pp. 3534-3549. Igersheimer, J.: Neuro-Ophthalmology Notes. Lancaster Courses, 1951, pp. 71-72. Kestenbaum, A . : Clinical Methods of Neuro-Ophthalmological Examination. New York, Grune & Stratton, 1947, pp. 93-94

TAPERED FOR INSERTION

IMPLANT

ALONG FLOOR OF ORBIT

WENDELL L . HUGHES, M . D . Hempstead, New

This

implant*

of

York

methyl

methacrylate

with a tantalum mesh o n its lower convex surface is designed for use along the floor o f the orbit for raising the contents o f the orbit. It is made in three thicknesses at the anterior part to gain more or less elevation o f the soft tissues o f the orbit. The

tapered end is placed in a prepared

pocket toward the apex o f the orbit, along the floor o f the orbit if possible, with the convex applied,

surface, to which the tantalum is being placed downward and

the

smooth, slightly concave surface up toward the soft tissues. This form

is designed to eliminate

the

necessity o f using cartilage o r bone f o r this purpose. It is useful in cases o f depressed fracture

with or without the eye present.

* Made by the Monoplex Division of the Ameri­ can Optical Company, Southbridge, Massachusetts.

Fig. 2 (Hughes). View from the front, showing the convex lower and concave upper surfaces.

The eye can be raised in this manner when depressed and in cases in which the eye is absent

and the upper

lid is sunken

even

without a fracture, the hollow in the upper lid can be filled out by the use o f this orbital implant. It serves to increase the volume o f the

orbital

contents and elevate them, so

that the eye ( o r the artificial e y e ) is held up to support the upper lid in a natural manner. The

original skin incision is arcuate and

made either a little above or below the dis­ placed lower orbital margin. T h e incision is then made down to the orbital margin and carried along the orbital The

floor.

f o r m must be placed well back and

the tarso-orbital fascia securely closed an­ teriorly with the skin incision being closed separately. In patients wearing an artificial eye, the lower fornix must be carefully pre­ served and re-anchored with sutures d o w n toward the orbital margin to preserve its integrity. T w o or three double-armed su­ tures passed through the fornix and brought out

through the skin below suffice f o r this

purpose. The

tantalum mesh serves as a

frame­

work for integration with the tissues to pre­ Fig. 1 (Hughes). Bottom view of implant, show­ ing tantalum mesh applied to the posterior two thirds of the lower surface.

vent extrusion 131

Fulton

forward. Avenue.