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Memphis Eye, Ear, Nose and Throat Society
SOCIETY PROCEEDINGS
1076
cases, the normal lid will fall after operation and this will give the appearance of overcorrection. To correct this situation, either the levator of the initially normal eye may be resected or the eye which was originally operated may be reoperated. Overcorrection can be improved by tenotomy of the levator on the operated side. In general, it is desirable to strive for overcorrection rather than undercorrection. Overcorrection will also be apparent if the check ligament of the levator is not severed at the time of the operation. If the sutures which are used to suture the resected levator to the tarsus are not properly spaced there may be drooping in the outer or inner third of the lid. It is also possible to destroy the lash follicles. In several cases, paralysis of the superior oblique has been produced by unwittingly severing the tendon. This can be corrected by surgery on the inferior oblique. Patients who have bilateral ptosis with poor levator action can be improved satis factorily by suspending the lids from the brow. Robert J. Herrn, Recorder.
M E M P H I S EYE, EAR, NOSE AND T H R O A T SOCIETY RETINOBLASTOMA
DR. MELVIN DEWEESE presented E. G., a
two and one-half-year-old white girl who was first seen on January 23, 1961, because the mother had noticed that the right eye had been red for approximately one week. There had been no previous eye inflamma tion or disease. This child had been followed by the Crippled Children's Hospital since January, 1960, because of a walking defect but she apparently had no eye examination during that time. There were two other siblings in this fam ily, one of whom had had an enucleation for monocular retinoblastoma at the age of two
years. This child has had a six-year followup with no recurrence. The other sibling died at the age of one and one-half years with cerebral palsy. The mother was nonspecific about the condition of this child. There were no other contributing factors in the patient's history. On examination the patient was a very small two and one-half year old white girl with no physical defects other than the eye condition. Eye examination showed a mild ciliary in jection in the right eye. The cornea was clear, the anterior chamber deep and clear, the iris normal. The pupil was moderately dilated and did not react to light. The entire vitreous cavity was filled with a whitish yellow mass which came from three sides. This tumor mass was covered by a normal number of blood vessels. The vitreous that remained was clear and the tumor could be visualized well. In the left eye the pathologic condition was limited to the f undus. There was a large, flat, white lesion located superior and tem poral to the disc, which encroached on the macula. The mass was very vascular, several large vessels entering the tumor which meas ured approximately three disc diameters. There was a much smaller tumor mass, about one-half disc diameter, in the extreme nasal periphery. This was also very vascular. A third tumor mass was located at the 2-o'clock position, approximately at the equator. It was also about one-half disc diameter in size and very vascular. The vitreous was clear and no other lesions were noted. The treatment of this patient was as fol lows: The right eye was enucleated with no im plant. On January 29, 1961, the left eye was treated with light coagulation to the three affected fundus regions. Intracarotid TEM was given to the left side. This treatment was followed with a 15-day course of X-rays to the left eye, as advocated by Reese. On Feb ruary 20th, the patient received a second course of intracarotid TEM. Light coagula tion was also applied to the large tumor mass,
SOCIETY PROCEEDINGS located just above the macula. Examination of the fundus now showed healed, scarred lesions at the site of the small tumors in the periphery. However, at the site of the large lesion just above the macula, the mass was completely surrounded by pigmentation. Lo cated just in front of the mass was a subretinal hemorrhage which had occurred after the last light coagulation. The last examination, September 12, 1961, brought the follow-up on this patient to ap proximately eight months. The tumor ap peared to be controlled. DIFFERENTIAL DIAGNOSIS OF MELANOMA DR. ALICE R. DEUTSCH presented the case of Mr. R. L. who was seen first on July 8, 1961. He had always been in good health and had never had any eye disease. Several eye examinations while in the Service showed normal vision. On May 14, 1961, he suf fered a severe sore throat. A few days later he noticed that he saw double and that the image of the left eye was smaller than that of the right eye. On this date he consulted an optometrist and glasses were prescribed. The diplopia became more and more trouble some, especially for distance.
When seen on July 8th, the right eye was found to be normal with vision of 20/20 with and without correction. The left eye showed no abnormality in position or motility. The pupil equaled the right and reacted well to light. The anterior segment was normal and the media clear. Temporal and below the macula a prominent grayish white lesion (three to four disc di ameters in size) was visible under the retinal vessels. The height of the lesion was six or seven diopters. It was surrounded by an edematous halo which extended nasally to ward the disc. Two small hemorrhages were visible on its superior border. The disc looked normal. The slitlamp showed a mild deep haze in the vitreous. A tentative diagnosis of in flammatory exudative external retinitis or choroiditis was made. Vision was 20/25 (cycloplegic refraction +2.0D. sph.) A
1077
steep sector-shaped defect in the nasal supe rior field reached the macula. Physical examination and dental check ups were negative. The uveitis survey made by Dr. C. D. Marsh disclosed a plus-four re action to several strains of streptococci. A corresponding serum was made and injec tions were begun. Systemic steroid was start ed with Deronil (0.75 mg., starting with 4.5 mg. a day and slowly decreasing the strength to a maintenance dose of 1.5 mg.). The only change in the appearance of the fundus lesion was a gradual fading of the edematous halo; however, this was re placed by numerous radial traction folds and two concentric folds. Several chalk-white dots appeared at the top of the lesion. Ophthalmoscopic retroillumination revealed a dark grayish nontransparent border. Vision and fields did not change remarkably during the observation period of two months. This lesion could be localized effusive choroiditis, with inspissated exudate but the absence of any inflammatory changes in the anterior segment or the region of the ora serrata and the absence of any choroidal scars refute this diagnosis, at least partially. There are no collarette homorrhages, vascular loops or new-formed vessels, considered to be characteristic of external exudative ret initis. On the other hand, the presence of a grayish nontranslucent zone on ophthalmoscopic retroillumination, the existence of tent-shaped radially arranged folds and the steep, absolute and extended defect in the visual field are suggestive, even if not ab solutely pathognomonic, of malignant mela noma. INFLAMMATORY RESPONSE TO INFLUENZA VIRUS VACCINE DR. ALICE R. DEUTSCH also presented the case of Mrs. D. D., aged 55 years, who was seen on March 9, 1961, as an emergency. She had always been in good health except for occasional respiratory diseases. In 1958, she took a series of "cold shots" and two shots of influenza virus vaccine without any local or
1078
SOCIETY PROCEEDINGS
systemic reaction. In the winter of 1960, she had been ill for several weeks with "virus pneumonia" for which she took a large amount of antibiotics. Recovery was very slow. As she planned a trip to Europe during the summer of 1961, she thought it wise to take the influenza vaccine again. She re ceived the first injection on February 21 and a few days later felt very tired, with aching of her legs and shoulders. There also was consid erable redness at the place of the injection. Nevertheless, the second injection was given on March 8. About 24 hours after this shot, she suddenly had severe discomfort in her lef-t eye and some blurring of vision. A few hours later, but just as rapidly, the same changes occurred in her right eye.
the local treatment, were gradually reduced and discontinued after 10 days. Tefronil also was discontinued after 10 days. At this time the anterior segments were also found to be normal except of the imprints of the broken posterior synechias on the anterior lens cap sule and pigment scattering on the posterior corneal surface. The corrected vision was 20/20 in both eyes, and the ocular tension 15.9 mm. Hg. The skin reaction from the second shot disappeared slowly but a deep abscess started in the area of the first shot and took about five weeks to heal.
The influenza-virus vaccine (A and B Lederle) is based on chicken cell agglutina tion units. Therefore, persons sensitized to eggs, chicken and feathers are cautioned not When seen at the office about 30 hours to take the shots. The patient under discus after the shot, both eyes showed considerable sion had no personal history of allergy or lid swelling, severe transparent chemosis, any history of allergy in her family. Also she mild haziness of the corneas, and anterior had never had an eye disease in the past. chambers filled with fibrin. The pupils were Iridocyclitis in association with general narrow. The eyes seemed to be very soft. ized serum-sickness is suggestive that the The site of the first influenza vaccine in uvea may participate in certain allergic re jection showed induration and redness of actions, but only very few cases have been about two cm., the site of the second injec published. Theodore and associates reported tion an area of erythema of about four cm. an acute iridocyclitis together with serumMrs. D. also complained of pains in all her sickness in a patient who was given type 1 joints, sore throat and fatigue. The tempera antipneumococcus vaccine for lobar pneu ture was 101.4°F. No urticaria was visible. monia (1959). Sedan and Guillot observed Although anaphylactic and atopic reactions a case of anterior uveitis together with a of the uvea are rare, this was considered to severe general reaction after the injection of be such a reaction because of the clinical tetanus antitoxin, and a worse reaction oc picture and history. Treatment was started curred in the same patient when a skin test accordingly. The pupils were very difficult with tetanus antitoxin was given a few years to dilate, in spite of the fact that the exuda later (1955). Hoover described a case of com tions were only a few hours old. Besides paratively mild uveitis during a spell of mydriatics, local treatment consisted of serum-sickness after tetanus antitoxin. Ex Metymid drops every two hours. Eighty perimentally, uveitis has been produced with units of Cortotropin-zinc were given and re horse serum by various authors and series of peated the next day. Decadron (3.0 mg. in di studies have been published. Viral uveitis is vided doses) and Tefronil (4.0 gr. [initial not uncommon, but no virus has been demon doses 3.0 gr.], also in divided doses) were strated so far which has a special tropism for the "uveal tract." There is, however, the added. possibility that the severe reaction in the case Recovery was miraculous. Both eyes showed under discussion might be referred to the practically no signs of external inflammation "pneumonia" the patient had about one year after 48 hours, and the fundi were found to earlier. be normal. ACTH and Decadron, as well as
SOCIETY PROCEEDINGS MÉNIÈRE'S
DISEASE
DR. W. W. WILDER presented the case of Mrs. O., a 28-year-old woman, who was first seen in September, 1960. Her eyes hurt, burned and were chronically inflamed. Mrs. O. was a highly nervous individual, smoked several packages of cigarettes per day and had intermittent hay fever plus a chronic postnasal drip. Several months prior to this she had an attack of acute dizziness diag nosed as Ménière's disease. The dizziness had recurred intermittently. Mrs. O. had per sonal problems which were difficult for her to cope with. She took Butisol regularly for her nervousness. Her father, aged 58 years, had glaucoma controlled by miotics. The examination was not abnormal except for moderate bulbar and palpebrai conjunctival congestion and compound hyperopic astigmatism ( + 1.25D. sph. 3 ~~ 0.50D. cyl. ax. 10°, O.D. ; +0.75D. sph. C -0.25D. cyl. ax. 162°, O.S.). These lenses and Neomedral drops were prescribed. Mrs. O. was not seen again until Decem ber 21, 1960, when she complained of blurred vision and a haze about lights, particularly in the left eye. The left pupil was somewhat larger than the right and did not react as readily to light. Intraocular pressure was 4 2 / 49 mm. Hg (Schi^tz). No keratic precipi tates, flare or anterior chamber cells were present. The vitreous was clear and the f undus normal. Two days later tension was 42/ 49 mm. Hg. Two weeks later it was 27/31.
1079
On January 31, 1961, it was 27/29 and on April 21, it was 25/29. Mrs. O. had been advised to have a tonogram but had postponed this because even the thought induced severe nervousness. It was finally done on June 7, 1961. The regular tonogram: O.D., P 0 25 (5.5 gm.) C = 0.25; OS., Po 28 (5.5 gm.) C = 0.27. After water: O.D., P 0 4 2 (lOgm.) C = 1.08; O.S., P„45 (10 gm.) C = 0.09. Gonioscopy revealed an open angle. The nonpigmented trabeculae were visible and not excessively pigmented. Central fields showed questionable enlargement of the blindspot. There was less than normal physi ologic cupping by ophthalmoscopy. The patient recently returned, stating that her tension was up again. She was nervous and, when she gets nervous, her tension goes up. If she can lie down and become quiet, the blurring of vision is relieved. The intra ocular pressure was 45/54 mm. Hg. One hour after pilocarpine (two-percent drops) in each eye the tension was 25/25 mm. Hg. Mrs. O. is presented because of several interesting factors : ( 1 ) her age and the vari ability of her intraocular pressure; (2) the probable relationship between the Meniere's syndrome, the emotional tension and the in traocular pressure; (3) the dramatic re sponse of the tonogram to the water drink ing test. Ralph S. Hamilton, Recorder, Eye Section.
OPHTHALMIC MINIATURE
The strongest rainfall in France does not get you as wet as the night dew here (Egypt). And so it happens that, on every march requiring more than three nights, one may be sure that one third of the men will be incapacitated for some time because of an eye ailment (ophthalmia). Col. Laugier, Cited by C. de Lajonquière, L'Expédition en Egypte, 1798-1801 ; iii:49, 1899-1907.
1076
cases, the normal lid will fall after operation and this will give the appearance of overcorrection. To correct this situation, either the levator of the initially normal eye may be resected or the eye which was originally operated may be reoperated. Overcorrection can be improved by tenotomy of the levator on the operated side. In general, it is desirable to strive for overcorrection rather than undercorrection. Overcorrection will also be apparent if the check ligament of the levator is not severed at the time of the operation. If the sutures which are used to suture the resected levator to the tarsus are not properly spaced there may be drooping in the outer or inner third of the lid. It is also possible to destroy the lash follicles. In several cases, paralysis of the superior oblique has been produced by unwittingly severing the tendon. This can be corrected by surgery on the inferior oblique. Patients who have bilateral ptosis with poor levator action can be improved satis factorily by suspending the lids from the brow. Robert J. Herrn, Recorder.
M E M P H I S EYE, EAR, NOSE AND T H R O A T SOCIETY RETINOBLASTOMA
DR. MELVIN DEWEESE presented E. G., a
two and one-half-year-old white girl who was first seen on January 23, 1961, because the mother had noticed that the right eye had been red for approximately one week. There had been no previous eye inflamma tion or disease. This child had been followed by the Crippled Children's Hospital since January, 1960, because of a walking defect but she apparently had no eye examination during that time. There were two other siblings in this fam ily, one of whom had had an enucleation for monocular retinoblastoma at the age of two
years. This child has had a six-year followup with no recurrence. The other sibling died at the age of one and one-half years with cerebral palsy. The mother was nonspecific about the condition of this child. There were no other contributing factors in the patient's history. On examination the patient was a very small two and one-half year old white girl with no physical defects other than the eye condition. Eye examination showed a mild ciliary in jection in the right eye. The cornea was clear, the anterior chamber deep and clear, the iris normal. The pupil was moderately dilated and did not react to light. The entire vitreous cavity was filled with a whitish yellow mass which came from three sides. This tumor mass was covered by a normal number of blood vessels. The vitreous that remained was clear and the tumor could be visualized well. In the left eye the pathologic condition was limited to the f undus. There was a large, flat, white lesion located superior and tem poral to the disc, which encroached on the macula. The mass was very vascular, several large vessels entering the tumor which meas ured approximately three disc diameters. There was a much smaller tumor mass, about one-half disc diameter, in the extreme nasal periphery. This was also very vascular. A third tumor mass was located at the 2-o'clock position, approximately at the equator. It was also about one-half disc diameter in size and very vascular. The vitreous was clear and no other lesions were noted. The treatment of this patient was as fol lows: The right eye was enucleated with no im plant. On January 29, 1961, the left eye was treated with light coagulation to the three affected fundus regions. Intracarotid TEM was given to the left side. This treatment was followed with a 15-day course of X-rays to the left eye, as advocated by Reese. On Feb ruary 20th, the patient received a second course of intracarotid TEM. Light coagula tion was also applied to the large tumor mass,
SOCIETY PROCEEDINGS located just above the macula. Examination of the fundus now showed healed, scarred lesions at the site of the small tumors in the periphery. However, at the site of the large lesion just above the macula, the mass was completely surrounded by pigmentation. Lo cated just in front of the mass was a subretinal hemorrhage which had occurred after the last light coagulation. The last examination, September 12, 1961, brought the follow-up on this patient to ap proximately eight months. The tumor ap peared to be controlled. DIFFERENTIAL DIAGNOSIS OF MELANOMA DR. ALICE R. DEUTSCH presented the case of Mr. R. L. who was seen first on July 8, 1961. He had always been in good health and had never had any eye disease. Several eye examinations while in the Service showed normal vision. On May 14, 1961, he suf fered a severe sore throat. A few days later he noticed that he saw double and that the image of the left eye was smaller than that of the right eye. On this date he consulted an optometrist and glasses were prescribed. The diplopia became more and more trouble some, especially for distance.
When seen on July 8th, the right eye was found to be normal with vision of 20/20 with and without correction. The left eye showed no abnormality in position or motility. The pupil equaled the right and reacted well to light. The anterior segment was normal and the media clear. Temporal and below the macula a prominent grayish white lesion (three to four disc di ameters in size) was visible under the retinal vessels. The height of the lesion was six or seven diopters. It was surrounded by an edematous halo which extended nasally to ward the disc. Two small hemorrhages were visible on its superior border. The disc looked normal. The slitlamp showed a mild deep haze in the vitreous. A tentative diagnosis of in flammatory exudative external retinitis or choroiditis was made. Vision was 20/25 (cycloplegic refraction +2.0D. sph.) A
1077
steep sector-shaped defect in the nasal supe rior field reached the macula. Physical examination and dental check ups were negative. The uveitis survey made by Dr. C. D. Marsh disclosed a plus-four re action to several strains of streptococci. A corresponding serum was made and injec tions were begun. Systemic steroid was start ed with Deronil (0.75 mg., starting with 4.5 mg. a day and slowly decreasing the strength to a maintenance dose of 1.5 mg.). The only change in the appearance of the fundus lesion was a gradual fading of the edematous halo; however, this was re placed by numerous radial traction folds and two concentric folds. Several chalk-white dots appeared at the top of the lesion. Ophthalmoscopic retroillumination revealed a dark grayish nontransparent border. Vision and fields did not change remarkably during the observation period of two months. This lesion could be localized effusive choroiditis, with inspissated exudate but the absence of any inflammatory changes in the anterior segment or the region of the ora serrata and the absence of any choroidal scars refute this diagnosis, at least partially. There are no collarette homorrhages, vascular loops or new-formed vessels, considered to be characteristic of external exudative ret initis. On the other hand, the presence of a grayish nontranslucent zone on ophthalmoscopic retroillumination, the existence of tent-shaped radially arranged folds and the steep, absolute and extended defect in the visual field are suggestive, even if not ab solutely pathognomonic, of malignant mela noma. INFLAMMATORY RESPONSE TO INFLUENZA VIRUS VACCINE DR. ALICE R. DEUTSCH also presented the case of Mrs. D. D., aged 55 years, who was seen on March 9, 1961, as an emergency. She had always been in good health except for occasional respiratory diseases. In 1958, she took a series of "cold shots" and two shots of influenza virus vaccine without any local or
1078
SOCIETY PROCEEDINGS
systemic reaction. In the winter of 1960, she had been ill for several weeks with "virus pneumonia" for which she took a large amount of antibiotics. Recovery was very slow. As she planned a trip to Europe during the summer of 1961, she thought it wise to take the influenza vaccine again. She re ceived the first injection on February 21 and a few days later felt very tired, with aching of her legs and shoulders. There also was consid erable redness at the place of the injection. Nevertheless, the second injection was given on March 8. About 24 hours after this shot, she suddenly had severe discomfort in her lef-t eye and some blurring of vision. A few hours later, but just as rapidly, the same changes occurred in her right eye.
the local treatment, were gradually reduced and discontinued after 10 days. Tefronil also was discontinued after 10 days. At this time the anterior segments were also found to be normal except of the imprints of the broken posterior synechias on the anterior lens cap sule and pigment scattering on the posterior corneal surface. The corrected vision was 20/20 in both eyes, and the ocular tension 15.9 mm. Hg. The skin reaction from the second shot disappeared slowly but a deep abscess started in the area of the first shot and took about five weeks to heal.
The influenza-virus vaccine (A and B Lederle) is based on chicken cell agglutina tion units. Therefore, persons sensitized to eggs, chicken and feathers are cautioned not When seen at the office about 30 hours to take the shots. The patient under discus after the shot, both eyes showed considerable sion had no personal history of allergy or lid swelling, severe transparent chemosis, any history of allergy in her family. Also she mild haziness of the corneas, and anterior had never had an eye disease in the past. chambers filled with fibrin. The pupils were Iridocyclitis in association with general narrow. The eyes seemed to be very soft. ized serum-sickness is suggestive that the The site of the first influenza vaccine in uvea may participate in certain allergic re jection showed induration and redness of actions, but only very few cases have been about two cm., the site of the second injec published. Theodore and associates reported tion an area of erythema of about four cm. an acute iridocyclitis together with serumMrs. D. also complained of pains in all her sickness in a patient who was given type 1 joints, sore throat and fatigue. The tempera antipneumococcus vaccine for lobar pneu ture was 101.4°F. No urticaria was visible. monia (1959). Sedan and Guillot observed Although anaphylactic and atopic reactions a case of anterior uveitis together with a of the uvea are rare, this was considered to severe general reaction after the injection of be such a reaction because of the clinical tetanus antitoxin, and a worse reaction oc picture and history. Treatment was started curred in the same patient when a skin test accordingly. The pupils were very difficult with tetanus antitoxin was given a few years to dilate, in spite of the fact that the exuda later (1955). Hoover described a case of com tions were only a few hours old. Besides paratively mild uveitis during a spell of mydriatics, local treatment consisted of serum-sickness after tetanus antitoxin. Ex Metymid drops every two hours. Eighty perimentally, uveitis has been produced with units of Cortotropin-zinc were given and re horse serum by various authors and series of peated the next day. Decadron (3.0 mg. in di studies have been published. Viral uveitis is vided doses) and Tefronil (4.0 gr. [initial not uncommon, but no virus has been demon doses 3.0 gr.], also in divided doses) were strated so far which has a special tropism for the "uveal tract." There is, however, the added. possibility that the severe reaction in the case Recovery was miraculous. Both eyes showed under discussion might be referred to the practically no signs of external inflammation "pneumonia" the patient had about one year after 48 hours, and the fundi were found to earlier. be normal. ACTH and Decadron, as well as
SOCIETY PROCEEDINGS MÉNIÈRE'S
DISEASE
DR. W. W. WILDER presented the case of Mrs. O., a 28-year-old woman, who was first seen in September, 1960. Her eyes hurt, burned and were chronically inflamed. Mrs. O. was a highly nervous individual, smoked several packages of cigarettes per day and had intermittent hay fever plus a chronic postnasal drip. Several months prior to this she had an attack of acute dizziness diag nosed as Ménière's disease. The dizziness had recurred intermittently. Mrs. O. had per sonal problems which were difficult for her to cope with. She took Butisol regularly for her nervousness. Her father, aged 58 years, had glaucoma controlled by miotics. The examination was not abnormal except for moderate bulbar and palpebrai conjunctival congestion and compound hyperopic astigmatism ( + 1.25D. sph. 3 ~~ 0.50D. cyl. ax. 10°, O.D. ; +0.75D. sph. C -0.25D. cyl. ax. 162°, O.S.). These lenses and Neomedral drops were prescribed. Mrs. O. was not seen again until Decem ber 21, 1960, when she complained of blurred vision and a haze about lights, particularly in the left eye. The left pupil was somewhat larger than the right and did not react as readily to light. Intraocular pressure was 4 2 / 49 mm. Hg (Schi^tz). No keratic precipi tates, flare or anterior chamber cells were present. The vitreous was clear and the f undus normal. Two days later tension was 42/ 49 mm. Hg. Two weeks later it was 27/31.
1079
On January 31, 1961, it was 27/29 and on April 21, it was 25/29. Mrs. O. had been advised to have a tonogram but had postponed this because even the thought induced severe nervousness. It was finally done on June 7, 1961. The regular tonogram: O.D., P 0 25 (5.5 gm.) C = 0.25; OS., Po 28 (5.5 gm.) C = 0.27. After water: O.D., P 0 4 2 (lOgm.) C = 1.08; O.S., P„45 (10 gm.) C = 0.09. Gonioscopy revealed an open angle. The nonpigmented trabeculae were visible and not excessively pigmented. Central fields showed questionable enlargement of the blindspot. There was less than normal physi ologic cupping by ophthalmoscopy. The patient recently returned, stating that her tension was up again. She was nervous and, when she gets nervous, her tension goes up. If she can lie down and become quiet, the blurring of vision is relieved. The intra ocular pressure was 45/54 mm. Hg. One hour after pilocarpine (two-percent drops) in each eye the tension was 25/25 mm. Hg. Mrs. O. is presented because of several interesting factors : ( 1 ) her age and the vari ability of her intraocular pressure; (2) the probable relationship between the Meniere's syndrome, the emotional tension and the in traocular pressure; (3) the dramatic re sponse of the tonogram to the water drink ing test. Ralph S. Hamilton, Recorder, Eye Section.
OPHTHALMIC MINIATURE
The strongest rainfall in France does not get you as wet as the night dew here (Egypt). And so it happens that, on every march requiring more than three nights, one may be sure that one third of the men will be incapacitated for some time because of an eye ailment (ophthalmia). Col. Laugier, Cited by C. de Lajonquière, L'Expédition en Egypte, 1798-1801 ; iii:49, 1899-1907.