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Memphis Eye, Ear, Nose, and Throat Society
SOCIETY
902
PROCEEDINGS
cases o f complete optic atrophy in which the amaurosis is complete. In the cases o f more or less marked amblyopia, the ophthalmoscopic appearance o f the papilla is misleading. W e often see papillas rather pale and almost atrophic looking associated with relatively g o o d vision; on the other hand, there are cases with marked loss o f vision in which the optic papillas appear almost normal. Joseph I. Pascal, Translator.
MEMPHIS EYE, EAR, NOSE, AND THROAT SOCIETY PSEUDOGLAUCOMA DR. H . C O N D R O N presented a 23-year-old white man, w h o was admitted to the K e n nedy Veterans Hospital as a transfer from Birmingham, Alabama, on March 29, 1954. T h e patient's chief complaint was chronic drainage from the left ear; his transfer diagnosis was suspected chronic otitis media, left ear. His ear difficulty dated back to childhood when he had recurrent drainage from the left ear; on several occasions it had to be "lanced." One month following entry into the service in 1951, he again had left-ear drainage because o f which he was given a medical discharge in late 1951. Since then he has had recurrent bouts o f drainage from the left ear.
T h e past history revealed nothing abnormal except for vague gastrointestinal complaints, not associated with any acute pain, hemoptysis, or melena. T h e patient had no ocular complaint or history. Physical examination: showed a well-developed, 23-year-old white man, in no acute distress. The blood pressure was 1 1 0 / 6 0 mm. H g . The only positive finding was a slurring of the apical systolic sound. T h e liver was palpable two finger breaths below the costal margin; it was nontender, smooth in outline, and sharply edged. Special eye examination revealed: V i s i o n : R.E., 2 0 / 2 0 ; L.E., 2 0 / 2 0 . Extraocular
muscles were normal. Corneas, lids, and conjunctivas were normal. T h e pupils were round, equal, and reacted to light and accommodation. Tension by Schiøtz: R . E . , 20 mm. H g ; L.E., 20 mm. H g . T h e corneas and media were clear. T h e nerveheads showed a deep, glaucomatous-type excavation. T h e retinal vessels appeared normal. There were no retinal lesions. Visual fields showed no contraction; however, the blindspots could not be charted. T h e patient would not admit to blindspots with any size target. Laboratory findings: Chest X - r a y films, negative; C B C , within normal limits; urinalysis, negative; S T S , negative. Tension readings were taken a number o f times and the highest recording was 20 mm. H g , O . U . T h e patient's eyes were dilated with 10-percent neosynephrine and the tension was again taken and recorded at oneand two-hour intervals. A t the end o f one hour the tension was 17 mm. H g , O . U . ; at the end o f the second hour the tension was unchanged. T h e patient has never had any ocular complaints, has never worn glasses, and states that he has never known anything to be w r o n g with his eyes. H e denies any noticeable field loss and seems confused by all the interest shown in his eyes. T h e problem in this case is whether a l o w tension glaucoma or a pseudocoloboma of both optic nerves may be present. T h e absence o f any field loss is against low-tension glaucoma. There appears to be normal nerve tissue about the entire circumference o f the disc. If a coloboma is present, it probably is limited to the lamina cribrosa. T h e clinical picture is certainly that o f glaucomatous cupp i n g ; however, with such a picture there should be some sort o f field defect. Still there is none. Diagnosis is deferred. ANGIOSPASTIC RETINOPATHY DR. H . G . P A R I S H reported A . F., a 49year-old Negress, w h o was presented to the society last year. A t that time she showed a macular lesion in the right eye, which was thought to be a disciform degeneration. The other possibilities considered at that time
903
SOCIETY PROCEEDINGS
were melanoma because o f questionable ele
hospital f o r a course o f typhoid-vaccine ther
vation in the region o f the macula, chorio
apy. Three injections were given
retinitis, and a metastatic tumor. Because o f
nously, with fever reactions up to 101.5°F.
a nodular mass at the sternoclavicular j u n c
each time. T h e last dose was 30,000,000 or
tion, she was seen by the orthopedic service
ganisms. Objectively, it was doubtful if the
intrave
which reported that the lesion was not malig
status o f the left eye had changed. It seemed
nant. Since that time she has been seen at
to be the logical conclusion that the vitreous
regular intervals with gradual apparent flat
haze was due to hemorrhage.
tening and recession o f the macular lesion.
Since this discharge she has had no ther
In July, vision was 2 0 / 4 0 , O . D . , and the
apy, more because she became intolerant to
staff was o f the opinion that this was defi
nicotinic acid than an independent decision
nitely a case o f angiospastic retinopathy. She
to cease treatment o n our part. T h e fundus
was placed on nicotinic acid, 50 mg., three
in the left eye can n o w be well visualized
times daily. N o local medication was given.
temporal to the disc. T h e nasal portion is still
O n August 30th, she returned f o r a rou
obscured by vitreous opacities and
floaters,
tine check up, complaining o f a "skim over
evidently posterior to the equator. T h e mac
the left e y e . " Despite the complaint, vision
ula o f the right eye is n o w quiescent but
w a s : O . D . , 2 0 / 2 5 4 - ; O . S . , 2 0 / 2 5 - f . In the
shows definite residual degeneration. T o d a y
left eye, there was a generalized
her vision with correction is 2 0 / 1 5 , O . U .
vitreous
haze, much more dense on the nasal side. T h e details o f the fundus could not be seen. T h e macular lesion in the right eye appeared somewhat flatter, with increased
pigmenta
tion.
RETROLENTAL FIBROPLASIA DR.
JAMES
E . W I L S O N reported cases o f
retroiental fibroplasia in identical twin boys, Stanley and Stephen P., aged six months,
O n this date, she was admitted to the hos
w h o were first seen January 26, 1954.
pital f o r observation and diagnosis. She was
T h e mother has one normal boy, aged five
observed for some time without change in the
years, and she has never had a miscarriage.
cloudiness in the left eye. A s there was n o
During pregnancy with the twins she had
improvement by bedrest foreign-protein in
never been ill in any way.
jections, and atropinization,
she was dis
charged on nicotinic acid.
A t seven and three-quarters months she went into labor spontaneously. Urine, blood
She was not seen again until September
work, and Kahn test did not indicate any dis
29th when she reported to the clinic with
ease. L a b o r was normal. She had scopola
vision o f 2 0 / 3 0 + 4, O . D . ; 2 0 / 2 0 , O . S . T h e
mine and Demarol followed b y 10 minutes
vitreous haze had cleared to the extent that
o f CaHs anesthesia during actual birth o f the
temporally.
twins. A l l three stages o f labor lasted a total
T h e nasal retina was still obscured by a deep
o f five hours. O n e child was born vertex and
vitreous haze. In the macula o f the right eye,
the other breech. Stanley, weighing four lb.
there was n o w a circumscribed area which
and eight oz., was born at 10:25 P . M . on
appeared to be a serous infiltration under the
July 28, 1953, and Stephen, weighing three
retina. She was continued on nicotinic acid.
lb. and 15 oz., was born two minutes later.
fundus
details
could be seen
T h e next visit, one week later, revealed
Physical examination o f each shortly after
two such circumscribed areas lateral and in
birth showed the heart to be normal, no
ferior to the macula. T h e y had a pinkish
anomalies were noted, but both had grunting
color. O n this date, October 8th, the disc in
respiration, poor aeration, and possibly atel
the left eye could be seen f o r the first time.
ectasis at the base o f the lungs.
There was little loss o f vision throughout these episodes. O n November 5th she was admitted
Orders f o r the t w o infants were identical: ( 1 ) Both were put into the same isolette and
to
o x y g e n was used at a rate o f four liters per
904
SOCIETY PROCEEDINGS
minute; ( 2 ) nothing by mouth for 24 hours
A t the papilla it was twice the size o f the
then glucose water; ( 3 ) Synkamin (I.O cc.
disc and completely obscured it. This band
hypodermically, d a i l y ) ; ( 4 ) caffeine sodium
stopped at the disc and joined a similar band
benzoate ( f o u r drops hypodermically when
which came from the periphery originating
necessary for stimulation).
from just above the horizontal on the tem
After one week Stephen was doing well and was removed from the isolette and put
poral side. This band came across the posi tion o f the macula involving it.
in an older type o f incubator in which the
Stephen's external eye examination was
oxygen concentration was not so high. A f t e r
similar except that there was a very poor re
21 days, they were both removed from o x y
action o f the left pupil.
gen without any tapering off in concentra tion.
The left fundus showed a completely gray ish detached and elevated retina. T h e right
Both babies were fed the same, receiving all the mother could supply augmented by
fundus
showed a band originating in the
middle o f the lower temporal quadrant. It broadened out to obscure the disc and partly
evaporated milk and sugar. O n the 12th day Stephen developed an ab
involve the macula. It continued upward to
scess o f the buttocks at an injection site and
the middle o f the upper temporal periphery.
was given penicillin (300,000 units daily for three d a y s ) .
Re-examination on March 5, 1954, did not show any change from the original examina
O n the 2Sth hospital day Stanley devel
tion on January 26, 1954.
oped diarrhea and was given paregoric (five drops twice daily for three d a y s ) . T h e y re ceived no other medications.
RACEMOSE DR.
A t the time of their discharge on Septem
H E M A N G I O M A OF RETINA
PHILIP
M E R I W E T H E R L E W I S and
DOUGLAS H A W K E S
DR.
( b y invitation) presented
ber 1, 1953, Stanley weighed five lb., two o z . ;
a patient having both ocular and intracranial
Stephen weighed four lb., 13 o z .
angiomatosis.
W h e n the parents brought the twins to the
D . W . F . , a white boy, aged 10 years, was
office on January 26, 1954, they complained
first seen in 1947 at the age o f three years.
that neither of them appeared to see nor
His mother stated he ran into things as if he
mally. The parents said that, when they tried
did not see well and he tilted his head to
to look at something the eyes moved slowly
ward his right shoulder. Vision could not be
in searching movements. A grayish reflex
determined but it was felt that he could see
had been noticed in one pupil o f each child.
with both eyes. N o limitation
o f motion
had
could be detected. There was congestion o f
searching and rolling movements but no nys
the conjuncti\fal vessels and a slight fullness
tagmus.
of the retinal vessels o f the left eye. Retinos
Examination
showed that
Stanley
Both pupils reacted but
the
left
quicker. H e followed a light with the right
copy showed two diopters o f hyperopia o f
but did so only poorly with the left eye.
both eyes.
The right fundus showed the entire tem
H e was not seen again until October 30,
poral retina to be detached and grayish and
1948, when he was convalescing from me-
a band came over and slightly beyond the
ningococcic meningitis. A t that time the blood
d i s c ; however, the nasal retina looked quite
vessels on the disc o f the left eye were
normal.
greatly dilated and angiomatosis was sus
The left fundus showed a bluish white
pected. H e was not seen again until three
band, similar to that seen in retinitis prolif
years later. Vision could then be determined.
erans, coming from the periphery where it
It w a s : 2 0 / 3 0 , R . E . , no light perception, L . E .
was narrow at the lower temporal position,
T h e vessels of the left temporal region and
spreading out as it went straight to the disc.
upper hd were engorged. There was an enor-
SOCIETY PROCEEDINGS
90S
mous dilatation o f the vessels o f the left disc
on July 28, 1953, revealed emmetropia, O . U .
and immediate surrounding retina. N o angi
T h e fundus examination was normal.
oma w^as seen.
A diagnosis o f convergent squint, due to
In September, 1952, the left eye was con
paralysis o f left external rectus and overac-
gested externally and highly divergent. There
tion o f left internal rectus with contracture,
was paralysis o f both elevators and o f the
was made. Consultation was obtained and a
medial rectus. The retinal vessels were enor
Hummelsheim procedure was decided upon.
mously dilated and tortuous and seemed to
O n August 22, 1953, a five-mm. recession
be much more numerous than normal. T h e
o f the internal rectus and a seven mm. re
engorgement was confined to the disc and
section o f external rectus plus a Hummel
the surrounding retina. This was the
sheim tendon transplant was performed and
first
time that proptosis was noticed. The periph ery o f the retina seemed to be normal and no angioma was present. T h e right eye was normal with vision of 2 0 / 3 0 .
Twenty-four
hours
later
the
dressings
were changed and the patient was discharged with a request to be in the cHnic in 24 hours.
In November, 1954, vision o f the right eye was 2 0 / 2 5 and the eye was still normal e x cept for coarse nystagmus
both eyes were patched.
on looking to
either side and paralysis o f both elevators. The left eye turned out about 20 degrees
Dressings were changed every other day for four times. O n September 2, 1953 ( 1 0 days after o p e r a t i o n ) , there was g o o d external
rotation
o f left e y e ; slight divergence was noted. O n
and slightly downward. There was complete
September 16th (three weeks postoperative)
paralysis o f both elevators and almost c o m
examination revealed 50 degrees' external r o
plete o f the medial rectus. There were four
tation o f the left eye.
mm. o f exophthalmos and a definite ptosis. The pupil reacted consensually but not di rectly. T h e veins o f the upper lid were en
DIAMOX DR.
IN ACUTE GLAUCOMA
ALICE
R . D E U T S C H reported the case
gorged and so were those o f the temporal
of M r . J. C , aged 76 years, w h o gave the
region. T h e coiled, medusalike vessels on the
history o f having had recurrent severe eye
disc and surrounding it were approximately
inflammation all o f his life and stated that
the same as they had been two years previ
he never saw well. H e also had many rounds
ously.
of sinus infection and bronchitis. H e was al
PARALYTIC CONVERGENT S Q U I N T
after the use o f penicillin and the broad-
lergic to many drugs and had severe reactions DR.
B . W E I S B A U M reported the case o f an
spectrum antibiotics.
11-year-old N e g r o girl seen f o r the first time
A b o u t four years ago his vision began to
on July 22, 1953, with vision o f : O . D . ,
fail, especially in his right eye. A cataract
20/25,
O . S . , counting
fingers.
She
operation was performed in 1952 and was
showed a convergent squint,
J2;
fixating
only
complicated by intolerance to every kind o f
with the right eye. There was paralysis o f
mydriatic. A glaucoma operation had to be
the external rectus, O . S . , indicated by inabil
performed several months later. Nevertheless
ity to abduct the left eye past the midline. A
the tension remained high, but could be con
paresis o f the external
trolled with 0.1-percent D F P once a day at
rectus, O . D . , was
evidenced by weakness in external rotation.
bed time.
There was overaction o f the internal rectus,
T h e left eye showed dense macula corneae,
O . S . , with contractions. Measurements, us
a normal anterior chamber, many posterior
ing the perimeter, were on three occasions
synechias, and a partial pupillary membrane.
25 degrees esotropia for near and 25 degrees
T h e pupil dilated incompletely and irregu
esotropia for distance. Cycloplegic refraction
larly on 10-percent neosynephrine. A poste-
SOCIETY PROCEEDINGS
906
rior cortical cataract made fundus inspection
dent, w h o was admitted to the Baptist M e
difficult. Vision equalled 6 / 2 0 0 . T h e intra
morial Hospital on April 1, 1954. H e had
ocular pressure was never higher than 18
been in good health until that day when he
mm. H g .
suddenly developed a left frontal headache
O n April 10, 1954, in the evening he in
without history of trauma. H e went to the
advertently put one drop o f D F P in his left
John Gaston Hospital emergency room be
eye. Severe headache started about 15 min
cause o f this headache and was given Cafer-
utes later. The headache continued all night,
got without relief. S o o n after the Cafergot,
associated with nausea. H o w e v e r , he did not
the headache and the pain over the left eye
attribute this to his eye until the next morn
became more severe. H e soon noticed some
ing when he noticed that he could not see.
difficulty with his speech, had some dizziness,
W h e n examined a f e w hours later the ciliary
and vomited. H e was brought to the Baptist
body o f the left eye was injected and the
Memorial Hospital where he was admitted
cornea edematous. T h e pupil was pinpoint
about 11:50 P . M .
and the anterior chamber shallow but there
At
was apparently no typical iris bombé. T h e
shortly
intraocular pressure was 80 mm. H g . H e was
equal and reacted to light. T h e r e was a hem
admitted to the hospital.
the
time
after
o f the
first
admission, his
examination, pupils
were
orrhage in the left optic fundus. There was
Besides the local use o f 10-percent neo
some mental confusion, probably due to his
synephrine and cyclogyl ( o n e percent), 250
mild aphasia. T h e cranial nerves were other
mg. o f D i a m o x were given to him and re
wise intact. There were no reflex, sensory,
peated after six hours, after which time the
o r motor changes. There was no stiffness o f
cornea was clearer and the tension 40 mm.
his neck.
H g . T h e third dose o f D i a m o x was given
The possibility o f a subarachnoid hemor
after eight hours after which time the ten
rhage was considered but a lumbar puncture
sion dropped to 21 mm. H g in spite o f the
was not done at the time o f his admission.
fact that the pupil was still pinpoint. D i a m o x
T h e following morning X - r a y films o f his
was continued every 12 hours f o r two doses
skull were obtained and thought to be within
and again after 24 hours until 1.5 gm. was
the limits o f normal. H e was examined by
given. Neosynephrine was continued.
an ophthalmologist w h o also thought spon
It was not until after the third day that
taneous subarachnoid hemorrhage was a pos
the pupil showed some dilatation. The intra
sibility. Subsequent to this a lumbar punc
ocular pressure varied from 18 to 21 mm.
ture revealed bloody spinal fluid under in
Hg.
creased pressure.
Epinephrine-bitartrate
ointment
was
used three times a day for one week and then discontinued. W h e n the patient was last
B y A p r i l 8th, he had improved clinically and a lumbar
puncture
revealed that the
seen on April 15th, the pupil was o f normal
spinal fluid was only faintly xanthochromic
size and the pupillary membrane seemed to
without gross blood. W e felt that bilateral
be denser; the intraocular pressure was nor
carotid arteriograms should be done in an
mal and the vision, 6 / 2 0 0 . D i a m o x seemed
attempt to locate the suspected
to be a definite help in the handling o f this
carotid arteriograms, to our surprise, were
case.
negative f o r aneurysm. W e thought that the
aneurysm;
middle cerebral complex on the left SUBARACHNOID HEMORRHAGE W I T H ALOID
SUBHY
HEMORRHAGE
slightly elevated and the anterior
was
cerebral
artery was pushed slightly to the right. These presented
findings, coupled with the fact that this stu
the case o f C. K., a 26-year-old medical stu
dent was not making the clinical progress w e
DR.
RICHARD
L. DESAUSSURE
SOCIETY PROCEEDINGS had hoped for, made us suspect an cerebral hematoma.
infra-
O n April 13th, a ventriculogram demon strated a shift o f the ventricular system to the right. A t operation, an intracerebral he matoma in the left temporal lobe was dis closed. It involved almost the entire left temporal lobe. T h e hematoma was evacuated and the edges o f the brain adjacent to the hematoma were biopsied but there was n o evidence o f tumor in the biopsy specimens. W e did not find the bleeding point; there was n o evidence o f an aneurysm, heman gioma, or tumor. Postoperatively, this student did quite well except that the subtemporal decompression became tense and papilledema increased. It was our feeling that the intracerebral swell ing was probably the result o f operative trauma and not the result of further bleed ing, although this was considered as a possi bility. B y A p r i l 2Sth, the subtemporal de compression had become soft and he was discharged from the hospital. A t the time o f his discharge he had some aphasia and, in particular, had difficulty understanding writ ten words. H e was re-examined on April 30, 1954, at which time his decompression had become much softer, the papilledema was subsiding, and the vision o f the left eye was improved. This is the eye in which the hemorrhage had occurred. H e was re-examined on M a y 14th and showed further improvement. This student falls within the group ( d e scribed by Margolis, O d o m , Woodhall, and Bloor in 1951) o f individuals with intra cerebral hematomas due to small angioma tous malformations. These occurred in y o u n g individuals with no history o f predisposing factors. Their headaches occurred suddenly;
907
generally, the patient became unconscious at a later date. Bleeding occurred in the white matter and, usually, the bleeding -point could not be demonstrated. In a few cases minute angiomatous malformations were discovered. These authors felt that, in the other cases, the angiomas had been destroyed by the he matomas. Subhyaloid hemorrhages have been re ported in association with subarachnoid hem orrhage. H o w e v e r , it seems that they are usually associated with intracerebral hema tomas. In a recent review. Golden, O d o m , and W o o d h a l l found that o f 321 cases o f subarachnoid hemorrhage only 15 had associ ated subhyaloid hemorrhages. In 51 cases o f intracerebral hematoma without subarach noid hemorrhage, seven had subhyaloid hem orrhage; however, in 13 cases o f subarach noid and subdural hemorrhage, six had sub hyaloid hemorrhages. This gives a percentage of five percent for the pure subarachnoid hemorrhages, 14 percent for the intracerebral hematomas alone, and ^ 2 percent for the subarachnoid plus subdural hematomas. T h e mechanism by which the preretinal or subhyaloid hemorrhage is produced is still debated but the consensus seems to be that it is due to occlusion o f the venous channels and is not a direct extension o f the hemor rhage into the subhyaloid space. This is usu ally caused by sudden increase in intracranial pressure. This case serves to illustrate: ( 1 ) W h e n a subhyaloid hemorrhage is noted in the presence o f subarachnoid hemorrhage, a space-occupying lesion should be suspected and searched f o r ; ( 2 ) the lack o f nuchal rigidity does not exclude subarachnoid hem orrhage. Daniel F. Fisher, Recorder for the Eye Section.
902
PROCEEDINGS
cases o f complete optic atrophy in which the amaurosis is complete. In the cases o f more or less marked amblyopia, the ophthalmoscopic appearance o f the papilla is misleading. W e often see papillas rather pale and almost atrophic looking associated with relatively g o o d vision; on the other hand, there are cases with marked loss o f vision in which the optic papillas appear almost normal. Joseph I. Pascal, Translator.
MEMPHIS EYE, EAR, NOSE, AND THROAT SOCIETY PSEUDOGLAUCOMA DR. H . C O N D R O N presented a 23-year-old white man, w h o was admitted to the K e n nedy Veterans Hospital as a transfer from Birmingham, Alabama, on March 29, 1954. T h e patient's chief complaint was chronic drainage from the left ear; his transfer diagnosis was suspected chronic otitis media, left ear. His ear difficulty dated back to childhood when he had recurrent drainage from the left ear; on several occasions it had to be "lanced." One month following entry into the service in 1951, he again had left-ear drainage because o f which he was given a medical discharge in late 1951. Since then he has had recurrent bouts o f drainage from the left ear.
T h e past history revealed nothing abnormal except for vague gastrointestinal complaints, not associated with any acute pain, hemoptysis, or melena. T h e patient had no ocular complaint or history. Physical examination: showed a well-developed, 23-year-old white man, in no acute distress. The blood pressure was 1 1 0 / 6 0 mm. H g . The only positive finding was a slurring of the apical systolic sound. T h e liver was palpable two finger breaths below the costal margin; it was nontender, smooth in outline, and sharply edged. Special eye examination revealed: V i s i o n : R.E., 2 0 / 2 0 ; L.E., 2 0 / 2 0 . Extraocular
muscles were normal. Corneas, lids, and conjunctivas were normal. T h e pupils were round, equal, and reacted to light and accommodation. Tension by Schiøtz: R . E . , 20 mm. H g ; L.E., 20 mm. H g . T h e corneas and media were clear. T h e nerveheads showed a deep, glaucomatous-type excavation. T h e retinal vessels appeared normal. There were no retinal lesions. Visual fields showed no contraction; however, the blindspots could not be charted. T h e patient would not admit to blindspots with any size target. Laboratory findings: Chest X - r a y films, negative; C B C , within normal limits; urinalysis, negative; S T S , negative. Tension readings were taken a number o f times and the highest recording was 20 mm. H g , O . U . T h e patient's eyes were dilated with 10-percent neosynephrine and the tension was again taken and recorded at oneand two-hour intervals. A t the end o f one hour the tension was 17 mm. H g , O . U . ; at the end o f the second hour the tension was unchanged. T h e patient has never had any ocular complaints, has never worn glasses, and states that he has never known anything to be w r o n g with his eyes. H e denies any noticeable field loss and seems confused by all the interest shown in his eyes. T h e problem in this case is whether a l o w tension glaucoma or a pseudocoloboma of both optic nerves may be present. T h e absence o f any field loss is against low-tension glaucoma. There appears to be normal nerve tissue about the entire circumference o f the disc. If a coloboma is present, it probably is limited to the lamina cribrosa. T h e clinical picture is certainly that o f glaucomatous cupp i n g ; however, with such a picture there should be some sort o f field defect. Still there is none. Diagnosis is deferred. ANGIOSPASTIC RETINOPATHY DR. H . G . P A R I S H reported A . F., a 49year-old Negress, w h o was presented to the society last year. A t that time she showed a macular lesion in the right eye, which was thought to be a disciform degeneration. The other possibilities considered at that time
903
SOCIETY PROCEEDINGS
were melanoma because o f questionable ele
hospital f o r a course o f typhoid-vaccine ther
vation in the region o f the macula, chorio
apy. Three injections were given
retinitis, and a metastatic tumor. Because o f
nously, with fever reactions up to 101.5°F.
a nodular mass at the sternoclavicular j u n c
each time. T h e last dose was 30,000,000 or
tion, she was seen by the orthopedic service
ganisms. Objectively, it was doubtful if the
intrave
which reported that the lesion was not malig
status o f the left eye had changed. It seemed
nant. Since that time she has been seen at
to be the logical conclusion that the vitreous
regular intervals with gradual apparent flat
haze was due to hemorrhage.
tening and recession o f the macular lesion.
Since this discharge she has had no ther
In July, vision was 2 0 / 4 0 , O . D . , and the
apy, more because she became intolerant to
staff was o f the opinion that this was defi
nicotinic acid than an independent decision
nitely a case o f angiospastic retinopathy. She
to cease treatment o n our part. T h e fundus
was placed on nicotinic acid, 50 mg., three
in the left eye can n o w be well visualized
times daily. N o local medication was given.
temporal to the disc. T h e nasal portion is still
O n August 30th, she returned f o r a rou
obscured by vitreous opacities and
floaters,
tine check up, complaining o f a "skim over
evidently posterior to the equator. T h e mac
the left e y e . " Despite the complaint, vision
ula o f the right eye is n o w quiescent but
w a s : O . D . , 2 0 / 2 5 4 - ; O . S . , 2 0 / 2 5 - f . In the
shows definite residual degeneration. T o d a y
left eye, there was a generalized
her vision with correction is 2 0 / 1 5 , O . U .
vitreous
haze, much more dense on the nasal side. T h e details o f the fundus could not be seen. T h e macular lesion in the right eye appeared somewhat flatter, with increased
pigmenta
tion.
RETROLENTAL FIBROPLASIA DR.
JAMES
E . W I L S O N reported cases o f
retroiental fibroplasia in identical twin boys, Stanley and Stephen P., aged six months,
O n this date, she was admitted to the hos
w h o were first seen January 26, 1954.
pital f o r observation and diagnosis. She was
T h e mother has one normal boy, aged five
observed for some time without change in the
years, and she has never had a miscarriage.
cloudiness in the left eye. A s there was n o
During pregnancy with the twins she had
improvement by bedrest foreign-protein in
never been ill in any way.
jections, and atropinization,
she was dis
charged on nicotinic acid.
A t seven and three-quarters months she went into labor spontaneously. Urine, blood
She was not seen again until September
work, and Kahn test did not indicate any dis
29th when she reported to the clinic with
ease. L a b o r was normal. She had scopola
vision o f 2 0 / 3 0 + 4, O . D . ; 2 0 / 2 0 , O . S . T h e
mine and Demarol followed b y 10 minutes
vitreous haze had cleared to the extent that
o f CaHs anesthesia during actual birth o f the
temporally.
twins. A l l three stages o f labor lasted a total
T h e nasal retina was still obscured by a deep
o f five hours. O n e child was born vertex and
vitreous haze. In the macula o f the right eye,
the other breech. Stanley, weighing four lb.
there was n o w a circumscribed area which
and eight oz., was born at 10:25 P . M . on
appeared to be a serous infiltration under the
July 28, 1953, and Stephen, weighing three
retina. She was continued on nicotinic acid.
lb. and 15 oz., was born two minutes later.
fundus
details
could be seen
T h e next visit, one week later, revealed
Physical examination o f each shortly after
two such circumscribed areas lateral and in
birth showed the heart to be normal, no
ferior to the macula. T h e y had a pinkish
anomalies were noted, but both had grunting
color. O n this date, October 8th, the disc in
respiration, poor aeration, and possibly atel
the left eye could be seen f o r the first time.
ectasis at the base o f the lungs.
There was little loss o f vision throughout these episodes. O n November 5th she was admitted
Orders f o r the t w o infants were identical: ( 1 ) Both were put into the same isolette and
to
o x y g e n was used at a rate o f four liters per
904
SOCIETY PROCEEDINGS
minute; ( 2 ) nothing by mouth for 24 hours
A t the papilla it was twice the size o f the
then glucose water; ( 3 ) Synkamin (I.O cc.
disc and completely obscured it. This band
hypodermically, d a i l y ) ; ( 4 ) caffeine sodium
stopped at the disc and joined a similar band
benzoate ( f o u r drops hypodermically when
which came from the periphery originating
necessary for stimulation).
from just above the horizontal on the tem
After one week Stephen was doing well and was removed from the isolette and put
poral side. This band came across the posi tion o f the macula involving it.
in an older type o f incubator in which the
Stephen's external eye examination was
oxygen concentration was not so high. A f t e r
similar except that there was a very poor re
21 days, they were both removed from o x y
action o f the left pupil.
gen without any tapering off in concentra tion.
The left fundus showed a completely gray ish detached and elevated retina. T h e right
Both babies were fed the same, receiving all the mother could supply augmented by
fundus
showed a band originating in the
middle o f the lower temporal quadrant. It broadened out to obscure the disc and partly
evaporated milk and sugar. O n the 12th day Stephen developed an ab
involve the macula. It continued upward to
scess o f the buttocks at an injection site and
the middle o f the upper temporal periphery.
was given penicillin (300,000 units daily for three d a y s ) .
Re-examination on March 5, 1954, did not show any change from the original examina
O n the 2Sth hospital day Stanley devel
tion on January 26, 1954.
oped diarrhea and was given paregoric (five drops twice daily for three d a y s ) . T h e y re ceived no other medications.
RACEMOSE DR.
A t the time of their discharge on Septem
H E M A N G I O M A OF RETINA
PHILIP
M E R I W E T H E R L E W I S and
DOUGLAS H A W K E S
DR.
( b y invitation) presented
ber 1, 1953, Stanley weighed five lb., two o z . ;
a patient having both ocular and intracranial
Stephen weighed four lb., 13 o z .
angiomatosis.
W h e n the parents brought the twins to the
D . W . F . , a white boy, aged 10 years, was
office on January 26, 1954, they complained
first seen in 1947 at the age o f three years.
that neither of them appeared to see nor
His mother stated he ran into things as if he
mally. The parents said that, when they tried
did not see well and he tilted his head to
to look at something the eyes moved slowly
ward his right shoulder. Vision could not be
in searching movements. A grayish reflex
determined but it was felt that he could see
had been noticed in one pupil o f each child.
with both eyes. N o limitation
o f motion
had
could be detected. There was congestion o f
searching and rolling movements but no nys
the conjuncti\fal vessels and a slight fullness
tagmus.
of the retinal vessels o f the left eye. Retinos
Examination
showed that
Stanley
Both pupils reacted but
the
left
quicker. H e followed a light with the right
copy showed two diopters o f hyperopia o f
but did so only poorly with the left eye.
both eyes.
The right fundus showed the entire tem
H e was not seen again until October 30,
poral retina to be detached and grayish and
1948, when he was convalescing from me-
a band came over and slightly beyond the
ningococcic meningitis. A t that time the blood
d i s c ; however, the nasal retina looked quite
vessels on the disc o f the left eye were
normal.
greatly dilated and angiomatosis was sus
The left fundus showed a bluish white
pected. H e was not seen again until three
band, similar to that seen in retinitis prolif
years later. Vision could then be determined.
erans, coming from the periphery where it
It w a s : 2 0 / 3 0 , R . E . , no light perception, L . E .
was narrow at the lower temporal position,
T h e vessels of the left temporal region and
spreading out as it went straight to the disc.
upper hd were engorged. There was an enor-
SOCIETY PROCEEDINGS
90S
mous dilatation o f the vessels o f the left disc
on July 28, 1953, revealed emmetropia, O . U .
and immediate surrounding retina. N o angi
T h e fundus examination was normal.
oma w^as seen.
A diagnosis o f convergent squint, due to
In September, 1952, the left eye was con
paralysis o f left external rectus and overac-
gested externally and highly divergent. There
tion o f left internal rectus with contracture,
was paralysis o f both elevators and o f the
was made. Consultation was obtained and a
medial rectus. The retinal vessels were enor
Hummelsheim procedure was decided upon.
mously dilated and tortuous and seemed to
O n August 22, 1953, a five-mm. recession
be much more numerous than normal. T h e
o f the internal rectus and a seven mm. re
engorgement was confined to the disc and
section o f external rectus plus a Hummel
the surrounding retina. This was the
sheim tendon transplant was performed and
first
time that proptosis was noticed. The periph ery o f the retina seemed to be normal and no angioma was present. T h e right eye was normal with vision of 2 0 / 3 0 .
Twenty-four
hours
later
the
dressings
were changed and the patient was discharged with a request to be in the cHnic in 24 hours.
In November, 1954, vision o f the right eye was 2 0 / 2 5 and the eye was still normal e x cept for coarse nystagmus
both eyes were patched.
on looking to
either side and paralysis o f both elevators. The left eye turned out about 20 degrees
Dressings were changed every other day for four times. O n September 2, 1953 ( 1 0 days after o p e r a t i o n ) , there was g o o d external
rotation
o f left e y e ; slight divergence was noted. O n
and slightly downward. There was complete
September 16th (three weeks postoperative)
paralysis o f both elevators and almost c o m
examination revealed 50 degrees' external r o
plete o f the medial rectus. There were four
tation o f the left eye.
mm. o f exophthalmos and a definite ptosis. The pupil reacted consensually but not di rectly. T h e veins o f the upper lid were en
DIAMOX DR.
IN ACUTE GLAUCOMA
ALICE
R . D E U T S C H reported the case
gorged and so were those o f the temporal
of M r . J. C , aged 76 years, w h o gave the
region. T h e coiled, medusalike vessels on the
history o f having had recurrent severe eye
disc and surrounding it were approximately
inflammation all o f his life and stated that
the same as they had been two years previ
he never saw well. H e also had many rounds
ously.
of sinus infection and bronchitis. H e was al
PARALYTIC CONVERGENT S Q U I N T
after the use o f penicillin and the broad-
lergic to many drugs and had severe reactions DR.
B . W E I S B A U M reported the case o f an
spectrum antibiotics.
11-year-old N e g r o girl seen f o r the first time
A b o u t four years ago his vision began to
on July 22, 1953, with vision o f : O . D . ,
fail, especially in his right eye. A cataract
20/25,
O . S . , counting
fingers.
She
operation was performed in 1952 and was
showed a convergent squint,
J2;
fixating
only
complicated by intolerance to every kind o f
with the right eye. There was paralysis o f
mydriatic. A glaucoma operation had to be
the external rectus, O . S . , indicated by inabil
performed several months later. Nevertheless
ity to abduct the left eye past the midline. A
the tension remained high, but could be con
paresis o f the external
trolled with 0.1-percent D F P once a day at
rectus, O . D . , was
evidenced by weakness in external rotation.
bed time.
There was overaction o f the internal rectus,
T h e left eye showed dense macula corneae,
O . S . , with contractions. Measurements, us
a normal anterior chamber, many posterior
ing the perimeter, were on three occasions
synechias, and a partial pupillary membrane.
25 degrees esotropia for near and 25 degrees
T h e pupil dilated incompletely and irregu
esotropia for distance. Cycloplegic refraction
larly on 10-percent neosynephrine. A poste-
SOCIETY PROCEEDINGS
906
rior cortical cataract made fundus inspection
dent, w h o was admitted to the Baptist M e
difficult. Vision equalled 6 / 2 0 0 . T h e intra
morial Hospital on April 1, 1954. H e had
ocular pressure was never higher than 18
been in good health until that day when he
mm. H g .
suddenly developed a left frontal headache
O n April 10, 1954, in the evening he in
without history of trauma. H e went to the
advertently put one drop o f D F P in his left
John Gaston Hospital emergency room be
eye. Severe headache started about 15 min
cause o f this headache and was given Cafer-
utes later. The headache continued all night,
got without relief. S o o n after the Cafergot,
associated with nausea. H o w e v e r , he did not
the headache and the pain over the left eye
attribute this to his eye until the next morn
became more severe. H e soon noticed some
ing when he noticed that he could not see.
difficulty with his speech, had some dizziness,
W h e n examined a f e w hours later the ciliary
and vomited. H e was brought to the Baptist
body o f the left eye was injected and the
Memorial Hospital where he was admitted
cornea edematous. T h e pupil was pinpoint
about 11:50 P . M .
and the anterior chamber shallow but there
At
was apparently no typical iris bombé. T h e
shortly
intraocular pressure was 80 mm. H g . H e was
equal and reacted to light. T h e r e was a hem
admitted to the hospital.
the
time
after
o f the
first
admission, his
examination, pupils
were
orrhage in the left optic fundus. There was
Besides the local use o f 10-percent neo
some mental confusion, probably due to his
synephrine and cyclogyl ( o n e percent), 250
mild aphasia. T h e cranial nerves were other
mg. o f D i a m o x were given to him and re
wise intact. There were no reflex, sensory,
peated after six hours, after which time the
o r motor changes. There was no stiffness o f
cornea was clearer and the tension 40 mm.
his neck.
H g . T h e third dose o f D i a m o x was given
The possibility o f a subarachnoid hemor
after eight hours after which time the ten
rhage was considered but a lumbar puncture
sion dropped to 21 mm. H g in spite o f the
was not done at the time o f his admission.
fact that the pupil was still pinpoint. D i a m o x
T h e following morning X - r a y films o f his
was continued every 12 hours f o r two doses
skull were obtained and thought to be within
and again after 24 hours until 1.5 gm. was
the limits o f normal. H e was examined by
given. Neosynephrine was continued.
an ophthalmologist w h o also thought spon
It was not until after the third day that
taneous subarachnoid hemorrhage was a pos
the pupil showed some dilatation. The intra
sibility. Subsequent to this a lumbar punc
ocular pressure varied from 18 to 21 mm.
ture revealed bloody spinal fluid under in
Hg.
creased pressure.
Epinephrine-bitartrate
ointment
was
used three times a day for one week and then discontinued. W h e n the patient was last
B y A p r i l 8th, he had improved clinically and a lumbar
puncture
revealed that the
seen on April 15th, the pupil was o f normal
spinal fluid was only faintly xanthochromic
size and the pupillary membrane seemed to
without gross blood. W e felt that bilateral
be denser; the intraocular pressure was nor
carotid arteriograms should be done in an
mal and the vision, 6 / 2 0 0 . D i a m o x seemed
attempt to locate the suspected
to be a definite help in the handling o f this
carotid arteriograms, to our surprise, were
case.
negative f o r aneurysm. W e thought that the
aneurysm;
middle cerebral complex on the left SUBARACHNOID HEMORRHAGE W I T H ALOID
SUBHY
HEMORRHAGE
slightly elevated and the anterior
was
cerebral
artery was pushed slightly to the right. These presented
findings, coupled with the fact that this stu
the case o f C. K., a 26-year-old medical stu
dent was not making the clinical progress w e
DR.
RICHARD
L. DESAUSSURE
SOCIETY PROCEEDINGS had hoped for, made us suspect an cerebral hematoma.
infra-
O n April 13th, a ventriculogram demon strated a shift o f the ventricular system to the right. A t operation, an intracerebral he matoma in the left temporal lobe was dis closed. It involved almost the entire left temporal lobe. T h e hematoma was evacuated and the edges o f the brain adjacent to the hematoma were biopsied but there was n o evidence o f tumor in the biopsy specimens. W e did not find the bleeding point; there was n o evidence o f an aneurysm, heman gioma, or tumor. Postoperatively, this student did quite well except that the subtemporal decompression became tense and papilledema increased. It was our feeling that the intracerebral swell ing was probably the result o f operative trauma and not the result of further bleed ing, although this was considered as a possi bility. B y A p r i l 2Sth, the subtemporal de compression had become soft and he was discharged from the hospital. A t the time o f his discharge he had some aphasia and, in particular, had difficulty understanding writ ten words. H e was re-examined on April 30, 1954, at which time his decompression had become much softer, the papilledema was subsiding, and the vision o f the left eye was improved. This is the eye in which the hemorrhage had occurred. H e was re-examined on M a y 14th and showed further improvement. This student falls within the group ( d e scribed by Margolis, O d o m , Woodhall, and Bloor in 1951) o f individuals with intra cerebral hematomas due to small angioma tous malformations. These occurred in y o u n g individuals with no history o f predisposing factors. Their headaches occurred suddenly;
907
generally, the patient became unconscious at a later date. Bleeding occurred in the white matter and, usually, the bleeding -point could not be demonstrated. In a few cases minute angiomatous malformations were discovered. These authors felt that, in the other cases, the angiomas had been destroyed by the he matomas. Subhyaloid hemorrhages have been re ported in association with subarachnoid hem orrhage. H o w e v e r , it seems that they are usually associated with intracerebral hema tomas. In a recent review. Golden, O d o m , and W o o d h a l l found that o f 321 cases o f subarachnoid hemorrhage only 15 had associ ated subhyaloid hemorrhages. In 51 cases o f intracerebral hematoma without subarach noid hemorrhage, seven had subhyaloid hem orrhage; however, in 13 cases o f subarach noid and subdural hemorrhage, six had sub hyaloid hemorrhages. This gives a percentage of five percent for the pure subarachnoid hemorrhages, 14 percent for the intracerebral hematomas alone, and ^ 2 percent for the subarachnoid plus subdural hematomas. T h e mechanism by which the preretinal or subhyaloid hemorrhage is produced is still debated but the consensus seems to be that it is due to occlusion o f the venous channels and is not a direct extension o f the hemor rhage into the subhyaloid space. This is usu ally caused by sudden increase in intracranial pressure. This case serves to illustrate: ( 1 ) W h e n a subhyaloid hemorrhage is noted in the presence o f subarachnoid hemorrhage, a space-occupying lesion should be suspected and searched f o r ; ( 2 ) the lack o f nuchal rigidity does not exclude subarachnoid hem orrhage. Daniel F. Fisher, Recorder for the Eye Section.