- Email: [email protected]
Memphis Eye, Ear, Nose and Throat Society
SOCIETY PROCEEDINGS EDITED BY
DoNi1
M E M P H I S EYE, EAR, N O S E AND T H R O A T SOCIETY
D J. LYLE,
M.D.
surgery be done? (2) If surgery is done, what procedure on which eye or both should be performed ?
PARALYSIS OF INFERIOR OBLIQUE
HYPOPYON AFTER INJURY
P H I L I P MERIWETHER LEWIS, M.D., pre sented a patient with complete paralysis of the left inferior oblique, possibly due to Brown's "sheath syndrome of the superior oblique." D. S., a white boy, aged eight years, was first seen in 1955 at the age of four years. The history was that the eyes had been crossed since birth. Family and past history were negative. There was a complaint of nausea at times on looking at television. Examination showed that this right eye was dominant and the left hypotropic. Vision was 20/40, right, and 20/50, left. On looking down the position of his eyes was good and he had fusion. Looking straight ahead the left eye was too low and its image suppressed but the general appearance was not too bad. On looking up the left eye failed to follow when fixing with the right eye. When fixing with the left eye the right turned up beneath the upper lid. Prism measurements showed 40Δ left hypotropia and 10Δ exotropia in the pri mary position. Looking up and right with the right eye fixing, the left eye did not move up quite to the horizontal position. On look ing up and left the lag of the left eye was not nearly so marked but, when made to fix with the left eye, the right hypertropia was extreme. There was no limitation of motion on looking down. Refraction was negligible, + 1.0D. sph., O.U. This case fulfills some of the criteria for the diagnosis of the "superior oblique sheath syndrome" as described by Harold Brown. However, in this patient there is also a par tial paralysis of the left superior rectus. The questions in this case are: (1) Should any
18-month-old white girl. On February 21, 1959, at about 5:00 P.M., the patient was in the yard with her father. She screamed and, when her father ran to her, she was standing beside a rose bush crying. The family pedia trician was called first. He then called me. When I arrived the child was completely quiet and happy, with both eyes opened equally. The pupil of the left eye was tented upward. At the 12-o'clock position, two mm. down from the limbus was a horizontal lacer ation through the cornea approximately twomm. long. The iris was tented upward and adherent to the posterior surface of the wound but it did not prolapse through it. The anterior chamber was well formed. The right eye was normal. There were superficial fine scratches on the left upper and lower lids and the fingers of the left hand. Repair of the laceration was done about three hours after the initial injury. Vinemar, endotracheal tube and closed ether were used for anesthesia. After routine prep and drape, the corneal incision was closed with two in terrupted 6-0 chromic sutures. A limbal in cision was made through the conjunctiva and sciera with a keratome at about the 10o'clock position. The iris was stroked from the posterior surface of the wound with an iris spatula. When the anterior chamber was refilled with saline, the limbal incision leaked. Several sutures were required and the an terior chamber was still shallow when the patient left the operating room. It was felt this difficulty was due to a jagged edge made by the sawing type movement of the kera tome when performing the incision. Postoperatively one-percent pilocarpine drops and
W. WIGGINS WILDER, M.D., presented an
382
SOCIETY PROCEEDINGS
neosporin ointment were placed in the eye. action in the conjunctiva and lids. The lids Both eyes were patched. Chloromycetin pal- were so edematous a Desmarres lid retractor mitate (125 mg.) every six hours was was necessary to examine the eye. The con ordered postoperatively. A booster dose of junctiva was very chemotic and alternately purplish and white. Streptomycin (250 mg.) tetanus toxoid was given. At 10 o'clock next morning, the media was given intramuscularly. of the anterior segment appeared slightly The following morning the hypopyon was turbid and cloudy so the eye was re-examined practically gone and continued to clear. No at 3:00 P.M. At this time the pupillary area more subtenon's injections were given. By was definitely filled with yellowish exudate. February 26th the anterior chamber was The anterior chamber was deep. Because of clear and has remained so. Another injection rasping respiration, cough and some fever of 1,200,000 units of penicillin was given. the pediatrician was asked to recheck the Chloromycetin (1.0 gm. per day) was con child prior to subsequent anesthesia. The tinued through March 2nd. When dressing pediatrician felt the symptoms were due to the eye, neosoporin and atropine ointment, mechanical trauma from the endotracheal usually with 10-percent neosynephrine drops, tube. was used. On one occasion after the hy At 5:00 P.M., about 24 hours after the popyon had cleared, the pupil appeared to be original injury, the baby was again put to pulled toward the limbal incision and pilosleep. Only Vinemar without intubation was carpine (one-percent) drops were used. used and only enough to hold the patient still. On March 7th, two weeks after the injec Aqueous penicillin (100,000 units), strepto tion, the left lid and conjunctiva still showed mycin (100 mg.) and polymyxin (15 mg.) some edema. The lid could be opened to just were mixed together in about 1.0 cc. of saline. above the lower limbus. The anterior cham The mixture was injected at the 6-o'clock ber was clear and deep and no anterior or position about four mm. from the limbus. posterior synechias could be seen. The media Special effort was made to get this under of the posterior segment were clear and Tenon's capsule. A swab was used to obtain what could be visualized of the fundus ap material from the conjunctival surface for peared normal. culture and sensitivity tests. No growth had occurred 72 hours later. Neosynephrine (10 GLIOMA OF OPTIC NERVE percent) drops, one-percent atropine and P H I L I P MERIWETHER LEWIS, M.D., pre neosporin ointment were placed in the eye. sented a case of probable glioma of the optic The left eye was patched. General medication nerve. consisted of Chloromycetin (1.0 gm.) intra A white girl, aged 11 years, was first seen muscularly to be followed 10 hours later by about six years previously at the age of five 250 mg. by mouth every six hours ; 1,200,000 years. Her mother thought that her right eye units of all-purpose Bicillin and 250 mg. of looked larger than the left and that it could streptomycin were given intramuscularly. not see well. Intramuscular polymyxin was not used. Examination showed the right eye slightly The following morning the condition ap divergent and proptosed about two mm. The peared about the same—no better and no pupil was slightly larger than the left. It worse. That evening the subtenon's injection reacted very slightly to direct light but well was repeated. consensually. Vision was only the perception The next morning the hypopyon was not of light. Palpation of the orbit was negative. quite so large. The exudative material was There was considerable edema of the disc less fluffy and tended to precipitate out in and surrounding retina, (about three to four the lower angle. There was a tremendous re diopters). The disc was congested and the
SOCIETY PROCEEDINGS veins engorged. It was thought to be a severe optic neuritis. The left eye was normal. General physical and neurologic examinations were negative as were X-ray studies of the skull, orbit and optic foramen. The patient was seen at infrequent inter vals and the appearance remained about the same. In 1955, it was possible to obtain a good fundus photograph for the first time. The disc was elevated about six diopters, was quite congested and the veins were en gorged. Over the next three years the disc lost its congestion. In fact it became quite pale but remained elevated six diopters. The eye still had a slight proptosis, two to three mm. No tumor could be palpated. It was felt that this was a glioma of the optic nerve and that further X-ray studies were indicated and that surgical intervention might be necessary. BENIGN MELANOMA OF RETINAL PIGMENT EPITHELIUM
ALICE R. DEUTSCH, M.D., presented Mrs.
H. D., aged 46 years. She was seen for the first time in July, 1954, when she complained about impairment of close vision. The ophthalmologic findings were negative, except a grade II diabetic retinopathy. Her vision equalled: O.D., +0.25, 20/20; O.S., 20/20, add +1.50D. sph., J l . She was not aware of having diabetes. A subsequent checkup re vealed urine negative for sugar and a fast ing blood sugar of borderline value. The glucose tolerance test definitely was abnor mal. She was not seen again until June, 1958, when her only complaints were impairment of close vision. She also gave the information that for about one and a half years it had been necessary for her to use insulin ( 10 to 14 units N.P.H.) as the diabetes could not be controlled with diet alone following a breast operation (excision of a fibroma) in 1956. Her vision was: O.D., +0.75D. sph. C +0.25D. cyl. ax. 180°, 20/20; O.S., +0.5D. sph. C +0.25D. cyl. ax. 170°.
383
20/20. With an add of +2.0D. sph. she saw
J1·
Both fundi showed a congestion of the retinal veins and a few microaneurysms but neither hemorrhages or exudates. In the right fundus a slate-gray flat lesion, measuring 1.0 to 1.5 disc diameters was visible tem porally below the disc. The pigmentation was uniform all over the surface and the lesion seemed to be sharply outlined. The retinal vascular pattern was not disturbed. No signs of present or former inflammation could be seen with the slitlamp and the vitre ous appeared normal for the patient's age. Under the contact lens the borders of the lesion appeared less sharp and they looked transparent in indirect light. The optical sec tion revealed a normal curvature of the an terior retinal profile, a mottling of the pos terior half of the retinal band and a raised thickened and heavily granulated posterior profile. The choroidal band apparently was normal but mildly opaque in its internal part. No scotoma could be found on the tangent screen (2/1,000). The fundus was inspected again after two and four weeks, respectively, and no change could be demonstrated. The next office call was made eight months later on February 20, 1959. There were no complaints. The ophthalmoscopic appearance of the lesion was unchanged. Under slitlamp and contact glass the halo previously visible in indirect light had disappeared. The optical section showed a clear retinal band. A pro nounced distention of the posterior profile (pigment-epithelium) was present, with a definite sheath between the line of the pig ment epithelium and the otherwise normal choroidal band. The vision was 20/20 with her own correction. There was no scotoma, and no metamorphopsy or micropsy could be demonstrated on the Amsler-test. Pigmented growths of the fundus often are diagnostic problems. The flatness and even dark color of the lesion in this case were not characteristic signs for either a be nign or malignant melanoma of the choroid. A metastatic tumor of the choroid, however,
384
SOCIETY PROCEEDINGS
could not be excluded on the first ophthalmoscopic examination ; only the inspection of the fundus under slitlamp and contact lens revealed the normal choroid and localized the lesion in the pigment epithelium. Reese emphasized in his book and in several papers that, in spite of the fact that the pigment epithelial cells proliferate on the slightest provocation, a true neoplasm of this layer was very rare and tumors de scribed as such were really only hyperplasias, associated with prolonged irritation in the surrounding tissues. The tumors which he called benign melanomas of the retinal pig ment epithelium were very similar in their clinical manifestations to the lesion observed here, but they are supposedly congenital and therefore do not coincide with this diagnosis. The blurring of the borders of the lesion and the presence of a deep retinal edema at the first examination, as well as the presence of a thin subretinal sheath at the last ex amination could well be interpreted as the sequelae of a serous choriopathy. This diag nosis again is not quite satisfactory because of the uniform proliferation of the pigment epithelium and because of the absence of any functional disorder but it seems to be more appropriate than plain pathologic hyperplasia of the pigment epithelium, at least at present. Further regular follow-up examinations were advised. D R U S E N OF T H E OPTIC DISC P H I L I P MERIWETHER LEWIS, M.D., pre sented two patients with hyaline bodies of the discs, one of whom showed a bitemporal hemianopia. Case 1. J. W. N., a white man, aged 32 years, was first examined in May 1959 be cause of blurred vision of his right eye, noticed for several months, was thought by him to be getting worse. His family and per sonal history were negative. The eyes were negative externally. Vision was 20/70, J3, right; 20/20, J l , left. The media were clear. Both discs were elevated about two diopters. Fairly large rounded hyaline bodies were visible. The veins were
rather full and the arterioles smaller than normal and slightly sclerosed. Practically the entire temporal field of the right eye was de stroyed (to 14 degrees from fixation). There was a peripheral contraction of the nasal field and some irregular sector defects. There was a moderate but definite loss of periphery of the temporal field of the left eye extend ing into the nasal field superiorly. The blindspot was about three times the normal size. Homatropine refraction revealed a negligible error of each eye. It was felt that some intracranial disease, such as a lesion of the pituitary or a meningioma, probably was present. The patient was therefore referred to a neurosurgeon who agreed that the drusen alone were not entirely responsible for the visual loss. X-ray films of the skull and sella turcica were nor mal. The spinal fluid was negative. There was no evidence of multiple sclerosis or other neurologic diseases. Bilateral carotid arteriograms showed no evidence of a vascular anomaly, aneurysm or neoplasm. A ventriculogram was done and this was also within normal limits. The conclusion was reached that the hyaline bodies were responsible for the visual loss. The patient was seen again five months later. There was some decrease in near vision of the right eye, from J3, in May, to J6, in October. The visual fields were practically unchanged. There was now more swelling of the left disc than the right. The vision of the left eye was normal for distance and near. Case 2. The second patient presented had unilateral drusen principally involving the retina. J. B., a white man, aged 42 years, was presented before this society in 1946. He was first seen in 1942 at the age of 26 years. The hyaline bodies in this case were clustered in a group at the upper temporal border of the disc and extended in arcuate fashion to just above the macula. The mass was. pale yellow and about two and one-half times the size of the disc. Its surface was irregular or shingled in appearance. The right eye was normal in every way. He said the vision of his left
SOCIETY PROCEEDINGS eye had always been defective. Uncorrected it was 20/100, J8 in 1942, and about the same in 1946 and 1959. With a plus 1.75D. cyl. ax. 45°, vision could be improved to 20/30, J3. The refraction and vision were un changed in 1959. A very large arcuate scotoma extended from the blindspot downward and medially to the 90-degree meridian. The peripheral field was normal. Slides of the central fields and fundus photographs made in 1946 and in November 1959 were shown demonstrating that the lesion was nonpro gressive. Comment. Usually drusen are nonprogres sive and harmless. This seemed to be true in Case 2 but not in Case 1. They may be found in several members of a family, suggesting an hereditary tendency. Reese feels that they may be part of the congenital developmental anomaly known as tuberous sclerosis. There is apparently no known treatment that alters the course of progressive cases. Eugene A. Vaccaro, Recorder. HUNGARIAN OPHTHALMOLOGICAL SOCIETY May 27, 1960 A. KETTESY, M.D., Chairman OPHTHALMOLOGY AND METEOROLOGY
Â. KNOLL, M.D.: Meteorotropia has been observed in cases of acute glaucoma, anterior chamber bleeding following cataract opera tion, thrombosis of the central retinal vein, embolism of the central retinal artery, iritis and scleritis of rheumatic nature, and herpes corneae. The correlation with marked mété orologie changes has been particularly con spicuous in acute glaucoma, thrombosis and embolism. Drugs acting on the autonomie nervous system have been helpful in lessen ing the sensitivity of the patients to mété orologie changes. I. LUDWIG, M.D., AND I. ÖRMENYI,
M.D.:
Of the 812 cataract operations performed in
385
the course of two years 167 (20.56 per cent) were followed by anterior chamber hemor rhage. The meteoropathologic factors taken into consideration were (1) fronts, (2) kind of air masses, (3) major météorologie situa tions, (4) chronologic vertical sections, (5) variability of atmospheric pressure, (6) earth magnetic activity. The anterior cham ber hemorrhages could be correlated with upgliding fronts and with the inflow of warm air masses. Discussion. E. WALLNER, M.D.: It is pos sible that chymotrypsin introduced into the eye is diluted in the aqueous. It accelerates blood clotting and eventually may promote formation of thrombi. This may possibly be one of the explanations for the low incidence of hemorrhage after cataract operations. K. TURI, M.D.: The incidence of late bleeding is decisively influenced by the site of the wound created at operation; post operative hemorrhage is uncommon when corneoscleral sutures are used. The effects of météorologie factors on the nursing staff and even the nursing itself may indirectly pro duce postoperative bleeding. L. N É M E T H , M.D.: The fronts charac terizing the exchange of air masses around us may produce a wide variety of ophthalmologic diseases. The incidence of such condi tions seems to be increasing. Modern pre operative treatment can greatly neutralize un toward météorologie effects. J. GALL, M.D.: Hibernation seems to play a very important role in lowering the in cidence of postoperative bleedings. A. KETTESY, M.D.: Have the lecturers de voted attention to the climatologie factors more or less correlated with the météorologie ones? GY. LUGOSSY, M.D.: Among patients fac ing ophthalmologic operations, an increased number now have heart disease requiring preoperative cardiac treatment As surgery exposes the ailing heart to a considerable stress, it is advisable to postpone operation (irrespective of the availabiltiy of modern preparatory drugs) when the météorologie prognosis is unfavorable.
DoNi1
M E M P H I S EYE, EAR, N O S E AND T H R O A T SOCIETY
D J. LYLE,
M.D.
surgery be done? (2) If surgery is done, what procedure on which eye or both should be performed ?
PARALYSIS OF INFERIOR OBLIQUE
HYPOPYON AFTER INJURY
P H I L I P MERIWETHER LEWIS, M.D., pre sented a patient with complete paralysis of the left inferior oblique, possibly due to Brown's "sheath syndrome of the superior oblique." D. S., a white boy, aged eight years, was first seen in 1955 at the age of four years. The history was that the eyes had been crossed since birth. Family and past history were negative. There was a complaint of nausea at times on looking at television. Examination showed that this right eye was dominant and the left hypotropic. Vision was 20/40, right, and 20/50, left. On looking down the position of his eyes was good and he had fusion. Looking straight ahead the left eye was too low and its image suppressed but the general appearance was not too bad. On looking up the left eye failed to follow when fixing with the right eye. When fixing with the left eye the right turned up beneath the upper lid. Prism measurements showed 40Δ left hypotropia and 10Δ exotropia in the pri mary position. Looking up and right with the right eye fixing, the left eye did not move up quite to the horizontal position. On look ing up and left the lag of the left eye was not nearly so marked but, when made to fix with the left eye, the right hypertropia was extreme. There was no limitation of motion on looking down. Refraction was negligible, + 1.0D. sph., O.U. This case fulfills some of the criteria for the diagnosis of the "superior oblique sheath syndrome" as described by Harold Brown. However, in this patient there is also a par tial paralysis of the left superior rectus. The questions in this case are: (1) Should any
18-month-old white girl. On February 21, 1959, at about 5:00 P.M., the patient was in the yard with her father. She screamed and, when her father ran to her, she was standing beside a rose bush crying. The family pedia trician was called first. He then called me. When I arrived the child was completely quiet and happy, with both eyes opened equally. The pupil of the left eye was tented upward. At the 12-o'clock position, two mm. down from the limbus was a horizontal lacer ation through the cornea approximately twomm. long. The iris was tented upward and adherent to the posterior surface of the wound but it did not prolapse through it. The anterior chamber was well formed. The right eye was normal. There were superficial fine scratches on the left upper and lower lids and the fingers of the left hand. Repair of the laceration was done about three hours after the initial injury. Vinemar, endotracheal tube and closed ether were used for anesthesia. After routine prep and drape, the corneal incision was closed with two in terrupted 6-0 chromic sutures. A limbal in cision was made through the conjunctiva and sciera with a keratome at about the 10o'clock position. The iris was stroked from the posterior surface of the wound with an iris spatula. When the anterior chamber was refilled with saline, the limbal incision leaked. Several sutures were required and the an terior chamber was still shallow when the patient left the operating room. It was felt this difficulty was due to a jagged edge made by the sawing type movement of the kera tome when performing the incision. Postoperatively one-percent pilocarpine drops and
W. WIGGINS WILDER, M.D., presented an
382
SOCIETY PROCEEDINGS
neosporin ointment were placed in the eye. action in the conjunctiva and lids. The lids Both eyes were patched. Chloromycetin pal- were so edematous a Desmarres lid retractor mitate (125 mg.) every six hours was was necessary to examine the eye. The con ordered postoperatively. A booster dose of junctiva was very chemotic and alternately purplish and white. Streptomycin (250 mg.) tetanus toxoid was given. At 10 o'clock next morning, the media was given intramuscularly. of the anterior segment appeared slightly The following morning the hypopyon was turbid and cloudy so the eye was re-examined practically gone and continued to clear. No at 3:00 P.M. At this time the pupillary area more subtenon's injections were given. By was definitely filled with yellowish exudate. February 26th the anterior chamber was The anterior chamber was deep. Because of clear and has remained so. Another injection rasping respiration, cough and some fever of 1,200,000 units of penicillin was given. the pediatrician was asked to recheck the Chloromycetin (1.0 gm. per day) was con child prior to subsequent anesthesia. The tinued through March 2nd. When dressing pediatrician felt the symptoms were due to the eye, neosoporin and atropine ointment, mechanical trauma from the endotracheal usually with 10-percent neosynephrine drops, tube. was used. On one occasion after the hy At 5:00 P.M., about 24 hours after the popyon had cleared, the pupil appeared to be original injury, the baby was again put to pulled toward the limbal incision and pilosleep. Only Vinemar without intubation was carpine (one-percent) drops were used. used and only enough to hold the patient still. On March 7th, two weeks after the injec Aqueous penicillin (100,000 units), strepto tion, the left lid and conjunctiva still showed mycin (100 mg.) and polymyxin (15 mg.) some edema. The lid could be opened to just were mixed together in about 1.0 cc. of saline. above the lower limbus. The anterior cham The mixture was injected at the 6-o'clock ber was clear and deep and no anterior or position about four mm. from the limbus. posterior synechias could be seen. The media Special effort was made to get this under of the posterior segment were clear and Tenon's capsule. A swab was used to obtain what could be visualized of the fundus ap material from the conjunctival surface for peared normal. culture and sensitivity tests. No growth had occurred 72 hours later. Neosynephrine (10 GLIOMA OF OPTIC NERVE percent) drops, one-percent atropine and P H I L I P MERIWETHER LEWIS, M.D., pre neosporin ointment were placed in the eye. sented a case of probable glioma of the optic The left eye was patched. General medication nerve. consisted of Chloromycetin (1.0 gm.) intra A white girl, aged 11 years, was first seen muscularly to be followed 10 hours later by about six years previously at the age of five 250 mg. by mouth every six hours ; 1,200,000 years. Her mother thought that her right eye units of all-purpose Bicillin and 250 mg. of looked larger than the left and that it could streptomycin were given intramuscularly. not see well. Intramuscular polymyxin was not used. Examination showed the right eye slightly The following morning the condition ap divergent and proptosed about two mm. The peared about the same—no better and no pupil was slightly larger than the left. It worse. That evening the subtenon's injection reacted very slightly to direct light but well was repeated. consensually. Vision was only the perception The next morning the hypopyon was not of light. Palpation of the orbit was negative. quite so large. The exudative material was There was considerable edema of the disc less fluffy and tended to precipitate out in and surrounding retina, (about three to four the lower angle. There was a tremendous re diopters). The disc was congested and the
SOCIETY PROCEEDINGS veins engorged. It was thought to be a severe optic neuritis. The left eye was normal. General physical and neurologic examinations were negative as were X-ray studies of the skull, orbit and optic foramen. The patient was seen at infrequent inter vals and the appearance remained about the same. In 1955, it was possible to obtain a good fundus photograph for the first time. The disc was elevated about six diopters, was quite congested and the veins were en gorged. Over the next three years the disc lost its congestion. In fact it became quite pale but remained elevated six diopters. The eye still had a slight proptosis, two to three mm. No tumor could be palpated. It was felt that this was a glioma of the optic nerve and that further X-ray studies were indicated and that surgical intervention might be necessary. BENIGN MELANOMA OF RETINAL PIGMENT EPITHELIUM
ALICE R. DEUTSCH, M.D., presented Mrs.
H. D., aged 46 years. She was seen for the first time in July, 1954, when she complained about impairment of close vision. The ophthalmologic findings were negative, except a grade II diabetic retinopathy. Her vision equalled: O.D., +0.25, 20/20; O.S., 20/20, add +1.50D. sph., J l . She was not aware of having diabetes. A subsequent checkup re vealed urine negative for sugar and a fast ing blood sugar of borderline value. The glucose tolerance test definitely was abnor mal. She was not seen again until June, 1958, when her only complaints were impairment of close vision. She also gave the information that for about one and a half years it had been necessary for her to use insulin ( 10 to 14 units N.P.H.) as the diabetes could not be controlled with diet alone following a breast operation (excision of a fibroma) in 1956. Her vision was: O.D., +0.75D. sph. C +0.25D. cyl. ax. 180°, 20/20; O.S., +0.5D. sph. C +0.25D. cyl. ax. 170°.
383
20/20. With an add of +2.0D. sph. she saw
J1·
Both fundi showed a congestion of the retinal veins and a few microaneurysms but neither hemorrhages or exudates. In the right fundus a slate-gray flat lesion, measuring 1.0 to 1.5 disc diameters was visible tem porally below the disc. The pigmentation was uniform all over the surface and the lesion seemed to be sharply outlined. The retinal vascular pattern was not disturbed. No signs of present or former inflammation could be seen with the slitlamp and the vitre ous appeared normal for the patient's age. Under the contact lens the borders of the lesion appeared less sharp and they looked transparent in indirect light. The optical sec tion revealed a normal curvature of the an terior retinal profile, a mottling of the pos terior half of the retinal band and a raised thickened and heavily granulated posterior profile. The choroidal band apparently was normal but mildly opaque in its internal part. No scotoma could be found on the tangent screen (2/1,000). The fundus was inspected again after two and four weeks, respectively, and no change could be demonstrated. The next office call was made eight months later on February 20, 1959. There were no complaints. The ophthalmoscopic appearance of the lesion was unchanged. Under slitlamp and contact glass the halo previously visible in indirect light had disappeared. The optical section showed a clear retinal band. A pro nounced distention of the posterior profile (pigment-epithelium) was present, with a definite sheath between the line of the pig ment epithelium and the otherwise normal choroidal band. The vision was 20/20 with her own correction. There was no scotoma, and no metamorphopsy or micropsy could be demonstrated on the Amsler-test. Pigmented growths of the fundus often are diagnostic problems. The flatness and even dark color of the lesion in this case were not characteristic signs for either a be nign or malignant melanoma of the choroid. A metastatic tumor of the choroid, however,
384
SOCIETY PROCEEDINGS
could not be excluded on the first ophthalmoscopic examination ; only the inspection of the fundus under slitlamp and contact lens revealed the normal choroid and localized the lesion in the pigment epithelium. Reese emphasized in his book and in several papers that, in spite of the fact that the pigment epithelial cells proliferate on the slightest provocation, a true neoplasm of this layer was very rare and tumors de scribed as such were really only hyperplasias, associated with prolonged irritation in the surrounding tissues. The tumors which he called benign melanomas of the retinal pig ment epithelium were very similar in their clinical manifestations to the lesion observed here, but they are supposedly congenital and therefore do not coincide with this diagnosis. The blurring of the borders of the lesion and the presence of a deep retinal edema at the first examination, as well as the presence of a thin subretinal sheath at the last ex amination could well be interpreted as the sequelae of a serous choriopathy. This diag nosis again is not quite satisfactory because of the uniform proliferation of the pigment epithelium and because of the absence of any functional disorder but it seems to be more appropriate than plain pathologic hyperplasia of the pigment epithelium, at least at present. Further regular follow-up examinations were advised. D R U S E N OF T H E OPTIC DISC P H I L I P MERIWETHER LEWIS, M.D., pre sented two patients with hyaline bodies of the discs, one of whom showed a bitemporal hemianopia. Case 1. J. W. N., a white man, aged 32 years, was first examined in May 1959 be cause of blurred vision of his right eye, noticed for several months, was thought by him to be getting worse. His family and per sonal history were negative. The eyes were negative externally. Vision was 20/70, J3, right; 20/20, J l , left. The media were clear. Both discs were elevated about two diopters. Fairly large rounded hyaline bodies were visible. The veins were
rather full and the arterioles smaller than normal and slightly sclerosed. Practically the entire temporal field of the right eye was de stroyed (to 14 degrees from fixation). There was a peripheral contraction of the nasal field and some irregular sector defects. There was a moderate but definite loss of periphery of the temporal field of the left eye extend ing into the nasal field superiorly. The blindspot was about three times the normal size. Homatropine refraction revealed a negligible error of each eye. It was felt that some intracranial disease, such as a lesion of the pituitary or a meningioma, probably was present. The patient was therefore referred to a neurosurgeon who agreed that the drusen alone were not entirely responsible for the visual loss. X-ray films of the skull and sella turcica were nor mal. The spinal fluid was negative. There was no evidence of multiple sclerosis or other neurologic diseases. Bilateral carotid arteriograms showed no evidence of a vascular anomaly, aneurysm or neoplasm. A ventriculogram was done and this was also within normal limits. The conclusion was reached that the hyaline bodies were responsible for the visual loss. The patient was seen again five months later. There was some decrease in near vision of the right eye, from J3, in May, to J6, in October. The visual fields were practically unchanged. There was now more swelling of the left disc than the right. The vision of the left eye was normal for distance and near. Case 2. The second patient presented had unilateral drusen principally involving the retina. J. B., a white man, aged 42 years, was presented before this society in 1946. He was first seen in 1942 at the age of 26 years. The hyaline bodies in this case were clustered in a group at the upper temporal border of the disc and extended in arcuate fashion to just above the macula. The mass was. pale yellow and about two and one-half times the size of the disc. Its surface was irregular or shingled in appearance. The right eye was normal in every way. He said the vision of his left
SOCIETY PROCEEDINGS eye had always been defective. Uncorrected it was 20/100, J8 in 1942, and about the same in 1946 and 1959. With a plus 1.75D. cyl. ax. 45°, vision could be improved to 20/30, J3. The refraction and vision were un changed in 1959. A very large arcuate scotoma extended from the blindspot downward and medially to the 90-degree meridian. The peripheral field was normal. Slides of the central fields and fundus photographs made in 1946 and in November 1959 were shown demonstrating that the lesion was nonpro gressive. Comment. Usually drusen are nonprogres sive and harmless. This seemed to be true in Case 2 but not in Case 1. They may be found in several members of a family, suggesting an hereditary tendency. Reese feels that they may be part of the congenital developmental anomaly known as tuberous sclerosis. There is apparently no known treatment that alters the course of progressive cases. Eugene A. Vaccaro, Recorder. HUNGARIAN OPHTHALMOLOGICAL SOCIETY May 27, 1960 A. KETTESY, M.D., Chairman OPHTHALMOLOGY AND METEOROLOGY
Â. KNOLL, M.D.: Meteorotropia has been observed in cases of acute glaucoma, anterior chamber bleeding following cataract opera tion, thrombosis of the central retinal vein, embolism of the central retinal artery, iritis and scleritis of rheumatic nature, and herpes corneae. The correlation with marked mété orologie changes has been particularly con spicuous in acute glaucoma, thrombosis and embolism. Drugs acting on the autonomie nervous system have been helpful in lessen ing the sensitivity of the patients to mété orologie changes. I. LUDWIG, M.D., AND I. ÖRMENYI,
M.D.:
Of the 812 cataract operations performed in
385
the course of two years 167 (20.56 per cent) were followed by anterior chamber hemor rhage. The meteoropathologic factors taken into consideration were (1) fronts, (2) kind of air masses, (3) major météorologie situa tions, (4) chronologic vertical sections, (5) variability of atmospheric pressure, (6) earth magnetic activity. The anterior cham ber hemorrhages could be correlated with upgliding fronts and with the inflow of warm air masses. Discussion. E. WALLNER, M.D.: It is pos sible that chymotrypsin introduced into the eye is diluted in the aqueous. It accelerates blood clotting and eventually may promote formation of thrombi. This may possibly be one of the explanations for the low incidence of hemorrhage after cataract operations. K. TURI, M.D.: The incidence of late bleeding is decisively influenced by the site of the wound created at operation; post operative hemorrhage is uncommon when corneoscleral sutures are used. The effects of météorologie factors on the nursing staff and even the nursing itself may indirectly pro duce postoperative bleeding. L. N É M E T H , M.D.: The fronts charac terizing the exchange of air masses around us may produce a wide variety of ophthalmologic diseases. The incidence of such condi tions seems to be increasing. Modern pre operative treatment can greatly neutralize un toward météorologie effects. J. GALL, M.D.: Hibernation seems to play a very important role in lowering the in cidence of postoperative bleedings. A. KETTESY, M.D.: Have the lecturers de voted attention to the climatologie factors more or less correlated with the météorologie ones? GY. LUGOSSY, M.D.: Among patients fac ing ophthalmologic operations, an increased number now have heart disease requiring preoperative cardiac treatment As surgery exposes the ailing heart to a considerable stress, it is advisable to postpone operation (irrespective of the availabiltiy of modern preparatory drugs) when the météorologie prognosis is unfavorable.