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Memphis eye, ear, Nose, and Throat Society
934
SOCIETY PROCEEDINGS
tages that the heliocauter has demonstrated. Strangely enough, for this we are indebted to Becker's speculative misconception which inspired this study. David Shoch, Corresponding Secretary.
MEMPHIS EYE, EAR, NOSE, AND THROAT SOCIETY BILATERAL DENDRITIC ULCERS
DR. ALICE R. DEUTSCH presented Mrs.
W. R., aged 43 years, with the history of a mild, inflammation of both eyes several years ago, for which she used eyedrops prescribed at that time. In April, 1956, her eyes felt scratchy again. As she did not have her eyedrops she used some milky drops given to her by a friend. Those drops did very well for a few days. For the last week, however, lid swelling and lacrimation occurred and her vision seemed blurred. She had never worn glasses except for reading. Her gen eral health had always been good. When she was seen for the first time late in April, 1956, she had bilateral edema of the lids, foamy secretion between the lashes and in the lid angle, and a diffuse swelling of the conjunctiva of the lids. The bulbar con junctiva was also injected. Both corneas showed a fine punctate staining in the center. The preauricular glands were not enlarged. The pupils reacted to light. Fundus examina tion was impossible because of the severe photophobia. Only epithelial cells and lym phocytes were found in the conjunctival scraping. A prescription for Chloromycetin drops and aureomycin ointment was given to her. When she returned two days later the right cornea had numerous star-shaped superficial ulcers, and the left cornea was unchanged. At this time the right cornea was denuded, cauterized with tincture of iodine; homatropine, paredrine, and a pressure bandage were applied. The treatment for the left eye was not changed. She was asked to return the
next day but did not come back until four days later. On that day the right cornea did not stain and was clear with exception of a very fine epithelial haze. The left cornea had a large dendritic ulcer, the pupil was narrow, and the iris swollen and hyperemic. The left cornea was denuded, cauterized with tincture of iodine; atropine and a pressure bandage were applied and aureomycin (250 mg., four times daily) was prescribed. While the right eye returned to normal during the following days, the left eye de veloped a central disc-shaped opacity in Bow man's zone with recurrent breakdowns of the epithelium in this area. By the end of May the left eye was quiet. A central super ficial corneal opacity remained. She reported by mail that she had been well ever since. Bilateral dendritic keratitis used to be a very rare disease but since World War II more cases of this kind have been observed (Thygeson, P.: Am. J. Ophth., 36:269, 1953). Dendritic keratitis has developed in patients undergoing systemic and topical cor tisone therapy. The question was raised as to whether certain stimuli may call the dor mant herpes virus into activity and allow it to be liberated into susceptible tissue. It was also assumed that cortisone might release the virus from the nuclei of the affected cells and spread the infection by disturbing the local immunity (Braley, A. E.: Am. J. Ophth., 35: 1737, 1952). The patient presented gave the informa tion that she had never had a fever blister. It is, however, possible that the mild attack of conjunctivitis which she mentioned in her history was an acute herpetic keratoconjunctivitis (though this disease mostly occurs in much younger persons) and that this latent infection was reactivated by cortisone. This case was reported to demonstrate that it is not only necessary to evaluate carefully the use of cortisone for every case, but that the patient should be warned that this medi cation is only for himself and should never be given to anybody else.
SOCIETY PROCEEDINGS ACUTE GLAUCOMA AFTER CATARACT EXTRAC TION DR. P H I L I P MERIWETHER LEWIS reported
an unusual complication after cataract opera tion. M. M., a Negress, aged 63 years, had been under observation and treatment since 1943. She was quite myopic, —8.0D., O.D.; —20D., O.S. There was vitreous degenera tion and myopic stretching in both eyes, much worse in the left where there was a posterior staphyloma. Best vision was: O.D., 20/70, J 4 ; O.S., counting fingers at two feet. She was seen every year or two but it was not until 1950 that chronic simple glaucoma was diagnosed. The tension was 34 mm. Hg, O.D., and 46 mm. Hg, O.S. The tension was not permanently controlled well by miotics so a cycloelectrolysis was done on both eyes in 1952. By means of miotics the tension was then controlled and vision and fields main tained until 1955 when, in spite of the regu lar use of miotics, the tension rose and re mained in the upper thirties. Small doses of Diamox controlled this fairly well and was well tolerated. Over the years there was a gradual advance in nuclear cataracts so that vision in her better eye fell to 20/200, J12. On April 26, 1956, a round-pupil intracapsular cataract extraction, with two pe ripheral iridotomies, was done without any difficulty. A bubble of air was placed in the anterior chamber and both pilocarpine and eserine were instilled. Twenty-four hours later the eye was dressed. The lower half of the iris was plastered against the cornea. The bubble oc cupied the upper half of the anterior cham ber where the iris was pushed back so that the upper half of the chamber was deep. The position of the bubble was due to the fact that the patient had spent her entire time with her head and torso elevated on a back rest. The pupil was dilated in spite of twopercent pilocarpine and eserine being used in the operating room. The eye was quite hard. By lowering the head over the side of the bed, the air bubble was made to go to the
935
lower half of the anterior chamber, pushing the iris away from the cornea. The iris re mained stuck to the extreme periphery, ap parently blocking the angle. Frequent mi otics, including D F P four times, were used to try to contract the pupil and draw the iris away from the angle. Diamox (500 mg.) was given at once and 250 mg. every four hours. Examination eight hours later showed the cornea quite steamy and the eye stony hard. The bubble was back in the upper half of the chamber with the lower half of the iris against the cornea. Vision was reduced to light perception. The eye was anesthetized and a retrobulbar injection of procaine and adrenalin given. Paracentesis was performed in the lower temporal quadrant and the air let out. Immediately the cornea cleared and the pa tient said "I can see." The following morn ing, 48 hours after operation, the eye was again hard, the cornea steamy, and the pupil dilated. However, the anterior chamber had reformed and was fairly deep. Strong mi otics and Diamox were continued. The next day the cornea had cleared, the tension was normal, and the patient could see. No further complications occurred and the patient left the hospital on the seventh postoperative day in good condition. When seen a few days later, the tension was normal and vision was 20/100 with out glasses. It was felt that this eye would have been permanently blinded if appropriate treatment had not been promptly instituted. Therefore, this case serves as another bit of evidence in favor of the daily inspection and dressing of all postoperative cataract cases. Eugene A. Vaccaro, Recording Secretary.
SOCIETY PROCEEDINGS
tages that the heliocauter has demonstrated. Strangely enough, for this we are indebted to Becker's speculative misconception which inspired this study. David Shoch, Corresponding Secretary.
MEMPHIS EYE, EAR, NOSE, AND THROAT SOCIETY BILATERAL DENDRITIC ULCERS
DR. ALICE R. DEUTSCH presented Mrs.
W. R., aged 43 years, with the history of a mild, inflammation of both eyes several years ago, for which she used eyedrops prescribed at that time. In April, 1956, her eyes felt scratchy again. As she did not have her eyedrops she used some milky drops given to her by a friend. Those drops did very well for a few days. For the last week, however, lid swelling and lacrimation occurred and her vision seemed blurred. She had never worn glasses except for reading. Her gen eral health had always been good. When she was seen for the first time late in April, 1956, she had bilateral edema of the lids, foamy secretion between the lashes and in the lid angle, and a diffuse swelling of the conjunctiva of the lids. The bulbar con junctiva was also injected. Both corneas showed a fine punctate staining in the center. The preauricular glands were not enlarged. The pupils reacted to light. Fundus examina tion was impossible because of the severe photophobia. Only epithelial cells and lym phocytes were found in the conjunctival scraping. A prescription for Chloromycetin drops and aureomycin ointment was given to her. When she returned two days later the right cornea had numerous star-shaped superficial ulcers, and the left cornea was unchanged. At this time the right cornea was denuded, cauterized with tincture of iodine; homatropine, paredrine, and a pressure bandage were applied. The treatment for the left eye was not changed. She was asked to return the
next day but did not come back until four days later. On that day the right cornea did not stain and was clear with exception of a very fine epithelial haze. The left cornea had a large dendritic ulcer, the pupil was narrow, and the iris swollen and hyperemic. The left cornea was denuded, cauterized with tincture of iodine; atropine and a pressure bandage were applied and aureomycin (250 mg., four times daily) was prescribed. While the right eye returned to normal during the following days, the left eye de veloped a central disc-shaped opacity in Bow man's zone with recurrent breakdowns of the epithelium in this area. By the end of May the left eye was quiet. A central super ficial corneal opacity remained. She reported by mail that she had been well ever since. Bilateral dendritic keratitis used to be a very rare disease but since World War II more cases of this kind have been observed (Thygeson, P.: Am. J. Ophth., 36:269, 1953). Dendritic keratitis has developed in patients undergoing systemic and topical cor tisone therapy. The question was raised as to whether certain stimuli may call the dor mant herpes virus into activity and allow it to be liberated into susceptible tissue. It was also assumed that cortisone might release the virus from the nuclei of the affected cells and spread the infection by disturbing the local immunity (Braley, A. E.: Am. J. Ophth., 35: 1737, 1952). The patient presented gave the informa tion that she had never had a fever blister. It is, however, possible that the mild attack of conjunctivitis which she mentioned in her history was an acute herpetic keratoconjunctivitis (though this disease mostly occurs in much younger persons) and that this latent infection was reactivated by cortisone. This case was reported to demonstrate that it is not only necessary to evaluate carefully the use of cortisone for every case, but that the patient should be warned that this medi cation is only for himself and should never be given to anybody else.
SOCIETY PROCEEDINGS ACUTE GLAUCOMA AFTER CATARACT EXTRAC TION DR. P H I L I P MERIWETHER LEWIS reported
an unusual complication after cataract opera tion. M. M., a Negress, aged 63 years, had been under observation and treatment since 1943. She was quite myopic, —8.0D., O.D.; —20D., O.S. There was vitreous degenera tion and myopic stretching in both eyes, much worse in the left where there was a posterior staphyloma. Best vision was: O.D., 20/70, J 4 ; O.S., counting fingers at two feet. She was seen every year or two but it was not until 1950 that chronic simple glaucoma was diagnosed. The tension was 34 mm. Hg, O.D., and 46 mm. Hg, O.S. The tension was not permanently controlled well by miotics so a cycloelectrolysis was done on both eyes in 1952. By means of miotics the tension was then controlled and vision and fields main tained until 1955 when, in spite of the regu lar use of miotics, the tension rose and re mained in the upper thirties. Small doses of Diamox controlled this fairly well and was well tolerated. Over the years there was a gradual advance in nuclear cataracts so that vision in her better eye fell to 20/200, J12. On April 26, 1956, a round-pupil intracapsular cataract extraction, with two pe ripheral iridotomies, was done without any difficulty. A bubble of air was placed in the anterior chamber and both pilocarpine and eserine were instilled. Twenty-four hours later the eye was dressed. The lower half of the iris was plastered against the cornea. The bubble oc cupied the upper half of the anterior cham ber where the iris was pushed back so that the upper half of the chamber was deep. The position of the bubble was due to the fact that the patient had spent her entire time with her head and torso elevated on a back rest. The pupil was dilated in spite of twopercent pilocarpine and eserine being used in the operating room. The eye was quite hard. By lowering the head over the side of the bed, the air bubble was made to go to the
935
lower half of the anterior chamber, pushing the iris away from the cornea. The iris re mained stuck to the extreme periphery, ap parently blocking the angle. Frequent mi otics, including D F P four times, were used to try to contract the pupil and draw the iris away from the angle. Diamox (500 mg.) was given at once and 250 mg. every four hours. Examination eight hours later showed the cornea quite steamy and the eye stony hard. The bubble was back in the upper half of the chamber with the lower half of the iris against the cornea. Vision was reduced to light perception. The eye was anesthetized and a retrobulbar injection of procaine and adrenalin given. Paracentesis was performed in the lower temporal quadrant and the air let out. Immediately the cornea cleared and the pa tient said "I can see." The following morn ing, 48 hours after operation, the eye was again hard, the cornea steamy, and the pupil dilated. However, the anterior chamber had reformed and was fairly deep. Strong mi otics and Diamox were continued. The next day the cornea had cleared, the tension was normal, and the patient could see. No further complications occurred and the patient left the hospital on the seventh postoperative day in good condition. When seen a few days later, the tension was normal and vision was 20/100 with out glasses. It was felt that this eye would have been permanently blinded if appropriate treatment had not been promptly instituted. Therefore, this case serves as another bit of evidence in favor of the daily inspection and dressing of all postoperative cataract cases. Eugene A. Vaccaro, Recording Secretary.