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Memphis Eye, Ear, Nose and Throat Society
SOCIETY PROCEEDINGS E d i t e d by D O N A L D J . L Y L E , M . D .
Maddox rod measurment now shows 14 prism diopters esophoria for distance and eight prisms diopters exophoria for near. There is, however, no deviation to cover for distance and slight exophoria for near. W o r t h four-dot test shows good fusion for distance and there is good fusion and stere opsis for near.
MEMPHIS EYE, EAR, N O S E A N D T H R O A T SOCIETY OPERATION
FOR DIVERGENCE PARALYSIS
D R . J . W E S L E Y M C K I N N E Y reported the
case of M r s . W . S. S., aged 24 years, who was first seen for examination on February 5, 1954. She stated that in early childhood her eyes had crossed but had later straight ened out. During pregnancy, a little more than a year previously, the eyes had again crossed and had seemed to get worse in stead of better. She had worn glasses since the age of three years and most of the time the glasses had been bifocals. She had diplopia most of the time for distance. She had taken exercises without benefit. Examination revealed a possible slight limitation of external rotation of each eye. Fixation was with either eye, with some preference for the left. In the midline there was homonymous diplopia beyond four feet, increasing as the light or object was moved away. Within four feet there was good fusion and stereopsis. Cover test showed esotropia for distance and orthophoria for near. T h e diplopia was the same in all fields. A t one meter the Lancaster diplopia field showed a homonymous diplopia of 23 prism diopters and the separation of images w a s approxi mately equal in all fields. T h e eyes were grossly convergent when the patient looked in the distance. A complete neurologic study was carried out and all findings were nega tive. These findings, together with the history of convergent strabismus, and the absence of other neurologic findings, indicated a probable congenital basis for the divergence paralysis. O n March 2, 1954, a five-mm. resection of each external rectus muscle w a s done. T h e postoperative course was uneventful, and the diplopia was completely relieved.
PRECANCEROUS
MELANOSIS
D R . A L I C E R. D E U T S C H reported the case
of M r . H . P., aged 75 years. H e was seen for the first time in February, 1958. H e had no special complaints but wanted his eyes examined as he had lost his glasses. T h e examination revealed some lens and pro nounced vascular changes of the fundi, which is compatible with the patient's age. T h e vision equalled: O.D., + 3 . 2 5 D . sph. 3 + 1.0D. cyl. ax. 145°, 2 0 / 4 0 ; O . S . + 3 . 2 5 D . sph. C + 1 - 0 D . cyl. ax. 180°, 2 / 4 0 . T h e intraocular pressure was 17.3 mm. H g . in both eyes. T h e only unusual finding was the appear ance of the left eye. A dense smooth pigmen tation surrounded the limbal area from the 12:30 to the 7-o'clock position with an aver age diameter of three mm. ; two tongues of pigmentation were visible in the cornea im mediately in front of Bowman's zone; the larger of those projections started at the 5-o'clock position and reached the corneal center. T h e corneal surface was unchanged. Plaques of granular pigmentation and pigmented dots occupied the temporal half of the bulbar conjunctiva, reaching toward the fornices and the temporal lid-angle, respec tively. T w o stripes of atrophie conjunctiva were visible in the lower temporal quad rant. N o real tumefactions were present but one small place at the 2-o'clock position, close to the limbus, seemed to be more ele vated. Several enlarged vessels were quite apparent and around them the conjunctiva was thickened like that in chronic inflamma-
678
SOCIETY PROCEEDINGS tory reactions but without loss of normal luster. The patient gave the information that he was not aware of the pigmentation himself but that it had been mentioned to him dur ing his last two or three eye examinations and referred to as "nevus" or "freckles." He noticed, however, that during the last two or three years his left eye had been inflamed several times but that the inflammation had subsided mostly by itself in several weeks. One time a prescription for drops had been given to him. The clinical picture described does not re semble any kind of congenital melanosis or a nevus ; even a flat diffuse nevus is some what elevated and also mostly includes microcysts. This case undoubtedly belongs to the group of acquired melanoses. The diffuseness of the pigmentation, their superficial locations, and the striae of atrophie mucosa could well be interpreted as signs of precancerous melanosis. The presence of in flammatory reactions and enlarged vessels might even suggest a change toward the malignant phase. Reese (Am. J. Ophth., 39:96 [Apr.] 1955) reported successes with irradiation in in his series of precancerous melanosis. He also asserts that the prognosis would not be jeopardized by an excision for biopsy. On the other hand he maintains that the patho logic diagnosis is often just as difficult as the clinical. In view of the known slow prog ress of the disease and the age of the pa tient, the question arises whether or not it would be best to do nothing in this case— even in view of the potentially poor prog nosis. Eugene A. Vaccaro, Secretary, Eye Section. OPHTHALMOLOGICAL SOCIETY O F T H E U N I T E D KINGDOM T H E 79th annual congress was held in London, at the Royal Society of Medicine, on April 9 to 11, 1959. Over 300 members
679
and their guests attended, including several distinguished foreign visitors. Mr. R. C. DAVENPORT, president of the society, was in the chair. In his presidential address on glaucoma he considered the relationship be tween myopia and glaucoma, recalling that association of the two conditions was not as rare as was often supposed, and he discussed the connection between glaucoma and obliterative arterial disease and its possible etiologic significance. SWOLLEN OPTIC DISC
Mr. DESMOND GREAVES emphasized the need to recognize the wide limits of normal and congenital anomalies of the optic disc and to distinguish them from early pathologic changes. He discussed the vascular arrange ment at the nervehead, and the absence of any considerable connection between the cen tral artery of the optic nerve and the circle of Zinn on the one hand and the central retinal artery on the other. The relationship between the degree of swelling of the optic disc and the loss of function gave much help in diagnosis. In the discussion all agreed that papilledema was an unsatisfactory term, especially for universal application to the swollen optic disc, but its use was so well established that attempts to abolish it were probably unrealistic. Dr. S. P. MEADOWS said that raised intracranial pressure could not be ruled out merely because the optic nerve was not swollen. The degree of swelling varied even in cases of cerebellar tumor, which are particularly prone to early papilledema. An unusal picture which Dr. Meadows showed was of papilledema and retinal hemorrhages in a patient with emphysema. Mr. CHARLES COOK illustrated the his tologie changes in the swollen disc and showed how the retina in the immediate neighborhood was shallowly detached. The course taken by the optic nerve fibers in papilledema, and the importance of the culde-sac of the subarachnoid space, were both demonstrated.
Maddox rod measurment now shows 14 prism diopters esophoria for distance and eight prisms diopters exophoria for near. There is, however, no deviation to cover for distance and slight exophoria for near. W o r t h four-dot test shows good fusion for distance and there is good fusion and stere opsis for near.
MEMPHIS EYE, EAR, N O S E A N D T H R O A T SOCIETY OPERATION
FOR DIVERGENCE PARALYSIS
D R . J . W E S L E Y M C K I N N E Y reported the
case of M r s . W . S. S., aged 24 years, who was first seen for examination on February 5, 1954. She stated that in early childhood her eyes had crossed but had later straight ened out. During pregnancy, a little more than a year previously, the eyes had again crossed and had seemed to get worse in stead of better. She had worn glasses since the age of three years and most of the time the glasses had been bifocals. She had diplopia most of the time for distance. She had taken exercises without benefit. Examination revealed a possible slight limitation of external rotation of each eye. Fixation was with either eye, with some preference for the left. In the midline there was homonymous diplopia beyond four feet, increasing as the light or object was moved away. Within four feet there was good fusion and stereopsis. Cover test showed esotropia for distance and orthophoria for near. T h e diplopia was the same in all fields. A t one meter the Lancaster diplopia field showed a homonymous diplopia of 23 prism diopters and the separation of images w a s approxi mately equal in all fields. T h e eyes were grossly convergent when the patient looked in the distance. A complete neurologic study was carried out and all findings were nega tive. These findings, together with the history of convergent strabismus, and the absence of other neurologic findings, indicated a probable congenital basis for the divergence paralysis. O n March 2, 1954, a five-mm. resection of each external rectus muscle w a s done. T h e postoperative course was uneventful, and the diplopia was completely relieved.
PRECANCEROUS
MELANOSIS
D R . A L I C E R. D E U T S C H reported the case
of M r . H . P., aged 75 years. H e was seen for the first time in February, 1958. H e had no special complaints but wanted his eyes examined as he had lost his glasses. T h e examination revealed some lens and pro nounced vascular changes of the fundi, which is compatible with the patient's age. T h e vision equalled: O.D., + 3 . 2 5 D . sph. 3 + 1.0D. cyl. ax. 145°, 2 0 / 4 0 ; O . S . + 3 . 2 5 D . sph. C + 1 - 0 D . cyl. ax. 180°, 2 / 4 0 . T h e intraocular pressure was 17.3 mm. H g . in both eyes. T h e only unusual finding was the appear ance of the left eye. A dense smooth pigmen tation surrounded the limbal area from the 12:30 to the 7-o'clock position with an aver age diameter of three mm. ; two tongues of pigmentation were visible in the cornea im mediately in front of Bowman's zone; the larger of those projections started at the 5-o'clock position and reached the corneal center. T h e corneal surface was unchanged. Plaques of granular pigmentation and pigmented dots occupied the temporal half of the bulbar conjunctiva, reaching toward the fornices and the temporal lid-angle, respec tively. T w o stripes of atrophie conjunctiva were visible in the lower temporal quad rant. N o real tumefactions were present but one small place at the 2-o'clock position, close to the limbus, seemed to be more ele vated. Several enlarged vessels were quite apparent and around them the conjunctiva was thickened like that in chronic inflamma-
678
SOCIETY PROCEEDINGS tory reactions but without loss of normal luster. The patient gave the information that he was not aware of the pigmentation himself but that it had been mentioned to him dur ing his last two or three eye examinations and referred to as "nevus" or "freckles." He noticed, however, that during the last two or three years his left eye had been inflamed several times but that the inflammation had subsided mostly by itself in several weeks. One time a prescription for drops had been given to him. The clinical picture described does not re semble any kind of congenital melanosis or a nevus ; even a flat diffuse nevus is some what elevated and also mostly includes microcysts. This case undoubtedly belongs to the group of acquired melanoses. The diffuseness of the pigmentation, their superficial locations, and the striae of atrophie mucosa could well be interpreted as signs of precancerous melanosis. The presence of in flammatory reactions and enlarged vessels might even suggest a change toward the malignant phase. Reese (Am. J. Ophth., 39:96 [Apr.] 1955) reported successes with irradiation in in his series of precancerous melanosis. He also asserts that the prognosis would not be jeopardized by an excision for biopsy. On the other hand he maintains that the patho logic diagnosis is often just as difficult as the clinical. In view of the known slow prog ress of the disease and the age of the pa tient, the question arises whether or not it would be best to do nothing in this case— even in view of the potentially poor prog nosis. Eugene A. Vaccaro, Secretary, Eye Section. OPHTHALMOLOGICAL SOCIETY O F T H E U N I T E D KINGDOM T H E 79th annual congress was held in London, at the Royal Society of Medicine, on April 9 to 11, 1959. Over 300 members
679
and their guests attended, including several distinguished foreign visitors. Mr. R. C. DAVENPORT, president of the society, was in the chair. In his presidential address on glaucoma he considered the relationship be tween myopia and glaucoma, recalling that association of the two conditions was not as rare as was often supposed, and he discussed the connection between glaucoma and obliterative arterial disease and its possible etiologic significance. SWOLLEN OPTIC DISC
Mr. DESMOND GREAVES emphasized the need to recognize the wide limits of normal and congenital anomalies of the optic disc and to distinguish them from early pathologic changes. He discussed the vascular arrange ment at the nervehead, and the absence of any considerable connection between the cen tral artery of the optic nerve and the circle of Zinn on the one hand and the central retinal artery on the other. The relationship between the degree of swelling of the optic disc and the loss of function gave much help in diagnosis. In the discussion all agreed that papilledema was an unsatisfactory term, especially for universal application to the swollen optic disc, but its use was so well established that attempts to abolish it were probably unrealistic. Dr. S. P. MEADOWS said that raised intracranial pressure could not be ruled out merely because the optic nerve was not swollen. The degree of swelling varied even in cases of cerebellar tumor, which are particularly prone to early papilledema. An unusal picture which Dr. Meadows showed was of papilledema and retinal hemorrhages in a patient with emphysema. Mr. CHARLES COOK illustrated the his tologie changes in the swollen disc and showed how the retina in the immediate neighborhood was shallowly detached. The course taken by the optic nerve fibers in papilledema, and the importance of the culde-sac of the subarachnoid space, were both demonstrated.