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Memphis Eye Ear, Nose, and Throat Society
SOCIETY
PROCEEDINGS
even suggest a right hypertropia o n gaze down and to the left. Measurements showed 2.0D. right hypertropia down and t o the right and 2.0D. left hypertropia down and to the left. Until more o f these cases can be collected and studied, as D r . Harbert has done, it would seem wise to me to admit that o u r knowledge o f the arrangement o f the nuclei in the third-nerve mass in man is still en tirely conjectural. The evidence he has pre sented is valuable and points in the direction he has suggested. DR. EISENBERG : D r . Harbert placed the lesion in the nuclei. I would just like to speculate on the possibility o f a retro-orbital lesion causing the paresis o f elevation. W o u l d y o u mind commenting o n that please ?
433
try to find a better data to substantiate my theory and, if I can, I will present the find ings to you. William E . Krewson, 3rd, Clerk.
EAR,
OPTIC
MEMPHIS EYE NOSE, A N D T H R O A T SOCIETY
NEURITIS
TREATED
WITH
CORTICO
TROPIN DR.
PHILIP
MERIWETHER
LEWIS
pre
sented a 37-year-old Negress with an acute fulminating optic neuritis w h o was under treatment at the Memphis E y e and Ear Hospital. She first noticed marked blurring of vision o f her left e y e five weeks pre viously. There had been practically no head CAPT. HARBERT : I n answer to D r . Eisenache and n o pain. H e r health had always berg's question about a retro-orbital lesion, I would presume he w a s thinking o f some been excellent. She had seven children, all thing between the sphenoidal fissue and the living and well, the youngest being four years old. brain stem? DR. EISENBERG: N O , in the orbit itself, space-taking lesions. CAPT.
H A R B E R T : In
the
first
place,
the
third nerve divides at the superior orbital fissure or perhaps just before it enters the orbit. T h e superior branch carries levator and superior rectus fibers while the inferior oblique fibers g o with the inferior branch. In the cases reported we have a mechani cal involvement o f superior and inferior muscles which are innervated b y diiferent branches o f the nerve. O n that basis, I think we can rule out a single lesion that could account f o r this. W e also have the medial rectus completely spared in all these cases, which again rules out an. orbital lesion. It would take a peculiar lesion t o spare the medial rectus and give maximal involvement of the other two muscles that are innervated by the inferior division. I certainly think D r . Adler's criticism is very proper. Perhaps I was a little t o o enthu siastic in reading inferior rectus involve ment in some o f the cases. H o w e v e r , I will
Examination showed both eyes normal externally, the media clear, and the fundus of the right eye normal. T h e disc o f the left eye was greatly swollen, the peak o f the elevation being eight diopters and the lowest portion four diopters above the normal level. The retina surrounding the disc was greatly swollen, the veins enormously engorged and there were many flame-shaped hemorrhages. Vision was 2 0 / 2 0 in the right eye and 2 0 / 2 0 0 eccentrically in the left eye. T h e visual fields and blindspot o f the right eye were normal. T h e peripheral field o f the left eye f o r large test objects w a s normal and there was a fairly large central scotoma. There was no limitation o f motion, n o prop tosis, and n o tenderness t o pressure. H e r physical examination was entirely normal e x cept f o r two diseased teeth which she had removed during the early stage o f her trouble. X - r a y studies o f the remaining teeth, gums, sinu.ses, and chest were nega tive. The
removal o f the diseased teeth, injec-
434
SOCIETY
PROCEEDINGS
tions o f typhoid-Η antigen intravenously, and large doses o f nicotinic acid failed to cause any improvement in the appearance of the fundus or in the vision. Corticotro pin was therefore started by a slow intra venous drop over an eight-hour period. The medium used was five-percent glucose solution in distilled water; 1 , 0 0 0 cc. con taining 4 0 mg. o f corticotropin were admin istered over an eight-hour period. The same dose was repeated the next day and there after the amount was gradually reduced. It was planned to "taper" off with cortisone by mouth after discontinuing the corticotropin. Considerable reduction of swelling and some visual improvement were noticed, but it was too early to claim great benefit from the drug. A subsequent report will be made after the process has completed its course. P I T U I T A R Y TUMOR
D R . C . C . SHIPP reported the case o f a 51-year-old Negress w h o came to the clinic on April 2 0 , 1 9 5 3 , with a complaint of failing vision for over two years. Her present glasses were six months' old, purchased from an optometrist at a jewelry store, and she said she could not see out of them. There was no history o f ocular pain or trauma and no previous eye complaints. Examination. T h e eyes were white and external examination was negative. Visual acuity w a s : O . D . , counting fingers; O . S . , light perception; with a - f - 2 . 0 D . sph., add +2.0Ό. sph., O . U . ; . T 1 8 , ( ? ) O . D . Cornea and media were clear. Pupils were small but equal, reacted to light and accommodation, consensual reactions were positive, O . U . Tension was : 2 0 mm. H g (Schi^^tz), O . U . Fundus examination. There was optic atrophy, O . U . , especially the temporal sides of the discs. Grade 1 arteriolosclerosis o f the vessels was present; no cupping was seen. Primary optic atrophy was considered though n o history o f any antiluetic therapy was found. Blood Kahn was obtained and the patient was told to return for re-exam ination o f the fundus and possibly field studies.
Ten days later, on April 30, 1953, when she returned, it was noted that she could get around very well for being able to see fin gers only. A consultant recommended field studies and a spinal fluid Kahn, although blood Kahn was negative. A re-check o f the fundi showed advanced optic atrophy, O . S . ; moderate, O . D . , and a few cortical lens changes below. Peripheral field studies showed irregular constriction for the right eye and only the inferior nasal quadrant and a small segment o f the superior nasal field remaining in the left eye. Lumbar puncture was done on M a y 1, 1953, with an initial pressure o f 120 mm. H 2 O . Quaeckenstedt rose to 260 mm. with a final pressure falling quickly to 65 m m . H 2 O ; the fluid was crystal clear. Labora tory studies showed total protein 4 0 mg. percent; cell count: 2.5 c.mm. 100 percent lymphocytes. Spinal fluid Kahn was nega tive. Anteroposterior and lateral skull X - r a y films showed destruction o f the pituitary fossa with preservation o f the anterior clinoid process. T h e sella dimension measured over 3.0 cm. in the anteroposterior diameter. Neurosurgical consultation was obtained May 4, 1953, and a tentative diagnosis o f chromophobe adenoma o f the pituitary gland was made with the possibility of an aneu rysm. N o other neurologic findings were found. The patient was operated on M a y 11, 1953 and a craniotomy revealed a pituitary tumor (probably c h r o m o p h o b e ) . Because o f cerebral edema and a stormy postoperative course the craniotomy was reopened next day, but the patient died later in the day. The pathologic report was nonspecific pi tuitary tumor. T h e pathologist thought it was an atypical chromophobe-type tumor. UVKITIS A N D TONSIL INFECTION
D R . FRED C . W A L L A C E presented the case
of N . C , a 15-year-old Negress, in g o o d gen eral health, w h o was seen first on June 19, 1953, with a painful, red right eye o f one week's duration. Examination revealed an acute uveitis in-
SOCIETY
PROCEEDINGS
volving both anterior a n d posterior seg ments of her right eye. T h e i
435
benefit. T y p h o i d - H antigen intravenously had been given intermittently without defin ite benefit. After a re-check examination of her throat, it was decided to remove her tonsils; this was done three months after onset of the uveitis of her right eye. Previously her tonsils had not been thought an active focus of infection so the tonsillectomy was done with little hope of it helping her. Immedi ately upon removal of her tonsils a vio lent exacerbation of the uveitis of her right eye occurred. This suggestion that the source of trouble must have been h e r tonsils was borne out when the uveitis subsided com pletely within two weeks. This was approx imately four months after onset of the disease in her right eye. A s the vitreous haze subsided a retinal separation was noted inferiorly and four retinal tears were seen in the superotemporal quadrant with retinitis proliferans at the operculum portions of the retina. T h e de tachment increased until the inferior half of the retina was bullous. Vision was 20/100 with pinhole at this time. O n November 5, 1953, the right eye was operated using sur face and penetrating diathermy. Only a small amount of subretinal fluid was evacuated. At the present time she is wearing pinhole glasses a n d has a vision of 20/60. T h e ret ina is reattached. T h e salient features of this case point out how important it is to classify, if possible, a uveitis. Time was lost in treating this case as a granulomatous disease. H o w difficult it is to assess possible foci of infection. H a d this patient had a tonsillectomy at the be ginning she probably would have sight in both eyes rather than one blind eye a n d one with reduced vision a n d a poor prognosis because of the possibility of further retinal separation, cataract, glaucoma, or phthisis. G U M M A OF ORBIT D R . OSCAR D A H L E N E , JR., reported a 46-year-old Negress with massive proptosis of the right eye. T h e patient stated that the right eye began to swell and bulge forward
436
SOCIETY PROCEEDINGS
on October 22, 1952, after getting dust in her eyes at cotton piciving. She had a throb bing frontal headache, pain in the orbit, fever and chills. At admission to the John Gaston Hospital on October 27, 1952, she denied any residual pain and was not febrile. She also denied any knowledge of previous illness. Examination revealed the right eye proptosed straight forward, massive edema of the lids and conjunctiva, and no motion of the globe. T h e cornea was clear and the pupil dilated, fixed, and with no reaction to light or accomiTiodation. Visual acuity was ques tionable light perception, O.D., and 16/200, O.S. T h e orbital tissues were painless, did not pulsate, and had no bruit. T h e eye could not be forced backward into the orbit. T h e preauricular and submental nodes were en larged but not tender. Intraocular pressure w a s : 32 mm. Hg, O.D., and 22 i n m . H g , O.S. (Schii^tz). Fundus examination revealed a hyperemic disc, O.D., with blurred margins. T h e veins were dilated, sausage-shaped, tortuous, and constricted at the arteriovenous crossings. No hemorrhages or exudates were seen. There was a flat detachment of the retina nasally. The left eye exhibited no abnormal find ings. The general examination showed nothing remarkable except a perforation of the nasal septum. Papilledema, O.D., increased following admission. Ear, nose, and throat examination
showed complete destruction of the septum and the right turbinates except for the pos terior tips. N o granulation tissue was seen. Laboratory reported blood count and uri nalysis normal, but a positive serologic test for syphilis. X-ray films showed destruc tion of the medial orbital wall and the pre viously noted loss of nasal bones. A diagnosis of gumina of the orbit with inflammation was made and intensive treat ment was begun. T h e patient was given 10 million units of penicillin over a period of 10 days, one gm. of Gantrisin every four hours while awake for four weeks, potas sium-iodide drops in water, and multiple vitamins. Foreign-protein therapy was given with intravenous typhoid vaccine. T h e ex posed cornea was protected with a conjunc tival flap, antibiotic ointments, and a Buller shield. The edema of the orbital tissues and prop tosis began to recede in the second week of therapy and, on discharge four weeks after admission, the pupil had contracted and ocular motility had returned to a great ex tent. There was still some residual propto sis but the lids completely covered the globe in sleep. Light perception was questionable and never improved. T h e disc was pale. T h e patient was seen at monthly intervals for several months and the proptosis gradu ally subsided, although the eye never re turned to normal. Daniel F . Fisher, Secretary of Eye Section.
PROCEEDINGS
even suggest a right hypertropia o n gaze down and to the left. Measurements showed 2.0D. right hypertropia down and t o the right and 2.0D. left hypertropia down and to the left. Until more o f these cases can be collected and studied, as D r . Harbert has done, it would seem wise to me to admit that o u r knowledge o f the arrangement o f the nuclei in the third-nerve mass in man is still en tirely conjectural. The evidence he has pre sented is valuable and points in the direction he has suggested. DR. EISENBERG : D r . Harbert placed the lesion in the nuclei. I would just like to speculate on the possibility o f a retro-orbital lesion causing the paresis o f elevation. W o u l d y o u mind commenting o n that please ?
433
try to find a better data to substantiate my theory and, if I can, I will present the find ings to you. William E . Krewson, 3rd, Clerk.
EAR,
OPTIC
MEMPHIS EYE NOSE, A N D T H R O A T SOCIETY
NEURITIS
TREATED
WITH
CORTICO
TROPIN DR.
PHILIP
MERIWETHER
LEWIS
pre
sented a 37-year-old Negress with an acute fulminating optic neuritis w h o was under treatment at the Memphis E y e and Ear Hospital. She first noticed marked blurring of vision o f her left e y e five weeks pre viously. There had been practically no head CAPT. HARBERT : I n answer to D r . Eisenache and n o pain. H e r health had always berg's question about a retro-orbital lesion, I would presume he w a s thinking o f some been excellent. She had seven children, all thing between the sphenoidal fissue and the living and well, the youngest being four years old. brain stem? DR. EISENBERG: N O , in the orbit itself, space-taking lesions. CAPT.
H A R B E R T : In
the
first
place,
the
third nerve divides at the superior orbital fissure or perhaps just before it enters the orbit. T h e superior branch carries levator and superior rectus fibers while the inferior oblique fibers g o with the inferior branch. In the cases reported we have a mechani cal involvement o f superior and inferior muscles which are innervated b y diiferent branches o f the nerve. O n that basis, I think we can rule out a single lesion that could account f o r this. W e also have the medial rectus completely spared in all these cases, which again rules out an. orbital lesion. It would take a peculiar lesion t o spare the medial rectus and give maximal involvement of the other two muscles that are innervated by the inferior division. I certainly think D r . Adler's criticism is very proper. Perhaps I was a little t o o enthu siastic in reading inferior rectus involve ment in some o f the cases. H o w e v e r , I will
Examination showed both eyes normal externally, the media clear, and the fundus of the right eye normal. T h e disc o f the left eye was greatly swollen, the peak o f the elevation being eight diopters and the lowest portion four diopters above the normal level. The retina surrounding the disc was greatly swollen, the veins enormously engorged and there were many flame-shaped hemorrhages. Vision was 2 0 / 2 0 in the right eye and 2 0 / 2 0 0 eccentrically in the left eye. T h e visual fields and blindspot o f the right eye were normal. T h e peripheral field o f the left eye f o r large test objects w a s normal and there was a fairly large central scotoma. There was no limitation o f motion, n o prop tosis, and n o tenderness t o pressure. H e r physical examination was entirely normal e x cept f o r two diseased teeth which she had removed during the early stage o f her trouble. X - r a y studies o f the remaining teeth, gums, sinu.ses, and chest were nega tive. The
removal o f the diseased teeth, injec-
434
SOCIETY
PROCEEDINGS
tions o f typhoid-Η antigen intravenously, and large doses o f nicotinic acid failed to cause any improvement in the appearance of the fundus or in the vision. Corticotro pin was therefore started by a slow intra venous drop over an eight-hour period. The medium used was five-percent glucose solution in distilled water; 1 , 0 0 0 cc. con taining 4 0 mg. o f corticotropin were admin istered over an eight-hour period. The same dose was repeated the next day and there after the amount was gradually reduced. It was planned to "taper" off with cortisone by mouth after discontinuing the corticotropin. Considerable reduction of swelling and some visual improvement were noticed, but it was too early to claim great benefit from the drug. A subsequent report will be made after the process has completed its course. P I T U I T A R Y TUMOR
D R . C . C . SHIPP reported the case o f a 51-year-old Negress w h o came to the clinic on April 2 0 , 1 9 5 3 , with a complaint of failing vision for over two years. Her present glasses were six months' old, purchased from an optometrist at a jewelry store, and she said she could not see out of them. There was no history o f ocular pain or trauma and no previous eye complaints. Examination. T h e eyes were white and external examination was negative. Visual acuity w a s : O . D . , counting fingers; O . S . , light perception; with a - f - 2 . 0 D . sph., add +2.0Ό. sph., O . U . ; . T 1 8 , ( ? ) O . D . Cornea and media were clear. Pupils were small but equal, reacted to light and accommodation, consensual reactions were positive, O . U . Tension was : 2 0 mm. H g (Schi^^tz), O . U . Fundus examination. There was optic atrophy, O . U . , especially the temporal sides of the discs. Grade 1 arteriolosclerosis o f the vessels was present; no cupping was seen. Primary optic atrophy was considered though n o history o f any antiluetic therapy was found. Blood Kahn was obtained and the patient was told to return for re-exam ination o f the fundus and possibly field studies.
Ten days later, on April 30, 1953, when she returned, it was noted that she could get around very well for being able to see fin gers only. A consultant recommended field studies and a spinal fluid Kahn, although blood Kahn was negative. A re-check o f the fundi showed advanced optic atrophy, O . S . ; moderate, O . D . , and a few cortical lens changes below. Peripheral field studies showed irregular constriction for the right eye and only the inferior nasal quadrant and a small segment o f the superior nasal field remaining in the left eye. Lumbar puncture was done on M a y 1, 1953, with an initial pressure o f 120 mm. H 2 O . Quaeckenstedt rose to 260 mm. with a final pressure falling quickly to 65 m m . H 2 O ; the fluid was crystal clear. Labora tory studies showed total protein 4 0 mg. percent; cell count: 2.5 c.mm. 100 percent lymphocytes. Spinal fluid Kahn was nega tive. Anteroposterior and lateral skull X - r a y films showed destruction o f the pituitary fossa with preservation o f the anterior clinoid process. T h e sella dimension measured over 3.0 cm. in the anteroposterior diameter. Neurosurgical consultation was obtained May 4, 1953, and a tentative diagnosis o f chromophobe adenoma o f the pituitary gland was made with the possibility of an aneu rysm. N o other neurologic findings were found. The patient was operated on M a y 11, 1953 and a craniotomy revealed a pituitary tumor (probably c h r o m o p h o b e ) . Because o f cerebral edema and a stormy postoperative course the craniotomy was reopened next day, but the patient died later in the day. The pathologic report was nonspecific pi tuitary tumor. T h e pathologist thought it was an atypical chromophobe-type tumor. UVKITIS A N D TONSIL INFECTION
D R . FRED C . W A L L A C E presented the case
of N . C , a 15-year-old Negress, in g o o d gen eral health, w h o was seen first on June 19, 1953, with a painful, red right eye o f one week's duration. Examination revealed an acute uveitis in-
SOCIETY
PROCEEDINGS
volving both anterior a n d posterior seg ments of her right eye. T h e i
435
benefit. T y p h o i d - H antigen intravenously had been given intermittently without defin ite benefit. After a re-check examination of her throat, it was decided to remove her tonsils; this was done three months after onset of the uveitis of her right eye. Previously her tonsils had not been thought an active focus of infection so the tonsillectomy was done with little hope of it helping her. Immedi ately upon removal of her tonsils a vio lent exacerbation of the uveitis of her right eye occurred. This suggestion that the source of trouble must have been h e r tonsils was borne out when the uveitis subsided com pletely within two weeks. This was approx imately four months after onset of the disease in her right eye. A s the vitreous haze subsided a retinal separation was noted inferiorly and four retinal tears were seen in the superotemporal quadrant with retinitis proliferans at the operculum portions of the retina. T h e de tachment increased until the inferior half of the retina was bullous. Vision was 20/100 with pinhole at this time. O n November 5, 1953, the right eye was operated using sur face and penetrating diathermy. Only a small amount of subretinal fluid was evacuated. At the present time she is wearing pinhole glasses a n d has a vision of 20/60. T h e ret ina is reattached. T h e salient features of this case point out how important it is to classify, if possible, a uveitis. Time was lost in treating this case as a granulomatous disease. H o w difficult it is to assess possible foci of infection. H a d this patient had a tonsillectomy at the be ginning she probably would have sight in both eyes rather than one blind eye a n d one with reduced vision a n d a poor prognosis because of the possibility of further retinal separation, cataract, glaucoma, or phthisis. G U M M A OF ORBIT D R . OSCAR D A H L E N E , JR., reported a 46-year-old Negress with massive proptosis of the right eye. T h e patient stated that the right eye began to swell and bulge forward
436
SOCIETY PROCEEDINGS
on October 22, 1952, after getting dust in her eyes at cotton piciving. She had a throb bing frontal headache, pain in the orbit, fever and chills. At admission to the John Gaston Hospital on October 27, 1952, she denied any residual pain and was not febrile. She also denied any knowledge of previous illness. Examination revealed the right eye proptosed straight forward, massive edema of the lids and conjunctiva, and no motion of the globe. T h e cornea was clear and the pupil dilated, fixed, and with no reaction to light or accomiTiodation. Visual acuity was ques tionable light perception, O.D., and 16/200, O.S. T h e orbital tissues were painless, did not pulsate, and had no bruit. T h e eye could not be forced backward into the orbit. T h e preauricular and submental nodes were en larged but not tender. Intraocular pressure w a s : 32 mm. Hg, O.D., and 22 i n m . H g , O.S. (Schii^tz). Fundus examination revealed a hyperemic disc, O.D., with blurred margins. T h e veins were dilated, sausage-shaped, tortuous, and constricted at the arteriovenous crossings. No hemorrhages or exudates were seen. There was a flat detachment of the retina nasally. The left eye exhibited no abnormal find ings. The general examination showed nothing remarkable except a perforation of the nasal septum. Papilledema, O.D., increased following admission. Ear, nose, and throat examination
showed complete destruction of the septum and the right turbinates except for the pos terior tips. N o granulation tissue was seen. Laboratory reported blood count and uri nalysis normal, but a positive serologic test for syphilis. X-ray films showed destruc tion of the medial orbital wall and the pre viously noted loss of nasal bones. A diagnosis of gumina of the orbit with inflammation was made and intensive treat ment was begun. T h e patient was given 10 million units of penicillin over a period of 10 days, one gm. of Gantrisin every four hours while awake for four weeks, potas sium-iodide drops in water, and multiple vitamins. Foreign-protein therapy was given with intravenous typhoid vaccine. T h e ex posed cornea was protected with a conjunc tival flap, antibiotic ointments, and a Buller shield. The edema of the orbital tissues and prop tosis began to recede in the second week of therapy and, on discharge four weeks after admission, the pupil had contracted and ocular motility had returned to a great ex tent. There was still some residual propto sis but the lids completely covered the globe in sleep. Light perception was questionable and never improved. T h e disc was pale. T h e patient was seen at monthly intervals for several months and the proptosis gradu ally subsided, although the eye never re turned to normal. Daniel F . Fisher, Secretary of Eye Section.