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Memphis Society of Ophthalmology and Otolaryngology
SOCIETY PROCEEDINGS two cases of corneal dystrophy which he treated with quinine bisulphate iontopho resis. Both cases showed improvement after several treatments of the one-quar ter-percent solution of quinine bisulphate. T h e first improved in vision from 2 0 / 6 0 to 2 0 / 2 0 and the second from 20/100 to 20/20. HAROLD F . W H A L M A N ,
Editor.
M E M P H I S SOCIETY O F OPH THALMOLOGY AND OTOLARYNGOLOGY March 8, 1938 D R . C. H . GLOVER,
presiding
IRIDENCLEISIS FOR GLAUCOMA
D R . E . C. E L L E T T reported a case of simple glaucoma for which an iridenclei sis had been performed on one eye. I n this eye there was very little impairment of the central vision, but the tension was persistently around 40 mm. in spite of miotics, and there was a beginning cata ract. T h e operation was performed a week before, with inclusion of one pillar in the wound. T h e healing was satisfactory and the tension 11 m m . T h e other eye also has glaucoma, but the field and vision are normal, and the tension is kept down with miotics. T h e patient is 66 years old. In answer to a question as to the choice of operation in this case, it was deter mined by the fact that there is a begin ning cataract and that probably some day a cataract operation will be required. IRIDENCLEISIS FOR GLAUCOMA
D R . P H I L M. L E W I S presented a white
man, aged 65 years, upon whom he had operated for glaucoma three days previ ously. This patient was first seen in Au gust, 1935, and in spite of the regular use of miotics the tension continued high, O.D. 35 and O . S . 50 mm. H g ( S c h i o t z ) .
191
T h e visual fields of the right eye were moderately contracted, those of the left eye decidedly narrow. Central vision was 20/100 in each eye, unimproved by lenses. A bilateral iridencleisis had been per formed three days ago. T h e technique w a s that recommended by Constantine and described by him in the American J o u r nal of Ophthalmology for July, 1937. C o m m e n t : T h e reason for presenting this patient was to bring to the attention of the Society the operation of iridenclei sis. T h e writer has performed quite a number of these operations during the past three years and the results have been so satisfactory that he now prefers it to any other procedure. At first he was ex tremely skeptical, because h e w a s opposed to any type of operation in which the iris was drawn into and left in the wound, but to date there have been no untoward complications. D E T A C H M E N T OF RETINA
D R . E . C. E L L E T T presented the case of O. W . , colored, aged 40 years, who had a cataract operation in 1929 on each eye, and failed to regain vision in the left eye. H e had a good visual result in t h e right eye until July, 1937, when it suddenly failed. Examination showed almost total retinal detachment O.D., although the area up and in was barely loose and re tained good color. T h e disc was not visi ble. N o tear was seen. T h e r e was a good upward iris coloboma, with a dense sec ondary membrane, but good opening. T h e outer half of the eye was exposed, the external rectus divided, and about 2 0 diathermy needles applied to the eye. T h e sclera was then trephined down and out. O n November 20th the fundus was clearly seen and the whole retina reattached. T h e macular region shows a white scar be tween it and the disc. O n November 6th, O.D. vision w a s 5/15 with + 1 1 . 0 0 D . sph. =C= + 1 . 0 0 D. cyl. ax. 150°.
192
SOCIETY PROCEEDINGS
H Y S T E R I C A L AMBLYOPIA
DR. E. C. ELLETT reported the case of Sister L. B., aged 29 years, seen Septem ber 30, 1937, giving a history of con vergence of the left eye and poor vision in it all of her life. There had been no other trouble until sinus disease began four years ago. After two operations on the sinuses she had double vision, relieved by another operation. In July, 1936, she got a piece of glass in the right eye, which was removed by incision. Since then she sees little more than hand motion with the right eye, at best not better than 1/60. There is no inflammation, but the left eye gives her pain. The ophthalmoscopic examination showed a normal condition: pupils equal and active. There is no or ganic trouble. The left eye converges 15 degrees. The fauces and conjunctiva were anesthetic. Diagnosis: hysterical ambly opia. The right-eye field was contracted to 10 degrees. Rest in bed with occlusion of both eyes for several days gave no results. It developed in conversation that she was very much concerned about the strabismic left eye and thought if it would be straightened her sight could be re stored. On November 9th, a recession of the left internus was performed, and her vision was greatly improved the r.ext day. Four days later the next test was made and her vision in both eyes was 6/6. PODOPHYLLUM KERATITIS
DR. R. O. RYCHENER reported a case of keratitis in a chemist, aged 28 years, which followed closely the accidental in stillation in the eye of powdered podophyllum. Within four hours the eye was quite painful and swollen, with acute visual failure. The appearance after 48 hours was that of a deep central keratitis with ciliary injection, and vision was re duced to 3/60. The conjunctival reaction had already receded. The corneal infiltra tion simulated the character of a disci-
form keratitis, but there was no staining point nor wound of entrance visible with the slitlamp. Local treatment with atropine, dionin, and hot applications was maintained for five days, during which the corneal infiltration cleared rapidly and within a week the vision was 6/6. This was apparently a specific allergic tissue reaction to a substance which has not been previously responsible for any such reactions, for a recent bibliographic review of the ill effects produced by the dust of the root of podophyllum recorded only one such case. This was reported by Hutchinson (Medical Times and Gazette, 1872, v. 2, p. 516) and concerned a case of keratitis and dermatitis pro duced by powdered podophyllum. A re cent query in the Journal of the American Medical Association included the report of several cases of gingivitis following the use of capsules containing podophyllum, and the answer raised the question of sen sitivity of some additional medicament in the capsules. In the case here reported, no other drug was present and the pow dered podophyllum was the sole causative agent in producing the reaction. OCULAR PAIN DR. R. O. RYCHENER reported five cases, the chief complaint of each being severe pain in the eye, the cause of each being found at a remote point outside the eyeball. Patients vary greatly in their sensibility to pain, but all these patients were at times in acute distress because of the discomfort described. This small se ries served to call attention to the ramifi cations of the sensory fibers of the fifth cranial nerve. (1) Retained dental root and low basal metabolism. Mrs. B. W. V., aged 45 years, suffered for five years with attacks of pain and a patchy inflammation of episcleritis in the left eye, for which many examinations were made, and a cholecys-
SOCIETY PROCEEDINGS
tectomy and hysterectomy were per formed without relief. She was known to have an old dental root remaining after an extraction, which her dentist had not seen fit to remove, as the X-ray examina tion disclosed no infection about it. Reexamination disclosed a low basal metab olism, and thyroid extract was prescribed with immediate improvement generally and marked improvement locally with no return of symptoms. Nine months later the dental root, present for seventeen years, was extracted. In the two years which have followed there had been no recurrence of the ocular pain nor of the inflammations. (2) Dental pulp stone. Mr. W. A. B., 42 years old, suffered with attacks of lancinating pain in the left eyeball radiat ing supraorbitally to the parietal region, often necessitating an opiate hypodermically for relief. Numerous general and special examinations including dental and skull X-ray studies were normal. Cocainization of the sphenopalatine ganglion af forded temporary relief. Finally, due to increased sensitivity to electrical stimu lation, a sound second molar tooth was extracted, which upon crushing proved to contain a pulp stone. Complete relief had continued during the ensuing eight een months. (3) Mucocele in lacrimal sac. Mrs. A. W. M c , aged 48 years, complained of severe aching and shooting pain in and about the right eye and orbital region. The eye was perfectly normal in every way, but a lacrimal obstruction in the lower end of the duct caused the forma tion of a small mucocele in the lacrimal sac. There was no visible inflammatory reaction. Mild pressure over the sac evacuated the contents into the nose with prompt relief of the pressure symptoms
193
which she had related as being in the eye. Fluid could be passed through the duct without probing, and local treatment af forded continued relief. (4) Brain abscess. A. B., 10 years old, was seen in the hospital following mastoid surgery on the right side, complain ing of excruciating pain in the right eye, which would cause him to scream vio lently and to burrow his head in the pillow seeking relief. There was bilateral papilledema of high degree, and a diag nosis of brain abscess was made and verified by puncture and drainage. Re covery was uneventful, and pain in the eye ceased as soon as the intracranial pressure was relieved. The pain was ap parently a reflex one, due to the pull on the dura about the exit of the fifth cranial nerve or its supraorbital branch. (5) Herpes zoster ophthalmicus. Mrs. J. F. M c , aged 68 years, was seen at home with disabling pain in and behind the left eye, already present for four days. She had been examined at one of the hospital clinics where no cause was found, and this examination showed nothing to explain the symptoms. The eye was nor mal to the ophthalmoscope, and there was no tenderness in or behind it on pressure, but severe pain in it persisted day and night. A general physician was called, who found the blood pressure 200/120 and an impending cerebral vascular acci dent was feared. Eight days after the on set of the pain, her physician reported the presence of erysipelas, which on ex amination proved to be typical herpes zoster ophthalmicus. Pituitrin and X-ray treatment for the pain were suggested but not used because of family prejudice to such treatment. J. Wesley McKinney, Secretary.
Editor.
M E M P H I S SOCIETY O F OPH THALMOLOGY AND OTOLARYNGOLOGY March 8, 1938 D R . C. H . GLOVER,
presiding
IRIDENCLEISIS FOR GLAUCOMA
D R . E . C. E L L E T T reported a case of simple glaucoma for which an iridenclei sis had been performed on one eye. I n this eye there was very little impairment of the central vision, but the tension was persistently around 40 mm. in spite of miotics, and there was a beginning cata ract. T h e operation was performed a week before, with inclusion of one pillar in the wound. T h e healing was satisfactory and the tension 11 m m . T h e other eye also has glaucoma, but the field and vision are normal, and the tension is kept down with miotics. T h e patient is 66 years old. In answer to a question as to the choice of operation in this case, it was deter mined by the fact that there is a begin ning cataract and that probably some day a cataract operation will be required. IRIDENCLEISIS FOR GLAUCOMA
D R . P H I L M. L E W I S presented a white
man, aged 65 years, upon whom he had operated for glaucoma three days previ ously. This patient was first seen in Au gust, 1935, and in spite of the regular use of miotics the tension continued high, O.D. 35 and O . S . 50 mm. H g ( S c h i o t z ) .
191
T h e visual fields of the right eye were moderately contracted, those of the left eye decidedly narrow. Central vision was 20/100 in each eye, unimproved by lenses. A bilateral iridencleisis had been per formed three days ago. T h e technique w a s that recommended by Constantine and described by him in the American J o u r nal of Ophthalmology for July, 1937. C o m m e n t : T h e reason for presenting this patient was to bring to the attention of the Society the operation of iridenclei sis. T h e writer has performed quite a number of these operations during the past three years and the results have been so satisfactory that he now prefers it to any other procedure. At first he was ex tremely skeptical, because h e w a s opposed to any type of operation in which the iris was drawn into and left in the wound, but to date there have been no untoward complications. D E T A C H M E N T OF RETINA
D R . E . C. E L L E T T presented the case of O. W . , colored, aged 40 years, who had a cataract operation in 1929 on each eye, and failed to regain vision in the left eye. H e had a good visual result in t h e right eye until July, 1937, when it suddenly failed. Examination showed almost total retinal detachment O.D., although the area up and in was barely loose and re tained good color. T h e disc was not visi ble. N o tear was seen. T h e r e was a good upward iris coloboma, with a dense sec ondary membrane, but good opening. T h e outer half of the eye was exposed, the external rectus divided, and about 2 0 diathermy needles applied to the eye. T h e sclera was then trephined down and out. O n November 20th the fundus was clearly seen and the whole retina reattached. T h e macular region shows a white scar be tween it and the disc. O n November 6th, O.D. vision w a s 5/15 with + 1 1 . 0 0 D . sph. =C= + 1 . 0 0 D. cyl. ax. 150°.
192
SOCIETY PROCEEDINGS
H Y S T E R I C A L AMBLYOPIA
DR. E. C. ELLETT reported the case of Sister L. B., aged 29 years, seen Septem ber 30, 1937, giving a history of con vergence of the left eye and poor vision in it all of her life. There had been no other trouble until sinus disease began four years ago. After two operations on the sinuses she had double vision, relieved by another operation. In July, 1936, she got a piece of glass in the right eye, which was removed by incision. Since then she sees little more than hand motion with the right eye, at best not better than 1/60. There is no inflammation, but the left eye gives her pain. The ophthalmoscopic examination showed a normal condition: pupils equal and active. There is no or ganic trouble. The left eye converges 15 degrees. The fauces and conjunctiva were anesthetic. Diagnosis: hysterical ambly opia. The right-eye field was contracted to 10 degrees. Rest in bed with occlusion of both eyes for several days gave no results. It developed in conversation that she was very much concerned about the strabismic left eye and thought if it would be straightened her sight could be re stored. On November 9th, a recession of the left internus was performed, and her vision was greatly improved the r.ext day. Four days later the next test was made and her vision in both eyes was 6/6. PODOPHYLLUM KERATITIS
DR. R. O. RYCHENER reported a case of keratitis in a chemist, aged 28 years, which followed closely the accidental in stillation in the eye of powdered podophyllum. Within four hours the eye was quite painful and swollen, with acute visual failure. The appearance after 48 hours was that of a deep central keratitis with ciliary injection, and vision was re duced to 3/60. The conjunctival reaction had already receded. The corneal infiltra tion simulated the character of a disci-
form keratitis, but there was no staining point nor wound of entrance visible with the slitlamp. Local treatment with atropine, dionin, and hot applications was maintained for five days, during which the corneal infiltration cleared rapidly and within a week the vision was 6/6. This was apparently a specific allergic tissue reaction to a substance which has not been previously responsible for any such reactions, for a recent bibliographic review of the ill effects produced by the dust of the root of podophyllum recorded only one such case. This was reported by Hutchinson (Medical Times and Gazette, 1872, v. 2, p. 516) and concerned a case of keratitis and dermatitis pro duced by powdered podophyllum. A re cent query in the Journal of the American Medical Association included the report of several cases of gingivitis following the use of capsules containing podophyllum, and the answer raised the question of sen sitivity of some additional medicament in the capsules. In the case here reported, no other drug was present and the pow dered podophyllum was the sole causative agent in producing the reaction. OCULAR PAIN DR. R. O. RYCHENER reported five cases, the chief complaint of each being severe pain in the eye, the cause of each being found at a remote point outside the eyeball. Patients vary greatly in their sensibility to pain, but all these patients were at times in acute distress because of the discomfort described. This small se ries served to call attention to the ramifi cations of the sensory fibers of the fifth cranial nerve. (1) Retained dental root and low basal metabolism. Mrs. B. W. V., aged 45 years, suffered for five years with attacks of pain and a patchy inflammation of episcleritis in the left eye, for which many examinations were made, and a cholecys-
SOCIETY PROCEEDINGS
tectomy and hysterectomy were per formed without relief. She was known to have an old dental root remaining after an extraction, which her dentist had not seen fit to remove, as the X-ray examina tion disclosed no infection about it. Reexamination disclosed a low basal metab olism, and thyroid extract was prescribed with immediate improvement generally and marked improvement locally with no return of symptoms. Nine months later the dental root, present for seventeen years, was extracted. In the two years which have followed there had been no recurrence of the ocular pain nor of the inflammations. (2) Dental pulp stone. Mr. W. A. B., 42 years old, suffered with attacks of lancinating pain in the left eyeball radiat ing supraorbitally to the parietal region, often necessitating an opiate hypodermically for relief. Numerous general and special examinations including dental and skull X-ray studies were normal. Cocainization of the sphenopalatine ganglion af forded temporary relief. Finally, due to increased sensitivity to electrical stimu lation, a sound second molar tooth was extracted, which upon crushing proved to contain a pulp stone. Complete relief had continued during the ensuing eight een months. (3) Mucocele in lacrimal sac. Mrs. A. W. M c , aged 48 years, complained of severe aching and shooting pain in and about the right eye and orbital region. The eye was perfectly normal in every way, but a lacrimal obstruction in the lower end of the duct caused the forma tion of a small mucocele in the lacrimal sac. There was no visible inflammatory reaction. Mild pressure over the sac evacuated the contents into the nose with prompt relief of the pressure symptoms
193
which she had related as being in the eye. Fluid could be passed through the duct without probing, and local treatment af forded continued relief. (4) Brain abscess. A. B., 10 years old, was seen in the hospital following mastoid surgery on the right side, complain ing of excruciating pain in the right eye, which would cause him to scream vio lently and to burrow his head in the pillow seeking relief. There was bilateral papilledema of high degree, and a diag nosis of brain abscess was made and verified by puncture and drainage. Re covery was uneventful, and pain in the eye ceased as soon as the intracranial pressure was relieved. The pain was ap parently a reflex one, due to the pull on the dura about the exit of the fifth cranial nerve or its supraorbital branch. (5) Herpes zoster ophthalmicus. Mrs. J. F. M c , aged 68 years, was seen at home with disabling pain in and behind the left eye, already present for four days. She had been examined at one of the hospital clinics where no cause was found, and this examination showed nothing to explain the symptoms. The eye was nor mal to the ophthalmoscope, and there was no tenderness in or behind it on pressure, but severe pain in it persisted day and night. A general physician was called, who found the blood pressure 200/120 and an impending cerebral vascular acci dent was feared. Eight days after the on set of the pain, her physician reported the presence of erysipelas, which on ex amination proved to be typical herpes zoster ophthalmicus. Pituitrin and X-ray treatment for the pain were suggested but not used because of family prejudice to such treatment. J. Wesley McKinney, Secretary.