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Monocular Interstitial Keratitis
A. EDWARD DAVIS
296
remedy being given in this second series of injections. At this date, the tension of the right eye had increased to Hg. 13 mm., all the cortex lens mate rial had absorbed and V. equalled 15/200. A membrane still blocked the pupil however. The cataract in left eye had cleared slightly, V. equals 15/70 with minus 3.50 D. Nov. 23rd, the patient was sent to the hospital, where with a nar row cataract knife, I made a clear hori zontal incision thru the membrane in the right eye. There was no reaction, a clear pupil was obtained and on Dec. 9th, with plus 10 D. combined with plus 3 D. ax. 90, the patient obtained 15/30 minus vision. Following the suggestion of G. Burdon-Cooper, in the Doyne Memorial Lecture, Etiology of Cataract 1 , that potash is valuable in the retardation of cataract formation, in beginning the second series of lens antigen injections
in this case, the patient was placed on small doses of potassium iodid, 15 grs. in full glass of water after meals. To judge from one case, which is of course hazardous, it would appear in those cases following cataract ex traction, in which considerable lens cortex has been left, that lens antigen injections are indicated. It goes with out saying, that the sensitization test should be made before the treatment is begun. Not the least pleasing phase in this case is, that the tension of a softened eye should be sufficiently re stored to justify further operative measures. In closing, I may say, I am using lens antigen injections in all cases of traumatic cataract, where the sensiti zation test does not show the patient hypersensitive to the lens antigen, and when secondary glaucoma is not present.
REFERENCES.
1. The British Jour. Oph., Sept., 1922, p. 400.
NOTES, CASES, INSTRUMENTS MONOCULAR INTERSTITIAL KERATITIS. JOHN N. HOFFMAN, M.
D.
CANTON, OHIO.
The following case is deemed worthy of report because of two interesting features. One is the age of the patient, and the second is the fact that the pathology has been confined to one eye. The patient is a young lady aged 22. The previous history is negative, and the family history secured from the parents is also negative. The pa tient is a college graduate, and a teacher by occupation. She was first seen in June 1922, about six weeks after the onset of her eye symptoms, having been under the care of an oculist of wide experience. When first seen her left eye pre sented the appearance of a typical in terstitial infiltration of the cornea. Her treatment had consisted solely of the use of atropin in the affected eye
three times daily. A general examin ation revealed none of the signs of lues, altho the blood Wassermann was strongly plus. She was put on intensive antiluetic treatment, and was referred to another oculist for his opinion as to the etiology. He also thought the con dition as luetic in origin. The reaction of the blood Wasser mann has been very obstinate, altho the proper general treatment has been vigorously given. Several subconjunctival injections of mercuric cyanid and novacain following the method of C. A. Campbell, as described in the December 1920 number of the Ameri can Journal of Ophthalmology (v. 3, p. 884) have been painlessly given, at intervals of seven to ten days. Vision has slowly improved from hand move ments at one meter to 4/30. Physical examinations have been negative, and the diagnosis of an in terstitial keratitis probably due to con genital lues seems to be the most
NOTES, CASES AND INSTRUMENTS
logical. This case also emphasizes the great value of Wassermann reac tions in all suspicious cases, no matter how much above reproach the personal and family history may be. By intensive antiluetic treatment in this case is meant the use of mercury by inunctions and per mouth. For fear of exciting the process in the other eye the arsenic preparation were not given intravenously.
KERATOCONUS.
Iridectomy and Corneal Trephining With a Conjunctival Flap. GEORGE W.
JEAN,
M.D.
SANTA BARBARA, CAL.
Spanish girl, age seventeen years, was first seen October 27th, 1922. Previous history: Weight 128 pounds, height 63 inches. Usual dis eases of childhood, typhoid six years ago, absolutely no illness since then. Parents, three sisters and four brothers —no eye trouble. Vision has been get ting bad in each eye for the last year, and she has had frequent changes of glasses. In school until one year ago. Physical examination by an internist negative. Eye examination : Vision, right eye, equals fingers at four feet; vision, left eye, equals fingers at twelve feet. Vi sion, each eye, unimproved with glasses. Corneas were conical. The right eye was slightly injected and the tip of the cone was opaque over an area of 2 mm. and denuded of epithel ium. Two small, narrow streaks of opacity ran inward nasally from the tip of the cone for 2 mm. The right and left cornea measured 10 1/2 mm. in diameter with Wessely's keratometer, and the measurements taken laterally with the keratometer showed the dis tance from the limbus to the apex of the right cornea to be 5 mm.; left cor nea, 4 mm. The apex of the right cone was 1 mm. below the horizontal meri dian and 1 mm. to the nasal side of the center. With the exophthalmometer the readings were, right, 18 mm.;
297
left 17 mm. Tonometer (Schiotz): Right eye with 7 1/2 wt. — 11 = 10 Hg. mm.; left eye, 7 1/2 wt. — 11 = 10 Hg. mm. With the ophthalmometer, the mires were so small and sepa rated and overlapped so violently that no reading could be gotten. Retinoscopy unsatisfactory. The left cornea was clear and the left eye white. I could get no pulsations in either cor nea with oblique illumination, the ophthalmometer or the slit lamp. Operations : Iridectomy, right eye, upward, same day (October 27th). Atropin 3 % , firm bandage. Daily dressings until November 3rd, when the opaque apex of the cone was trephined with a 2 mm. Stevenson's trephine which had to be done care fully because the cornea dented easily. No traumatic cataract followed. The button was cut off with a small iris scissors rather easily. The conjunctiva was freed from the limbus above, nasally and below, undermined and a heavy conjunctival flap drawn over the trephine opening and anchored with a mattress suture thru it and the con junctiva above and below. Atropin, firm bandage, binocular dressing. Dressing and atropin daily. The ante rior chamber was definitely reformed November 6th. Stitches out on the fifth day, and the flap allowed to re tract since it had served its purpose. Patient was discharged from the hos pital November 13th. On November 16th: Vision was 20/30 plus two with + 4 . sph. = -f-7. cyl. axis 165. Patient was seen daily, and this eye was kept under a built-up dressing over which was put an elastic webbing, two inches wide, constructed with a series of hooks and eyes at the ends, and kept fastened as tightly as she could possi bly stand the pressure on the eye ball. Discharged, December 8th, 1922. Vision, right eye, with + 2 . sph. 3 + 8 , cyl. axis 165 equals 20/30. The apex of the cornea was about 2 mm. flatter than before the operation, measured by the keratometer and the exophthalmometer. Tension was still 10 Hg. mm.
296
remedy being given in this second series of injections. At this date, the tension of the right eye had increased to Hg. 13 mm., all the cortex lens mate rial had absorbed and V. equalled 15/200. A membrane still blocked the pupil however. The cataract in left eye had cleared slightly, V. equals 15/70 with minus 3.50 D. Nov. 23rd, the patient was sent to the hospital, where with a nar row cataract knife, I made a clear hori zontal incision thru the membrane in the right eye. There was no reaction, a clear pupil was obtained and on Dec. 9th, with plus 10 D. combined with plus 3 D. ax. 90, the patient obtained 15/30 minus vision. Following the suggestion of G. Burdon-Cooper, in the Doyne Memorial Lecture, Etiology of Cataract 1 , that potash is valuable in the retardation of cataract formation, in beginning the second series of lens antigen injections
in this case, the patient was placed on small doses of potassium iodid, 15 grs. in full glass of water after meals. To judge from one case, which is of course hazardous, it would appear in those cases following cataract ex traction, in which considerable lens cortex has been left, that lens antigen injections are indicated. It goes with out saying, that the sensitization test should be made before the treatment is begun. Not the least pleasing phase in this case is, that the tension of a softened eye should be sufficiently re stored to justify further operative measures. In closing, I may say, I am using lens antigen injections in all cases of traumatic cataract, where the sensiti zation test does not show the patient hypersensitive to the lens antigen, and when secondary glaucoma is not present.
REFERENCES.
1. The British Jour. Oph., Sept., 1922, p. 400.
NOTES, CASES, INSTRUMENTS MONOCULAR INTERSTITIAL KERATITIS. JOHN N. HOFFMAN, M.
D.
CANTON, OHIO.
The following case is deemed worthy of report because of two interesting features. One is the age of the patient, and the second is the fact that the pathology has been confined to one eye. The patient is a young lady aged 22. The previous history is negative, and the family history secured from the parents is also negative. The pa tient is a college graduate, and a teacher by occupation. She was first seen in June 1922, about six weeks after the onset of her eye symptoms, having been under the care of an oculist of wide experience. When first seen her left eye pre sented the appearance of a typical in terstitial infiltration of the cornea. Her treatment had consisted solely of the use of atropin in the affected eye
three times daily. A general examin ation revealed none of the signs of lues, altho the blood Wassermann was strongly plus. She was put on intensive antiluetic treatment, and was referred to another oculist for his opinion as to the etiology. He also thought the con dition as luetic in origin. The reaction of the blood Wasser mann has been very obstinate, altho the proper general treatment has been vigorously given. Several subconjunctival injections of mercuric cyanid and novacain following the method of C. A. Campbell, as described in the December 1920 number of the Ameri can Journal of Ophthalmology (v. 3, p. 884) have been painlessly given, at intervals of seven to ten days. Vision has slowly improved from hand move ments at one meter to 4/30. Physical examinations have been negative, and the diagnosis of an in terstitial keratitis probably due to con genital lues seems to be the most
NOTES, CASES AND INSTRUMENTS
logical. This case also emphasizes the great value of Wassermann reac tions in all suspicious cases, no matter how much above reproach the personal and family history may be. By intensive antiluetic treatment in this case is meant the use of mercury by inunctions and per mouth. For fear of exciting the process in the other eye the arsenic preparation were not given intravenously.
KERATOCONUS.
Iridectomy and Corneal Trephining With a Conjunctival Flap. GEORGE W.
JEAN,
M.D.
SANTA BARBARA, CAL.
Spanish girl, age seventeen years, was first seen October 27th, 1922. Previous history: Weight 128 pounds, height 63 inches. Usual dis eases of childhood, typhoid six years ago, absolutely no illness since then. Parents, three sisters and four brothers —no eye trouble. Vision has been get ting bad in each eye for the last year, and she has had frequent changes of glasses. In school until one year ago. Physical examination by an internist negative. Eye examination : Vision, right eye, equals fingers at four feet; vision, left eye, equals fingers at twelve feet. Vi sion, each eye, unimproved with glasses. Corneas were conical. The right eye was slightly injected and the tip of the cone was opaque over an area of 2 mm. and denuded of epithel ium. Two small, narrow streaks of opacity ran inward nasally from the tip of the cone for 2 mm. The right and left cornea measured 10 1/2 mm. in diameter with Wessely's keratometer, and the measurements taken laterally with the keratometer showed the dis tance from the limbus to the apex of the right cornea to be 5 mm.; left cor nea, 4 mm. The apex of the right cone was 1 mm. below the horizontal meri dian and 1 mm. to the nasal side of the center. With the exophthalmometer the readings were, right, 18 mm.;
297
left 17 mm. Tonometer (Schiotz): Right eye with 7 1/2 wt. — 11 = 10 Hg. mm.; left eye, 7 1/2 wt. — 11 = 10 Hg. mm. With the ophthalmometer, the mires were so small and sepa rated and overlapped so violently that no reading could be gotten. Retinoscopy unsatisfactory. The left cornea was clear and the left eye white. I could get no pulsations in either cor nea with oblique illumination, the ophthalmometer or the slit lamp. Operations : Iridectomy, right eye, upward, same day (October 27th). Atropin 3 % , firm bandage. Daily dressings until November 3rd, when the opaque apex of the cone was trephined with a 2 mm. Stevenson's trephine which had to be done care fully because the cornea dented easily. No traumatic cataract followed. The button was cut off with a small iris scissors rather easily. The conjunctiva was freed from the limbus above, nasally and below, undermined and a heavy conjunctival flap drawn over the trephine opening and anchored with a mattress suture thru it and the con junctiva above and below. Atropin, firm bandage, binocular dressing. Dressing and atropin daily. The ante rior chamber was definitely reformed November 6th. Stitches out on the fifth day, and the flap allowed to re tract since it had served its purpose. Patient was discharged from the hos pital November 13th. On November 16th: Vision was 20/30 plus two with + 4 . sph. = -f-7. cyl. axis 165. Patient was seen daily, and this eye was kept under a built-up dressing over which was put an elastic webbing, two inches wide, constructed with a series of hooks and eyes at the ends, and kept fastened as tightly as she could possi bly stand the pressure on the eye ball. Discharged, December 8th, 1922. Vision, right eye, with + 2 . sph. 3 + 8 , cyl. axis 165 equals 20/30. The apex of the cornea was about 2 mm. flatter than before the operation, measured by the keratometer and the exophthalmometer. Tension was still 10 Hg. mm.