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Nashville Academy of Ophthalmology and Otolaryngology
450
SOCIETY PROCEEDINGS
appearance was that of beginning panophthalmitis. The iris was muddy, the pupil inactive; apparently the iris was adherent to the anterior lens surface. X-ray was negative for foreign bod)'. An ophthalmoscopic examination was impossible. The treatment consisted of instillation of two percent atropin, boric acid compresses every three hours, and morphine for the pain. The patient was placed in hospital. During the period between the time he was seen at the office and at the hospital, one hour, there was distinctly perceptible increase in the corneal hazi ness and conjunctival chemosis. Twenty-four hours after admission to the hospital the eye was pushed for ward by the swollen orbital contents, and was outside the lids. The cornea had apparently sloughed away so that the corneal area appeared as a yellow saucer-shaped depression. T h e lids were markedly swollen and tense. There was a profuse serosanguinous discharge. The eyeball was collapsed. Leukocytes were 13,800; tempera ture 100°. Culture taken from the dis charge showed mixed organisms, strep tococcus predominating. Two days after admission the condition remained unchanged. The temperature ranged from 99° to 100°. The patient had very little pain. After three days there was no change. On the fourth day there was slightly less swelling of the lids and tissues about the orbit. On the fifth day the swelling was definitely less. The patient was comfortable and cheerful. ITe had no fever and leuko cytes were 8,500. The condition as to swelling of lids and so on gradually im proved. It was decided to do an evis ceration of the globe nine days after the accident. The reason for deciding on evisceration was that the infection apparently was so virulent that menin gitis was feared if an ordinary enucleation was done. When the operation was attempted, the sclera was so friable that any grasp with forceps promptly broke through. It was thought that the sclera would slough following op eration and enucleation was therefore done. This was accomplished with
great difficulty on account of the fria bility of the tissues and the adhesions between the globe and orbital contents. No attempt was made to suture the conjunctiva. The patient had a prompt and un eventful convalescence. An x-ray pic ture of the eyeball after enucleation showed two pieces of steel. Discussion.
DR. ROBERT SULLIVAN,
who had seen the patient in consulta tion, said this was the most unusual case he had ever seen. Either the man had no resistance, or else he had the most violent form of infection that could be imagined. DR. HILLIARD WOOD asked for the opinion of the members with reference to enucleation in panopthalmitis. It was the general opinion that it was best to wait as long as possible before removing an eye with acute symptoms. Only one member had ever seen menin gitis following enucleation. H. C. S M I T H ,
Secretary.
NASHVILLE ACADEMY OF OPHTHALMOLOGY A N D OTOLARYNGOLOGY January 19, 1931 DR. HILLIARD WOOD presiding
Style in lacrimal duct for twenty-five years DR. F. E. HASTY reported that Mrs. W. W. N., aged thirty-five years, had come to him October 3, 1930, com plaining of pain and discharge in the right ear of two months' duration. Hearing in the right ear had not been normal since the patient was nineteen years of age, at which time she had palsy of the right side of the face which lasted a few days. Examination of the right ear showed suggestions of a tuberculous condition of the mastoid. X-ray of the mastoid and of the paranasal sinuses demon strated a style in the right nasolacrimal duct. DR. H. C. SMITH, by request, had'examined the patient's eyes on October 3,
SOCIETY PROCEEDINGS 1930. There had been tearing- of the left eye and continual discharge of pus from a small fistula below the inner canthus since the patient was four years of age, at which time she had acute dacryocystitis. At seven years of age a silver style had been placed in the left nasolacrimal canal; the patient wore this until the age of eighteen years, at which time it was discovered that the tip of the style was no longer visible at the lid margin and the sup position was that it had slipped entirely out. A series of probings was done without improving the epiphora. Several years afterward an operation for removal of the left lacrimal sac was performed. Following this, the fistula reappeared and the symptoms returned. One year later, another operation for removal of the lacrimal sac was ad vised, but the patient refused. On examination, October 3, 1930, there was a small fistula 6 mm. below the inner canthus of the left eye, through which mucopurulent material could be expressed. The canaliculus had been slit. There was no external evidence of the presence of the style in the lacrimal canal. The style was removed through the fistulous opening. On January 13, 1931, when last ex amined, the patient had no epiphora, and there was only slight lacrimal dis charge from the fistula. H. C. S M I T H ,
Secretary-treasurer. KANSAS CITY SOCIETY OF OPHTHALMOLOGY A N D OTOLARYNGOLOGY December 18, 1930 DR. ROBERT FORGRAVE presiding
Incipient cataract DR. ROBERT FORGRAVE of Saint Joseph, Missouri, speaking on this subject, stated that in this condition chronic focal infection was very common, and that the question was even being raised whether there really was such a thing as senile cataract. He quoted Dr. Frank Wilson Dean of Council Bluffs,
451
Iowa, as using subconjunctival injec tions of cyanide of mercury; but this should not be used in nuclear cataract nor in patients with poor nutrition. He also quoted Dr. Harry Gradle of Chi cago as saying that no treatment was efficacious but that iodine salts should be used internally as well as locally. Dr. Forgraves said that he had used mercury cyanide as well as dionin but that one should not promise results. Discussion. DR. H. B. DAVIS stated that in some cases early treatment with dionin and subconjunctival injections of cyanide of mercury gave good re sults. Styes DR. F. C. BOGGS of Topeka, Kansas, said that the literature wyas, peculiarly, very limited on this subject but that with the laity superstitions were many. There was frequently an underlying physical disability such as tuberculo sis, anemia, or diabetes. Sometimes hordeola were caused by chronic in flammation of the contiguous organs such as the nose, throat, or sinuses. Errors of refraction seemed to have some casual relationship but were cer tainly not the sole etiological factors. Treatment was both general and local, and it was important to stress hygiene. Attention should be given to exercise and diet. Sweets and starches should be reduced to a minimum. Sixty to fifty percent alcohol and tin chloride gave good results locally. Discussion. DR. H. B. HENDRICK said that many different methods of treat ment must be used, depending on the individual. He also stressed focal in fection as an etiological factor and said that the vitamin intake was important. DR. ALBERT N. LEMOINE said that gen eral care was important and that some cases were limited to the follicles of the cilia. This was usually a low grade staphylococcus infection and for these cases a five percent silver nitrate solu tion applied to the lid margins often gave good results. DR. ALVIN J. BAER mentioned autoge
nous vaccines as helping to clear up some of the more aggravated cases.
SOCIETY PROCEEDINGS
appearance was that of beginning panophthalmitis. The iris was muddy, the pupil inactive; apparently the iris was adherent to the anterior lens surface. X-ray was negative for foreign bod)'. An ophthalmoscopic examination was impossible. The treatment consisted of instillation of two percent atropin, boric acid compresses every three hours, and morphine for the pain. The patient was placed in hospital. During the period between the time he was seen at the office and at the hospital, one hour, there was distinctly perceptible increase in the corneal hazi ness and conjunctival chemosis. Twenty-four hours after admission to the hospital the eye was pushed for ward by the swollen orbital contents, and was outside the lids. The cornea had apparently sloughed away so that the corneal area appeared as a yellow saucer-shaped depression. T h e lids were markedly swollen and tense. There was a profuse serosanguinous discharge. The eyeball was collapsed. Leukocytes were 13,800; tempera ture 100°. Culture taken from the dis charge showed mixed organisms, strep tococcus predominating. Two days after admission the condition remained unchanged. The temperature ranged from 99° to 100°. The patient had very little pain. After three days there was no change. On the fourth day there was slightly less swelling of the lids and tissues about the orbit. On the fifth day the swelling was definitely less. The patient was comfortable and cheerful. ITe had no fever and leuko cytes were 8,500. The condition as to swelling of lids and so on gradually im proved. It was decided to do an evis ceration of the globe nine days after the accident. The reason for deciding on evisceration was that the infection apparently was so virulent that menin gitis was feared if an ordinary enucleation was done. When the operation was attempted, the sclera was so friable that any grasp with forceps promptly broke through. It was thought that the sclera would slough following op eration and enucleation was therefore done. This was accomplished with
great difficulty on account of the fria bility of the tissues and the adhesions between the globe and orbital contents. No attempt was made to suture the conjunctiva. The patient had a prompt and un eventful convalescence. An x-ray pic ture of the eyeball after enucleation showed two pieces of steel. Discussion.
DR. ROBERT SULLIVAN,
who had seen the patient in consulta tion, said this was the most unusual case he had ever seen. Either the man had no resistance, or else he had the most violent form of infection that could be imagined. DR. HILLIARD WOOD asked for the opinion of the members with reference to enucleation in panopthalmitis. It was the general opinion that it was best to wait as long as possible before removing an eye with acute symptoms. Only one member had ever seen menin gitis following enucleation. H. C. S M I T H ,
Secretary.
NASHVILLE ACADEMY OF OPHTHALMOLOGY A N D OTOLARYNGOLOGY January 19, 1931 DR. HILLIARD WOOD presiding
Style in lacrimal duct for twenty-five years DR. F. E. HASTY reported that Mrs. W. W. N., aged thirty-five years, had come to him October 3, 1930, com plaining of pain and discharge in the right ear of two months' duration. Hearing in the right ear had not been normal since the patient was nineteen years of age, at which time she had palsy of the right side of the face which lasted a few days. Examination of the right ear showed suggestions of a tuberculous condition of the mastoid. X-ray of the mastoid and of the paranasal sinuses demon strated a style in the right nasolacrimal duct. DR. H. C. SMITH, by request, had'examined the patient's eyes on October 3,
SOCIETY PROCEEDINGS 1930. There had been tearing- of the left eye and continual discharge of pus from a small fistula below the inner canthus since the patient was four years of age, at which time she had acute dacryocystitis. At seven years of age a silver style had been placed in the left nasolacrimal canal; the patient wore this until the age of eighteen years, at which time it was discovered that the tip of the style was no longer visible at the lid margin and the sup position was that it had slipped entirely out. A series of probings was done without improving the epiphora. Several years afterward an operation for removal of the left lacrimal sac was performed. Following this, the fistula reappeared and the symptoms returned. One year later, another operation for removal of the lacrimal sac was ad vised, but the patient refused. On examination, October 3, 1930, there was a small fistula 6 mm. below the inner canthus of the left eye, through which mucopurulent material could be expressed. The canaliculus had been slit. There was no external evidence of the presence of the style in the lacrimal canal. The style was removed through the fistulous opening. On January 13, 1931, when last ex amined, the patient had no epiphora, and there was only slight lacrimal dis charge from the fistula. H. C. S M I T H ,
Secretary-treasurer. KANSAS CITY SOCIETY OF OPHTHALMOLOGY A N D OTOLARYNGOLOGY December 18, 1930 DR. ROBERT FORGRAVE presiding
Incipient cataract DR. ROBERT FORGRAVE of Saint Joseph, Missouri, speaking on this subject, stated that in this condition chronic focal infection was very common, and that the question was even being raised whether there really was such a thing as senile cataract. He quoted Dr. Frank Wilson Dean of Council Bluffs,
451
Iowa, as using subconjunctival injec tions of cyanide of mercury; but this should not be used in nuclear cataract nor in patients with poor nutrition. He also quoted Dr. Harry Gradle of Chi cago as saying that no treatment was efficacious but that iodine salts should be used internally as well as locally. Dr. Forgraves said that he had used mercury cyanide as well as dionin but that one should not promise results. Discussion. DR. H. B. DAVIS stated that in some cases early treatment with dionin and subconjunctival injections of cyanide of mercury gave good re sults. Styes DR. F. C. BOGGS of Topeka, Kansas, said that the literature wyas, peculiarly, very limited on this subject but that with the laity superstitions were many. There was frequently an underlying physical disability such as tuberculo sis, anemia, or diabetes. Sometimes hordeola were caused by chronic in flammation of the contiguous organs such as the nose, throat, or sinuses. Errors of refraction seemed to have some casual relationship but were cer tainly not the sole etiological factors. Treatment was both general and local, and it was important to stress hygiene. Attention should be given to exercise and diet. Sweets and starches should be reduced to a minimum. Sixty to fifty percent alcohol and tin chloride gave good results locally. Discussion. DR. H. B. HENDRICK said that many different methods of treat ment must be used, depending on the individual. He also stressed focal in fection as an etiological factor and said that the vitamin intake was important. DR. ALBERT N. LEMOINE said that gen eral care was important and that some cases were limited to the follicles of the cilia. This was usually a low grade staphylococcus infection and for these cases a five percent silver nitrate solu tion applied to the lid margins often gave good results. DR. ALVIN J. BAER mentioned autoge
nous vaccines as helping to clear up some of the more aggravated cases.