- Email: [email protected]
New England Ophthalmological Society
574
SOCIETY PROCEEDINGS
aches were almost gone. The vision was somewhat improved in the eye most recently involved. There was continued improvement, although the patient required a rather large amount of cortisone therapy. In looking back, it would seem that the eyes were affected after corticoid therapy, administered over a period of a year or longer, was stopped when this patient developed an ear infection. It is likely that a continuation of cortisone therapy might have prevented the exacerbation which involved the retinal vessels and affected the vision. One should always bear in mind that individuals who are under prolonged corti coid therapy may be potential subjects for temporal arteritis. Whenever such therapy is terminated, one should be alert for the de velopment of a temporal arteritis syndrome. I believe I have seen in consultation some "burned out" cases of unrecognized temporal arteritis. Ophthalmologists should review any cases that might show the clinical picture presented here this evening. Early diagnosis is essential because, when blindness has de veloped, it is too late to expect results from corticoid therapy. DR. I. S. TASSMAN: It is difficult to rec ognize temporal arteritis and important to make an early diagnosis. After the eyes are involved, the visual impairment is usually permanent, as it was in this case. This par ticular patient presented symptoms which gave little reason to think of temporal ar teritis until rather late in the course of the disease. I would just like to ask whether the patient is still under treatment? DR. PAUL DAVIDSON: Yes, the patient is still receiving 200 mg. cortisone a day, and her doctor has been unable to reduce the dosage because of exacerbations. William E. Krewson, 3rd, Clerk.
NEW ENGLAND OPHTHALMOLOGICAL SOCIETY 436th Meeting, March 20, 1957 DR. EDWARD
A.
CRAMTON,
presiding
CASE PRESENTATIONS
Case 1—Tumor of the eye. DR. ALFRED W. SCOTT: I think the history of this woman is somewhat misleading. On Friday she had a headache over the right eye. On Saturday morning when she awakened, she noticed a blur in the right eye. This blur has fluc tuated a little since that time. It was also noted on Saturday morning that the con junctiva was definitely red, not markedly so, however. This has continued. When I ex amined her in the office on Tuesday, she had vision of 20/20 with pinhole. The media were clear. The conjunctiva of the right eye was about one- or two-plus injected but not on the left. The anterior chamber was clear, with no cells or flares. The pupils were equal in both eyes. There was an absolute field defect in the lower outer quadrant. Corre sponding to this, there was a lesion in the upper nasal quadrant. This lesion had two or three small hemorrhages on its surface. This is why I bring her in for diagnosis. Consensus: Malignant melanoma. Case 2—Melanotic sarcoma of the iris. DR. GARRETT L. SULLIVAN presented a 41-
year-old man. Twenty years ago a tiny spot was noted on the iris of the right eye. Fifteen years ago, when the man was inducted into the Army, the spot was noted by the Army doctors. In recent years this spot has grown larger. The man has noticed no interference with vision. On examination, he now shows a mush room-shaped, brownish-black lesion in the iris at the 6-o'clock position, coining almost to the pupillary border. The pupil is drawn very slightly at the 6-o'clock position and there is definite limited mobility of the pupil at this point. Fundus examination shows pos terior cortical lens opacities, superiorly.
575
SOCIETY PROCEEDINGS These do not involve the central portion of the lens. A limited view of the fundus shows normal disc and vessels. Vision in the right eye is 20/30, correctible with pinhole to 20/20. Uncorrected vision in the left eye is 20/15. Under the corneal microscope the lesion is noticeably elevated and has rather a bumpy surface. There are no vessels to be observed in the vicinity of the lesion. Under gonioscopy, the elevated area appears to slope off into the angle and to extend out to about the 3-o'clock position on one side and around to the 10-o'clock position on the opposite side. There was noticeable pigmentation in the angle, consisting of varied sized dark, black spots; most of these were on the ex treme face of the cornea. There were many little fine iris frills going toward the cornea. Tension was 17 mm. Hg (Schi0tz). The other eye is completely normal. I feel the diagnosis is melanotic sarcoma and that the eye should be enucleated. I would welcome any opinions. Discussion. DR. FREDERICK H. VERHOEFF:
I used to think, when I saw a tumor like this, that the only thing to do was to take the eye out. But so many of these cases have gone for such a long time without anything happening that I have begun to wonder if I was right about it. Wouldn't it be a good idea in this particular case just to watch for awhile? Measure the lesion. You are not sure that it has grown, are you ? Nobody has measured it, have they? I should think it would be worth while to do that. I think the patient ought to be told that the only absolutely safe thing to do is to take his eye out. But then I would tell him if it were my eye I wouldn't have it out right away. I say this because of the records of these cases. This is really a small tumor. On the skin, as a mole somewhere, it would be a very small mole. A lot of them have gone on a long time. In measuring them, do not worry too much about great accuracy. Take a pair of calipers and approximate the thing; this should tell if it is growing; or
take a series of pictures over a period of time and compare them. DR. EDWIN B. D U N P H Y : This might be a good case in which to try a P 32 test. The lesion seems to be fairly accessible. CATARACT
EXTRACTION
AND TONOGRAPHY
AND GONIOSCOPY DR. P E I - F F I L E E : Tonographic and gonioscopic studies before and after cataract ex traction offer much valuable information in handling postoperative cases with and with out complications. Postoperatively die facility of outflow may be temporarily decreased, increased, or un changed. With temporarily decreased out flow, there often is definite elevated tension. Most of these eyes do not require any antiglaucomatous therapy but should be watched closely and carefully in order to prevent un necessary damage. In our series the facility of outflow of patients with pseudoexfoliation, glaucoma capsulare, and open-angle glaucoma was es sentially unchanged before and after the cataract extraction. On the other hand, the cataract extraction did not help the openangle glaucoma symptoms so far as intra ocular pressure and tonographic findings were concerned. The deposition of pigment at the inferior angle, transparent vessels on the surface of the peripheral iris, and the discoloration of the posterior meshwork are purely senile phenomena. However, in a patient with the later stages of diabetes mellitus combined with advanced cataract, preoperative gonioscopic examination is necessary in order to detect abnormal vessels and to warn of the danger of hemorrhage. About 95 percent or more of the inner scars were located anteriorly in the cornea and, postoperatively, did not interfere with maintenance of a normal intraocular pres sure and corrected vision. Separation of Descemet's membrane often occurred at the area where the surgical wound was extended with scissors.
576
SOCIETY PROCEEDINGS
In handling patients with flat anterior chambers postoperatively, gonioscopic ex amination should be done after the anterior chamber is reformed and the indicated therapy is being given. C O R N E A L DYSTROPHIES A N D DEGENERATIONS
D R . DAVID D. DONALDSON: I would like
to say something about the definitions of dystrophies, degenerations, and keratopathies. These terms are used for all the noninflammatory conditions of the cornea. Generally speaking, we think of a dystrophy as being a condition in which there is an hereditary factor; there is no other known cause. Degenerations are associated with old age or with eyes in which the vitality of the tissues is decreased. It is often difficult to differentiate between dystrophies and degen erations. I might also say that a number of dystrophies are really degenerations. Keratopathies are those corneal conditions that have a definite cause or are secondary to some systemic condition. T h e classification I have worked out for dystrophies and degenerations is a modifica tion of the system proposed in 1950 by Franceschetti. I have added to it and changed it a bit to fit the ideas I have. T h e first general group is termed " P a r e n chymatous." U n d e r this heading are first the classical forms which include granular dystrophy (Groenouw's type I ) ; lattice dys trophy ; and macular dystrophy (Groenouw's type I I ) . T h e second "Parenchymatous" group includes the congenital forms of pos terior embryotoxon of Axenfeld and sclerocornea. I n the last group are the diverse forms of crystalline dystrophy; lipoid dys trophy; furrow dystrophy; arcus senilis (gerontoxon) ; arcus juvenilis (anterior em bryotoxon) ; keratoconus; and cornea farinata. T h e second general group is placed under the heading of "Limiting zones." I n this grouping, the anterior group includes Salzmann's nodular " d y s t r o p h y " ; band-shaped dystrophy; Vogt's limbus girdle; Coats' cor
neal r i n g ; crocodile shagreen ( a n t e r i o r ) ; primary essential corneal edema; juvenile epithelial degeneration; and recurrent heredi tary erosion. T h e posterior group includes cornea guttata ("epithelial" degeneration of Fuchs) ; crocodile shagreen (posterior) ; and posterior polymorphous degeneration. The last general group is termed "Cor neal degenerations in general affections." U n d e r this heading are the metabolic dis turbances of Hurler's disease; cystinosis ; Ffand-Schiiller-Christian disease; and ochronosis. U n d e r the heading of "Cutaneous con ditions" are ichthyosis; Rothmund's syn drome ; and keratoma palmare et plantare hereditarium. Charles Snyder, Recorder.
YALE CLINICAL
UNIVERSITY CONFERENCES
November 9 and 16, 1956 D R . R O C K O M. PSYCHOLOGIC DR.
EDITH
FASANELLA,
CONSIDERATIONS JACKSON
presiding IN
SURGERY
AND IRVING
JANIS,
P H . D . , presented a very interesting discus sion of the psychologic aspects in patients undergoing surgery. At this time one is con fronted with a problem in emotional inocu lation, that is, preparing a person for a situ ation of stress. A purely intellectual approach may not be very successful. Three aspects were discussed: 1. H o w do people with different levels of preoperative anxiety react in the postopera tive situation? 2. Does preoperative information affect postoperative behavior ? 3. H o w is the stress before surgery cor related with other stress situations, as in combat, and so forth? In connection with the first point, were three general types of reactions to exposure to threat of a dangerous situation: ( a ) fear,
SOCIETY PROCEEDINGS
aches were almost gone. The vision was somewhat improved in the eye most recently involved. There was continued improvement, although the patient required a rather large amount of cortisone therapy. In looking back, it would seem that the eyes were affected after corticoid therapy, administered over a period of a year or longer, was stopped when this patient developed an ear infection. It is likely that a continuation of cortisone therapy might have prevented the exacerbation which involved the retinal vessels and affected the vision. One should always bear in mind that individuals who are under prolonged corti coid therapy may be potential subjects for temporal arteritis. Whenever such therapy is terminated, one should be alert for the de velopment of a temporal arteritis syndrome. I believe I have seen in consultation some "burned out" cases of unrecognized temporal arteritis. Ophthalmologists should review any cases that might show the clinical picture presented here this evening. Early diagnosis is essential because, when blindness has de veloped, it is too late to expect results from corticoid therapy. DR. I. S. TASSMAN: It is difficult to rec ognize temporal arteritis and important to make an early diagnosis. After the eyes are involved, the visual impairment is usually permanent, as it was in this case. This par ticular patient presented symptoms which gave little reason to think of temporal ar teritis until rather late in the course of the disease. I would just like to ask whether the patient is still under treatment? DR. PAUL DAVIDSON: Yes, the patient is still receiving 200 mg. cortisone a day, and her doctor has been unable to reduce the dosage because of exacerbations. William E. Krewson, 3rd, Clerk.
NEW ENGLAND OPHTHALMOLOGICAL SOCIETY 436th Meeting, March 20, 1957 DR. EDWARD
A.
CRAMTON,
presiding
CASE PRESENTATIONS
Case 1—Tumor of the eye. DR. ALFRED W. SCOTT: I think the history of this woman is somewhat misleading. On Friday she had a headache over the right eye. On Saturday morning when she awakened, she noticed a blur in the right eye. This blur has fluc tuated a little since that time. It was also noted on Saturday morning that the con junctiva was definitely red, not markedly so, however. This has continued. When I ex amined her in the office on Tuesday, she had vision of 20/20 with pinhole. The media were clear. The conjunctiva of the right eye was about one- or two-plus injected but not on the left. The anterior chamber was clear, with no cells or flares. The pupils were equal in both eyes. There was an absolute field defect in the lower outer quadrant. Corre sponding to this, there was a lesion in the upper nasal quadrant. This lesion had two or three small hemorrhages on its surface. This is why I bring her in for diagnosis. Consensus: Malignant melanoma. Case 2—Melanotic sarcoma of the iris. DR. GARRETT L. SULLIVAN presented a 41-
year-old man. Twenty years ago a tiny spot was noted on the iris of the right eye. Fifteen years ago, when the man was inducted into the Army, the spot was noted by the Army doctors. In recent years this spot has grown larger. The man has noticed no interference with vision. On examination, he now shows a mush room-shaped, brownish-black lesion in the iris at the 6-o'clock position, coining almost to the pupillary border. The pupil is drawn very slightly at the 6-o'clock position and there is definite limited mobility of the pupil at this point. Fundus examination shows pos terior cortical lens opacities, superiorly.
575
SOCIETY PROCEEDINGS These do not involve the central portion of the lens. A limited view of the fundus shows normal disc and vessels. Vision in the right eye is 20/30, correctible with pinhole to 20/20. Uncorrected vision in the left eye is 20/15. Under the corneal microscope the lesion is noticeably elevated and has rather a bumpy surface. There are no vessels to be observed in the vicinity of the lesion. Under gonioscopy, the elevated area appears to slope off into the angle and to extend out to about the 3-o'clock position on one side and around to the 10-o'clock position on the opposite side. There was noticeable pigmentation in the angle, consisting of varied sized dark, black spots; most of these were on the ex treme face of the cornea. There were many little fine iris frills going toward the cornea. Tension was 17 mm. Hg (Schi0tz). The other eye is completely normal. I feel the diagnosis is melanotic sarcoma and that the eye should be enucleated. I would welcome any opinions. Discussion. DR. FREDERICK H. VERHOEFF:
I used to think, when I saw a tumor like this, that the only thing to do was to take the eye out. But so many of these cases have gone for such a long time without anything happening that I have begun to wonder if I was right about it. Wouldn't it be a good idea in this particular case just to watch for awhile? Measure the lesion. You are not sure that it has grown, are you ? Nobody has measured it, have they? I should think it would be worth while to do that. I think the patient ought to be told that the only absolutely safe thing to do is to take his eye out. But then I would tell him if it were my eye I wouldn't have it out right away. I say this because of the records of these cases. This is really a small tumor. On the skin, as a mole somewhere, it would be a very small mole. A lot of them have gone on a long time. In measuring them, do not worry too much about great accuracy. Take a pair of calipers and approximate the thing; this should tell if it is growing; or
take a series of pictures over a period of time and compare them. DR. EDWIN B. D U N P H Y : This might be a good case in which to try a P 32 test. The lesion seems to be fairly accessible. CATARACT
EXTRACTION
AND TONOGRAPHY
AND GONIOSCOPY DR. P E I - F F I L E E : Tonographic and gonioscopic studies before and after cataract ex traction offer much valuable information in handling postoperative cases with and with out complications. Postoperatively die facility of outflow may be temporarily decreased, increased, or un changed. With temporarily decreased out flow, there often is definite elevated tension. Most of these eyes do not require any antiglaucomatous therapy but should be watched closely and carefully in order to prevent un necessary damage. In our series the facility of outflow of patients with pseudoexfoliation, glaucoma capsulare, and open-angle glaucoma was es sentially unchanged before and after the cataract extraction. On the other hand, the cataract extraction did not help the openangle glaucoma symptoms so far as intra ocular pressure and tonographic findings were concerned. The deposition of pigment at the inferior angle, transparent vessels on the surface of the peripheral iris, and the discoloration of the posterior meshwork are purely senile phenomena. However, in a patient with the later stages of diabetes mellitus combined with advanced cataract, preoperative gonioscopic examination is necessary in order to detect abnormal vessels and to warn of the danger of hemorrhage. About 95 percent or more of the inner scars were located anteriorly in the cornea and, postoperatively, did not interfere with maintenance of a normal intraocular pres sure and corrected vision. Separation of Descemet's membrane often occurred at the area where the surgical wound was extended with scissors.
576
SOCIETY PROCEEDINGS
In handling patients with flat anterior chambers postoperatively, gonioscopic ex amination should be done after the anterior chamber is reformed and the indicated therapy is being given. C O R N E A L DYSTROPHIES A N D DEGENERATIONS
D R . DAVID D. DONALDSON: I would like
to say something about the definitions of dystrophies, degenerations, and keratopathies. These terms are used for all the noninflammatory conditions of the cornea. Generally speaking, we think of a dystrophy as being a condition in which there is an hereditary factor; there is no other known cause. Degenerations are associated with old age or with eyes in which the vitality of the tissues is decreased. It is often difficult to differentiate between dystrophies and degen erations. I might also say that a number of dystrophies are really degenerations. Keratopathies are those corneal conditions that have a definite cause or are secondary to some systemic condition. T h e classification I have worked out for dystrophies and degenerations is a modifica tion of the system proposed in 1950 by Franceschetti. I have added to it and changed it a bit to fit the ideas I have. T h e first general group is termed " P a r e n chymatous." U n d e r this heading are first the classical forms which include granular dystrophy (Groenouw's type I ) ; lattice dys trophy ; and macular dystrophy (Groenouw's type I I ) . T h e second "Parenchymatous" group includes the congenital forms of pos terior embryotoxon of Axenfeld and sclerocornea. I n the last group are the diverse forms of crystalline dystrophy; lipoid dys trophy; furrow dystrophy; arcus senilis (gerontoxon) ; arcus juvenilis (anterior em bryotoxon) ; keratoconus; and cornea farinata. T h e second general group is placed under the heading of "Limiting zones." I n this grouping, the anterior group includes Salzmann's nodular " d y s t r o p h y " ; band-shaped dystrophy; Vogt's limbus girdle; Coats' cor
neal r i n g ; crocodile shagreen ( a n t e r i o r ) ; primary essential corneal edema; juvenile epithelial degeneration; and recurrent heredi tary erosion. T h e posterior group includes cornea guttata ("epithelial" degeneration of Fuchs) ; crocodile shagreen (posterior) ; and posterior polymorphous degeneration. The last general group is termed "Cor neal degenerations in general affections." U n d e r this heading are the metabolic dis turbances of Hurler's disease; cystinosis ; Ffand-Schiiller-Christian disease; and ochronosis. U n d e r the heading of "Cutaneous con ditions" are ichthyosis; Rothmund's syn drome ; and keratoma palmare et plantare hereditarium. Charles Snyder, Recorder.
YALE CLINICAL
UNIVERSITY CONFERENCES
November 9 and 16, 1956 D R . R O C K O M. PSYCHOLOGIC DR.
EDITH
FASANELLA,
CONSIDERATIONS JACKSON
presiding IN
SURGERY
AND IRVING
JANIS,
P H . D . , presented a very interesting discus sion of the psychologic aspects in patients undergoing surgery. At this time one is con fronted with a problem in emotional inocu lation, that is, preparing a person for a situ ation of stress. A purely intellectual approach may not be very successful. Three aspects were discussed: 1. H o w do people with different levels of preoperative anxiety react in the postopera tive situation? 2. Does preoperative information affect postoperative behavior ? 3. H o w is the stress before surgery cor related with other stress situations, as in combat, and so forth? In connection with the first point, were three general types of reactions to exposure to threat of a dangerous situation: ( a ) fear,