- Email: [email protected]
New England Ophthalmological Society
SOCIETY PROCEEDINGS E D I T E D BY D O N A
) J. L Y L E ,
M.D.
ing a n d vomiting. Thereafter h e rapidly de veloped deafness in both ears which was marked in degree and had not improved since onset. A s the deafness progressed difficulty December 2 1 , 1960 in walking decreased. T w o weeks after the onset of deafness his eyes became red and BlTEMPORAL HEMIANOPIA photophobic. T h e only abnormality on routine DAVID D . DONALDSON, M.D., presented a laboratory testing was a highly elevated white 56-year-old m a n w h o had suffered multiple count which is characteristic of this syn skull and facial fractures on the left side drome. E y e examination showed patch in when his head was crushed between the pilot filtration of the corneal stroma which has house of a boat and the steel girder of a been variable day to day. This type of infil bridge. H i s left eye had been pushed 14 mm. tration differs from the luetic type of inter into the orbit, due to multiple orbital frac stitial keratitis in that it is variable from tures and loss of fat. Skull X-ray films day to day, there is no intraocular involve demonstrated air in the ventricular system ment, and there is n o swelling of the stroma. which nicely outlined the chiasm. NeuroThere is also much less vascularization in surgical exploration revealed no brain dam this type of keratitis than in luetic intersti age a n d only a tear in the dura in the left tial keratitis. This patient is typical of a syn frontal area, which was repaired. E y e exami drome first described by Cogan in 1945 nation some time after the injury revealed which he has called nonsyphilitic interstitial a vision of 20/20 in the right eye and 20/50 keratitis with vestibuloauditory symptoms. in the left eye. There was residual enophT h e visual aspects carry a good prognosis thalmos of the left eye, plus restricted ocular but the auditory aspects do not. There is no motility on the left and diplopia. H e demon adequate treatment for this condition, nor strated a bitemporal hemianopia. Bitemporal has an etiologic agent been discovered. Serohemianopia due to trauma has rarely been logic tests for syphilis are always negative. described. NEW ENGLAND OPHTHALMOLOGICAL SOCIETY
W E R N I C K E ' S SYNDROME
CATARACT SURGERY
M A U R I C E VICTOR, M.D., presented a 39-
E D W I N B. D U N P H Y , M . D . , discussed some
year-old woman who had been an alcoholic for 11 years. She was admitted with W e r nicke's syndrome and treated with a vitaminfree diet plus thiamine. O n this regimen there has been marked improvement in ocu lar motility. During discussion of this case it was pointed out that only five percent of patients with Wernicke's syndrome have toxic amblyopia.
of the complications of cataract surgery and their management. Retrobulbar hemorrhage following injection of anesthesia calls for cancellation of surgery. Hemorrhage which occurs subconjunctivally as a fixation suture is being placed around the superior rectus can often be controlled by tightening the fix ation suture around the muscle. If a cataract knife is introduced upside down, it is best to withdraw the knife and reinsert it. If the chamber is not formed, a small incison can be made, using scissors to complete the section. Sutures placed too deeply should be withdrawn and replaced.
N O N S Y P H I L I T I C I N T E R S T I T I A L KERATITIS D A V I D G. COGAN, M . D . , presented a 14-
year-old boy who several weeks before first being examined had developed trouble walk-
SOCIETY PROCEEDINGS Continued prolapsing of the iris following corneal section forebodes trouble and meas ures must be taken to reduce any pressure on the globe. An eye in which expulsive choroidal hem orrhage occurs can sometimes be saved by rapid drainage of the subchoroidal space. One may be forewarned of this complica tion by a complaint of sudden severe pain on the part of the patient who up till this point has been satisfactorily anesthetized. Posterior dislocation of the lens at the time of application of forceps or cystotome requires extraction by lens loop. If the lens falls into the vitreous, it may be irrigated therefrom by a strong stream of saline di rected back into the eye. If this procedure is unsuccessful, the lens may be left in the vitreous cavity and, if the capsule has not ruptured, the eye will tolerate the lens in definitely; however, if the capsule has been ruptured, the eye is usually lost. Loss of completely fluid vitreous is of no consequence. Loss of formed vitreous is a serious complication. When formed vitreous is lost, it is necessary to release all tension on the globe to allow the vitreous to retract into the globe. If formed vitreous is lost be fore the lens is extracted and a firm hold is had on the lens capsule, then the lens may gradually be withdrawn from the eye by traction alone. If the lens is not firmly held, it should be removed with a loop. Following the loss of formed vitreous a full iridectomy should be done, if this has not already been done. Rupture of the lens capsule cannot be con sidered a real complication but rather a dis appointment. If anesthesia and akinesia are still good, it is important to remove as much of fragmented capsule and cortex as possible. The use of small forceps to pick up pieces of capsule on the iris surface is justifiable but, when used in the pupil, this procedure carries certain dangers. Nausea occurring during cataract surgery can sometimes by counteracted by inhalation of oxygen. If vomiting occurs, the patient's
991
face should be turned away from the oper ated eye. If vomitus should enter the eye before the lens has been removed, the eye should be irrigated and the wound closed and further surgery postponed. If vomitus enters the eye after removal of the lens, the eye should be irrigated and large doses of anti biotics should be used prophylactically. GLAUCOMA SURGERY PAUL A. CHANDLER, M.D.: Nearly all patients with angle-closure glaucoma are operated on no matter what the stage of the disease. In early stages all closure can be prevented by peripheral iridectomy; in later stages further closure of the angle can be prevented. In some patients who generally have dilated pupils following an acute attack of glaucoma, or a dilation in one meridian, the pupillary block is permanently relieved. In these cases iridectomy will add nothing further. In angle-closure glaucoma, if all or a large portion of the angle is open gonioscopically, iridectomy is the treatment of choice. If one third or more of the angle appears to be closed by synechias, a filtering operation is necessary. In cases in which it is not possible to determine by gonioscopic examination whether or not sufficient angle is open for iridectomy to be effective, it still can be tried if the tension can be normalized by miotics alone; if the C value was high before glau coma appeared (as determined by tonography) ; or if gonioscopy at the time of sur gery after the chamber is deepened shows the angle to be more than two thirds open. Dr. Chandler then described his technique of peripheral iridectomy. He cautioned against the use of scleral cautery in doing peripheral iridectomy so that the danger of producing a filtering scar would be mini mized. He also cautioned against making too small an iridectomy in order to avoid obtain ing only the stroma of the iris and leaving the pigment epithelium intact and therefore, in effect, creating no iridectomy. Following peripheral iridectomy it is important to ob-
992
SOCIETY PROCEEDINGS
serve carefully for signs of iritis and, if they are present, to treat actively with mydriasis and the usual steroids. If a flat chamber oc curs, it must be reformed immediately in order to prevent permanent peripheral an terior synechias. Everyone has his own indications for surgery in open-angle glaucoma. It is axio matic, however, that, in the presence of ad vanced cupping and atrophy, surgery must be done to keep the tension in the teens or low twenties (1948 scale), since eyes with advanced glaucoma will not tolerate tensions higher than this. The operation of choice in open-angle glaucoma is the one with which the individual surgeon is most familiar. In the presence of shallow chambers, trephination may lead to incarceration of the lens in the trephine opening. Dr. Chandler person ally favors trephination in young patients and in cases of so-called low-tension glau coma where marked hypotony is desirable. Certain points of surgical technique which Dr. Chandler has found helpful were de scribed. The first is to make a slanting in cision in the lower portion of the cornea with a needle knife as the first step in any surgical procedure for open-angle glaucoma. This in cision is useful in many ways. In trephining operations it is helpful to deepen the chamber markedly, with saline introduced through this opening prior to trephining the sclera. (In trephining the sclera, it is extremely useful to have a Grieshaber trephine with a guard.) Deepening the anterior chamber through the slanting corneal incision is also useful in cases in which one prefers to use a knife or keratome for making an incision in iris in clusion operations or sclerectomies. At the conclusion of any filtering operation it is useful to inject saline through the slant ing corneal incision in order to determine whether or not the bleb can be formed. If the bleb cannot be formed by this procedure, there is no chance of a successful operation. It is then necessary to examine the wound and correct any obstruction to the opening which may exist.
If buttonholing of the conjunctiva occurs during preparation of the flap, the effect of this can be avoided by moving to a different site to make the scleral incision. If the con junctiva is buttonholed after the sclerectomy has been made, or if the buttonhole is first noted after sclerectomy has been done, it is possible to convert this round hole into a narrow slit by pulling the conjunctiva around the limbus and tacking it to the episclera in an area remote from the wound. This tech nique has been extended to cases in which no buttonhole has been formed in order to tighten the conjunctiva over the sclerectomy and appears to have reduced the incidence of postoperative flat chambers. In angle-closure glaucoma requiring a filtering operation it is essential to open the sclera by an ab-externo incision. Suturing of the conjunctival wound is im portant in avoiding flat chambers. Dr. Chan dler feels that the development of flat cham bers postoperatively is the largest cause of failure of filtering operations. A pressure dressing is useful in helping to form flat chambers. If a chamber remains flat longer than five days, there is not only danger of peripheral anterior synechias occluding the angle but also of failure of the bleb. If the chamber is formed surgically by release of subchoroidal fluid and injection of saline into the anterior chamber and the bleb does not form as the anterior chamber is expanded, forceful injection of saline will sometimes suddenly open the bleb and lead to successful operation. UREA IN ACUTE ANGLE-CLOSURE GLAUCOMA KEVIN H I L L , M.D., JEREMY W H I T N E Y , M.D., AND ROBERT TROTTER, M.D.: The
effects of intravenous hypertonic urea on the tension in 13 patients with acute elevation of intraocular pressure were evaluated. The in traocular pressure was reduced in each of 13 eyes with acute angle-closure glaucoma. In 10 eyes, the tension was lowered to 23 mm. Hg or less. In three other eyes the tension fell only to 40 to 45 mm. Hg. Two of these pa-
SOCIETY PROCEEDINGS tients had pupillary membrane with iris bombe and the third had had elevated ten sion for a considerable period of time. These patients differed in no other way, however, from the other 10. Two elderly women of this series devel oped agitation and confusion following the administration of urea. One of these two patients inadvertently received almost two gm. of urea per kg. of body weight. Both patients returned to a normal mental status following a night of sleep. All other sideeffects were mild. Gonioscopy following lowering of tension by urea revealed that the angle remained closed despite lowering of tension. Hence it may be assumed that urea acts independently of the state of the angle of the anterior chamber. HEMORRHAGIC DIABETIC RETINOPATHY TREATED BY HYPOPHYSEAL STALK SECTION JOEL S. CONTRERAS, M.D., RICHARD A. FIELD, M.D., W. A. HALL, M.D., AND W. H. SWEET, M.D., presented case re
ports on three patients with hemorrhagic retinopathy due to diabetes mellitus in whom favorable effects on the retinopathy were seen after hypophyseal stalk section. In each patient preoperative visual acuity was re corded, slitlamp examination of the anterior segment was performed, and drawings, which were actual mappings of every ves sel aneurysm and hemorrhage, were made. Aneurysms and hemorrhage were related to vascular pattern. Thus location and size of these abnormalities could be accurately fol lowed in relation to the vascular pattern. Photographs of the pre- and postoperative fundus drawings of each patient were pre sented and discussed. Postoperative examination in all three pa tients revealed a dramatic cessation of hem orrhage. Blood absorption was enhanced and proliferation of tissue underneath hemor rhage was prevented. Blood flow within the vessels was improved. Neovascularization was strikingly affected. Racemose aneurysms
993
remained the same but they underwent a shrinking phenomenon. Exudates showed a tendency to slow migration both vertically and horizontally but the exudates themselves have not disappeared. Disappearance of ab normal vitreous turbidity occurred within a few days after the operation. M l G R A I N O I D S Y M P T O M S W I T H CEREBRAL ANOMALIES
ROBERT REINECKE, M.D., reported a case of migrainoid symptoms with certain unusual features. Its pattern of headaches was un usual in that it was always limited to the distribution of the second division of the left trigeminal nerve. A parieto-occipital arteriovenous abnormality was demonstrated which could account for the visual aura. Two aneurysms were demonstrated and a third postulated to explain the salient features of this case. The patient was a 43-year-old woman who had had recurrent headaches since the age of 15years which were preceded by a rightvisual field aura. Three weeks prior to admission she had developed almost daily headaches. She developed a stiff neck nine days prior to admission and vertigo, diplopia and left ptosis developed. On physical examination the left eye showed ptosis, dilation of pupil, and deviation outward, with retention of intorsion. On lumbar puncture the spinal fluid was orange and showed 60,000 red cells per c.mm. Arteriogram showed a balloon-type aneurysm at the origin of the right posterior communicating artery. This aneurysm, how ever, does not explain die patient's left third nerve palsy and left cephalalgia. A left arteri ogram showed an arteriovenous abnormality in the left parietal occipital area. It is neces sary to postulate a third aneurysm of the left posterior communicating artery to explain the third cranial nerve palsy on the left and the cephalalgia. This was not demonstrated on the arteriogram. It is assumed that a clot in this anuerysm prevented demonstration by arteriography. Despite the demonstration of organic
994
SOCIETY PROCEEDINGS
causes of this patient's migraine type dis turbances, it is necessary to postulate idiopathic features to explain the periodicity. This case demonstrates that migraine symp toms might mask pathologic intracranial changes until overt intracranial bleeding oc curs. A constant visual or trigeminal cephalalgia may be sufficient cause for a complete neurosurgical work up. DIAGNOSIS OF ORBITAL LESIONS
IRA S. JONES, M.D., discussed the diagno sis of orbital lesions and said this is primarily a discussion of unilateral exophthalmos. Recognition of exophthalmos can some times be difficult. False readings with the Hertel exophthalmometer are common. A bet ter idea of the presence of exophthalmos and its degree can be obtained by having the pa tient bend his head forward and sighting down the forehead toward the cornea of each eye. It is possible to confuse enophthalmos on one side for exophthalmos on the other. Retraction of the upper lid can also give the appearance of exophthalmos. Paralysis of the extraocular muscles may lead to two mm. or more of exophthalmos. Asymmetry of the skull or orbits may give a true exophthalmos without disease. A large globe may give a false impression of ex ophthalmos. History, inspection, auscultation, study of ocular motility, and palpation are indicated in each patient with exophthalmos in order to make proper differential diagnosis. Gen eral medical examination should follow. Infiltrative exophthalmos due to old thyroid disease may appear many years after a his tory of thyroid disease. The Werner pro vocative test is useful in differentiating thy roid exophthalmos from exophthalmos of other causes. On palpation of the orbit the patient should be asked to look in the direction in which you are palpating. If, for example, the patient looks upward while you are pal pating below, the orbital septum is placed
under tension and a false idea of mass is ob tained. If the patient looks down while the lower orbit is palpated the septum is relaxed' and a truer idea of the contents of the orbit can be obtained. When a mass lies in the muscle cone, there are frequently striae in the posterior portion of the retina. If striae occur more anteriorly, they are not as helpful in establishing the presence of a mass within the muscle cone. In a recent analysis of 100 X-ray films of patients with exophthalmos, 80 percent had abnormal findings. Usual X-ray examination includes the skull, orbits and optic canals. Stereoscopic X-ray films are preferred. Xray findings are calcifications within the or bit, differences in appearances between the two orbits, changes in shape of the orbit, compression of bone from erosion and frac ture, enlargement of the optic canal, and in creased bone density. All other changes are combinations of these six changes. In cases in which the diagnosis is in doubt following the diagnostic procedures outlined herein, exploration of the orbit is carried out. Photographs and radiographs of a number of different patients with different causes of exophthalmos were presented. The Kronlein operation with modifications is the operation of choice for exploration of the orbit and removal of orbital tumors. A technique of exenteration with temporalis graft into the orbit was described. In a series of 230 cases with unilateral exoph thalmos, thyroid disease was the most fre quent cause. Hemangiomas, lymphomas, granulomas, lacrimal gland tumors and meningiomas followed in decreasing fre quency as the causes of unilateral exoph thalmos. Dr. Virgil Casten followed this presenta tion with a description of surgical tech niques in the management of orbital tumors, illustrated by a large number of representa tive cases. Robert J. Herm, Recorder.
) J. L Y L E ,
M.D.
ing a n d vomiting. Thereafter h e rapidly de veloped deafness in both ears which was marked in degree and had not improved since onset. A s the deafness progressed difficulty December 2 1 , 1960 in walking decreased. T w o weeks after the onset of deafness his eyes became red and BlTEMPORAL HEMIANOPIA photophobic. T h e only abnormality on routine DAVID D . DONALDSON, M.D., presented a laboratory testing was a highly elevated white 56-year-old m a n w h o had suffered multiple count which is characteristic of this syn skull and facial fractures on the left side drome. E y e examination showed patch in when his head was crushed between the pilot filtration of the corneal stroma which has house of a boat and the steel girder of a been variable day to day. This type of infil bridge. H i s left eye had been pushed 14 mm. tration differs from the luetic type of inter into the orbit, due to multiple orbital frac stitial keratitis in that it is variable from tures and loss of fat. Skull X-ray films day to day, there is no intraocular involve demonstrated air in the ventricular system ment, and there is n o swelling of the stroma. which nicely outlined the chiasm. NeuroThere is also much less vascularization in surgical exploration revealed no brain dam this type of keratitis than in luetic intersti age a n d only a tear in the dura in the left tial keratitis. This patient is typical of a syn frontal area, which was repaired. E y e exami drome first described by Cogan in 1945 nation some time after the injury revealed which he has called nonsyphilitic interstitial a vision of 20/20 in the right eye and 20/50 keratitis with vestibuloauditory symptoms. in the left eye. There was residual enophT h e visual aspects carry a good prognosis thalmos of the left eye, plus restricted ocular but the auditory aspects do not. There is no motility on the left and diplopia. H e demon adequate treatment for this condition, nor strated a bitemporal hemianopia. Bitemporal has an etiologic agent been discovered. Serohemianopia due to trauma has rarely been logic tests for syphilis are always negative. described. NEW ENGLAND OPHTHALMOLOGICAL SOCIETY
W E R N I C K E ' S SYNDROME
CATARACT SURGERY
M A U R I C E VICTOR, M.D., presented a 39-
E D W I N B. D U N P H Y , M . D . , discussed some
year-old woman who had been an alcoholic for 11 years. She was admitted with W e r nicke's syndrome and treated with a vitaminfree diet plus thiamine. O n this regimen there has been marked improvement in ocu lar motility. During discussion of this case it was pointed out that only five percent of patients with Wernicke's syndrome have toxic amblyopia.
of the complications of cataract surgery and their management. Retrobulbar hemorrhage following injection of anesthesia calls for cancellation of surgery. Hemorrhage which occurs subconjunctivally as a fixation suture is being placed around the superior rectus can often be controlled by tightening the fix ation suture around the muscle. If a cataract knife is introduced upside down, it is best to withdraw the knife and reinsert it. If the chamber is not formed, a small incison can be made, using scissors to complete the section. Sutures placed too deeply should be withdrawn and replaced.
N O N S Y P H I L I T I C I N T E R S T I T I A L KERATITIS D A V I D G. COGAN, M . D . , presented a 14-
year-old boy who several weeks before first being examined had developed trouble walk-
SOCIETY PROCEEDINGS Continued prolapsing of the iris following corneal section forebodes trouble and meas ures must be taken to reduce any pressure on the globe. An eye in which expulsive choroidal hem orrhage occurs can sometimes be saved by rapid drainage of the subchoroidal space. One may be forewarned of this complica tion by a complaint of sudden severe pain on the part of the patient who up till this point has been satisfactorily anesthetized. Posterior dislocation of the lens at the time of application of forceps or cystotome requires extraction by lens loop. If the lens falls into the vitreous, it may be irrigated therefrom by a strong stream of saline di rected back into the eye. If this procedure is unsuccessful, the lens may be left in the vitreous cavity and, if the capsule has not ruptured, the eye will tolerate the lens in definitely; however, if the capsule has been ruptured, the eye is usually lost. Loss of completely fluid vitreous is of no consequence. Loss of formed vitreous is a serious complication. When formed vitreous is lost, it is necessary to release all tension on the globe to allow the vitreous to retract into the globe. If formed vitreous is lost be fore the lens is extracted and a firm hold is had on the lens capsule, then the lens may gradually be withdrawn from the eye by traction alone. If the lens is not firmly held, it should be removed with a loop. Following the loss of formed vitreous a full iridectomy should be done, if this has not already been done. Rupture of the lens capsule cannot be con sidered a real complication but rather a dis appointment. If anesthesia and akinesia are still good, it is important to remove as much of fragmented capsule and cortex as possible. The use of small forceps to pick up pieces of capsule on the iris surface is justifiable but, when used in the pupil, this procedure carries certain dangers. Nausea occurring during cataract surgery can sometimes by counteracted by inhalation of oxygen. If vomiting occurs, the patient's
991
face should be turned away from the oper ated eye. If vomitus should enter the eye before the lens has been removed, the eye should be irrigated and the wound closed and further surgery postponed. If vomitus enters the eye after removal of the lens, the eye should be irrigated and large doses of anti biotics should be used prophylactically. GLAUCOMA SURGERY PAUL A. CHANDLER, M.D.: Nearly all patients with angle-closure glaucoma are operated on no matter what the stage of the disease. In early stages all closure can be prevented by peripheral iridectomy; in later stages further closure of the angle can be prevented. In some patients who generally have dilated pupils following an acute attack of glaucoma, or a dilation in one meridian, the pupillary block is permanently relieved. In these cases iridectomy will add nothing further. In angle-closure glaucoma, if all or a large portion of the angle is open gonioscopically, iridectomy is the treatment of choice. If one third or more of the angle appears to be closed by synechias, a filtering operation is necessary. In cases in which it is not possible to determine by gonioscopic examination whether or not sufficient angle is open for iridectomy to be effective, it still can be tried if the tension can be normalized by miotics alone; if the C value was high before glau coma appeared (as determined by tonography) ; or if gonioscopy at the time of sur gery after the chamber is deepened shows the angle to be more than two thirds open. Dr. Chandler then described his technique of peripheral iridectomy. He cautioned against the use of scleral cautery in doing peripheral iridectomy so that the danger of producing a filtering scar would be mini mized. He also cautioned against making too small an iridectomy in order to avoid obtain ing only the stroma of the iris and leaving the pigment epithelium intact and therefore, in effect, creating no iridectomy. Following peripheral iridectomy it is important to ob-
992
SOCIETY PROCEEDINGS
serve carefully for signs of iritis and, if they are present, to treat actively with mydriasis and the usual steroids. If a flat chamber oc curs, it must be reformed immediately in order to prevent permanent peripheral an terior synechias. Everyone has his own indications for surgery in open-angle glaucoma. It is axio matic, however, that, in the presence of ad vanced cupping and atrophy, surgery must be done to keep the tension in the teens or low twenties (1948 scale), since eyes with advanced glaucoma will not tolerate tensions higher than this. The operation of choice in open-angle glaucoma is the one with which the individual surgeon is most familiar. In the presence of shallow chambers, trephination may lead to incarceration of the lens in the trephine opening. Dr. Chandler person ally favors trephination in young patients and in cases of so-called low-tension glau coma where marked hypotony is desirable. Certain points of surgical technique which Dr. Chandler has found helpful were de scribed. The first is to make a slanting in cision in the lower portion of the cornea with a needle knife as the first step in any surgical procedure for open-angle glaucoma. This in cision is useful in many ways. In trephining operations it is helpful to deepen the chamber markedly, with saline introduced through this opening prior to trephining the sclera. (In trephining the sclera, it is extremely useful to have a Grieshaber trephine with a guard.) Deepening the anterior chamber through the slanting corneal incision is also useful in cases in which one prefers to use a knife or keratome for making an incision in iris in clusion operations or sclerectomies. At the conclusion of any filtering operation it is useful to inject saline through the slant ing corneal incision in order to determine whether or not the bleb can be formed. If the bleb cannot be formed by this procedure, there is no chance of a successful operation. It is then necessary to examine the wound and correct any obstruction to the opening which may exist.
If buttonholing of the conjunctiva occurs during preparation of the flap, the effect of this can be avoided by moving to a different site to make the scleral incision. If the con junctiva is buttonholed after the sclerectomy has been made, or if the buttonhole is first noted after sclerectomy has been done, it is possible to convert this round hole into a narrow slit by pulling the conjunctiva around the limbus and tacking it to the episclera in an area remote from the wound. This tech nique has been extended to cases in which no buttonhole has been formed in order to tighten the conjunctiva over the sclerectomy and appears to have reduced the incidence of postoperative flat chambers. In angle-closure glaucoma requiring a filtering operation it is essential to open the sclera by an ab-externo incision. Suturing of the conjunctival wound is im portant in avoiding flat chambers. Dr. Chan dler feels that the development of flat cham bers postoperatively is the largest cause of failure of filtering operations. A pressure dressing is useful in helping to form flat chambers. If a chamber remains flat longer than five days, there is not only danger of peripheral anterior synechias occluding the angle but also of failure of the bleb. If the chamber is formed surgically by release of subchoroidal fluid and injection of saline into the anterior chamber and the bleb does not form as the anterior chamber is expanded, forceful injection of saline will sometimes suddenly open the bleb and lead to successful operation. UREA IN ACUTE ANGLE-CLOSURE GLAUCOMA KEVIN H I L L , M.D., JEREMY W H I T N E Y , M.D., AND ROBERT TROTTER, M.D.: The
effects of intravenous hypertonic urea on the tension in 13 patients with acute elevation of intraocular pressure were evaluated. The in traocular pressure was reduced in each of 13 eyes with acute angle-closure glaucoma. In 10 eyes, the tension was lowered to 23 mm. Hg or less. In three other eyes the tension fell only to 40 to 45 mm. Hg. Two of these pa-
SOCIETY PROCEEDINGS tients had pupillary membrane with iris bombe and the third had had elevated ten sion for a considerable period of time. These patients differed in no other way, however, from the other 10. Two elderly women of this series devel oped agitation and confusion following the administration of urea. One of these two patients inadvertently received almost two gm. of urea per kg. of body weight. Both patients returned to a normal mental status following a night of sleep. All other sideeffects were mild. Gonioscopy following lowering of tension by urea revealed that the angle remained closed despite lowering of tension. Hence it may be assumed that urea acts independently of the state of the angle of the anterior chamber. HEMORRHAGIC DIABETIC RETINOPATHY TREATED BY HYPOPHYSEAL STALK SECTION JOEL S. CONTRERAS, M.D., RICHARD A. FIELD, M.D., W. A. HALL, M.D., AND W. H. SWEET, M.D., presented case re
ports on three patients with hemorrhagic retinopathy due to diabetes mellitus in whom favorable effects on the retinopathy were seen after hypophyseal stalk section. In each patient preoperative visual acuity was re corded, slitlamp examination of the anterior segment was performed, and drawings, which were actual mappings of every ves sel aneurysm and hemorrhage, were made. Aneurysms and hemorrhage were related to vascular pattern. Thus location and size of these abnormalities could be accurately fol lowed in relation to the vascular pattern. Photographs of the pre- and postoperative fundus drawings of each patient were pre sented and discussed. Postoperative examination in all three pa tients revealed a dramatic cessation of hem orrhage. Blood absorption was enhanced and proliferation of tissue underneath hemor rhage was prevented. Blood flow within the vessels was improved. Neovascularization was strikingly affected. Racemose aneurysms
993
remained the same but they underwent a shrinking phenomenon. Exudates showed a tendency to slow migration both vertically and horizontally but the exudates themselves have not disappeared. Disappearance of ab normal vitreous turbidity occurred within a few days after the operation. M l G R A I N O I D S Y M P T O M S W I T H CEREBRAL ANOMALIES
ROBERT REINECKE, M.D., reported a case of migrainoid symptoms with certain unusual features. Its pattern of headaches was un usual in that it was always limited to the distribution of the second division of the left trigeminal nerve. A parieto-occipital arteriovenous abnormality was demonstrated which could account for the visual aura. Two aneurysms were demonstrated and a third postulated to explain the salient features of this case. The patient was a 43-year-old woman who had had recurrent headaches since the age of 15years which were preceded by a rightvisual field aura. Three weeks prior to admission she had developed almost daily headaches. She developed a stiff neck nine days prior to admission and vertigo, diplopia and left ptosis developed. On physical examination the left eye showed ptosis, dilation of pupil, and deviation outward, with retention of intorsion. On lumbar puncture the spinal fluid was orange and showed 60,000 red cells per c.mm. Arteriogram showed a balloon-type aneurysm at the origin of the right posterior communicating artery. This aneurysm, how ever, does not explain die patient's left third nerve palsy and left cephalalgia. A left arteri ogram showed an arteriovenous abnormality in the left parietal occipital area. It is neces sary to postulate a third aneurysm of the left posterior communicating artery to explain the third cranial nerve palsy on the left and the cephalalgia. This was not demonstrated on the arteriogram. It is assumed that a clot in this anuerysm prevented demonstration by arteriography. Despite the demonstration of organic
994
SOCIETY PROCEEDINGS
causes of this patient's migraine type dis turbances, it is necessary to postulate idiopathic features to explain the periodicity. This case demonstrates that migraine symp toms might mask pathologic intracranial changes until overt intracranial bleeding oc curs. A constant visual or trigeminal cephalalgia may be sufficient cause for a complete neurosurgical work up. DIAGNOSIS OF ORBITAL LESIONS
IRA S. JONES, M.D., discussed the diagno sis of orbital lesions and said this is primarily a discussion of unilateral exophthalmos. Recognition of exophthalmos can some times be difficult. False readings with the Hertel exophthalmometer are common. A bet ter idea of the presence of exophthalmos and its degree can be obtained by having the pa tient bend his head forward and sighting down the forehead toward the cornea of each eye. It is possible to confuse enophthalmos on one side for exophthalmos on the other. Retraction of the upper lid can also give the appearance of exophthalmos. Paralysis of the extraocular muscles may lead to two mm. or more of exophthalmos. Asymmetry of the skull or orbits may give a true exophthalmos without disease. A large globe may give a false impression of ex ophthalmos. History, inspection, auscultation, study of ocular motility, and palpation are indicated in each patient with exophthalmos in order to make proper differential diagnosis. Gen eral medical examination should follow. Infiltrative exophthalmos due to old thyroid disease may appear many years after a his tory of thyroid disease. The Werner pro vocative test is useful in differentiating thy roid exophthalmos from exophthalmos of other causes. On palpation of the orbit the patient should be asked to look in the direction in which you are palpating. If, for example, the patient looks upward while you are pal pating below, the orbital septum is placed
under tension and a false idea of mass is ob tained. If the patient looks down while the lower orbit is palpated the septum is relaxed' and a truer idea of the contents of the orbit can be obtained. When a mass lies in the muscle cone, there are frequently striae in the posterior portion of the retina. If striae occur more anteriorly, they are not as helpful in establishing the presence of a mass within the muscle cone. In a recent analysis of 100 X-ray films of patients with exophthalmos, 80 percent had abnormal findings. Usual X-ray examination includes the skull, orbits and optic canals. Stereoscopic X-ray films are preferred. Xray findings are calcifications within the or bit, differences in appearances between the two orbits, changes in shape of the orbit, compression of bone from erosion and frac ture, enlargement of the optic canal, and in creased bone density. All other changes are combinations of these six changes. In cases in which the diagnosis is in doubt following the diagnostic procedures outlined herein, exploration of the orbit is carried out. Photographs and radiographs of a number of different patients with different causes of exophthalmos were presented. The Kronlein operation with modifications is the operation of choice for exploration of the orbit and removal of orbital tumors. A technique of exenteration with temporalis graft into the orbit was described. In a series of 230 cases with unilateral exoph thalmos, thyroid disease was the most fre quent cause. Hemangiomas, lymphomas, granulomas, lacrimal gland tumors and meningiomas followed in decreasing fre quency as the causes of unilateral exoph thalmos. Dr. Virgil Casten followed this presenta tion with a description of surgical tech niques in the management of orbital tumors, illustrated by a large number of representa tive cases. Robert J. Herm, Recorder.