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New York Society for Clinical Ophthalmology November 7, 1955
126
SOCIETY PROCEEDINGS
intraocular pressure in the experimental ani mal. T h e site of effect of this hypotensive agent was not identified in these studies. Clinical lowering of intraocular pressure by Thorazine has been reported by Bierent in acute glaucomatous eyes and by Nutt and Wilson after employing Thorazine as a preoperative anesthetic agent. November 17, 1955 18th A N N U A L D E S C H W E I N I T Z OBSERVATIONS
ON OCULAR
LECTURE
PIGMENT AND
PIGMENTATION DR. ALFRED COWAN (Philadelphia): The
characteristics of natural pigment were considered in general, followed by a dis cussion of some particular aspects—normal, anomalous, and pathologic—of pigment and pigmentation of the anterior parts of the eye. Observations and conclusions were based on the slitlamp-microscopic examina tions of actual cases in clinics and private practice over a period of many years. William E . Krewson, 3rd, Clerk. NEW YORK SOCIETY FOR CLINICAL OPHTHALMOLOGY November 7, 1955 D R . BERNARD K R O N E N B E R G ,
of age is the time preferred for operation. Operation is not indicated if vision is good enough to carry on in a normal class room or job. In the case of the completely dislocated congenital lens, surgery is not done unless complications develop, such as uveitis or secondary glaucoma. In the trau matic cases, the partially dislocated lens re quires immediate operation. Lens removal can usually be accomplished with ease; it is not considered a dangerous procedure, and it averts later complications. As for the completely dislocated traumatic lens, operation is not advisable unless uveitis or secondary glaucoma develop. Cases were followed for many years maintaining good aphakic vision without complication. Dr. Iliff presented an excellent color film showing his method of extracting a com pletely dislocated lens by the use of two erisophakes. General anesthesia supple mented by local anesthesia is employed. Iridectomy is performed. A n erisophake of the Floyd-Grant type with the syringe con taining saline solution is introduced behind the lens and solution is injected, causing the lens to bobble u p beneath the iris shelf and, at the same time, separating the vitreous from the lens. T h e second erisophake, of the Bell type, is used to extract the lens in the usual manner after the lens has been brought forward. Preplaced sutures are tied. Miotics are used.
President I N J U R I E S OF T H E EYE
M A N A G E M E N T OF T H E DISLOCATED L E N S
D R . M E Y E R H . R I W C H U N said that, with the availability of corticosteroids, antibi vided the cases into the congenital and trau otics, better needles, sutures, and surgical matic types, a n d considered each from t h e techniques, it is possible to postpone enucleastandpoint of partial or complete dislocation. tion of a severely injured eye until every I n the congenital type, other conditions may effort to save the eye has been exhausted. be associated, such as miosis, amblyopia, or One should bear in mind that sympathetic detachment. The partially dislocated congeni ophthalmia is a rather rare disease. There is tal lens should be removed if vision can be a so-called incubation period of two to improved when the pupil is dilated by giving three weeks, giving one a chance for conserv aphakic vision, if the dislocation of the lens ative therapy. If an enucleation is impera is progressive, o r if t h e lens is becoming tive a second opinion is desirable. cataractous. Between three and seven years Minor injuries and hopelessly injured eyes DR.
CHARLES E.
ILIFF
(Baltimore)
di
SOCIETY PROCEEDINGS were not discussed, only the category of severely injured eyes. These are classified as (1) blunt contusions, and (2) perforat ing intraocular injuries without retained foreign bodies and with retained foreign bodies. Case reports were illustrated by Kodachrome slides. It was pointed out that in the Group 2 category adequate preoperative preparation be made. Sedation, antibiotic therapy, and corticosteroids are used. Whether or not a general anesthetic is employed, thorough local anesthesia, including orbicularis and retrobulbar infiltration, is indicated. In summarizing the entire group of severe eye injuries, certain generalities may be noted: «. 1. Every severely injured eye should have an X-ray study to rule out a metallic or opaque foreign body. If present, it should be accurately localized and removal attempted. 2. A small localized subconjunctival hemorrhage should make one suspect a pene trating injury at the point of hemorrhage, 3. A prolapse of iris or ciliary body usually means that there is no retained foreign body. 4. Sympathetic ophthalmia is not a com mon disease. Its onset, when it does occur, is from two to three weeks following injury, giving one sufficient time to try conservative therapy. 5. If light perception is present, particu larly in all planes, and if there is an absence of pain, an attempt should be made to save the eye. Regardless of what type implant is used with enucleation, the resulting motion is never so good and so lasting as one's own eye. 6. Conversely, if no light perception is present and the ciliary body is badly damaged and there is severe pain, plus the presence of a good remaining eye, then the time-honored therapy of enucleation is indi cated. 7. If enucleation is decided upon, have another ophthalmologist confirm your opin ion.
127
Aside from the specific local or surgical treatment, there is a common denominator of general therapy which can and should be employed: 1. A tetanus toxoid booster shot should be given or if toxoid was never administered tetanus antitoxin, 1,500 units should be given. When this is done, always do an intradermal skin sensitivity test first. 2. A wide choice of antibiotics is avail able. All of us have our own particular favorite. If the patient is not sensitive to penicillin or streptomycin, my choice is penicillin (400,000 units) and streptomycin (0.5 gm.) intramuscularly two hours before surgery, eight hours following surgery, and then daily until danger of infection has dis appeared. In old or contaminated wounds, local subconjunctival "penicillin (100,000 units) is also administered at the conclusion of surgery. 3. ACTH or Metacorten or both, the former intravenously or intramuscularly and the latter orally, is given if there is no infection present, and if an iridocyclitis is anticipated. Discussion. DR. FREDERICK H. THEODORE
asked about the use of the Berman localizer and also commented that there is a certain amount of danger in giving steroids to an injured eye to cut down the postoperative inflammation. DR. R I W C H U N said that the Berman local izer is a valuable adjunct to localizing intra ocular foreign bodies. It is very useful, especially in large nonmagnetic foreign bodies or small magnetic foreign bodies. As far as nonmagnetic foreign bodies are con cerned, the most difficult ones that I have encountered are splinters of glass or wood. At times it has been impossible to remove them with preservation of the eye. As for the use of steroids in an injured eye, these would be given whenever an iritis or irido cyclitis is anticipated or whenever there is a great deal of edema and exudate. If in fection is present, one must be sure to sup plement steroid therapy with antibiotics. If
SOCIETY PROCEEDINGS
128
a severe infection is present, I would not recommend the use of steroid therapy but would concentrate on antibiotics. Steroid therapy should not be used if a virus disease is present. DR. FREED asked about the use of mydriatics in a case in which the anterior chamber is filled with blood. DR. RIWCHUN replied that the only mydriatic he would use would be homatropine so that one could inspect the interior of the eye, if possible, to rule out a dislocated lens, and so forth. Homatropine could be con trolled with eserine or pilocarpine, if neces sary. One should not use atropine if the chamber has a great deal of blood. DR. MAX CHAMLIN asked about the in jection of air into the orbit to help localize a foreign body. DR. RIWCHUN stated that the air should be injected into Tenon's capsule, which gives us a good outline of the globe and shows whether the foreign body is in the globe itself or outside the globe. This fre quently is quite helpful in the differential diagnosis. About two cc. of air would be employed. DR. BERNARD KRONENBERG asked about the use of Diamox in hyphemas. DR. RIWCHUN recommended its use when the tension is elevated. If this does not help, one should resort to paracentesis and re moval of the blood from the chamber. December 5, 1955 AQUEOUS VEINS AND THEIR RELATION TO GLAUCOMA DR. GEORGIANA DVORAK-THEOBALD
(Oak
Park, Illinois) delivered the ninth annual Mark J. Schoenberg Memorial Lecture, under the auspices of the New York Society for Clinical Ophthalmology and the National Society for the Prevention of Blindness. By means of serial sections, aqueous path ways were studied in three normal eyes. The sections were studied in consecutive order; reconstructions were made by means of
drawings and models. Instead of being an oval channel as pictured in text books, the canal of Schlemm is a slit in the sclera, irregular in form, and in places it divides into two to four channels. From the anterior surface of the canal, collector channels make their way through the sclera. These are slits, lined with a single layer of endothelium, and have no other wall. These external channels anastomose freely in the depths of the sclera; they anas tomose occasionally with the other three plexuses in this region. When a branch of the collector channels reaches the episcleral veins to anastomose with the episcleral ves sels, it is seen clinically and is called an aqueous vein. Openings were found between the intratrabecular spaces into the canal of Schlemm. These had been described by Sondermann. Just as the external collector channels and the scleral veins are slits in the sclera lined with a single layer of endothelium, so the inner canals are slits in the outermost layers of the trabeculae and, as such, their walls have all the tough qualities of the trabecular fibers. By means of superimposed drawings on transparent paper, it was possible to trace and reproduce the drainage system from the anterior chamber through the intratrabecular spaces, and through the inner canals of Sondermann into the canal of Schlemm. This anatomic study shows unobstructed pathways for the outflow of aqueous from the anterior chamber to the anterior ciliary veins and the ciliary body. Ascher and Goldmann were the first to write about aqueous veins, both in normal eyes and in eyes suffering with glaucoma. Their findings on these veins in glaucoma led to investigation of what happens to these veins in this disease. Since these pathways are simple slits in the sclera lined with endo thelium, obstruction to outflow can happen in several ways. In inflammation, cells may block the passages by massing inside the vein or by gathering between the endothelium and sclera. In pseudocapsular exfoliation, the
SOCIETY PROCEEDINGS
intraocular pressure in the experimental ani mal. T h e site of effect of this hypotensive agent was not identified in these studies. Clinical lowering of intraocular pressure by Thorazine has been reported by Bierent in acute glaucomatous eyes and by Nutt and Wilson after employing Thorazine as a preoperative anesthetic agent. November 17, 1955 18th A N N U A L D E S C H W E I N I T Z OBSERVATIONS
ON OCULAR
LECTURE
PIGMENT AND
PIGMENTATION DR. ALFRED COWAN (Philadelphia): The
characteristics of natural pigment were considered in general, followed by a dis cussion of some particular aspects—normal, anomalous, and pathologic—of pigment and pigmentation of the anterior parts of the eye. Observations and conclusions were based on the slitlamp-microscopic examina tions of actual cases in clinics and private practice over a period of many years. William E . Krewson, 3rd, Clerk. NEW YORK SOCIETY FOR CLINICAL OPHTHALMOLOGY November 7, 1955 D R . BERNARD K R O N E N B E R G ,
of age is the time preferred for operation. Operation is not indicated if vision is good enough to carry on in a normal class room or job. In the case of the completely dislocated congenital lens, surgery is not done unless complications develop, such as uveitis or secondary glaucoma. In the trau matic cases, the partially dislocated lens re quires immediate operation. Lens removal can usually be accomplished with ease; it is not considered a dangerous procedure, and it averts later complications. As for the completely dislocated traumatic lens, operation is not advisable unless uveitis or secondary glaucoma develop. Cases were followed for many years maintaining good aphakic vision without complication. Dr. Iliff presented an excellent color film showing his method of extracting a com pletely dislocated lens by the use of two erisophakes. General anesthesia supple mented by local anesthesia is employed. Iridectomy is performed. A n erisophake of the Floyd-Grant type with the syringe con taining saline solution is introduced behind the lens and solution is injected, causing the lens to bobble u p beneath the iris shelf and, at the same time, separating the vitreous from the lens. T h e second erisophake, of the Bell type, is used to extract the lens in the usual manner after the lens has been brought forward. Preplaced sutures are tied. Miotics are used.
President I N J U R I E S OF T H E EYE
M A N A G E M E N T OF T H E DISLOCATED L E N S
D R . M E Y E R H . R I W C H U N said that, with the availability of corticosteroids, antibi vided the cases into the congenital and trau otics, better needles, sutures, and surgical matic types, a n d considered each from t h e techniques, it is possible to postpone enucleastandpoint of partial or complete dislocation. tion of a severely injured eye until every I n the congenital type, other conditions may effort to save the eye has been exhausted. be associated, such as miosis, amblyopia, or One should bear in mind that sympathetic detachment. The partially dislocated congeni ophthalmia is a rather rare disease. There is tal lens should be removed if vision can be a so-called incubation period of two to improved when the pupil is dilated by giving three weeks, giving one a chance for conserv aphakic vision, if the dislocation of the lens ative therapy. If an enucleation is impera is progressive, o r if t h e lens is becoming tive a second opinion is desirable. cataractous. Between three and seven years Minor injuries and hopelessly injured eyes DR.
CHARLES E.
ILIFF
(Baltimore)
di
SOCIETY PROCEEDINGS were not discussed, only the category of severely injured eyes. These are classified as (1) blunt contusions, and (2) perforat ing intraocular injuries without retained foreign bodies and with retained foreign bodies. Case reports were illustrated by Kodachrome slides. It was pointed out that in the Group 2 category adequate preoperative preparation be made. Sedation, antibiotic therapy, and corticosteroids are used. Whether or not a general anesthetic is employed, thorough local anesthesia, including orbicularis and retrobulbar infiltration, is indicated. In summarizing the entire group of severe eye injuries, certain generalities may be noted: «. 1. Every severely injured eye should have an X-ray study to rule out a metallic or opaque foreign body. If present, it should be accurately localized and removal attempted. 2. A small localized subconjunctival hemorrhage should make one suspect a pene trating injury at the point of hemorrhage, 3. A prolapse of iris or ciliary body usually means that there is no retained foreign body. 4. Sympathetic ophthalmia is not a com mon disease. Its onset, when it does occur, is from two to three weeks following injury, giving one sufficient time to try conservative therapy. 5. If light perception is present, particu larly in all planes, and if there is an absence of pain, an attempt should be made to save the eye. Regardless of what type implant is used with enucleation, the resulting motion is never so good and so lasting as one's own eye. 6. Conversely, if no light perception is present and the ciliary body is badly damaged and there is severe pain, plus the presence of a good remaining eye, then the time-honored therapy of enucleation is indi cated. 7. If enucleation is decided upon, have another ophthalmologist confirm your opin ion.
127
Aside from the specific local or surgical treatment, there is a common denominator of general therapy which can and should be employed: 1. A tetanus toxoid booster shot should be given or if toxoid was never administered tetanus antitoxin, 1,500 units should be given. When this is done, always do an intradermal skin sensitivity test first. 2. A wide choice of antibiotics is avail able. All of us have our own particular favorite. If the patient is not sensitive to penicillin or streptomycin, my choice is penicillin (400,000 units) and streptomycin (0.5 gm.) intramuscularly two hours before surgery, eight hours following surgery, and then daily until danger of infection has dis appeared. In old or contaminated wounds, local subconjunctival "penicillin (100,000 units) is also administered at the conclusion of surgery. 3. ACTH or Metacorten or both, the former intravenously or intramuscularly and the latter orally, is given if there is no infection present, and if an iridocyclitis is anticipated. Discussion. DR. FREDERICK H. THEODORE
asked about the use of the Berman localizer and also commented that there is a certain amount of danger in giving steroids to an injured eye to cut down the postoperative inflammation. DR. R I W C H U N said that the Berman local izer is a valuable adjunct to localizing intra ocular foreign bodies. It is very useful, especially in large nonmagnetic foreign bodies or small magnetic foreign bodies. As far as nonmagnetic foreign bodies are con cerned, the most difficult ones that I have encountered are splinters of glass or wood. At times it has been impossible to remove them with preservation of the eye. As for the use of steroids in an injured eye, these would be given whenever an iritis or irido cyclitis is anticipated or whenever there is a great deal of edema and exudate. If in fection is present, one must be sure to sup plement steroid therapy with antibiotics. If
SOCIETY PROCEEDINGS
128
a severe infection is present, I would not recommend the use of steroid therapy but would concentrate on antibiotics. Steroid therapy should not be used if a virus disease is present. DR. FREED asked about the use of mydriatics in a case in which the anterior chamber is filled with blood. DR. RIWCHUN replied that the only mydriatic he would use would be homatropine so that one could inspect the interior of the eye, if possible, to rule out a dislocated lens, and so forth. Homatropine could be con trolled with eserine or pilocarpine, if neces sary. One should not use atropine if the chamber has a great deal of blood. DR. MAX CHAMLIN asked about the in jection of air into the orbit to help localize a foreign body. DR. RIWCHUN stated that the air should be injected into Tenon's capsule, which gives us a good outline of the globe and shows whether the foreign body is in the globe itself or outside the globe. This fre quently is quite helpful in the differential diagnosis. About two cc. of air would be employed. DR. BERNARD KRONENBERG asked about the use of Diamox in hyphemas. DR. RIWCHUN recommended its use when the tension is elevated. If this does not help, one should resort to paracentesis and re moval of the blood from the chamber. December 5, 1955 AQUEOUS VEINS AND THEIR RELATION TO GLAUCOMA DR. GEORGIANA DVORAK-THEOBALD
(Oak
Park, Illinois) delivered the ninth annual Mark J. Schoenberg Memorial Lecture, under the auspices of the New York Society for Clinical Ophthalmology and the National Society for the Prevention of Blindness. By means of serial sections, aqueous path ways were studied in three normal eyes. The sections were studied in consecutive order; reconstructions were made by means of
drawings and models. Instead of being an oval channel as pictured in text books, the canal of Schlemm is a slit in the sclera, irregular in form, and in places it divides into two to four channels. From the anterior surface of the canal, collector channels make their way through the sclera. These are slits, lined with a single layer of endothelium, and have no other wall. These external channels anastomose freely in the depths of the sclera; they anas tomose occasionally with the other three plexuses in this region. When a branch of the collector channels reaches the episcleral veins to anastomose with the episcleral ves sels, it is seen clinically and is called an aqueous vein. Openings were found between the intratrabecular spaces into the canal of Schlemm. These had been described by Sondermann. Just as the external collector channels and the scleral veins are slits in the sclera lined with a single layer of endothelium, so the inner canals are slits in the outermost layers of the trabeculae and, as such, their walls have all the tough qualities of the trabecular fibers. By means of superimposed drawings on transparent paper, it was possible to trace and reproduce the drainage system from the anterior chamber through the intratrabecular spaces, and through the inner canals of Sondermann into the canal of Schlemm. This anatomic study shows unobstructed pathways for the outflow of aqueous from the anterior chamber to the anterior ciliary veins and the ciliary body. Ascher and Goldmann were the first to write about aqueous veins, both in normal eyes and in eyes suffering with glaucoma. Their findings on these veins in glaucoma led to investigation of what happens to these veins in this disease. Since these pathways are simple slits in the sclera lined with endo thelium, obstruction to outflow can happen in several ways. In inflammation, cells may block the passages by massing inside the vein or by gathering between the endothelium and sclera. In pseudocapsular exfoliation, the