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Ophthalmoplegia and Optic Neuritis
APPARENT ACCOMMODATION IN APHAKIA
6. Forward bulging of the anterior surface of the vitreous, or an increase in corneal curvature by pressure of the external muscles. 7. Spherical aberration (largely compensated for by the lens in the normal condition) (Kroner). 6 8. Thru adjustment of the cataract lens. It is probably true, as Donder's asserts, that many who have written upon the subject have had no idea of the degree of distinctness of vision even in imperfect accommodation and that many of the cases of apparent accommodation may thus be explained. Schmidt-Rimpler 7 states that with his own aphakic eye on close observation of single letters he finds vision to be perfectly sharp only at a single distance. I believe that many are unaware of the ability of an eye without accommodation to read without a glass very fine print up to within a few cm. of the cornea, thru a pin hole aperture in a card held close to the cornea (of course we are all aware of the fact that an uncorrected highly astigmatic eye can have normal vision thru a. pin
571
hole). This ability to read by cutting down the circles of diffusion I believe explains my own case as Collins and also Landrieu explain their cases. Other contributing factors are, no doubt, irregular astigmatism and also regular astigmatism, tho Kroner found that the region of accommodation does not correspond to the optical distances between the two foci; and that it is generally greater in eyes with little astigmatism and less in highly astigmatic eyes. This author believes that in general it results from influences which by diminished visual acuity lessens the necessity of exact focussing. Fuerst believes it to be caused by a vicarious function from the pressure of the orbicularis and external muscles which develops sometimes after the operation and only when the correcting lenses have been withheld from the patient (this is disproved by Collins' case and also by my o w n ) , and further believes that it finds a certain analogue in- isolated observations of abnormal refraction in eyes containing their crystalline lens.
BIBLIOGRAPHY.
1. 2. 3. 4. 5. 6. 7.
Donders. Accommodation and Refraction of the Eye, p. 319. Fuerst. Graefe's ATch. f. Ophih., v. 65, Ht. 1. Pfalz. Zeit. f.( Augenh., v. 25, p. 102. Landrieu. La Clinique Ophtalmologique, v. 20, p. 203. Collins. Ophthalmic Record, v. 24, p. 380. Kroner. Zeit. f. Augenh., v. 24, p. 346. Schmidt-Rimpler. Klin. Monatsbl. f. Augenh. 1911, 1, p. 692.
NOTES, CASES, INSTRUMENTS OPHTHALMOPLEGIA AND OPTIC NEURITIS. Report of Cases. FRANK A.
MORRISON.
INDIANAPOLIS,
IND.
OPHTHALMOPLEGIA FOLLOWING PROPHY' L A C T I C DOSE OF A N T I T O X I N .
Boy, age 7. History as given by the mother, and grandmother. Last Sep-
tember one of the other children of the family was attacked by diphtheria. This boy was given a prophylactic injection of antitoxin. Three days later his eyelids began to droop, and have continued to do so up to this time, altho the mother thought at times they were better. The child presented the ordinary picture of complete ophthalmoplegia. The mother persisted in the statement that
FRANK A. MORRISON
572
the child had never been sick and that nothing peculiar in its gait in walking, speech or swallowing had ever been noticed. Unfortunately it was not possible to communicate with the physician in attendance and the amount of antitoxin injected could not be learned. Diagnosis: uncertain, ophthalmoplegia possibly from antitoxin or possibly from a mild and unrecognized diphtheria or even the possibility of a mere coincidence must not be overlooked. OPTIC
NEURITIS
W I T H - RECOVERY.
Girl twelve years of age. Had been perfectly well, but noticed one morning about a week before coming to my office that she could not see the largest writing on the blackboard at school, with her right eye, even when a few inches away. She was positive she could see when she went home the .night before. This child was an unusually bright girl and mentioned several experiments which she had made in the way of testing her vision a few ■days before she discovered her condition. Her home surroundings had not been good and she had been subjected to a great deal of distress owing to the misconduct of her father. She had no headache, vomiting nor indeed symptoms of any kind. Reflexes all normal. No indication of paralysis or lack of coordination. Pupils responded to light and accommodation normally. Fundus of right eye showed typical choked disc of three diopters with a few retinal hemorrhages. Further questioning as to the possibility of injury brought out the fact that she had fallen upon her back a few days before the appearance of the eye symptoms; but she insisted she had not been hurt. Being pressed to tell just how she struck when she slipped she finally said, " W h y I never thought of it but I don't believe I remember. Do you think I could have jarred my senses away?" There was no bruise upon the head or spine to indicate injury. She returned home in a neighboring town with a rather uncertain diagnosis relative to the cause of her condition and a still more uncertain prognosis.
A few weeks later she was sent to a hospital in this city for observation and again came under my notice. An examination of the fundus showed the same condition as when last seen but somewhat less marked. She was selected as one of the patients to have a mydriatic put into the eyes for class demonstration four days later. When she came before the class at the end of this period the fundus was almost normal and the improvement continued to complete recovery. While in the hospital X-ray pictures of the head showed in the language of the resident surgeon "a faint shadow in the occipital region which might indicate a slight fracture." CASE O F H O L E I N DISC. CHARLES B. HARWOOD, M. HOUSTON,
D.
TEXAS.
The patient, Mr. K., aged 28, had vision in the right eye of 20/200. Ophthalmoscopic examination of the right
FIG. 1. Harwood's case of hole in disc. Diagram showing vessel at bottom of hole near temporal margin of disc.
eye showed a triangular hole on the temporal side of the disc just below the center. The edges of the hole overhung the floor as shown by two minute blood vessels which disappeared at its edge. A —8 D. lens showed another blood vessel at the bottom of the hole crossing it diagonally.
6. Forward bulging of the anterior surface of the vitreous, or an increase in corneal curvature by pressure of the external muscles. 7. Spherical aberration (largely compensated for by the lens in the normal condition) (Kroner). 6 8. Thru adjustment of the cataract lens. It is probably true, as Donder's asserts, that many who have written upon the subject have had no idea of the degree of distinctness of vision even in imperfect accommodation and that many of the cases of apparent accommodation may thus be explained. Schmidt-Rimpler 7 states that with his own aphakic eye on close observation of single letters he finds vision to be perfectly sharp only at a single distance. I believe that many are unaware of the ability of an eye without accommodation to read without a glass very fine print up to within a few cm. of the cornea, thru a pin hole aperture in a card held close to the cornea (of course we are all aware of the fact that an uncorrected highly astigmatic eye can have normal vision thru a. pin
571
hole). This ability to read by cutting down the circles of diffusion I believe explains my own case as Collins and also Landrieu explain their cases. Other contributing factors are, no doubt, irregular astigmatism and also regular astigmatism, tho Kroner found that the region of accommodation does not correspond to the optical distances between the two foci; and that it is generally greater in eyes with little astigmatism and less in highly astigmatic eyes. This author believes that in general it results from influences which by diminished visual acuity lessens the necessity of exact focussing. Fuerst believes it to be caused by a vicarious function from the pressure of the orbicularis and external muscles which develops sometimes after the operation and only when the correcting lenses have been withheld from the patient (this is disproved by Collins' case and also by my o w n ) , and further believes that it finds a certain analogue in- isolated observations of abnormal refraction in eyes containing their crystalline lens.
BIBLIOGRAPHY.
1. 2. 3. 4. 5. 6. 7.
Donders. Accommodation and Refraction of the Eye, p. 319. Fuerst. Graefe's ATch. f. Ophih., v. 65, Ht. 1. Pfalz. Zeit. f.( Augenh., v. 25, p. 102. Landrieu. La Clinique Ophtalmologique, v. 20, p. 203. Collins. Ophthalmic Record, v. 24, p. 380. Kroner. Zeit. f. Augenh., v. 24, p. 346. Schmidt-Rimpler. Klin. Monatsbl. f. Augenh. 1911, 1, p. 692.
NOTES, CASES, INSTRUMENTS OPHTHALMOPLEGIA AND OPTIC NEURITIS. Report of Cases. FRANK A.
MORRISON.
INDIANAPOLIS,
IND.
OPHTHALMOPLEGIA FOLLOWING PROPHY' L A C T I C DOSE OF A N T I T O X I N .
Boy, age 7. History as given by the mother, and grandmother. Last Sep-
tember one of the other children of the family was attacked by diphtheria. This boy was given a prophylactic injection of antitoxin. Three days later his eyelids began to droop, and have continued to do so up to this time, altho the mother thought at times they were better. The child presented the ordinary picture of complete ophthalmoplegia. The mother persisted in the statement that
FRANK A. MORRISON
572
the child had never been sick and that nothing peculiar in its gait in walking, speech or swallowing had ever been noticed. Unfortunately it was not possible to communicate with the physician in attendance and the amount of antitoxin injected could not be learned. Diagnosis: uncertain, ophthalmoplegia possibly from antitoxin or possibly from a mild and unrecognized diphtheria or even the possibility of a mere coincidence must not be overlooked. OPTIC
NEURITIS
W I T H - RECOVERY.
Girl twelve years of age. Had been perfectly well, but noticed one morning about a week before coming to my office that she could not see the largest writing on the blackboard at school, with her right eye, even when a few inches away. She was positive she could see when she went home the .night before. This child was an unusually bright girl and mentioned several experiments which she had made in the way of testing her vision a few ■days before she discovered her condition. Her home surroundings had not been good and she had been subjected to a great deal of distress owing to the misconduct of her father. She had no headache, vomiting nor indeed symptoms of any kind. Reflexes all normal. No indication of paralysis or lack of coordination. Pupils responded to light and accommodation normally. Fundus of right eye showed typical choked disc of three diopters with a few retinal hemorrhages. Further questioning as to the possibility of injury brought out the fact that she had fallen upon her back a few days before the appearance of the eye symptoms; but she insisted she had not been hurt. Being pressed to tell just how she struck when she slipped she finally said, " W h y I never thought of it but I don't believe I remember. Do you think I could have jarred my senses away?" There was no bruise upon the head or spine to indicate injury. She returned home in a neighboring town with a rather uncertain diagnosis relative to the cause of her condition and a still more uncertain prognosis.
A few weeks later she was sent to a hospital in this city for observation and again came under my notice. An examination of the fundus showed the same condition as when last seen but somewhat less marked. She was selected as one of the patients to have a mydriatic put into the eyes for class demonstration four days later. When she came before the class at the end of this period the fundus was almost normal and the improvement continued to complete recovery. While in the hospital X-ray pictures of the head showed in the language of the resident surgeon "a faint shadow in the occipital region which might indicate a slight fracture." CASE O F H O L E I N DISC. CHARLES B. HARWOOD, M. HOUSTON,
D.
TEXAS.
The patient, Mr. K., aged 28, had vision in the right eye of 20/200. Ophthalmoscopic examination of the right
FIG. 1. Harwood's case of hole in disc. Diagram showing vessel at bottom of hole near temporal margin of disc.
eye showed a triangular hole on the temporal side of the disc just below the center. The edges of the hole overhung the floor as shown by two minute blood vessels which disappeared at its edge. A —8 D. lens showed another blood vessel at the bottom of the hole crossing it diagonally.