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Paracentral Homonymous Hemianopic Scotoma
NOTES, CASES, INSTRUMENTS PARACENTRAL HOMONYMOUS HEMIANOPIC SCOTOMA
homonymous field defects are more likely to be incongruous. Since the scotoma is paracentral, F. H. NEWTON, M.D. central vision is left intact. This spar DALLAS, TEXAS ing of the point of fixation brings up A case of paracentral homonymous again the old controversy concerning hemianopic scotoma is of sufficient the distribution of the macular fibers. rarity and interest to justify reporting. Consensus of investigators points to a Such a condition occurring spontane broad but definite localization of the ously is characterized by (1) sudden macula in the visual pathway. A con onset, (2) field changes consisting of servative cross section of opinion is typical, congruous, almost superim- probably represented by the position posable scotomas, (3) retention of of Duke-Elder. He feels that the cor central visual acuity, (4) difficulty in tical representation of the macula is reading due to loss of indirect vision proportionately large and is located at immediately adjacent to the macula, the occipital pole. This representation is very broad but not bilateral. The sparing of the fixation point can be at tributed to the broad representation Xy ±_.it*X with its double blood supply. The 5hh:::::±d|:S 5 farther back in the visual pathway the :::::: S-:|jJ | : : : lesion is located the more definite is the :::|::-i::li!|j;: sparing of the fixation point, which fact, : :: : also, indicates that a posterior location j =5^ = j-i# 5 of the lesion causes the type of scotoma pSSi 3£KX under consideration. iSftiiii M i n i m i ^ When the scotoma is on the right, Fig. 1 (Newton). Paracentral homonymous there is difficulty in reading because we hemianopic scotoma. fixate the first word or syllable by di rect vision and depend on seeing the and (5) absence of ophthalmoscopic rest of the word or second word by in findings if uncomplicated. direct vision. When the scotoma is on Since in most instances the origin has the left, there is difficulty in finding the a vascular basis, the sudden onset is first word of succeeding lines. to be expected. The patients in the fewThe absence of ophthalmoscopic find cases reported were usually past 60 ings, aside from possible evidence of years of age, when cardiac and vascular arteriosclerosis, is, of course, due to pathology is common. The lesion is the central location of the lesion. often neither progressive nor regres Case report. Mrs. W . H. C , white, sive. Thrombosis of a small artery in aged 66 years, applied for examina the calcarine region is probably the tion on November 25, 1929, com most usual cause, though an embolus plaining of difficulty in reading and may produce the same result. worry through fear of losing her sight. As stated, the typical change is a In reading there was difficulty in seeing paracentral, homonymous, hemianopic, the last part of a word or the next word usually complete scotoma, with the without fixating each part separately. blind area for each eye almost superim- This condition had developed suddenly posable. This congruity points to. a a few days before this examination. lesion in the posterior part of the gen- She had been reading extensively to a iculocalcarine pathway where vascular sick husband and was worried on ac changes constitute the chief causal count of his physical condition. Direct factor involving the visual tract. When vision was normal in each eye. Oph the lesions are farther anterior, the thalmoscopic examination was nega600
?^m#s
NOTES, CASES, INSTRUMENTS
tive, as was complete physical examina tion by an internist, with exception of moderate arteriosclerosis. Blood pres sure was 130 systolic and 80 diastolic. Field studies showed paracentral scotomas as indicated in the illustration. Subsequent examination showed no change in direct vision or refraction until November, 1935, at which time there had developed a moderate myopia with chronic uveitis evidenced by a con siderable number of vitreous floating particles. No real change occurred in the size of the scotomas over a period of six years. Slight differences are easily ascribed to personal variations of
601
the patient or individual taking the field. Comment. This case illustrates the importance of being on the watch for such scotomas to explain certain read ing difficulties. The prognosis for im provement is not good but may be quite good as far as further loss of vision is concerned. In nontraumatic cases the lesion is usually vascular in origin and often due to a thrombosis in the calcarine area. This patient was seen by Dr. Ernst Fuchs, who ascribed the con dition to an arterial thrombosis in the region of the right calcarine fissure. Mercantile Bank Building.
References Barkan, O., and Barkan, H. Central and paracentral homonymous hemianopic scotoma. Artier. Jour. Ophth., 1930, v. 13, Oct., p. 853. Barkan, O., and Boyle, S. F. Paracentral homonymous hemianopic scotoma. Arch, of Ophth., 1935, v. 14, Dec, p. 957. Duke-Elder. Recent advances in ophthalmology. Ed. 1, 1928. Lillie, W. I. Homonymous hemianopsia. Trans., Sect. Ophth., Amer. Med. Assoc, 1929.
THE USE OF CALLAHAN TUBES IN THE TREATMENT OF CHRONIC DACRYOCYSTITIS CHARLES NELSON SPRATT, MINNEAPOLIS
M.D.
Epiphora due to lacrimal obstruc tion is often endured for many years; whereas an acute lacrimal abscess or corneal ulcer following injury causes the patient promptly to seek medical aid. Every infected sac is a menace to the safety of the eye, and a slight corneal lesion may become infected. The increased secretion of the lacrimal gland due to the reflex irritation causes a lessened lysozyme content of the tears, consequently the inhibiting ac tion of the latter is diminished and the pneumococcus, frequently present in the sac, becomes the infecting agent. Many methods have been suggested for the relief of lacrimal stenosis and chronic dacryocystitis. If the obstruc tion is due to swelling of the lining of the sac following a catarrhal condition, relief may be obtained by irrigation with a mild astringent and antiseptics as suggested by Anel (1712). Such
treatment is of little value if a true stric ture is present. Bowman, in 1851, used probes to di late lacrimal structures. Credit is due Theobald (1877) for the use of largesized probes. He advocated the number 12 to 14 size (3 to 3.5 mm. in diameter) as measurements showed that in the cadaver the average diameter of 10 adult male lacrimal ducts was 4.47 mm.; one was as large as 7 mm. The persistent use of the large probes will in most cases relieve the stenosis and permit drainage, just as the use of large sounds will relieve urethral strictures. Few patients will spend the time and endure the pain of a course of probing with the Theobald probes. Lagrange and others have advocated the use of electrolysis to relieve stric tures. The negative pole is connected to an electrode in the lacrimal duct and a current of 2 milliamperes is used for 30 seconds. This method is of question able value and has been adopted by few surgeons. Incision of the skin and destruction of the sac by means of the actual cau tery or by escharotics was suggested by
homonymous field defects are more likely to be incongruous. Since the scotoma is paracentral, F. H. NEWTON, M.D. central vision is left intact. This spar DALLAS, TEXAS ing of the point of fixation brings up A case of paracentral homonymous again the old controversy concerning hemianopic scotoma is of sufficient the distribution of the macular fibers. rarity and interest to justify reporting. Consensus of investigators points to a Such a condition occurring spontane broad but definite localization of the ously is characterized by (1) sudden macula in the visual pathway. A con onset, (2) field changes consisting of servative cross section of opinion is typical, congruous, almost superim- probably represented by the position posable scotomas, (3) retention of of Duke-Elder. He feels that the cor central visual acuity, (4) difficulty in tical representation of the macula is reading due to loss of indirect vision proportionately large and is located at immediately adjacent to the macula, the occipital pole. This representation is very broad but not bilateral. The sparing of the fixation point can be at tributed to the broad representation Xy ±_.it*X with its double blood supply. The 5hh:::::±d|:S 5 farther back in the visual pathway the :::::: S-:|jJ | : : : lesion is located the more definite is the :::|::-i::li!|j;: sparing of the fixation point, which fact, : :: : also, indicates that a posterior location j =5^ = j-i# 5 of the lesion causes the type of scotoma pSSi 3£KX under consideration. iSftiiii M i n i m i ^ When the scotoma is on the right, Fig. 1 (Newton). Paracentral homonymous there is difficulty in reading because we hemianopic scotoma. fixate the first word or syllable by di rect vision and depend on seeing the and (5) absence of ophthalmoscopic rest of the word or second word by in findings if uncomplicated. direct vision. When the scotoma is on Since in most instances the origin has the left, there is difficulty in finding the a vascular basis, the sudden onset is first word of succeeding lines. to be expected. The patients in the fewThe absence of ophthalmoscopic find cases reported were usually past 60 ings, aside from possible evidence of years of age, when cardiac and vascular arteriosclerosis, is, of course, due to pathology is common. The lesion is the central location of the lesion. often neither progressive nor regres Case report. Mrs. W . H. C , white, sive. Thrombosis of a small artery in aged 66 years, applied for examina the calcarine region is probably the tion on November 25, 1929, com most usual cause, though an embolus plaining of difficulty in reading and may produce the same result. worry through fear of losing her sight. As stated, the typical change is a In reading there was difficulty in seeing paracentral, homonymous, hemianopic, the last part of a word or the next word usually complete scotoma, with the without fixating each part separately. blind area for each eye almost superim- This condition had developed suddenly posable. This congruity points to. a a few days before this examination. lesion in the posterior part of the gen- She had been reading extensively to a iculocalcarine pathway where vascular sick husband and was worried on ac changes constitute the chief causal count of his physical condition. Direct factor involving the visual tract. When vision was normal in each eye. Oph the lesions are farther anterior, the thalmoscopic examination was nega600
?^m#s
NOTES, CASES, INSTRUMENTS
tive, as was complete physical examina tion by an internist, with exception of moderate arteriosclerosis. Blood pres sure was 130 systolic and 80 diastolic. Field studies showed paracentral scotomas as indicated in the illustration. Subsequent examination showed no change in direct vision or refraction until November, 1935, at which time there had developed a moderate myopia with chronic uveitis evidenced by a con siderable number of vitreous floating particles. No real change occurred in the size of the scotomas over a period of six years. Slight differences are easily ascribed to personal variations of
601
the patient or individual taking the field. Comment. This case illustrates the importance of being on the watch for such scotomas to explain certain read ing difficulties. The prognosis for im provement is not good but may be quite good as far as further loss of vision is concerned. In nontraumatic cases the lesion is usually vascular in origin and often due to a thrombosis in the calcarine area. This patient was seen by Dr. Ernst Fuchs, who ascribed the con dition to an arterial thrombosis in the region of the right calcarine fissure. Mercantile Bank Building.
References Barkan, O., and Barkan, H. Central and paracentral homonymous hemianopic scotoma. Artier. Jour. Ophth., 1930, v. 13, Oct., p. 853. Barkan, O., and Boyle, S. F. Paracentral homonymous hemianopic scotoma. Arch, of Ophth., 1935, v. 14, Dec, p. 957. Duke-Elder. Recent advances in ophthalmology. Ed. 1, 1928. Lillie, W. I. Homonymous hemianopsia. Trans., Sect. Ophth., Amer. Med. Assoc, 1929.
THE USE OF CALLAHAN TUBES IN THE TREATMENT OF CHRONIC DACRYOCYSTITIS CHARLES NELSON SPRATT, MINNEAPOLIS
M.D.
Epiphora due to lacrimal obstruc tion is often endured for many years; whereas an acute lacrimal abscess or corneal ulcer following injury causes the patient promptly to seek medical aid. Every infected sac is a menace to the safety of the eye, and a slight corneal lesion may become infected. The increased secretion of the lacrimal gland due to the reflex irritation causes a lessened lysozyme content of the tears, consequently the inhibiting ac tion of the latter is diminished and the pneumococcus, frequently present in the sac, becomes the infecting agent. Many methods have been suggested for the relief of lacrimal stenosis and chronic dacryocystitis. If the obstruc tion is due to swelling of the lining of the sac following a catarrhal condition, relief may be obtained by irrigation with a mild astringent and antiseptics as suggested by Anel (1712). Such
treatment is of little value if a true stric ture is present. Bowman, in 1851, used probes to di late lacrimal structures. Credit is due Theobald (1877) for the use of largesized probes. He advocated the number 12 to 14 size (3 to 3.5 mm. in diameter) as measurements showed that in the cadaver the average diameter of 10 adult male lacrimal ducts was 4.47 mm.; one was as large as 7 mm. The persistent use of the large probes will in most cases relieve the stenosis and permit drainage, just as the use of large sounds will relieve urethral strictures. Few patients will spend the time and endure the pain of a course of probing with the Theobald probes. Lagrange and others have advocated the use of electrolysis to relieve stric tures. The negative pole is connected to an electrode in the lacrimal duct and a current of 2 milliamperes is used for 30 seconds. This method is of question able value and has been adopted by few surgeons. Incision of the skin and destruction of the sac by means of the actual cau tery or by escharotics was suggested by