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Posterior Subcapsular Cataracts*
NOTES, CASES, INSTRUMENTS there was any sign of irritation prior to bringing the patient in. The child has been wearing the lenses for three months without difficulty and with marked improvement in his nystagmus and, presumably, in his vision. COMMENT
Although it is dangerous to draw any con clusions from a single case, the ease with which an apparently adequate set of lenses was selected, the apparent visual improve ment immediately produced, as evidenced by the arrest of the nystagmus, the lack of dif ficulty which the parents experience on in serting and removing lenses and the ab
307
sence of irritation to the patient, all have been most encouraging. I am anxious to attempt this same method on other infants as the occasion arises and would hope that others would be encour aged to attempt to use contact lenses on in fants for whom there is such a definite op tical indication. A development of a satisfactory technique would permit the rehabilitation of many eyes which are otherwise optically badly handi capped in later life due to inability to cor rect, at an early critical age, high anisometropia and unilateral or bilateral aphakia. 105 East Jefferson Boulevard (1).
REFERENCES
1. Sato, T., and Saito, N.: Contact lenses for babies and children. Contacto, 3:419-424 (Dec), 1959. 2. Girard, L.: Personal interview: Corneal contact lenses. Highlights of Ophthal., 4:228-241, 1961.
cance at this time was a faint dotlike opacity of the central area of the posterior subcapsular zone in both lenses. The tension with a Schi^tz tonom eter was 18 mm. Hg in each eye. With a —0.75D. cyl. ax. 165°, the vision, R.E., was 20/30 ; L.E. could R E P O R T OF A CASE AT T H E AGE O F FORTY not be corrected. The diagnostic impression at this time was early bilateral complicated cataracts. Since YEARS I N A M A N UNDER PROLONGED STEROID there was a possibility of a very low-grade cyclitic THERAPY FOR M A R I E - S T R Ü M P E L L DISEASE process, Cortone ophthalmic solution was pre scribed. C. V. CRANE, M.D. The patient was seen one week later and there St. Petersburg, Florida were no objective changes. The corrected vision at this time with a —1.0D. cyl. ax. 180° was The patient to be reported had been under 20/20-2, R.E.; with a -0.5D. cyl. ax. 30° 20/20, corticosteroid medication for approximately L.E. When seen one week later, the corrected vision was the same; however, at this time, on seven years when he was first seen. transillumination, there was a very definite central posterior cortical and subcapsular lens opacity in C A S E REPORT each eye, more dense in the right eye than in the Mr. T. S. was first seen on April 20, 1959. At left. The patient was next seen on November 2, 1960, that time he complained of blurred vision in both at which time there was a dense large central pos eyes of one week's duration. He gave a history of having had an attack of iritis in the right eye four terior cortical and subcapsular opacity in each lens, years earlier which lasted about two weeks. This more dense in the right eye. The corrected vision was not confirmed by the record or by the objective in the right eye with a —2.0D. cyl. ax. 180° was findings. The visual acuity in the right eye was 20/50—1 ; in the left eye with a —0.5D. cyl. ax. 30° 20/40, J l at 7.5 inches; in the left eye 20/30, Jl the vision was 20/30 with difficulty. When seen on at 8.0 inches. The only findings of clinical signifi- February 15, 1961, there was very little objective change and the corrected vision in the right eye * From the Veterans Administration Regional Of was 20/30 and in the left eye 20/30. When seen on November 7, 1962, the patient fice.
POSTERIOR SUBCAPSULAR CATARACTS*
308
NOTES, CASES, INSTRUMENTS
stated he had not noted much change in vision but was experiencing considerable trouble in driving. At this time the posterior subcapsular and cortical opacities had reached maximum density, somewhat more dense on the right than the left, and seemed to have shrunk in size. There were fine linear ir regular opacities extending peripheralward into the lens. The best corrected vision at this time in the right eye was 20/80—2, and in the left eye 20/40. Slitlamp examination did not reveal evidence of previous iritis. The opacity in the right lens was confined to the central posterior subcapsular zone and was 3.0 mm. in diameter. It had the appearance of gold-tinged unpolished granite or iron pyrite. The left lens opacity was similar in every respect but was 1.5 to 2.0 mm. in diameter. Medical background. This patient's medical rec ords were completely reviewed by a rheumatologist in October, 1960, at which time he noted that this was a case of rheumatoid spondylitis with hypercortisonism of approximately 20 years' duration, with an onset of left sacroiliac pain in 1942. There had been almost daily recurrences through the years. The symptomatology had gradually wors ened and higher levels of the spinal column were in volved successively. At one point, the patient had five sessions with bee stings, 15 to 18 at a time. In 1952 he began to use cortisone in substantial dosage with some symptomatic relief. He switched to Meticorten in 1955 with the same result and, in late 1957, switched to Medrol which he is now using at a 12-mg. per day rate. The only periph eral joints involved have been the II metacarpophalangeal joint on the right and the right knee, and those only briefly. About April, 1960, he was told about having high blood pressure. At this particular time he noted frequent headaches. There was no history of renal disease nor family history of hypertension. Highest pressure noted was 170/110 mm. Hg. At this time the rheumatologist noted "in a man as typically Cushingoid as this one would believe it possible a mild hypertensive problem might be implicated in the medication." This patient has been seen at regular intervals in the Rheumatology Clinic, and there has been a gradual progression of the Marie-Strümpell dis ease. It has been noted that the patient has con sistently shown a high white count ranging from 17,500 to 21,000 dating back to 1957. "This eleva tion, as well as elevation of hemoglobin, is not un usual in either Cushing's or in a type of hypersteroidism that has been voluminously reported."
This case is presented because it fits into the 75-percent incidence group of cases re ported by Black, Oglesby, von Sallmann and Bunein in which 16 mg. of prednisone was taken daily for over a year. Further, since the patient has been observed for a period of* three years and eight months, the case demonstrates one possible course of this type of cataract ; it has remained morphologically and functionally stationary for over a year. COMMENT
A large number of cases of various arthritides are seen in this clinic. The patients have received courses of steroid therapy for varying lengths of time over a period of 10 years. In the past five years I have seen only two cases of posterior subcapsular cataracts, without objective evidence of previous an terior or posterior uveitis, in arthritics under 45 years of age who have received steroid therapy for three or more years. The ques tion arises: is the lens opacification due to the therapy per se, to circulatory changes resulting therefrom, or to some unidentified factor similar in nature to the causative factor in morphologically similar opacities occurring in eyes previously affected by uveitis ? Latex fixation tests will be done on all cases of lens opacification of various forms in individuals over 65 years of age in an at tempt to ascertain if any clinically signifi cant findings exist that would indicate a common denominator in all cases of lens opacification regardless of type, age of the patient, other ophthalmic and/or constitu tional disease. P.O. Box 1437.
REFERENCES
Black, R. L., Oglesby, R. B., von Sallmann, L., and Bunein, J. J.: Posterior subcapsular cataracts induced by corticosteroids in patients with rheumatoid arthritis. J.A.M.A., 174:166, 1960. Editorial: Cataracts caused by corticosteroids. AM A Arch. Ophth., 66:445 (Oct.) 1961.
Although it is dangerous to draw any con clusions from a single case, the ease with which an apparently adequate set of lenses was selected, the apparent visual improve ment immediately produced, as evidenced by the arrest of the nystagmus, the lack of dif ficulty which the parents experience on in serting and removing lenses and the ab
307
sence of irritation to the patient, all have been most encouraging. I am anxious to attempt this same method on other infants as the occasion arises and would hope that others would be encour aged to attempt to use contact lenses on in fants for whom there is such a definite op tical indication. A development of a satisfactory technique would permit the rehabilitation of many eyes which are otherwise optically badly handi capped in later life due to inability to cor rect, at an early critical age, high anisometropia and unilateral or bilateral aphakia. 105 East Jefferson Boulevard (1).
REFERENCES
1. Sato, T., and Saito, N.: Contact lenses for babies and children. Contacto, 3:419-424 (Dec), 1959. 2. Girard, L.: Personal interview: Corneal contact lenses. Highlights of Ophthal., 4:228-241, 1961.
cance at this time was a faint dotlike opacity of the central area of the posterior subcapsular zone in both lenses. The tension with a Schi^tz tonom eter was 18 mm. Hg in each eye. With a —0.75D. cyl. ax. 165°, the vision, R.E., was 20/30 ; L.E. could R E P O R T OF A CASE AT T H E AGE O F FORTY not be corrected. The diagnostic impression at this time was early bilateral complicated cataracts. Since YEARS I N A M A N UNDER PROLONGED STEROID there was a possibility of a very low-grade cyclitic THERAPY FOR M A R I E - S T R Ü M P E L L DISEASE process, Cortone ophthalmic solution was pre scribed. C. V. CRANE, M.D. The patient was seen one week later and there St. Petersburg, Florida were no objective changes. The corrected vision at this time with a —1.0D. cyl. ax. 180° was The patient to be reported had been under 20/20-2, R.E.; with a -0.5D. cyl. ax. 30° 20/20, corticosteroid medication for approximately L.E. When seen one week later, the corrected vision was the same; however, at this time, on seven years when he was first seen. transillumination, there was a very definite central posterior cortical and subcapsular lens opacity in C A S E REPORT each eye, more dense in the right eye than in the Mr. T. S. was first seen on April 20, 1959. At left. The patient was next seen on November 2, 1960, that time he complained of blurred vision in both at which time there was a dense large central pos eyes of one week's duration. He gave a history of having had an attack of iritis in the right eye four terior cortical and subcapsular opacity in each lens, years earlier which lasted about two weeks. This more dense in the right eye. The corrected vision was not confirmed by the record or by the objective in the right eye with a —2.0D. cyl. ax. 180° was findings. The visual acuity in the right eye was 20/50—1 ; in the left eye with a —0.5D. cyl. ax. 30° 20/40, J l at 7.5 inches; in the left eye 20/30, Jl the vision was 20/30 with difficulty. When seen on at 8.0 inches. The only findings of clinical signifi- February 15, 1961, there was very little objective change and the corrected vision in the right eye * From the Veterans Administration Regional Of was 20/30 and in the left eye 20/30. When seen on November 7, 1962, the patient fice.
POSTERIOR SUBCAPSULAR CATARACTS*
308
NOTES, CASES, INSTRUMENTS
stated he had not noted much change in vision but was experiencing considerable trouble in driving. At this time the posterior subcapsular and cortical opacities had reached maximum density, somewhat more dense on the right than the left, and seemed to have shrunk in size. There were fine linear ir regular opacities extending peripheralward into the lens. The best corrected vision at this time in the right eye was 20/80—2, and in the left eye 20/40. Slitlamp examination did not reveal evidence of previous iritis. The opacity in the right lens was confined to the central posterior subcapsular zone and was 3.0 mm. in diameter. It had the appearance of gold-tinged unpolished granite or iron pyrite. The left lens opacity was similar in every respect but was 1.5 to 2.0 mm. in diameter. Medical background. This patient's medical rec ords were completely reviewed by a rheumatologist in October, 1960, at which time he noted that this was a case of rheumatoid spondylitis with hypercortisonism of approximately 20 years' duration, with an onset of left sacroiliac pain in 1942. There had been almost daily recurrences through the years. The symptomatology had gradually wors ened and higher levels of the spinal column were in volved successively. At one point, the patient had five sessions with bee stings, 15 to 18 at a time. In 1952 he began to use cortisone in substantial dosage with some symptomatic relief. He switched to Meticorten in 1955 with the same result and, in late 1957, switched to Medrol which he is now using at a 12-mg. per day rate. The only periph eral joints involved have been the II metacarpophalangeal joint on the right and the right knee, and those only briefly. About April, 1960, he was told about having high blood pressure. At this particular time he noted frequent headaches. There was no history of renal disease nor family history of hypertension. Highest pressure noted was 170/110 mm. Hg. At this time the rheumatologist noted "in a man as typically Cushingoid as this one would believe it possible a mild hypertensive problem might be implicated in the medication." This patient has been seen at regular intervals in the Rheumatology Clinic, and there has been a gradual progression of the Marie-Strümpell dis ease. It has been noted that the patient has con sistently shown a high white count ranging from 17,500 to 21,000 dating back to 1957. "This eleva tion, as well as elevation of hemoglobin, is not un usual in either Cushing's or in a type of hypersteroidism that has been voluminously reported."
This case is presented because it fits into the 75-percent incidence group of cases re ported by Black, Oglesby, von Sallmann and Bunein in which 16 mg. of prednisone was taken daily for over a year. Further, since the patient has been observed for a period of* three years and eight months, the case demonstrates one possible course of this type of cataract ; it has remained morphologically and functionally stationary for over a year. COMMENT
A large number of cases of various arthritides are seen in this clinic. The patients have received courses of steroid therapy for varying lengths of time over a period of 10 years. In the past five years I have seen only two cases of posterior subcapsular cataracts, without objective evidence of previous an terior or posterior uveitis, in arthritics under 45 years of age who have received steroid therapy for three or more years. The ques tion arises: is the lens opacification due to the therapy per se, to circulatory changes resulting therefrom, or to some unidentified factor similar in nature to the causative factor in morphologically similar opacities occurring in eyes previously affected by uveitis ? Latex fixation tests will be done on all cases of lens opacification of various forms in individuals over 65 years of age in an at tempt to ascertain if any clinically signifi cant findings exist that would indicate a common denominator in all cases of lens opacification regardless of type, age of the patient, other ophthalmic and/or constitu tional disease. P.O. Box 1437.
REFERENCES
Black, R. L., Oglesby, R. B., von Sallmann, L., and Bunein, J. J.: Posterior subcapsular cataracts induced by corticosteroids in patients with rheumatoid arthritis. J.A.M.A., 174:166, 1960. Editorial: Cataracts caused by corticosteroids. AM A Arch. Ophth., 66:445 (Oct.) 1961.