Rapid Lens Changes in Diabetes Mellitus*

NOTES, CASES, INSTRUMENTS limit the term not only to lens opacities of characteristic morphologic type and clinical course, but also to those occurring in the WINSTON ROBERTS, M.D. younger diabetic patients. In general, the Winston-Salem, North Carolina age group for this lens change is from young It is well known that in diabetes mellitus childhood to about the age of 40 years, al­ rapid and extreme changes in the refractive though cases of opacities which seem to be condition of the eye occur, and these changes, diabetic in origin have been described in pa­ more frequently than not, are reversible. Di­ tients whose ages range from 11 months to abetic cataracts, outstanding among the lens 49 years. opacities dependent upon metabolic or en­ Although it has been experimentally docrine disturbances, have been striking for proved on laboratory animals that pancreatic the rapidity of their development. Although deficiency may cause cataracts, the exact these facts are well known, it is easy to lose cause and the mechanism of formation of true sight of the extreme degree of change which diabetic cataracts are still not known. It the lens can undergo within a short time in seems unlikely that these opacities form diabetes and especially to lose sight of the either as a direct action of the increased fact that advanced changes may sometimes sugar content in the blood or aqueous or as completely regress. the result of osmotic variations which occur Bellows1 has summarized both the common with hyperglycemia. A somewhat more likely refractive changes which occur with diabetes theory is that toxins which affect the lens mellitus and the information which is most material result from the disturbed metabo­ widely accepted with regard to diabetic cata­ lism in diabetes. ract. The clinical appearance and course of Among the transitory refractive changes diabetic cataract are well known.2"4 Outstand­ three are outstanding: (1) Development of ing among the features of this cataract are an increased hyperopia with a need for its very rapid development and growth. It stronger convex lenses. This is especially is well known that these lens changes may prone to occur with an improvement in the progress from clear lens to complete opacifigeneral condition of the patient and a lessen­ cation within a relatively few hours and that ing of the glycosuria. (2) Development of characteristically the cataracts mature within weakness of accommodation, especially in the a few months. younger diabetic patients. (3) Myopic The treatment of diabetic cataract is some­ change, which is much less common than what difficult to evaluate, especially since the hyperopic change and is found chiefly in course which the cataract may follow is by no cases with a high blood sugar and glycosuria. means constant. However, it appears that Myopic change in adults should arouse sus­ vigorous insulin therapy in the early stages picion of diabetes. of the development of the diabetic cataract Cataracts are a more serious and less fre­ may delay or stop its progress; although quently reversible lenticular complication of rarely, regression of diabetic opacities has diabetes. There is still much disagreement as been reported. Perhaps there is no better to the accurate classification of true diabetic proof that a lenticular opacity is diabetic cataracts, and there are some who would in origin than the fact that it is influenced by insulin administration. The case under discussion in this paper * From Department of Ophthalmology, Bowman is striking in that, after very rapid developGray School of Medicine. RAPID LENS CHANGES IN DIABETES MELLITUS*

NOTES, CASES, INSTRUMENTS

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ment of a moderately advanced diabetic cata­ ract, regression was complete and equally rapid with the patient under therapy with globin insulin. It is also unusual in that the opacities developed and regressed during the period of rapid fall of blood sugar with regu­ lation of an acute exacerbation of a mild dia­ betic, whose subsequent course suggests that she should be classified among the cases of so-called "acute" diabetes. CASE REPORT

History. This 48-year-old white married woman was admitted to Baptist Hospital on March 11, 1949, for study and regulation of what, by her story, appeared to be diabetes mellitus. She had been in the hospital on two previous occasions—the first in August, 1941, at which time she had an essentially unevent­ ful delivery of a male child. Her second admission was in September, 1943, at which time she complained of a lump in her right side which had been steadily growing while the patient lost about 15 pounds over the period of six months. Stud­ ies on that admission revealed the presence of a retroperitoneal mass outside the colon and kidney on the right side which was diag­ nosed as a retroperitoneal lymphosarcoma. Although, at that time, it seemed that her prognosis was bad, she was given deep X ray therapy (6,216 r, in divided doses). The mass regressed in size, and the patient had been essentially free of symptoms up to the pres­ ent admission. On both of these first two ad­ missions the patient had complete laboratory studies, and her urine was sugar free and her kidney function was good. At the present admission the patient had the classical symptoms of diabetes mellitus, including polyphagia, polydipsia, polyuria, repeated superficial infections, and a weight loss of 25 pounds within the past few months. She had noticed this symptom complex for six months before admission. She had re­ cently seen her family physician who, finding that she had sugar in her urine, had placed her on a low carbohydrate diet. In addition,

the patient stated that she had noticed a very marked change in her vision within the past few weeks. She had had her present glasses for five years but had been quite satisfied with them until the past 2 or 3 weeks, during which time she had become unable to read with them at all. She could see at a distance through the reading segments better than through the distance portion. The ocular condition showed a rather startling course. On the second hospital day the patient was seen because of her recent marked visual loss and at that time was found to have vision of: R.E., 20/50—2, unim­ proved by her glasses; L.E., 20/200, im­ proved to 20/50—2 by her old glasses, +0.5D. sph. C -0.25D. cyl. ax. 90°, O.U., with a + 1.50D. reading addition. At this time, extraocular movements, pu­ pillary reactions, phorias, and funduscopic examination were all essentially normal. There were early arteriosclerotic changes in the retinal arterioles, but no hemorrhages and exudates, and the lenses and media were entirely clear. Fogging refraction at this time revealed: R.E., improved to 20/15, with a +3.5D. sph. 3 — 1.0D. cyl. ax. 105°; L.E., improved to 20/15, with a +3.75D. sph. C - 1 . 0 D . cyl. ax. 80°; and +1.5D. reading addition, O.U., gave a most satisfactory reading dis­ tance of 36 to 38 cm. In view of the very marked change in the patient's lenses, it was felt unwise to give the patient the prescription which she took at this time, and it was decided to check her again after her diabetes was better regulated. Consequently she was again seen after four days of globin insulin therapy, at which time her urine was sugar free and her blood sugar below 200 mg. percent. At this time she told us that she had had extreme loss of vision just since the visit to the eye clinic a few days before, and that it was just as though a veil had come before her eyes so that she was unable to read any­ thing at all or to see clearly through the up­ per or lower portion of her old glasses.

NOTES, CASES, INSTRUMENTS Examination at this time showed a strik­ ing change which had taken place in the few days since the last examination. The pa­ tient had developed bilateral, rather advanced lenticular opacities of the posterior subcapsular type. T h e opacities were somewhat brownish, granular, saucer-shaped cataracts with very jagged, irregular margins. Only a very few vacuoles were noted at this time. At this time it was impossible to improve the patient's vision above 20/100 with any lenses which could be given her. Three days later the patient's vision was again checked and, once again, it was evi­ dent that startling changes had occurred within her lenses. The cataract on the left had completely disappeared and on the right there was only a tiny remnant of the pos­ terior subcapsular opacity which had been present three days before. Refraction w a s : R.E., 2 0 / 1 5 , with a + 5 . 7 5 D . sph. C - 0 . 7 5 D . cyl. ax. 1 1 5 ° ; L . E , about 2 0 / 1 5 , with a + 6 . D . sph. C - 0 . 7 5 D . cyl. ax. 90°. A + 1 . 7 5 D . reading addition, O.U., gave a best reading distance of about 37 cm.

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The patient was given this prescription after it was thoroughly explained to her that it was quite unlikely that these glasses would be satisfactory for long with her lenses un­ dergoing such rapid changes, but she was extremely anxious to leave the hospital and to have the glasses so that she could read and do her work. At this time her fasting blood sugar was again within normal limits, and her urine was sugar free. She was dis­ charged from the hospital on 50 units of globin insulin per day, to return for a check­ up within a month. Six weeks after her discharge the patient was seen again and at that time reported that she had been able to reduce her insulin in steps until it was stopped entirely and that she was now regulated on diet alone. At that time her corrected vision had fallen t o : R.E., 2 0 / 5 0 - 2 ; L.E., 2 0 / 1 0 0 + 1 . Once again she readily improved t o : R.E., 20/15, with a + 4 . 2 5 D . sph. C 0.75D. cyl. ax. 120°; L.E., + 4 . 0 D . sph. C - 0 . 2 5 D . cyl. ax. 65°. H e r lenses were entirely free of any opaci­ ties.

REFERENCES

1. Bellows, J. G.: Cataract and Anomalies of the Lens. St. Louis, Mosby, 1944, chap. IX, p. 431. 2. O'Brien, C. S., Molsberry, J. M., and Allen, J. H.: Diabetic cataract: Incidence and morphology in 126 young diabetic patients. J.A.M.A., 103 :892-897, 1934. 3. O'Brien, C. S., and Allen, J. H.: Ocular changes in young diabetic patients. J.A.M.A., 120:190-192, 1942. 4. Lawrence, R. D., Oakley, W., and Barne, I. C.: Temporary lens changes in diabetic coma. Lancet, 2 -.63-65, 1942.

SUBRETINAL HEMORRHAGE SIMULATING SARCOMA OF THE CHOROID* G Y U L A LUGOSSY,

M.D.

Budapest, Hungary A n interesting case, under the same title, was reported by Joseph Laval in the Janu­ ary,

1948,

issue of

the

AMERICAN

JOURNAL

OF OPHTHALMOLOGY. O n the left macula * From the Ophthalmological Department of the Hospital of the Order of Hospitalers, Budapest.

lutea of a 48-year-old woman there was a round pigmented tumor which had the diameter of six papillas and protruded for about 5.0D. It was continuous with the upper temporal border of the papilla. The author removed the globe following a diagnosis of melanosarcoma of the choroid. Histologic study revealed a hemorrhage between the retina and the choroid; there was no tumor in the eye, although serial sections had been made. In commenting on his case, Laval remarks that the hemorrhage occurring at the macula