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Relationship Between Degree of Anisometropia and Depth of Amblyopia
VOL. 62, NO. 4
757
NOTES, CASES, INSTRUMENTS
lymphatic elements, comprised of small lympho cytes and prominent foci of reticulum cells. Fibrosis is of moderate degree and there is a nota ble paucity of plasma cells. The cellular reaction extends between the fibers of the orbicularis mus cle. An unusual and florid picture which appears to be reactive in type. (Fig. 1). In view of this report, the histology report on the nasal polyps was obtained: Macroscopic. Nine polyps or pieces of polypoid mucosa ranging from about 6 by 4 by 4 mm to 10 by 10 by 6 mm were all of translucent, palegray appearance. Microscopic. The polyps consist of greatly edematous nasal mucosa, showing a chronic inflammatory infiltration in which eosinophils are sufficiently prominent to suggest an allergic factor. There is no sign of malignancy. Pathologic diagnosis. Chronic inflammatory nasal polyps. The patient made an uneventful recovery. COMMENT
The patient's long history of upper respi ratory tract allergy and the histologic findings make it reasonable to assume that the usual allergen (s) had settled in the lacrimal sac wall, perhaps travelling via the conjunctival sac and canaliculi, and there stimu lated an unusual type of chronic allergic re sponse. There does not appear to be a similar case previously reported. SUMMARY
An unusual type of inflammation of the lacrimal sac wall is described, clinically sim ulating a neoplasm and histologically show ing a benign, granulomatous reaction of the type found in chronic allergic reactions else where in the body. A theory of causation is advanced. Royal Infirmary ACKNOWLEDGMENT
I wish to thank Dr. J. L. Smith for the histology report on the sac and for Figure 1, and the Path ology Department, Manchester Royal Infirmary, for the histology report on the nasal polyps.
RELATIONSHIP BETWEEN DEGREE O F ANISOMETROPIA AND D E P T H O F AMBLYOPIA EUGENE M. HELVESTON,
M.D.
Indianapolis, Indiana
Lagleyze, quoted in Worth and Chavasse's Squint,1 stated that "similar degrees of anisometropia and amblyopia tend to exist together." From data used to study the incidence of amblyopia ex anopsia in a large group of men at an armed forces examining station,2 it was noted that, contrary to the teaching of Lagleyze, there appeared to be no relationship between the degree of ani sometropia and the depth of amblyopia in the anisometropic amblyopes examined. To show this relationship, or its lack, an analy sis of the cases examined personally and of data reported by Horwich 3 was made and it is the subject of this report. METHOD
Fifty-seven anisometropic amblyopes were divided into two groups: (1) strabismic (20cases) and (2) nonstrabismic (37cases). Strabismus was determined by cover-un cover and alternate-cover tests. For the pur poses of this study, amblyopia was defined as vision reduced to less than 20/40 in one eye, with no demonstrable disease. Between the two eyes, a difference in refractive error of 0.5D or more in sphere or cylindrical spherical equivalent was considered signif icant anisometropia. RESULTS
There appeared to be no relationship be tween the degree of anisometropia and the depth of amblyopia in anisometropic am blyopes with or without strabismus when visual acuity was plotted against degree of anisometropia (figs. 1 and 2 ) . Analysis of data originally published by Horwich 3 on the visual acuity of strabismic From the Department of Ophthalmology, Indi ana University School of Medicine.
758
AMERICAN JOURNAL OF OPHTHALMOLOGY 1
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ID 2D 3D 4D AMOUNT OF ANISOMETROPIA
Fig. 1 ('Helveston). Strabismic anisometropic amblyopes. The relationship between the degree of anisometropia and the depth of amblyopia in amblyopic squinters screened at an Armed Forces examining station. 1
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DISCUSSION
Although there is rather widespread be lief to the contrary, from the foregoing data it would appear that the loss of vision in an isometropic amblyopia does not tend to be proportional to the degree of anisometropia. The fact that there is sufficient anisometro pia present to trigger the development of amblyopia in some patients exists as a fact alone; the final depth of the amblyopia de pends on unknown factors. SUMMARY
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amblyopia, perhaps by reinforcement. From Figure 2 it can be seen that 65% of the am blyopes with anisometropia alone had less than 2.5D of anisometropia, a difference that is considered to be compatible with equal binocular vision under ideal condi tions.4
1
1
ID 2D 3D AMOUNT OF ANISOMETROPIA
OCTOBER, 1966
■
Data from 57 amblyopic subjects with an isometropia, divided into strabismic and nonstrabismic groups, revealed no relation ship between the degree of anisometropia and the depth of amblyopia. 1100 West Michigan Street (46207).
-
• •
h-
Fig. 2 (Helveston). Nonstrabismic anisometropic amblyopes. The relationship between the degree of anisometropia and the depth of amblyopia in nonsquinting patients screened at an Armed Forces examining station. (24 [65%] <2.5D anisome tropia.)
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amblyopes with anisometropia agrees with the findings in the strabismic group here, that there is no relationship between the de gree of anisometropia and the depth of am blyopia (fig. 3). Those cases with anisome tropia and strabismus tended to have deeper
20/20-
■+-
-t-
AMOUNT OF
3D 4D ANISOMETROPIA
Fig. 3 (Helveston). Strabismic anisometropic amblyopes. Data from Horwich3 arranged in scattergram to show the relationship between the de gree of anisometropia and the depth of amblyopia in squinters.
VOL. 62, NO. 4
NOTES, CASES, INSTRUMENTS REFERENCES
1. Lyie, T. K.: Worth and Chavasse's Squint. Philadelphia, Blaikston, 1950, ed. 8, p. 138. 2. Helveston, E. M.: The incidence of amblyopia ex anopsia. Am. J. Ophth. 60:75, 1965. 3. Horwich, H.: Anisometropia amblyopia. Am. Orthoptic J. 14:99, 1964. 4. Duke-Elder, S.: Textbook of Ophthalmol ogy. St. Louis, Mosby, 1949, v. 2, p. 4305.
NEW SIMPLIFIED LID-CLAMP RETRACTOR RAMON CASTROVIEJO,
759
signed to be used instead of sutures and to give the maximum possible exposure of the palpebral aperture with a minimum of inter ference in the operative field. This retractor had the advantage over sutures of being completely atraumatic and, in addition, an esthesia was not required for its insertion. The retractor was equipped with a screw with a knurled head which served to clamp it in position (fig. 1-A-circle inset). Trac tion to retract the lid was exerted by a thread passed through an eyelet in the
M.D.
New York In 1939 I reported a new instrument,* the mosquito lid-clamp retractor, which was deFrom the Department of Ophthalmology, New
York University Post-Graduate Medical School, and St. Vincent's Hospital and Medical Center of the City of New York. These lid-clamp retractors are manufactured by the Storz Instrument Com pany, 4570 Audubon Avenue, St. Louis, Missouri. * Castroviejo, R.: Am. J. Ophth. 22:1018, 1939.
Fig. 1 (Castroviejo). (A) Screw model (inset).(B) Simplified model without screw (inset) used in combination with the screw-model retractor. (C) The simplified model used alone.
757
NOTES, CASES, INSTRUMENTS
lymphatic elements, comprised of small lympho cytes and prominent foci of reticulum cells. Fibrosis is of moderate degree and there is a nota ble paucity of plasma cells. The cellular reaction extends between the fibers of the orbicularis mus cle. An unusual and florid picture which appears to be reactive in type. (Fig. 1). In view of this report, the histology report on the nasal polyps was obtained: Macroscopic. Nine polyps or pieces of polypoid mucosa ranging from about 6 by 4 by 4 mm to 10 by 10 by 6 mm were all of translucent, palegray appearance. Microscopic. The polyps consist of greatly edematous nasal mucosa, showing a chronic inflammatory infiltration in which eosinophils are sufficiently prominent to suggest an allergic factor. There is no sign of malignancy. Pathologic diagnosis. Chronic inflammatory nasal polyps. The patient made an uneventful recovery. COMMENT
The patient's long history of upper respi ratory tract allergy and the histologic findings make it reasonable to assume that the usual allergen (s) had settled in the lacrimal sac wall, perhaps travelling via the conjunctival sac and canaliculi, and there stimu lated an unusual type of chronic allergic re sponse. There does not appear to be a similar case previously reported. SUMMARY
An unusual type of inflammation of the lacrimal sac wall is described, clinically sim ulating a neoplasm and histologically show ing a benign, granulomatous reaction of the type found in chronic allergic reactions else where in the body. A theory of causation is advanced. Royal Infirmary ACKNOWLEDGMENT
I wish to thank Dr. J. L. Smith for the histology report on the sac and for Figure 1, and the Path ology Department, Manchester Royal Infirmary, for the histology report on the nasal polyps.
RELATIONSHIP BETWEEN DEGREE O F ANISOMETROPIA AND D E P T H O F AMBLYOPIA EUGENE M. HELVESTON,
M.D.
Indianapolis, Indiana
Lagleyze, quoted in Worth and Chavasse's Squint,1 stated that "similar degrees of anisometropia and amblyopia tend to exist together." From data used to study the incidence of amblyopia ex anopsia in a large group of men at an armed forces examining station,2 it was noted that, contrary to the teaching of Lagleyze, there appeared to be no relationship between the degree of ani sometropia and the depth of amblyopia in the anisometropic amblyopes examined. To show this relationship, or its lack, an analy sis of the cases examined personally and of data reported by Horwich 3 was made and it is the subject of this report. METHOD
Fifty-seven anisometropic amblyopes were divided into two groups: (1) strabismic (20cases) and (2) nonstrabismic (37cases). Strabismus was determined by cover-un cover and alternate-cover tests. For the pur poses of this study, amblyopia was defined as vision reduced to less than 20/40 in one eye, with no demonstrable disease. Between the two eyes, a difference in refractive error of 0.5D or more in sphere or cylindrical spherical equivalent was considered signif icant anisometropia. RESULTS
There appeared to be no relationship be tween the degree of anisometropia and the depth of amblyopia in anisometropic am blyopes with or without strabismus when visual acuity was plotted against degree of anisometropia (figs. 1 and 2 ) . Analysis of data originally published by Horwich 3 on the visual acuity of strabismic From the Department of Ophthalmology, Indi ana University School of Medicine.
758
AMERICAN JOURNAL OF OPHTHALMOLOGY 1
•
1
it
1
•
20/200 -
»
»
20/100 -
••
« •
-
•
• •
-
•
•-
20/80 -
•
20/70 -
-
•
•
20/400 ■
20/60 -
•
20/50 20/40 20/30 -
1
1
20/20 -
1
1
ID 2D 3D 4D AMOUNT OF ANISOMETROPIA
Fig. 1 ('Helveston). Strabismic anisometropic amblyopes. The relationship between the degree of anisometropia and the depth of amblyopia in amblyopic squinters screened at an Armed Forces examining station. 1
1
1
20/200 •
20/100 ■
•
• •
1 •
_
• •
-
•
•
20/80 -
•
20/70 -
•
•
20/60■ 20/50 -
•
20/40 -
•
20/3020/20-
— t —
1
'
1—
DISCUSSION
Although there is rather widespread be lief to the contrary, from the foregoing data it would appear that the loss of vision in an isometropic amblyopia does not tend to be proportional to the degree of anisometropia. The fact that there is sufficient anisometro pia present to trigger the development of amblyopia in some patients exists as a fact alone; the final depth of the amblyopia de pends on unknown factors. SUMMARY
•
•
20/400 •
amblyopia, perhaps by reinforcement. From Figure 2 it can be seen that 65% of the am blyopes with anisometropia alone had less than 2.5D of anisometropia, a difference that is considered to be compatible with equal binocular vision under ideal condi tions.4
1
1
ID 2D 3D AMOUNT OF ANISOMETROPIA
OCTOBER, 1966
■
Data from 57 amblyopic subjects with an isometropia, divided into strabismic and nonstrabismic groups, revealed no relation ship between the degree of anisometropia and the depth of amblyopia. 1100 West Michigan Street (46207).
-
• •
h-
Fig. 2 (Helveston). Nonstrabismic anisometropic amblyopes. The relationship between the degree of anisometropia and the depth of amblyopia in nonsquinting patients screened at an Armed Forces examining station. (24 [65%] <2.5D anisome tropia.)
20/10(1 -f
•
• • • • •
• •
•
• • • •
20/80"20/7020/60-
•
20/5020/40-
•
• • • •
•
20/30-
amblyopes with anisometropia agrees with the findings in the strabismic group here, that there is no relationship between the de gree of anisometropia and the depth of am blyopia (fig. 3). Those cases with anisome tropia and strabismus tended to have deeper
20/20-
■+-
-t-
AMOUNT OF
3D 4D ANISOMETROPIA
Fig. 3 (Helveston). Strabismic anisometropic amblyopes. Data from Horwich3 arranged in scattergram to show the relationship between the de gree of anisometropia and the depth of amblyopia in squinters.
VOL. 62, NO. 4
NOTES, CASES, INSTRUMENTS REFERENCES
1. Lyie, T. K.: Worth and Chavasse's Squint. Philadelphia, Blaikston, 1950, ed. 8, p. 138. 2. Helveston, E. M.: The incidence of amblyopia ex anopsia. Am. J. Ophth. 60:75, 1965. 3. Horwich, H.: Anisometropia amblyopia. Am. Orthoptic J. 14:99, 1964. 4. Duke-Elder, S.: Textbook of Ophthalmol ogy. St. Louis, Mosby, 1949, v. 2, p. 4305.
NEW SIMPLIFIED LID-CLAMP RETRACTOR RAMON CASTROVIEJO,
759
signed to be used instead of sutures and to give the maximum possible exposure of the palpebral aperture with a minimum of inter ference in the operative field. This retractor had the advantage over sutures of being completely atraumatic and, in addition, an esthesia was not required for its insertion. The retractor was equipped with a screw with a knurled head which served to clamp it in position (fig. 1-A-circle inset). Trac tion to retract the lid was exerted by a thread passed through an eyelet in the
M.D.
New York In 1939 I reported a new instrument,* the mosquito lid-clamp retractor, which was deFrom the Department of Ophthalmology, New
York University Post-Graduate Medical School, and St. Vincent's Hospital and Medical Center of the City of New York. These lid-clamp retractors are manufactured by the Storz Instrument Com pany, 4570 Audubon Avenue, St. Louis, Missouri. * Castroviejo, R.: Am. J. Ophth. 22:1018, 1939.
Fig. 1 (Castroviejo). (A) Screw model (inset).(B) Simplified model without screw (inset) used in combination with the screw-model retractor. (C) The simplified model used alone.