- Email: [email protected]
Retinal Ischemia with Cataract Formation
NOTES, CASES, INSTRUMENTS RETINAL ISCHEMIA W I T H CATARACT FORMATION A CASE REPORT F.
H.
NEWTON,
Dallas, J.
H.
M.D.
Texas
ARRINGTON,
M.D.
Wichita Falls, Texas AND R. GRADY BRUCE, M.D. Dallas, Texas An unmarried white woman, aged 69 years, was first seen by one of us (J. H. A.) in March, 1957, with a history of diaphragmatic hernia in 1951, thyroidectomy in 1954, acute respiratory virus infection and associated pleurisy in October, 1956, with a re lapse or second attack in November, 1956, lasting three weeks. In November, 1956, the vision suddenly became affected. The patient was able to drive her car and read without difficulty one day; the next day vision markedly diminished in each eye. A com petent ophthalmologist saw her at this time and made a diagnosis of bilateral heavy vitreous opacities with beginning cataract formation. Visual acuity reported w a s : R.E., 20/400; L.E., 20/100. The first recorded blood examination was made at Bethania Hospital, Wichita Falls, Texas, January 8, 1957. This showed RBC, 4,370,000; WBC, 10,150; HB, 13.5 gm., with normal differential, blood cholesteral 177 mg.; serology negative. Urine negative. The diagnosis of an internist was acute fibrinous pleurisy. When first seen by J. H. A. in March, 1957, the eye picture was about the same as already described. Because of the history of several attacks of pleurisy, streptomycin and one of the oral drugs for tuberculosis were administered by her internist with no effect. In June, 1957, a course of metacortone was given. There seemed to be a definite im provement in the number of vitreous opacities but little change in her vision. On July 11, 1957, the patient was seen in Dallas, Texas, in consultation by F. H. N. and R. G. B. This examination showed an edema of retina and ciliary body with numerous vitreous opacities, intact retina bilateral, moderate lens clouding, markedly con tracted fields simulating a right homonymous, in congruous hemianopsia. No definite cause for the trouble was suggested. The neurologic examination on July 31, 1957, was negative. The neurologist suggested the possibility of toxoplasmosis. The next examination on October 24, 1957, showed a decided swelling of each lens with very taut cap sules, presumably due to edema, with an associated marked edema of the ciliary bodies. This edema had not been so evident on July 11th. There was con siderable clouding of each lens but not enough to
prevent a fairly good view of the ciliary bodies. A satisfactory view of the fundi could not be obtained. Vitreous opacities remained about the same. A de layed reaction from metacortone was mentioned as a possible cause. Diamox was suggested to relieve the edema. Visual acuity was: R.E., form projec tion ; L.E., 5/400. Delay in removal of either lens until the edema had subsided was advised, unless intraocular pressure increased. The tension had remained in normal limits during all the time of observation. On December 11, 1957, the edema had subsided moderately with a slight increase in visual acuity and size of fields. On March 3, 1958, the cataracts were fully developed and the patient had become so upset about her loss of vision, with no satisfactory explanation and delay in getting relief that, on March 4, 1958, an uncomplicated intracapsular cata ract extraction with round pupil was carried out in the right eye without waiting for a general check up. The routine blood report made at St. Paul's Hospital, Dallas, Texas, on March 4, 1958, showed H B 6.7 gm., hematocrit, 20 percent. The operation was done despite the anemia for the reasons already mentioned. Her convalescence was uneventful and she returned to the care of J. H. A. in a week. The anemia was attributed to bleeding from her dia phragmatic hernia and blood transfusions were ad vised. On April 7, 1958, at Bethania Hospital, the blood report showed H B 6.8 gm. and again on April 9, 1958. Feces showed occult blood on April 9, 1958, and April 11, 1958. Blood transfusions were started on April 7, 1958. On April 12, 1958, H B had risen to 11.2 gm. Diagnosis of diaphragmatic hernia was confirmed by X-ray examination. On April 15, 1958, corrected vision was: RE, 20/400. On April 16, 1958, an intracapsular extrac tion was done on the left eye. No complications fol lowed. The blood report at St. Paul's Hospital, Dallas, Texas, on April 16, 1958, was H B 13.9 gm., hematocrit 43 percent; on April 17, 1958, H B 13.9 gm., hematocrit 46 percent; on April 19, 1958, H B 13.7 gm., hematocrit 42 percent. On May 23, 1958, examination by J. H. A. showed corrected vision to be: R.E., 20/30; L.E., 20/25. The intraocular changes had cleared up, with the fundus in each eye apparently normal. Examination by F. H. N. on June 26, 1958, showed the same visual acuity as found on May 23, 1958, with a normal field in the left eye and only slight contraction in the right. The fundi appeared normal. COMMENT
The report of this case was inspired by a recent article by Dr. Frederick Cordes* on * Cordes, F . C.: Retinal ischemia with visual loss. Am. J. Ophth., 45:79-88 (Apr., Pt. I I ) 1958.
862
NOTES, CASES, INSTRUMENTS "Retinal ischemia with visual loss." The long duration, the source of the bleeding, the de velopment of cataracts, and the final result seemed to make the report worthwhile. The recovery of vision in this patient was very slow but her ability to overcome her anemia was quite rapid, as demonstrated by her quick response to the transfusions in April, 1958. H e r rather sudden loss of vision in November, 1956, and a normal blood count in January, 1957, can only be explained as an interval of relative freedom from hemor rhages from November, 1956, to January, 1957, giving her time to restore the red cell deficiency. It is generally conceded that re peated small hemorrhages are more likely to produce visual changes than a single large loss of blood. 209 Medical Arts Building (1).
DERMOID TUMOR OF T H E ORBIT SIMULATING A NEOPLASM* RODERICK MACDONALD, J R . ,
M.D.
Louisville, Kentucky AND J E R O M E L. B Y E R S ,
M.D.t
New Orleans, Louisiana LITERATURE
Epidermoid tumor was first described in the literature by Cruveilhier 1 and was termed "pearly" tumor because of its highly refrac tive and nodular surface. Cholesteatoma as a descriptive term was introduced in 1838 by Mueller 2 because of the large mass of cho lesterol crystals in the lesion. The origin of dermoid tumors has been the subject of much discussion. Heimendinger, 3 Cushing,* McFarland, 5 Ewing, 6 Coates, 7 Critchley and Ferguson, 8 Love and Kernohan, 9 and Bailey 10 have all concurred * From the Department of Ophthalmology, TuIane University Medical School, and the Eye, Ear, Nose, and Throat Hospital of New Orleans, Lou isiana. This case was reported to the Ophthalmic Pathology Club in 1957 by Dr. James H. Allen. t Trainee, National Institute of Neurological Diseases and Blindness, Bethesda, Maryland.
863
in the belief that primary cholesteatomas or dermoids are congenital growths coming from misplaced, aberrant epithelial tissue. However, trauma may be a factor in the pro duction of dermoid tumors, as pointed out by Thacker. 1 1 Pfeiffer and Nicholl, 12 in an excellent re view, state that in a series of 200 consecutive cases of exophthalmos reported in 1941, these congenital growths comprised four per cent of the cases. Several reports of isolated cases of der moids or oil cysts affecting the orbit are to be found throughout the more recent litera ture. Knapp, 1 3 in an interesting report, ana lyzed the chemical constituents contained in a dermoid cyst. H e found that the oil contained no free fatty acids. It contained 36.2-percent cholesterol and had an iodine number of 124. This seemed to indicate that it consisted mostly of a triglyceride of fatty acids more unsaturated than oleic, the iodine number of cholesterol being 56. It would seem that a fatty acid of iodine number of about 180 was involved, while this oil was entirely soluble in fat contents the solid material was not. T h e solid material contained 72 percent choles terol and gave an iodine number of 55. T h e alcohol insoluble portion was probably pro tein. Borley 14 reported a tooth being present within the tumor in his case. Jones 1 5 in 1935 reported the case of an oil cyst becoming ma lignant with the patient dying of carcinomatosis. Palomar, 1 6 cited by Samuels, described a dermoid cyst of the orbit connected through the lateral orbital wall with a "knapsackshaped diverticulum under the temporal mus cle." C A S E REPORT
History. D. R., a 32-year-old Negress was ad mitted to the New Orleans Eye, Ear, Nose, and Throat Hospital on November 16, 1956, with a his tory of a growth beginning in the upper, outer half of the left lid in 1951. A biopsy was made at an other hospital early in 1952, and was reported as a lymphangioma of the lid. The lesion slowly in creased in size, and the left eye gradually became more prominent than the right. In November, 1952,
H.
NEWTON,
Dallas, J.
H.
M.D.
Texas
ARRINGTON,
M.D.
Wichita Falls, Texas AND R. GRADY BRUCE, M.D. Dallas, Texas An unmarried white woman, aged 69 years, was first seen by one of us (J. H. A.) in March, 1957, with a history of diaphragmatic hernia in 1951, thyroidectomy in 1954, acute respiratory virus infection and associated pleurisy in October, 1956, with a re lapse or second attack in November, 1956, lasting three weeks. In November, 1956, the vision suddenly became affected. The patient was able to drive her car and read without difficulty one day; the next day vision markedly diminished in each eye. A com petent ophthalmologist saw her at this time and made a diagnosis of bilateral heavy vitreous opacities with beginning cataract formation. Visual acuity reported w a s : R.E., 20/400; L.E., 20/100. The first recorded blood examination was made at Bethania Hospital, Wichita Falls, Texas, January 8, 1957. This showed RBC, 4,370,000; WBC, 10,150; HB, 13.5 gm., with normal differential, blood cholesteral 177 mg.; serology negative. Urine negative. The diagnosis of an internist was acute fibrinous pleurisy. When first seen by J. H. A. in March, 1957, the eye picture was about the same as already described. Because of the history of several attacks of pleurisy, streptomycin and one of the oral drugs for tuberculosis were administered by her internist with no effect. In June, 1957, a course of metacortone was given. There seemed to be a definite im provement in the number of vitreous opacities but little change in her vision. On July 11, 1957, the patient was seen in Dallas, Texas, in consultation by F. H. N. and R. G. B. This examination showed an edema of retina and ciliary body with numerous vitreous opacities, intact retina bilateral, moderate lens clouding, markedly con tracted fields simulating a right homonymous, in congruous hemianopsia. No definite cause for the trouble was suggested. The neurologic examination on July 31, 1957, was negative. The neurologist suggested the possibility of toxoplasmosis. The next examination on October 24, 1957, showed a decided swelling of each lens with very taut cap sules, presumably due to edema, with an associated marked edema of the ciliary bodies. This edema had not been so evident on July 11th. There was con siderable clouding of each lens but not enough to
prevent a fairly good view of the ciliary bodies. A satisfactory view of the fundi could not be obtained. Vitreous opacities remained about the same. A de layed reaction from metacortone was mentioned as a possible cause. Diamox was suggested to relieve the edema. Visual acuity was: R.E., form projec tion ; L.E., 5/400. Delay in removal of either lens until the edema had subsided was advised, unless intraocular pressure increased. The tension had remained in normal limits during all the time of observation. On December 11, 1957, the edema had subsided moderately with a slight increase in visual acuity and size of fields. On March 3, 1958, the cataracts were fully developed and the patient had become so upset about her loss of vision, with no satisfactory explanation and delay in getting relief that, on March 4, 1958, an uncomplicated intracapsular cata ract extraction with round pupil was carried out in the right eye without waiting for a general check up. The routine blood report made at St. Paul's Hospital, Dallas, Texas, on March 4, 1958, showed H B 6.7 gm., hematocrit, 20 percent. The operation was done despite the anemia for the reasons already mentioned. Her convalescence was uneventful and she returned to the care of J. H. A. in a week. The anemia was attributed to bleeding from her dia phragmatic hernia and blood transfusions were ad vised. On April 7, 1958, at Bethania Hospital, the blood report showed H B 6.8 gm. and again on April 9, 1958. Feces showed occult blood on April 9, 1958, and April 11, 1958. Blood transfusions were started on April 7, 1958. On April 12, 1958, H B had risen to 11.2 gm. Diagnosis of diaphragmatic hernia was confirmed by X-ray examination. On April 15, 1958, corrected vision was: RE, 20/400. On April 16, 1958, an intracapsular extrac tion was done on the left eye. No complications fol lowed. The blood report at St. Paul's Hospital, Dallas, Texas, on April 16, 1958, was H B 13.9 gm., hematocrit 43 percent; on April 17, 1958, H B 13.9 gm., hematocrit 46 percent; on April 19, 1958, H B 13.7 gm., hematocrit 42 percent. On May 23, 1958, examination by J. H. A. showed corrected vision to be: R.E., 20/30; L.E., 20/25. The intraocular changes had cleared up, with the fundus in each eye apparently normal. Examination by F. H. N. on June 26, 1958, showed the same visual acuity as found on May 23, 1958, with a normal field in the left eye and only slight contraction in the right. The fundi appeared normal. COMMENT
The report of this case was inspired by a recent article by Dr. Frederick Cordes* on * Cordes, F . C.: Retinal ischemia with visual loss. Am. J. Ophth., 45:79-88 (Apr., Pt. I I ) 1958.
862
NOTES, CASES, INSTRUMENTS "Retinal ischemia with visual loss." The long duration, the source of the bleeding, the de velopment of cataracts, and the final result seemed to make the report worthwhile. The recovery of vision in this patient was very slow but her ability to overcome her anemia was quite rapid, as demonstrated by her quick response to the transfusions in April, 1958. H e r rather sudden loss of vision in November, 1956, and a normal blood count in January, 1957, can only be explained as an interval of relative freedom from hemor rhages from November, 1956, to January, 1957, giving her time to restore the red cell deficiency. It is generally conceded that re peated small hemorrhages are more likely to produce visual changes than a single large loss of blood. 209 Medical Arts Building (1).
DERMOID TUMOR OF T H E ORBIT SIMULATING A NEOPLASM* RODERICK MACDONALD, J R . ,
M.D.
Louisville, Kentucky AND J E R O M E L. B Y E R S ,
M.D.t
New Orleans, Louisiana LITERATURE
Epidermoid tumor was first described in the literature by Cruveilhier 1 and was termed "pearly" tumor because of its highly refrac tive and nodular surface. Cholesteatoma as a descriptive term was introduced in 1838 by Mueller 2 because of the large mass of cho lesterol crystals in the lesion. The origin of dermoid tumors has been the subject of much discussion. Heimendinger, 3 Cushing,* McFarland, 5 Ewing, 6 Coates, 7 Critchley and Ferguson, 8 Love and Kernohan, 9 and Bailey 10 have all concurred * From the Department of Ophthalmology, TuIane University Medical School, and the Eye, Ear, Nose, and Throat Hospital of New Orleans, Lou isiana. This case was reported to the Ophthalmic Pathology Club in 1957 by Dr. James H. Allen. t Trainee, National Institute of Neurological Diseases and Blindness, Bethesda, Maryland.
863
in the belief that primary cholesteatomas or dermoids are congenital growths coming from misplaced, aberrant epithelial tissue. However, trauma may be a factor in the pro duction of dermoid tumors, as pointed out by Thacker. 1 1 Pfeiffer and Nicholl, 12 in an excellent re view, state that in a series of 200 consecutive cases of exophthalmos reported in 1941, these congenital growths comprised four per cent of the cases. Several reports of isolated cases of der moids or oil cysts affecting the orbit are to be found throughout the more recent litera ture. Knapp, 1 3 in an interesting report, ana lyzed the chemical constituents contained in a dermoid cyst. H e found that the oil contained no free fatty acids. It contained 36.2-percent cholesterol and had an iodine number of 124. This seemed to indicate that it consisted mostly of a triglyceride of fatty acids more unsaturated than oleic, the iodine number of cholesterol being 56. It would seem that a fatty acid of iodine number of about 180 was involved, while this oil was entirely soluble in fat contents the solid material was not. T h e solid material contained 72 percent choles terol and gave an iodine number of 55. T h e alcohol insoluble portion was probably pro tein. Borley 14 reported a tooth being present within the tumor in his case. Jones 1 5 in 1935 reported the case of an oil cyst becoming ma lignant with the patient dying of carcinomatosis. Palomar, 1 6 cited by Samuels, described a dermoid cyst of the orbit connected through the lateral orbital wall with a "knapsackshaped diverticulum under the temporal mus cle." C A S E REPORT
History. D. R., a 32-year-old Negress was ad mitted to the New Orleans Eye, Ear, Nose, and Throat Hospital on November 16, 1956, with a his tory of a growth beginning in the upper, outer half of the left lid in 1951. A biopsy was made at an other hospital early in 1952, and was reported as a lymphangioma of the lid. The lesion slowly in creased in size, and the left eye gradually became more prominent than the right. In November, 1952,