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Saint Louis Ophthalmic Society
SOCIETY PROCEEDINGS in convergent concomitant squint, and the use of prisms, base out, for externalrectus paralysis. His explanation of the reason for overaction of the inferior-oblique muscle is the only one that seems reasonable. It is usually not possible to demonstrate paraly sis of the superior rectus of the opposite eye to one's satisfaction. Another impor tant point is the fact that overaction of the inferior-oblique muscle is extremely common in children but is very seldom seen in adults. This would not be true if it were due to paralysis of the superior rectus of the other eye. In regard to the use of prisms, base out, undercorrecting the deviation in con vergent concomitant squint, one likes to think of the first page in Traquair's book on "Perimetry," in which he refers to the visual field as a "hill of vision in a sea of blindness." In this hill the peak corre sponds to the fixation point, the hill slopes off gradually on each side of the peak for about 10 degrees, then slopes off rapidly. The use of prisms, base out, undercor recting the deviation would be an attempt to make the image fall on the side of this hill, and the eye should then move out sufficiently to have the image fall on the fixation point. If this is so, why did Dr. Guibor not order prisms correcting all the deviation less 10 degrees, instead of correcting much less? It is disappointing that he finds that the use of prisms in this manner is not effective in cases of abnormal retinal correspondence. Would Dr. Guibor make a more definite state ment concerning the value of prisms in cases of alternating convergent squint? are they less effective than in cases of monocular squint? With reference to the use of strong prisms, base out, in cases of paralysis of the external-rectus muscle, he was not so enthusiastic as the essayist. It seems he is doing very little more with these un
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sightly lenses than the patient does by merely turning his head toward the side of the paralyzed muscle. The important point is whether or not there is contracture of the internal-rectus muscle. If that develops before the paralysis recovers it will take more than prisms, base out, to relieve it. Dr. George P. Guibor, in closing, said that motor defects are always undercorrected with prisms because one is unable to determine the amount of spasticity present. Likewise, it is easier to add more prism to a deviation that is not improving than to remove prism from a patient who is using full correction. Dr. Gamble is correct in his criticism of the use of prisms in treating paretic deviation, especially so when these devia tions are associated with severe suppres sion and contracture of the opponent muscle. However, in partial defects not associated with contracture, prisms are of considerable value. Robert Von der Heydt.
SAINT LOUIS O P H T H A L M I C SOCIETY November 27, 1942 DR. LESLIE DREWS, president DENDRITIC ULCER DR. F. O. SCHWARTZ read a paper on this subject which was published in this Journal (1943, v. 26, p. 394). Discussion. Dr. M. H. Post said that he had noticed repeatedly that dendritic ulcers heal rapidly on removal of foci of infection, but he had a feeling, too, that this disease is self-limiting to some ex tent. He had seen cases in which no foci of infection could be found, in which the lesion resisted all local treatment, but, continuing this same local treatment, something took place in the system, and
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SOCIETY PROCEEDINGS
the eye suddenly healed very rapidly. He said that he had not had much luck with the thermophore in this type of lesion. Dr. Post said that Dr. John G. Bellows had issued a word of warning about the use of sulfa drugs in lesions of the cor nea. Since the action takes place only in vascularized tissue, there is a tendency for these drugs to induce vascularization of the cornea in the region of the ulceration. Dr. William Shahan said he had found that local applications of 1-percent silver nitrate used very cautiously, tracing the open branches of the ulcer, make them well in three or four days. Of course, when the cases are protracted he also sent the patient to some rhinologist and then to the family doctor. Dr. Roy Mason said he would like to ask Dr. Schwartz about his case in which the patient was struck by the limb of a cherry tree. He had had a number of these cases preceded by some sort of trauma. One patient got cement dust in his eyes. In a few days he developed a dendritic ulcer. Did the accident activate it or aggravate it? There are very good textbooks that fail to answer this ques tion, but give the impression that trauma has something to do with dendritic ulcer. He has felt that the condition was not due to trauma but, like Dr. Schwartz, to some virus or toxin. So many cases, however, are preceded by slight trauma. Another phase of the subject is the use of the sulfa drugs. He has been using sulfathiazole internally in these cases and it seemed to him that the patients have been getting well much faster than before. Dr. F. O. Schwartz (closing) in an swer to Dr. Shahan, said he used the thermophore at 154°F. for one minute. He had seen a number of cases of dendritic ulcer following injuries; about half a dozen patients had been improved
after the removal of corneal foreign bodies but had returned in a week or 10 days with dendritic ulcer. He was in clined to think the injury paved the way for the development of the ulcer. He had never seen the condition occur in both eyes. CORNEAL RESECTION FOR DYSTROPHY
DR. VINCENT L. JONES presented the
case of a woman, aged 43 years, who had come under his observation in March, 1939. The corrected vision in each eye had been 20/20. Corneal dystrophy or de generation (without gutter formation) progressed from the periphery until, in February, 1942, the entire cornea in each eye was involved. Vision was limited to the detection of gross motions. On May 11, 1942, corneal resection was performed, following the method of Meyer Wiener. Erythema doses of X rays were given under the direction of Dr. Sherwood Moore. Healing was un eventful. On August 21st, vision in this eye was 20/400, and on November 25th the vision had improved to 20/200. Discussion. Dr. William James pointed out the need for better terminology to avoid confusion in discussing corneal conditions. In obscure, so-called dystro phies of the cornea he had used corneal resection in seven cases; four received beneficial results. Yet after about four or six months the cornea became opaque from what he judged was edema. The patients were not benefited permanently at all. To resect down to firm healthy tissue is worthwhile in a great number of cases of scars and erosions of the cornea. Dr. John Green wished to commend Dr. James on his technique of corneal re section. Dr. James was kind enough to assist him in one case. It was a beautiful demonstration of how the scar tissue can be dissected off in the proper plane of dissection.
SOCIETY PROCEEDINGS In cases of bullae it was quite remark able how one can get rid of them without regeneration. Not only Ewing but Allen of Chicago showed that the genesis of a bullous keratitis was a disease of Bow man's membrane. If one removes the su perficial layers of the cornea including Bowman's membrane a quiet eye will re sult. Most of his cases had been in blind eyes that could not be removed for some reason. James H. Bryan, Editor.
COLORADO OPHTHALMOLOGICAL SOCIETY November 28, 1942 DR. JAMES
M. SHIELDS, president
D E T A C H M E N T OF T H E RETINA AND CAT ARACT EXTRACTION DR. WILLIAM M. BANE presented the
case of Mr. R. B., aged 23 years, who was examined by Dr. J. L. Swigert on December 1, 1933. He had symptoms of eye strain with some blurring of vision and a chronic facial eczema. His vision was O.D. 20/20; O.S. 2 0 / 5 0 - 1 . There were also bilateral posterior capsular cataracts, larger in the left eye. Weak lenses were ordered but they did not im prove the vision. The fundi were normal. On May 9, 1939, the patient complained of more loss of vision. Examination re vealed numerous vitreous floaters in both eyes, also a retinal detachment in the right eye, lower temporal quadrant. This was operated on with immediate good results by Dr. Swigert. After the first operation there devel oped what was thought to be a secondary detachment. This was not at the periph ery, which seemed healed, but near the center of the original separation. A guarded prognosis was given. A second
287
operation was performed by Dr. Swigert, with good results and no complications. Early in 1942, the patient went to the Mayo Clinic for his eczema. A diagnosis of atopic dermatitis was made. On October 5, 1942, examination re vealed a mature cataract in the right eye. This was operated on by Dr. William M. Bane with excellent result. Vision with correction at this time was O.D. 5/20— 1; O.S. 5 / 2 0 - 1 . ENDOPHTHALMITIS SECONDARY TO TRAUMA, WITH RECOVERY DR. RALPH W . DANIELSON presented
a 13-year-old boy, who was first seen for refraction in March, 1941, at which time it was found that he was practically emmetropic, each eye, with a vision of 20/15. He was next seen on June 25, 1942, because on the day before he had been struck in the right eye with a piece of wood. On examination, it was found that a flat, more or less oblong, sliver of wood was extending through almost the entire thickness of the cornea in a slanting man ner. This was removed with considerable difficulty, the attempt being made to avoid pushing the piece of wood into the an terior chamber and injuring the lens. The patient was placed on sulfathiazole, about 0.5 grain per pound of body weight, but in a couple of days it was noted that the cornea was definitely becoming opaque and a hypopyon was developing in the anterior chamber. The sulfathiazole was increased to 0.75 grain per pound of body weight, but, in spite of this, by June 29th, there appeared to be a hopeless endoph thalmitis, the cornea showing an increase in opacity and the anterior chamber be ing so full of hypopyon that the iris could not be seen. It was felt that something drastic would have to be attempted. The sulfathiazole was, therefore, increased to
285
sightly lenses than the patient does by merely turning his head toward the side of the paralyzed muscle. The important point is whether or not there is contracture of the internal-rectus muscle. If that develops before the paralysis recovers it will take more than prisms, base out, to relieve it. Dr. George P. Guibor, in closing, said that motor defects are always undercorrected with prisms because one is unable to determine the amount of spasticity present. Likewise, it is easier to add more prism to a deviation that is not improving than to remove prism from a patient who is using full correction. Dr. Gamble is correct in his criticism of the use of prisms in treating paretic deviation, especially so when these devia tions are associated with severe suppres sion and contracture of the opponent muscle. However, in partial defects not associated with contracture, prisms are of considerable value. Robert Von der Heydt.
SAINT LOUIS O P H T H A L M I C SOCIETY November 27, 1942 DR. LESLIE DREWS, president DENDRITIC ULCER DR. F. O. SCHWARTZ read a paper on this subject which was published in this Journal (1943, v. 26, p. 394). Discussion. Dr. M. H. Post said that he had noticed repeatedly that dendritic ulcers heal rapidly on removal of foci of infection, but he had a feeling, too, that this disease is self-limiting to some ex tent. He had seen cases in which no foci of infection could be found, in which the lesion resisted all local treatment, but, continuing this same local treatment, something took place in the system, and
286
SOCIETY PROCEEDINGS
the eye suddenly healed very rapidly. He said that he had not had much luck with the thermophore in this type of lesion. Dr. Post said that Dr. John G. Bellows had issued a word of warning about the use of sulfa drugs in lesions of the cor nea. Since the action takes place only in vascularized tissue, there is a tendency for these drugs to induce vascularization of the cornea in the region of the ulceration. Dr. William Shahan said he had found that local applications of 1-percent silver nitrate used very cautiously, tracing the open branches of the ulcer, make them well in three or four days. Of course, when the cases are protracted he also sent the patient to some rhinologist and then to the family doctor. Dr. Roy Mason said he would like to ask Dr. Schwartz about his case in which the patient was struck by the limb of a cherry tree. He had had a number of these cases preceded by some sort of trauma. One patient got cement dust in his eyes. In a few days he developed a dendritic ulcer. Did the accident activate it or aggravate it? There are very good textbooks that fail to answer this ques tion, but give the impression that trauma has something to do with dendritic ulcer. He has felt that the condition was not due to trauma but, like Dr. Schwartz, to some virus or toxin. So many cases, however, are preceded by slight trauma. Another phase of the subject is the use of the sulfa drugs. He has been using sulfathiazole internally in these cases and it seemed to him that the patients have been getting well much faster than before. Dr. F. O. Schwartz (closing) in an swer to Dr. Shahan, said he used the thermophore at 154°F. for one minute. He had seen a number of cases of dendritic ulcer following injuries; about half a dozen patients had been improved
after the removal of corneal foreign bodies but had returned in a week or 10 days with dendritic ulcer. He was in clined to think the injury paved the way for the development of the ulcer. He had never seen the condition occur in both eyes. CORNEAL RESECTION FOR DYSTROPHY
DR. VINCENT L. JONES presented the
case of a woman, aged 43 years, who had come under his observation in March, 1939. The corrected vision in each eye had been 20/20. Corneal dystrophy or de generation (without gutter formation) progressed from the periphery until, in February, 1942, the entire cornea in each eye was involved. Vision was limited to the detection of gross motions. On May 11, 1942, corneal resection was performed, following the method of Meyer Wiener. Erythema doses of X rays were given under the direction of Dr. Sherwood Moore. Healing was un eventful. On August 21st, vision in this eye was 20/400, and on November 25th the vision had improved to 20/200. Discussion. Dr. William James pointed out the need for better terminology to avoid confusion in discussing corneal conditions. In obscure, so-called dystro phies of the cornea he had used corneal resection in seven cases; four received beneficial results. Yet after about four or six months the cornea became opaque from what he judged was edema. The patients were not benefited permanently at all. To resect down to firm healthy tissue is worthwhile in a great number of cases of scars and erosions of the cornea. Dr. John Green wished to commend Dr. James on his technique of corneal re section. Dr. James was kind enough to assist him in one case. It was a beautiful demonstration of how the scar tissue can be dissected off in the proper plane of dissection.
SOCIETY PROCEEDINGS In cases of bullae it was quite remark able how one can get rid of them without regeneration. Not only Ewing but Allen of Chicago showed that the genesis of a bullous keratitis was a disease of Bow man's membrane. If one removes the su perficial layers of the cornea including Bowman's membrane a quiet eye will re sult. Most of his cases had been in blind eyes that could not be removed for some reason. James H. Bryan, Editor.
COLORADO OPHTHALMOLOGICAL SOCIETY November 28, 1942 DR. JAMES
M. SHIELDS, president
D E T A C H M E N T OF T H E RETINA AND CAT ARACT EXTRACTION DR. WILLIAM M. BANE presented the
case of Mr. R. B., aged 23 years, who was examined by Dr. J. L. Swigert on December 1, 1933. He had symptoms of eye strain with some blurring of vision and a chronic facial eczema. His vision was O.D. 20/20; O.S. 2 0 / 5 0 - 1 . There were also bilateral posterior capsular cataracts, larger in the left eye. Weak lenses were ordered but they did not im prove the vision. The fundi were normal. On May 9, 1939, the patient complained of more loss of vision. Examination re vealed numerous vitreous floaters in both eyes, also a retinal detachment in the right eye, lower temporal quadrant. This was operated on with immediate good results by Dr. Swigert. After the first operation there devel oped what was thought to be a secondary detachment. This was not at the periph ery, which seemed healed, but near the center of the original separation. A guarded prognosis was given. A second
287
operation was performed by Dr. Swigert, with good results and no complications. Early in 1942, the patient went to the Mayo Clinic for his eczema. A diagnosis of atopic dermatitis was made. On October 5, 1942, examination re vealed a mature cataract in the right eye. This was operated on by Dr. William M. Bane with excellent result. Vision with correction at this time was O.D. 5/20— 1; O.S. 5 / 2 0 - 1 . ENDOPHTHALMITIS SECONDARY TO TRAUMA, WITH RECOVERY DR. RALPH W . DANIELSON presented
a 13-year-old boy, who was first seen for refraction in March, 1941, at which time it was found that he was practically emmetropic, each eye, with a vision of 20/15. He was next seen on June 25, 1942, because on the day before he had been struck in the right eye with a piece of wood. On examination, it was found that a flat, more or less oblong, sliver of wood was extending through almost the entire thickness of the cornea in a slanting man ner. This was removed with considerable difficulty, the attempt being made to avoid pushing the piece of wood into the an terior chamber and injuring the lens. The patient was placed on sulfathiazole, about 0.5 grain per pound of body weight, but in a couple of days it was noted that the cornea was definitely becoming opaque and a hypopyon was developing in the anterior chamber. The sulfathiazole was increased to 0.75 grain per pound of body weight, but, in spite of this, by June 29th, there appeared to be a hopeless endoph thalmitis, the cornea showing an increase in opacity and the anterior chamber be ing so full of hypopyon that the iris could not be seen. It was felt that something drastic would have to be attempted. The sulfathiazole was, therefore, increased to