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Spastic Myopia as a Complication of Glycosuria
CORRESPONDENCE M. Hayward Post, Jr., of St. Louis, was elected chairman, and Brittain F. Payne of New York, vice chairman, of the section for 1949. The section recorded its support of the resolution adopted by the House of Dele gates in 1947, condemning the acceptance of rebates and calling for punitive measures against members and fellows of the Ameri can Medical Association who are guilty of the practice. The secretary, Trygve Gundersen, was ap pointed to represent the section on a joint committee with other ophthalmic organiza tions to investigate the use of penicillin as a prophylactic agent against ophthalmia neonatorum. A committee of the section to act jointly with representatives of the other ophthalmic organizations to celebrate in 1950 the centenary of the discovery of the ophthalmoscope by Helmholtz was proposed. In spite of the rather small attendance, about 300 members having registered, the meeting was interesting and successful. The 1949 session will be held in Atlantic City, June 6th to 10th. Derrick Vail.
OBITUARY WALLACE PYLE 1875-1948 Dr. Wallace Pyle died June 10, 1948, at his residence in Orange, New Jersey, after several weeks' illness. He was born in Jersey City, New Jersey, a son of the late Dr. Edwin Pyle. He at tended the University of Michigan for two years, and then entered the Medical School of the University of Pennsylvania, from which he received his degree in medicine in 1897. He interned in Christ Hospital, Jer sey City, and later became ophthalmologist on the staff of that hospital and several other Hudson County hospitals, including the Jersey City Medical Center,
1017
He was a fellow of the New York Acad emy of Medicine, the American College of Surgeons, the American Academy of Ophthalmology and Otolaryngology, and the American Medical Association. He was also a member of several local medical societies. Dr. Pyle was always affable, courteous, and generous. These traits, together with his professional ability, endeared him to his patients and his fellow practitioners. His ethical standards were of the highest. His chief diversion was travel. He made numer ous trips to Europe, the far East, Alaska, the western part of .the United States, and South America. His wife, Ida Jarvis Pyle, a son, two daughters, and seven grandchildren survive him; also, a brother, Dr. Edwin Pyle, a physician in Waterbury, Connecticut. Elbert S. Sherman.
CORRESPONDENCE SPASTIC MYOPIA AS A COMPLICATION OF GLYCOSURIA
Editor, American Journal of Ophthalmology : Various writers have referred to refrac tive changes in diabetics. I should like to submit the following case which seems to be one of transient myopia accompanying transient glycosuria. A retired Anglo-Indian lieutenant, aged 61 years, came to the Eye Clinic at Kotagiri, the Nilgiris, South India, complaining of rapidly changing vision. His old glasses (+0.5D. sph. for distance; + 2 D . sph. for reading) were no longer comfortable and he found that he could read better with no glasses. However, his distant vision without glasses was only 6/9, O.Ü. Manifest acceptance on December 12, 1942, was: O.D., - 0 . 7 5 D . sph. C - 0 . 7 5 D . cyl. ax. 90° = 6 / 5 ; O.S., - 1 . 0 D . sph. C —0.25D. cyl. ax. 90° = 6/5. Reading ac ceptance was; O.D., +1.0D. sph. 3
1018
CORRESPONDENCE
+0.75Γλ cyl. ax. 180°; O.S., +1.25D. sph. C +0.2SD. cyl. ax. 180.° As the patient had been taking a strych nine tonic, he was advised to stop this and return for refraction and retinoscopy in 12 days. On December 24th, the repeated tests gave the same acceptance as before. Glasses with the new prescription were comfortable for a time but after the patient, who meanwhile had learned of a diabetic condition (2-percent sugar), took insulin (5 injections only) and followed a diabetic diet, he could no longer tolerate the new glasses but returned to wearing the ones with the old prescription. By February, 1943, he was no longer able to use the new glasses. A glucose tolerance test on March 6, 1943, showed: Fasting blood sugar, 75 mg. per 100 cc. After administration of 50 gm. glu cose, it rose to 106 mg. at the end of 30 minutes; at the end οί\]Λ. hours, it returned to fasting level, and reached 62 mg. at the end of two hours. Urinary sugar was absent throughout the test, the curve appeared to be normal, and there was no evidence of diabetes. For some weeks before he discovered 2percent sugar in his urine, the patient had noticed polyuria and polydipsia. By main taining a low-carbohydrate diet after the five injections of insulin, he has remained sugar free. Never, since he became sugar free, has he been able to tolerate the new minus lenses prescribed during the time when he was suffering from glycosuria. Parsons in his Diseases of the Eye (p. 591592) says that in addition to diabetic cat aract, retinitis, intraocular hemorrhages, and retrobulbar neuritis which may occur with diabetes, there are "remarkable changes in the refraction of the eye, both in the direc tion of hypermetropia and myopia," and he attributes this to "alterations in the refrac tive index of the cortex of the lens." On page 319 he refers to the lenticular changes in diabetic cataract, and says "there
is little doubt that osmotic changes are a prominent factor in the pathogenesis and account for the accumulation of droplets beneath the capsule of the lens." In 1929, K. K. K. Lundegaard in Copen hagen wrote, "In diabetes mellitus a sudden hypermetropia arises due to alteration in the lens." The onset he described as a "sudden mist" obscuring the vision. But in our pa tient, there was no such symptom, and the lens remained clear throughout. Instead of trying to explain the transient myopia with glycosuria in terms of osmosis beneath the lens capsule only, I would like to suggest the possible effect of diabetes on the ciliary muscle as well. I recall two cases admitted to a large American hospital at different times, and by different resident physicians, both of which had been rushed to the surgical ward as "emergency appendix." In each case, for tunately, the coma and the boardlike rigidity of the abdominal muscles were discovered to be due to diabetic coma before surgical intervention supervened. Insulin produced rapid cessation of all symptoms. Both pa tients were children from the same home who had formed the habit of frequenting their father's candy shop and feasting on sweets instead of eating the meals their mother prepared for them. If big abdominal muscles can become spas tic with diabetic crises, is it not possible that the transient myopia also is a spastic my opia. David O. Harrington of San Francisco, (J.A.M.A., 133: (Mar. 8) 1947) makes no reference to diabetes but in his discussion of "Psychosomatic Disorders" describes â tem porary visual disturbance which he considers to be due to a spastic myopia. ''This condi tion," he says, "sometimes called 'ciliary spasm,' is thought to be due to spastic con traction of the ciliary body with resultant increase in antero-posterior diameter of the lens." He considers this to be always asso ciated with emotional disturbance. The ex-
BOOK REVIEWS amination revealed "spastic myopia.'' Although Harrington makes no mention of the myopia of diabetes, or of transient glycosuria, is it not possible that the pathogenesis of transient myopia with transient hyperglycemia and glycosuria may be a "measurable temporary spastic myopia" which appears when there is sugar in excess and disappears when the patient's blood sugar returns to normal? (Signed) M. Pauline Jeffery, Buffalo, New York.
BOOK REVIEWS EL TRACHOMA. By Virgilio Victoria, M.D. Buenos Aires, El Ateneo, 1947. 315 pages, 76 illustrations. The book is motivated by the desire to correlate the bibliographic data on trachoma with the author's clinical observations, and to stimulate public-health activity for the control of the disease in Argentina. Practic ing in Tucumân, a trachoma-infested part of Argentina, Dr. Victoria has a large clini cal, administrative, and research experience with the disease. Of the six chapters into which the book is divided, three are devoted to a description of the clinical and laboratory features, one to therapy, one to the constitutional implica tions of the disease, and one to the publichealth problem, principally as it affects Ar gentina. A bibliography follows each chap ter. The author rejects the view that invasion with pathogenic microorganisms is a com plication of trachoma, and considers this in vasion as an integral and constant part of the pathogenic process. He therefore dis courages the use of the expression "com plicated trachoma" as a misnomer. In the first three chapters the trachomatous lesions in the conjunctiva, cornea, lids, and the lacrimal apparatus are described in detail, and illustrated with colored drawings
1019
and excellent microphotographs of patho logic material examined at the Institute of Regional Medicine of the University of Tucumân. In the chapter on therapy the various therapeutic procedures reported" in the litera ture are reviewed, and there is a useful and detailed account of the treatment patterns set up by Busacca, and followed in the main by the author in the management of the vari ous phases of the disease. While the procedure described by Busacca as "kneading-massage" is still the sheet anchor in the treatment pattern, the addition of sulfa therapy is recognized as of great value in hastening cicatrization, shortening the duration of treatment, and eliminating the need for subconjunctival injections. The chapter on surgical management of entropion and trichiasis is clear, concise, and illustrated with excellent drawings by Boltasar Isasi. No new viewpoints relative to etiology are presented; the author does not believe that lymphatic diathesis, nutritional deficiencies, malaria, syphilis, tuberculosis, and intestinal parasites play any role in the etiology of trachoma, and denies the existence of nat ural or acquired immunity. He believes that the great danger of in fection is in childhood, and considers tra choma infectious in all its stages. In support of this contention he cites the case of an infant, 35-days old, with follicular trachoma, whose contact was limited to his mother; she had a cicatrized conjunctiva and had had no clinical symptoms for over 10 years. Population density, low altitude, constant winds and dust, periodic migrations of labor groups without sanitary provisions, are fac tors favoring the spread of the disease ; tem perature and humidity appear to be without influence ; and hygienic living conditions and the availability of running water diminish its incidence. From the point of view of public health it may be said that Dr. Victoria is progrès-
OBITUARY WALLACE PYLE 1875-1948 Dr. Wallace Pyle died June 10, 1948, at his residence in Orange, New Jersey, after several weeks' illness. He was born in Jersey City, New Jersey, a son of the late Dr. Edwin Pyle. He at tended the University of Michigan for two years, and then entered the Medical School of the University of Pennsylvania, from which he received his degree in medicine in 1897. He interned in Christ Hospital, Jer sey City, and later became ophthalmologist on the staff of that hospital and several other Hudson County hospitals, including the Jersey City Medical Center,
1017
He was a fellow of the New York Acad emy of Medicine, the American College of Surgeons, the American Academy of Ophthalmology and Otolaryngology, and the American Medical Association. He was also a member of several local medical societies. Dr. Pyle was always affable, courteous, and generous. These traits, together with his professional ability, endeared him to his patients and his fellow practitioners. His ethical standards were of the highest. His chief diversion was travel. He made numer ous trips to Europe, the far East, Alaska, the western part of .the United States, and South America. His wife, Ida Jarvis Pyle, a son, two daughters, and seven grandchildren survive him; also, a brother, Dr. Edwin Pyle, a physician in Waterbury, Connecticut. Elbert S. Sherman.
CORRESPONDENCE SPASTIC MYOPIA AS A COMPLICATION OF GLYCOSURIA
Editor, American Journal of Ophthalmology : Various writers have referred to refrac tive changes in diabetics. I should like to submit the following case which seems to be one of transient myopia accompanying transient glycosuria. A retired Anglo-Indian lieutenant, aged 61 years, came to the Eye Clinic at Kotagiri, the Nilgiris, South India, complaining of rapidly changing vision. His old glasses (+0.5D. sph. for distance; + 2 D . sph. for reading) were no longer comfortable and he found that he could read better with no glasses. However, his distant vision without glasses was only 6/9, O.Ü. Manifest acceptance on December 12, 1942, was: O.D., - 0 . 7 5 D . sph. C - 0 . 7 5 D . cyl. ax. 90° = 6 / 5 ; O.S., - 1 . 0 D . sph. C —0.25D. cyl. ax. 90° = 6/5. Reading ac ceptance was; O.D., +1.0D. sph. 3
1018
CORRESPONDENCE
+0.75Γλ cyl. ax. 180°; O.S., +1.25D. sph. C +0.2SD. cyl. ax. 180.° As the patient had been taking a strych nine tonic, he was advised to stop this and return for refraction and retinoscopy in 12 days. On December 24th, the repeated tests gave the same acceptance as before. Glasses with the new prescription were comfortable for a time but after the patient, who meanwhile had learned of a diabetic condition (2-percent sugar), took insulin (5 injections only) and followed a diabetic diet, he could no longer tolerate the new glasses but returned to wearing the ones with the old prescription. By February, 1943, he was no longer able to use the new glasses. A glucose tolerance test on March 6, 1943, showed: Fasting blood sugar, 75 mg. per 100 cc. After administration of 50 gm. glu cose, it rose to 106 mg. at the end of 30 minutes; at the end οί\]Λ. hours, it returned to fasting level, and reached 62 mg. at the end of two hours. Urinary sugar was absent throughout the test, the curve appeared to be normal, and there was no evidence of diabetes. For some weeks before he discovered 2percent sugar in his urine, the patient had noticed polyuria and polydipsia. By main taining a low-carbohydrate diet after the five injections of insulin, he has remained sugar free. Never, since he became sugar free, has he been able to tolerate the new minus lenses prescribed during the time when he was suffering from glycosuria. Parsons in his Diseases of the Eye (p. 591592) says that in addition to diabetic cat aract, retinitis, intraocular hemorrhages, and retrobulbar neuritis which may occur with diabetes, there are "remarkable changes in the refraction of the eye, both in the direc tion of hypermetropia and myopia," and he attributes this to "alterations in the refrac tive index of the cortex of the lens." On page 319 he refers to the lenticular changes in diabetic cataract, and says "there
is little doubt that osmotic changes are a prominent factor in the pathogenesis and account for the accumulation of droplets beneath the capsule of the lens." In 1929, K. K. K. Lundegaard in Copen hagen wrote, "In diabetes mellitus a sudden hypermetropia arises due to alteration in the lens." The onset he described as a "sudden mist" obscuring the vision. But in our pa tient, there was no such symptom, and the lens remained clear throughout. Instead of trying to explain the transient myopia with glycosuria in terms of osmosis beneath the lens capsule only, I would like to suggest the possible effect of diabetes on the ciliary muscle as well. I recall two cases admitted to a large American hospital at different times, and by different resident physicians, both of which had been rushed to the surgical ward as "emergency appendix." In each case, for tunately, the coma and the boardlike rigidity of the abdominal muscles were discovered to be due to diabetic coma before surgical intervention supervened. Insulin produced rapid cessation of all symptoms. Both pa tients were children from the same home who had formed the habit of frequenting their father's candy shop and feasting on sweets instead of eating the meals their mother prepared for them. If big abdominal muscles can become spas tic with diabetic crises, is it not possible that the transient myopia also is a spastic my opia. David O. Harrington of San Francisco, (J.A.M.A., 133: (Mar. 8) 1947) makes no reference to diabetes but in his discussion of "Psychosomatic Disorders" describes â tem porary visual disturbance which he considers to be due to a spastic myopia. ''This condi tion," he says, "sometimes called 'ciliary spasm,' is thought to be due to spastic con traction of the ciliary body with resultant increase in antero-posterior diameter of the lens." He considers this to be always asso ciated with emotional disturbance. The ex-
BOOK REVIEWS amination revealed "spastic myopia.'' Although Harrington makes no mention of the myopia of diabetes, or of transient glycosuria, is it not possible that the pathogenesis of transient myopia with transient hyperglycemia and glycosuria may be a "measurable temporary spastic myopia" which appears when there is sugar in excess and disappears when the patient's blood sugar returns to normal? (Signed) M. Pauline Jeffery, Buffalo, New York.
BOOK REVIEWS EL TRACHOMA. By Virgilio Victoria, M.D. Buenos Aires, El Ateneo, 1947. 315 pages, 76 illustrations. The book is motivated by the desire to correlate the bibliographic data on trachoma with the author's clinical observations, and to stimulate public-health activity for the control of the disease in Argentina. Practic ing in Tucumân, a trachoma-infested part of Argentina, Dr. Victoria has a large clini cal, administrative, and research experience with the disease. Of the six chapters into which the book is divided, three are devoted to a description of the clinical and laboratory features, one to therapy, one to the constitutional implica tions of the disease, and one to the publichealth problem, principally as it affects Ar gentina. A bibliography follows each chap ter. The author rejects the view that invasion with pathogenic microorganisms is a com plication of trachoma, and considers this in vasion as an integral and constant part of the pathogenic process. He therefore dis courages the use of the expression "com plicated trachoma" as a misnomer. In the first three chapters the trachomatous lesions in the conjunctiva, cornea, lids, and the lacrimal apparatus are described in detail, and illustrated with colored drawings
1019
and excellent microphotographs of patho logic material examined at the Institute of Regional Medicine of the University of Tucumân. In the chapter on therapy the various therapeutic procedures reported" in the litera ture are reviewed, and there is a useful and detailed account of the treatment patterns set up by Busacca, and followed in the main by the author in the management of the vari ous phases of the disease. While the procedure described by Busacca as "kneading-massage" is still the sheet anchor in the treatment pattern, the addition of sulfa therapy is recognized as of great value in hastening cicatrization, shortening the duration of treatment, and eliminating the need for subconjunctival injections. The chapter on surgical management of entropion and trichiasis is clear, concise, and illustrated with excellent drawings by Boltasar Isasi. No new viewpoints relative to etiology are presented; the author does not believe that lymphatic diathesis, nutritional deficiencies, malaria, syphilis, tuberculosis, and intestinal parasites play any role in the etiology of trachoma, and denies the existence of nat ural or acquired immunity. He believes that the great danger of in fection is in childhood, and considers tra choma infectious in all its stages. In support of this contention he cites the case of an infant, 35-days old, with follicular trachoma, whose contact was limited to his mother; she had a cicatrized conjunctiva and had had no clinical symptoms for over 10 years. Population density, low altitude, constant winds and dust, periodic migrations of labor groups without sanitary provisions, are fac tors favoring the spread of the disease ; tem perature and humidity appear to be without influence ; and hygienic living conditions and the availability of running water diminish its incidence. From the point of view of public health it may be said that Dr. Victoria is progrès-