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St. Louis Ophthalmic Society
SOCIETY PROCEEDINGS Edited by DR. H . : ST. LOUIS OPHTHALMIC SOCIETY October 26, 1934 Dr. E. C. Spitze, president The significance of visual training in relationship to orthoptic methods in amblyopia ex anopsia Dr. M. L. Greene reported a series of cases of monocular convergent stra bismus. The treatment was all nonoperative. Development of vision as the first step in the correction of the strabismus was stressed. Not only did these cases show marked improvement in vision, but without any surgical in tervention or orthoptic training, there was a decided improvement in position. Discussion. Dr. J. F. Hardesty stated that he had had the privilege of seeing most of the cases discussed by Dr. Greene and that it was remarkable to see what patience and perseverence would do in these cases of amblyopia. He also stated that the use of constant occlusion could not be stressed too strongly, and if patients were permitted to use the amblyopic eye occasionally they did not do so well. Dr. W . H. Luedde stated that his own experience in amblyopia ex anopsia had been reported some years ago, and he likewise stressed the importance of constant occlusion. Dr. H. R. Hildreth spoke of a case which was reported in the Proceedings section of the American Journal of Ophthalmology by Dr. Luther Peter. The case in question was that of a 44year-old man who had suffered from paralysis of the left superior rectus and overaction of the right inferior oblique from childhood. After operation full fu sion had promptly developed. Dr. Hildreth drew a comparison between this case in which probably the fusion faculty had been early developed and those cases of concomitant convergent strabismus in which the fusion center was poorly developed. In other words,
3MMEL HILDRETH
there was probably an inherent differ ence in the child with strabismus, so often born in a family with strabismus. Fat emboli of the retinal arteries following bone fractures Dr. J. H. Gross reported the case of J. L., a 39-year-old man. A fracture of the left leg had been reduced and placed in a cast. On the following day the tem perature rose to 38.5 °C. accompanied by dyspnea, cyanosis, rapid pulse, and mental confusion. The condition im proved and then recurred and on the fifth day a retinitis hemorrhagica was found. Large white flame-shaped spots accompanied the hemorrhages. The general condition improved but the vi sion fell to 6/60 in the right eye and 6/36 in the left eye. The fields were not limited but there was a central scotoma in the right field. The patient recovered eventually but there were permanent changes in the maculae, a coarse "marbling," as well as narrowing of the retinal vessels and temporal pallor of the disc. Central vi sion was fully recovered. Discussion. Dr. L. C. Drews inquired if fat emboli occurred after trauma not associated with bone fractures. Dr. M. W . Jacobs asked if Dr. Gross found any cases reported in the litera ture as postoperative cases and how these cases differed from commotio retinae. He further asked how soon after the injuries these spots in the retina appeared. Dr. J. H. Gross stated in closing that these serious-injury cases were not all bone cases, many were the result of pressure on the body. Bones did not have to be fractured. The spots in the retina began to ap pear five or six days after the injury and sometimes even after the eighth day. In the first group of cases it was not known if the lesion were due to fat emboli. Only after several patients had died and sections of the eyes had been
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SOCIETY PROCEEDINGS
made was this revealed in the micro scopic findings. The white spots in the retina were not fat. The ocular manifestations of myasthenia gravis Dr. G. H. Poos stated that myasthenia gravis was a disease character ized by intermittent and usually pro gressive symptoms of fatigue or ex haustion of the muscular system. At first the patient complained of general fatigability increasing during the day. Further progress of the disease was manifested by a marked predilection for the muscles of the face, eyes, tongue, and those of deglutition. At this time there might be transient pe riods of ptosis, ophthalmoplegia, or both. The ocular symptoms were, in a large percentage of cases, the present ing symptoms. Dr. Poos said that his first patient was a 22-year-old girl who presented herself for refraction. She had first noted a peculiar weakness of the mus cles about her mouth, which later spread to her shoulders, arms, and legs. About two years later she had suddenly developed ptosis and diplopia in the right eye. Her generalized weakness improved under ephedrine treatment, but the ocular symptoms remained un changed. When examined, the right upper lid covered one half of the cornea. There was a right external ophthalmoplegia amounting to 36 prism diopters of ad duction. There was no nystagmus, the pupils were normal, the fundi were nor mal, and the visual fields grossly nor mal. Vision was 6/6 in each eye. The second case reported by Dr. Poos was that of a woman 37 years of age, who complained of a weakness of the right side of her face and a droop ing of the right eyelid. There was also difficulty in swallowing and chewing and generalized muscular fatigue which was improved by rest. Numerous op erations and treatments had failed to give her relief. Examination showed a drooping of the right side of the face and a ptosis of the right lid covering 2 mm. of the cornea. After reading a short period of time the right eye showed a
slight convergence. The fundi were nor mal and the visual fields grossly nor mal. No nystagmus was present; the pupils were normal. The faradic cur rent applied to the facial muscles showed a more rapid exhaustion on the right side. Vision in the right eye was 6/7.5 and with a plus 1.00 D. cyl. axis 90° equaled 6/6. Vision in the left eye was 6/6 and with a plus 0.75 D. cyl. axis 115° was 6/6. J. F. Hardesty, Editor.
COLORADO OPHTHALMOLOGICAL SOCIETY November 17, 1934 DR. D. H. O'ROURKE, presiding
Hemorrhagic cyst of the orbit Dr. M. E. Marcove presented Mrs. A. J., aged 29 years, for whom he had removed an orbital tumor two weeks previously. A large, protruding mass had been present at the inner side of the right upper lid since the patient was about ten years old; it grew very slow ly. About two years after it had been first noticed, an attempt was made to remove the growth from the conjunctival side, but this was unsuccessful be cause of bleeding. In 1931, an attempt to aspirate fluid from the tumor was also unsuccessful. The growth remained stationary in size until two weeks ago when it suddenly became very large and somewhat painful. A large, soft, fluctuant mass was seen protruding from the inner canthus through the upper lid. When pushed back into the orbit the mass caused a definite proptosis of the globe. There was no pulsation felt and no bruit heard with the stethoscope. When the eye was turned to the right, the growth came forward, and when turned to the left it receded. There was some limita tion of motion in adduction. Upon evert ing the upper lid, a large bluish-looking mass could be seen through the con junctiva of the upper cul-de-sac. The globe was normal, and the vision 20/20. There was no connection between the
3MMEL HILDRETH
there was probably an inherent differ ence in the child with strabismus, so often born in a family with strabismus. Fat emboli of the retinal arteries following bone fractures Dr. J. H. Gross reported the case of J. L., a 39-year-old man. A fracture of the left leg had been reduced and placed in a cast. On the following day the tem perature rose to 38.5 °C. accompanied by dyspnea, cyanosis, rapid pulse, and mental confusion. The condition im proved and then recurred and on the fifth day a retinitis hemorrhagica was found. Large white flame-shaped spots accompanied the hemorrhages. The general condition improved but the vi sion fell to 6/60 in the right eye and 6/36 in the left eye. The fields were not limited but there was a central scotoma in the right field. The patient recovered eventually but there were permanent changes in the maculae, a coarse "marbling," as well as narrowing of the retinal vessels and temporal pallor of the disc. Central vi sion was fully recovered. Discussion. Dr. L. C. Drews inquired if fat emboli occurred after trauma not associated with bone fractures. Dr. M. W . Jacobs asked if Dr. Gross found any cases reported in the litera ture as postoperative cases and how these cases differed from commotio retinae. He further asked how soon after the injuries these spots in the retina appeared. Dr. J. H. Gross stated in closing that these serious-injury cases were not all bone cases, many were the result of pressure on the body. Bones did not have to be fractured. The spots in the retina began to ap pear five or six days after the injury and sometimes even after the eighth day. In the first group of cases it was not known if the lesion were due to fat emboli. Only after several patients had died and sections of the eyes had been
464
SOCIETY PROCEEDINGS
made was this revealed in the micro scopic findings. The white spots in the retina were not fat. The ocular manifestations of myasthenia gravis Dr. G. H. Poos stated that myasthenia gravis was a disease character ized by intermittent and usually pro gressive symptoms of fatigue or ex haustion of the muscular system. At first the patient complained of general fatigability increasing during the day. Further progress of the disease was manifested by a marked predilection for the muscles of the face, eyes, tongue, and those of deglutition. At this time there might be transient pe riods of ptosis, ophthalmoplegia, or both. The ocular symptoms were, in a large percentage of cases, the present ing symptoms. Dr. Poos said that his first patient was a 22-year-old girl who presented herself for refraction. She had first noted a peculiar weakness of the mus cles about her mouth, which later spread to her shoulders, arms, and legs. About two years later she had suddenly developed ptosis and diplopia in the right eye. Her generalized weakness improved under ephedrine treatment, but the ocular symptoms remained un changed. When examined, the right upper lid covered one half of the cornea. There was a right external ophthalmoplegia amounting to 36 prism diopters of ad duction. There was no nystagmus, the pupils were normal, the fundi were nor mal, and the visual fields grossly nor mal. Vision was 6/6 in each eye. The second case reported by Dr. Poos was that of a woman 37 years of age, who complained of a weakness of the right side of her face and a droop ing of the right eyelid. There was also difficulty in swallowing and chewing and generalized muscular fatigue which was improved by rest. Numerous op erations and treatments had failed to give her relief. Examination showed a drooping of the right side of the face and a ptosis of the right lid covering 2 mm. of the cornea. After reading a short period of time the right eye showed a
slight convergence. The fundi were nor mal and the visual fields grossly nor mal. No nystagmus was present; the pupils were normal. The faradic cur rent applied to the facial muscles showed a more rapid exhaustion on the right side. Vision in the right eye was 6/7.5 and with a plus 1.00 D. cyl. axis 90° equaled 6/6. Vision in the left eye was 6/6 and with a plus 0.75 D. cyl. axis 115° was 6/6. J. F. Hardesty, Editor.
COLORADO OPHTHALMOLOGICAL SOCIETY November 17, 1934 DR. D. H. O'ROURKE, presiding
Hemorrhagic cyst of the orbit Dr. M. E. Marcove presented Mrs. A. J., aged 29 years, for whom he had removed an orbital tumor two weeks previously. A large, protruding mass had been present at the inner side of the right upper lid since the patient was about ten years old; it grew very slow ly. About two years after it had been first noticed, an attempt was made to remove the growth from the conjunctival side, but this was unsuccessful be cause of bleeding. In 1931, an attempt to aspirate fluid from the tumor was also unsuccessful. The growth remained stationary in size until two weeks ago when it suddenly became very large and somewhat painful. A large, soft, fluctuant mass was seen protruding from the inner canthus through the upper lid. When pushed back into the orbit the mass caused a definite proptosis of the globe. There was no pulsation felt and no bruit heard with the stethoscope. When the eye was turned to the right, the growth came forward, and when turned to the left it receded. There was some limita tion of motion in adduction. Upon evert ing the upper lid, a large bluish-looking mass could be seen through the con junctiva of the upper cul-de-sac. The globe was normal, and the vision 20/20. There was no connection between the