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St. Louis Ophthalmic Society
826
COLORADO OPHTHALMOLOGICAL SOCIETY
of the eyehds, in a child of eighteen months, apparently due to ethmoiditis. Less than a week before the onset of the eye disturbance, there had been an infection of the right ear without an ap parent cold. Swelling of the right eye lids developed rapidly, in the course of twenty-four hours, there being a red edema of the lids which extended to the orbital margin. The lids were easily opened for examination, and the eyeball appeared absolutely normal, without chemosis or redness of the bulbar con junctiva, altho twenty-four hours later there was a very slight watery appear ance of the bulbar conjunctiva. Within twenty-four hours after the eye disturb ance was first noticed, there was prop tosis of about 3 mm. The temperature was at that time 1 0 3 ° by rectum, and the child was bright and did not appear decidedly ill. There was doubtful slight tenderness to pressure on the eyelid. The case had been diagnosed as probably one of ethmoiditis with edema of the deep orbital tissues, perhaps purely toxic in character, or perhaps associated with a bulging of the lamina papyracea. Next day, under internal administration of saHcylates, the temperature was fairly steady around 1 0 2 ° rectal, and the lid edema not greater but perhaps slightly less. There was no distention of the ret inal veins. Again a day later, the temperature was about 1 0 0 ° rectal, and the general appearance of the child much better. There was a marked shrinkage of the lid edema and free discharge from the nose, altho the proptosis was still quite marked.
anatomy of the ciliary ganglion and re viewed the controversies on its nature and function, as recorded in the litera ture of the past seventy-five years. Angioneurotic Edema, Quincke's Dis ease. D R . J . F . SHOEMAKER reported
the
case. A. H . , female, 1 2 years of age, was brought by her mother, January 9, 1 9 2 5 . T h e mother stated that when the child arose from sleep that morn ing the lids of the right eye were swol len. There was no pain, itching, or inflammation. She had had several sim ilar attacks during the past summer and autumn, lasting about a day at a time. T h e patient was apparently en tirely healthy, not complaining of any indisposition.
On examination there was found present a marked swelling of the lower lid of the right eye, which extended down over the malar bone. T h e r e was no sign of any inflammation of the skin and but the mildest form of conjunc tivitis. Otherwise she seemed per fectly normal. She was given a mild collyrium to use at home and by the next day the edema had disappeared. Quincke's edema or angioneurotic edema are different names applied to ephemeral spots of edema which may appear in the skin on any part of the body, in the mucous membrane or even in the synovial membrane. These spots of edema frequently resemble urticarial spots, and Osier said they were "only urticarial wheals writ large." T h e on set is sudden, there is no inflammation or local pain, and the condition dis W M . H . CRISP, appears as quickly as it comes. Secretary. Etiologically the edema was first thought to be due to a neurotic factor. ST. L O U I S O P H T H A L M I C Later it was thought that it might be SOCIETY. due to sinus infection. B u t the past few years the tendency is to associate FEBRUARY 2 7 , 1 9 2 5 . it with a congenital hypersensitiveness D R . JOSEPH W . CHARLES, presiding. (allergy), or an artificial sensitization to a foreign protein (anaphylaxis). Hydrophthalmus. DR. H . D . LAMB read a paper, giving Further investigation seems necessary a clinical report and microscopic find before its true cause can be definitely ings in a case (see p. 7 8 4 , this issue.) assigned. Convergent Squint. Ciliary Ganglion. D R . SHAHAN contributed a discus sion on the human and comparative
D R . J . F . SHOEMAKER reported
the
case of a baby, 5 months old, who was
SOCIETY PROCEEDINGS
brought by her mother, October 31, 1924, with the following history: When ten weeks of age she got a small piece of lime in the right eye which the mother removed at once. The eye was slightly inflamed for sev eral days, but soon cleared up and was apparently all right. T w o weeks after this the right eye began to turn in. T h e mother, thinking the trouble might dis appear, waited until the baby was five months old, before seeking advice. During the two months' time the eye remained constantly crossed. On examination it was found that the right eye was markedly turned in, it being in line with the left eye on looking to the extreme left, but was crossed when looking straight in front of her, and never turned outward past the median line. Otherwise the eyes appeared perfectly normal. Retino scopy was very unsatisfactory but she apparently had between 3 and 3.50 diopters of hypermetropia. She had al ways been perfectly healthy. Atropin drops were used in the left eye, and later a bandage applied over this eye, hoping to increase the motil ity of the crossed eye by compelling its use. This treatment had no effect, apparently, on the afliected eye; so it was stopped. However, after several months the eye gradually turned past the median line at times and when last seen could be turned outward, possibly 15 or 20 degrees beyond this line, there being much better motility. Discussion. DR. J O H N GREEN, J R . , gave two possible explanations. First, that there may have been some birth injury of the external rectus. ( W a s inquiry made as to prolonged or instrumental delivery?) Second, there may be an absence of the external rectus or a re placement of this muscle by an inextensible fibrous band, whereby abduc tion is impossible and abduction is often accompanied by retraction of the globe. D R . J o s . W . C H A R L E S : Dr. Green has mentioned the two possibilities I have in mind. It is quite feasible to oper ate in some of these cases at any rate. In 1910, a child 27 months old was brought to me for left converging stra
R27
bismus and given plus 1.25 Sph. R. and L. In 1912 I prescribed - f 2 . Sph. C - f 1 eye. ax. 90°. W i t h this glass R. V . = 1 9 / 3 0 ; L . V . = 19/120. Constant occlusion of the right eye, and atropia at home did not improve vision; and in 1914 a diagnosis of congenital weak ness of both externi was made. In 1917 a very small but undoubted defect of the macula of the left eye was discovered. Tenotomy of the left internus was performed in 1920 after which it was found that an advance ment was not needed. She had dis carded her glasses. R . E m . V . 23/15. L., fingers at 2 feet. DR. J . F . SHOEMAKER (closing) : Sev eral things argue against this case be longing to that group of cases where there is an absence of the external rec tus. In the first place both eyes were apparently straight the first three months of the baby's life; and second ly, the improvement that has taken place after two or three months. Both of these facts seem to prove the pres ence of the external rectus muscle. THE
NASHVILLE ACADEMY OF O P H T H A L M O L O G Y AND OTO-LARYNGOLOGY. March 16, 1925.
CHAIRMAN, D R . ROBERT SULLIVAN.
Eye Injury. DR. E . B . CAYCE presented the case of W . D . F., a white male 22 years of age, who was first seen on the night of February 10, 1925, and gave the fol lowing history: W a s cutting a button off a pair of overalls and the scissors slipped and cut the right eye. Exam ination showed a large cut extending entirely thru the cornea, with iris pro truding thru the wound, which ex tended thru the sclerocorneal junction above. Protruding iris was clipped and he was given an injection of cyanid of mercury. T h e eye healed kindly and the absorption of the lens was as rapid as usual. On March 14th, the patient returned with the eye irritable and a rather marked circumcorneal injection. 6 cc.
COLORADO OPHTHALMOLOGICAL SOCIETY
of the eyehds, in a child of eighteen months, apparently due to ethmoiditis. Less than a week before the onset of the eye disturbance, there had been an infection of the right ear without an ap parent cold. Swelling of the right eye lids developed rapidly, in the course of twenty-four hours, there being a red edema of the lids which extended to the orbital margin. The lids were easily opened for examination, and the eyeball appeared absolutely normal, without chemosis or redness of the bulbar con junctiva, altho twenty-four hours later there was a very slight watery appear ance of the bulbar conjunctiva. Within twenty-four hours after the eye disturb ance was first noticed, there was prop tosis of about 3 mm. The temperature was at that time 1 0 3 ° by rectum, and the child was bright and did not appear decidedly ill. There was doubtful slight tenderness to pressure on the eyelid. The case had been diagnosed as probably one of ethmoiditis with edema of the deep orbital tissues, perhaps purely toxic in character, or perhaps associated with a bulging of the lamina papyracea. Next day, under internal administration of saHcylates, the temperature was fairly steady around 1 0 2 ° rectal, and the lid edema not greater but perhaps slightly less. There was no distention of the ret inal veins. Again a day later, the temperature was about 1 0 0 ° rectal, and the general appearance of the child much better. There was a marked shrinkage of the lid edema and free discharge from the nose, altho the proptosis was still quite marked.
anatomy of the ciliary ganglion and re viewed the controversies on its nature and function, as recorded in the litera ture of the past seventy-five years. Angioneurotic Edema, Quincke's Dis ease. D R . J . F . SHOEMAKER reported
the
case. A. H . , female, 1 2 years of age, was brought by her mother, January 9, 1 9 2 5 . T h e mother stated that when the child arose from sleep that morn ing the lids of the right eye were swol len. There was no pain, itching, or inflammation. She had had several sim ilar attacks during the past summer and autumn, lasting about a day at a time. T h e patient was apparently en tirely healthy, not complaining of any indisposition.
On examination there was found present a marked swelling of the lower lid of the right eye, which extended down over the malar bone. T h e r e was no sign of any inflammation of the skin and but the mildest form of conjunc tivitis. Otherwise she seemed per fectly normal. She was given a mild collyrium to use at home and by the next day the edema had disappeared. Quincke's edema or angioneurotic edema are different names applied to ephemeral spots of edema which may appear in the skin on any part of the body, in the mucous membrane or even in the synovial membrane. These spots of edema frequently resemble urticarial spots, and Osier said they were "only urticarial wheals writ large." T h e on set is sudden, there is no inflammation or local pain, and the condition dis W M . H . CRISP, appears as quickly as it comes. Secretary. Etiologically the edema was first thought to be due to a neurotic factor. ST. L O U I S O P H T H A L M I C Later it was thought that it might be SOCIETY. due to sinus infection. B u t the past few years the tendency is to associate FEBRUARY 2 7 , 1 9 2 5 . it with a congenital hypersensitiveness D R . JOSEPH W . CHARLES, presiding. (allergy), or an artificial sensitization to a foreign protein (anaphylaxis). Hydrophthalmus. DR. H . D . LAMB read a paper, giving Further investigation seems necessary a clinical report and microscopic find before its true cause can be definitely ings in a case (see p. 7 8 4 , this issue.) assigned. Convergent Squint. Ciliary Ganglion. D R . SHAHAN contributed a discus sion on the human and comparative
D R . J . F . SHOEMAKER reported
the
case of a baby, 5 months old, who was
SOCIETY PROCEEDINGS
brought by her mother, October 31, 1924, with the following history: When ten weeks of age she got a small piece of lime in the right eye which the mother removed at once. The eye was slightly inflamed for sev eral days, but soon cleared up and was apparently all right. T w o weeks after this the right eye began to turn in. T h e mother, thinking the trouble might dis appear, waited until the baby was five months old, before seeking advice. During the two months' time the eye remained constantly crossed. On examination it was found that the right eye was markedly turned in, it being in line with the left eye on looking to the extreme left, but was crossed when looking straight in front of her, and never turned outward past the median line. Otherwise the eyes appeared perfectly normal. Retino scopy was very unsatisfactory but she apparently had between 3 and 3.50 diopters of hypermetropia. She had al ways been perfectly healthy. Atropin drops were used in the left eye, and later a bandage applied over this eye, hoping to increase the motil ity of the crossed eye by compelling its use. This treatment had no effect, apparently, on the afliected eye; so it was stopped. However, after several months the eye gradually turned past the median line at times and when last seen could be turned outward, possibly 15 or 20 degrees beyond this line, there being much better motility. Discussion. DR. J O H N GREEN, J R . , gave two possible explanations. First, that there may have been some birth injury of the external rectus. ( W a s inquiry made as to prolonged or instrumental delivery?) Second, there may be an absence of the external rectus or a re placement of this muscle by an inextensible fibrous band, whereby abduc tion is impossible and abduction is often accompanied by retraction of the globe. D R . J o s . W . C H A R L E S : Dr. Green has mentioned the two possibilities I have in mind. It is quite feasible to oper ate in some of these cases at any rate. In 1910, a child 27 months old was brought to me for left converging stra
R27
bismus and given plus 1.25 Sph. R. and L. In 1912 I prescribed - f 2 . Sph. C - f 1 eye. ax. 90°. W i t h this glass R. V . = 1 9 / 3 0 ; L . V . = 19/120. Constant occlusion of the right eye, and atropia at home did not improve vision; and in 1914 a diagnosis of congenital weak ness of both externi was made. In 1917 a very small but undoubted defect of the macula of the left eye was discovered. Tenotomy of the left internus was performed in 1920 after which it was found that an advance ment was not needed. She had dis carded her glasses. R . E m . V . 23/15. L., fingers at 2 feet. DR. J . F . SHOEMAKER (closing) : Sev eral things argue against this case be longing to that group of cases where there is an absence of the external rec tus. In the first place both eyes were apparently straight the first three months of the baby's life; and second ly, the improvement that has taken place after two or three months. Both of these facts seem to prove the pres ence of the external rectus muscle. THE
NASHVILLE ACADEMY OF O P H T H A L M O L O G Y AND OTO-LARYNGOLOGY. March 16, 1925.
CHAIRMAN, D R . ROBERT SULLIVAN.
Eye Injury. DR. E . B . CAYCE presented the case of W . D . F., a white male 22 years of age, who was first seen on the night of February 10, 1925, and gave the fol lowing history: W a s cutting a button off a pair of overalls and the scissors slipped and cut the right eye. Exam ination showed a large cut extending entirely thru the cornea, with iris pro truding thru the wound, which ex tended thru the sclerocorneal junction above. Protruding iris was clipped and he was given an injection of cyanid of mercury. T h e eye healed kindly and the absorption of the lens was as rapid as usual. On March 14th, the patient returned with the eye irritable and a rather marked circumcorneal injection. 6 cc.