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Sympathetic Ophthalmia After Filtration Operations
AMERICAN JOURNAL OF OPHTHALMOLOGY P U B L I S H E D M O N T H L Y BY T H E O P H T H A L M I C P U B L I S H I N G COMPANY EDITORIAL STAFF H. ROMMEL H I L D R E T H L A W R E N C E T. POST, Editor 824 Metropolitan Building, Saint Louis 640 S. Kingshighway, Saint Louis PARK L E W I S WILLIAM H. CRISP, Consulting Editor 454 Franklin Street, Buffalo 530 Metropolitan Building, Denver C. S. O'BRIEN EDWARD JACKSON, Consulting Editor The State University of Iowa, College of Republic Building, Denver Medicine, Iowa City HANS BARKAN M. U R I B E TRONCOSO Stanford University Hospital, San Fran 350 West 85th Street, New York cisco JOHN M. W H E E L E R HARRY S. GRADLE 635 West One Hundred Sixty-fifth Street, 58 East Washington Street, Chicago New York EMMA S. BUSS, Manuscript Editor 4907 Maryland Avenue, Saint Louis Address original papers, other scientific communications including correspondence, also books for review, and reports of society proceedings to Dr. Lawrence T. Post, 640 S. Kingshighway, Saint Louis. Exchange copies of medical journals should be sent to Dr. William H. Crisp, 530 Metropolitan Building, Denver. Subscriptions, applications for single copies, notices of change of address, and com munications with reference to advertising should be addressed to the Manager of Sub scriptions and Advertising, 640 S. Kingshighway, Saint Louis. Copy of advertisements must be sent to the manager by the fifteenth of the month preceding its appearance. Authors' proofs should be corrected and returned within forty-eight hours to the manuscript editor. Twenty-five reprints of each article will be supplied to the author without charge. Additional reprints may be obtained from the printer, the George Banta Publishing Company, 450-458 Ahnaip Street, Menasha, Wisconsin, if ordered at the time proofs are returned. But reprints to contain colored plates must be ordered when the article is accepted. SYMPATHETIC OPHTHALMIA AFTER FILTRATION OPERATIONS A recent short c o m m u n i c a t i o n b y Verhoeff ( A m e r i c a n J o u r n a l of O p h t h a l m o l o g y , 1936, v o l u m e 19, p a g e 46) o p e n s w i t h the following s t a t e m e n t : " O w i n g to t h e d a n g e r of s y m p a t h e t i c uveitis incident to iridotasis, in cases of chronic g l a u c o m a I h a v e w i t h i n c r e a s i n g frequency r e s o r t e d to t r e p h i n i n g . " T h i s r e m a r k is m a d e w i t h o u t a m p l i fication, and simply as i n t r o d u c t o r y t o description of a n e w conjunctival flap for t r e p h i n e o p e r a t i o n s . T h e i m p o r t a n c e of such a r e m a r k lies in the influence its implication of fact m a y h a v e c o n c e r n i n g an o p e r a t i o n w h i c h m a n y o p h t h a l mic s u r g e o n s h a v e come to r e g a r d as e x t r e m e l y valuable, a n d as a t least p r e s e n t i n g no g r e a t e r e l e m e n t of risk t h a n a c c o m p a n i e s o t h e r o p e r a t i o n s used for a like p u r p o s e . I t is g e n e r a l l y u n d e r s t o o d t h a t a n y injury, w h e t h e r accidental or surgical,
which opens the eyeball in the region of t h e iris or ciliary b o d y carries w i t h it an e l e m e n t of risk as to s u b s e q u e n t d e v e l o p m e n t of s y m p a t h e t i c o p h t h a l mia. After skillful p e r f o r m a n c e of in t r a o c u l a r o p e r a t i o n s such as those for removal of c a t a r a c t or for relief of in t r a o c u l a r tension, the e l e m e n t of risk is statistically very r e m o t e , b u t it exists. I n selecting a m e t h o d for either of these p u r p o s e s , t h e q u e s t i o n w h e t h e r such m e t h o d involves u n d u e risk of s y m p a t h e t i c o p h t h a l m i a is of g r e a t impor tance. F e w will d o u b t t h a t the risk of s y m p a t h e t i c o p h t h a l m i a is in close p r o p o r tion to t h e incidence of prolonged uveal inflammation. I r i s prolapse o c c u r r i n g after c a t a r a c t e x t r a c t i o n has a l w a y s been an u n w e l c o m e complication, lead i n g not m e r e l y to delayed h e a l i n g but also to t h e possibility of s y m p a t h e t i c d i s t u r b a n c e . I t w a s largely because of this experience t h a t the proposal to in carcerate the iris in a limbal incision 430
EDITORIALS
for the cure of glaucoma was at first strongly criticized by many surgeons. They felt that the procedure was con trary to good surgical principle. But it is noteworthy that some prominent ophthalmologists who at first rejected iridencleisis (or iridotasis) on this ground were later numbered among its most enthusiastic advocates. In the history of the trephine opera tion, consideration of uveal infection as a late complication has played a very important part. Thus, Wilmer's survey of the literature concerning almost 3,500 trephine operations showed late infection in 1.2 percent. On the other hand, the same author was able to find only 0.38 percent of cases of late infec tion among 517 iris-incarceration opera tions (including Borthen's iridotasis). Gjessing's review of 122 cases in which iridencleisis was performed in the course of twenty years showed no case of late infection, and this author em phasizes the almost complete absence of such a complication in his experience. A similar impression was derived by Pillat from reexamination of about one hundred cases after intervals of from one to seven years. The question why there is less danger of late infection after iridencleisis than after trephining has been discussed by Holth. He points out that in his opera tion (iridencleisis) the fistula is placed farther from the limbus than is the tre phine fistula, and therefore has a thicker conjunctival covering. He makes the in teresting observation that Seidel's fluorescein test is much more frequently positive after trephining than after iri dencleisis. Olsson has just reported a case of sympathetic ophthalmia after iriden cleisis (Acta Ophthalmologica, 1935, volume 13, page 61). His comprehensive review of the literature includes a num ber of the references here mentioned. He was able to find only one case (that of Herbert) in which sympathetic oph thalmia had been directly associated with iridencleisis performed for simple glaucoma. Pillat's case followed per formance of this operation for glau coma secondary to tuberculous cyclitis. Lundsgaard had done a sclerotomy. He
431
subsequently excised and cauterized a resulting fistula, and this secondary op eration was followed by sympathetic ophthalmia fourteen days later. In 1930, Schonenberger gathered from the literature three cases of sym pathetic ophthalmia following the tre phine operation. One of these occurred shortly after the operation, one three years later, and the third five years later. To these three he added three more that had occurred in Vogt's clinic at Zurich. Two of them arose shortly after the operation, the third after two years. Schonenberger raises the question whether this complication of the tre phine operation is really so rare as the literature would indicate; and of course the same question may be asked with regard to iridencleisis. Hoist reported in 1934 (Acta Ophthalmologica, 1934, volume 12, page 348) a case which had occurred in the Oslo clinic in 1931, after iridencleisis. The experience of any single case of sympathetic ophthalmia is so tragic that the surgeon involved is likely to have misgivings as to his operative method. On the other hand, the most faultless technique does not seem to offer safety against this complication. From the evi dence available it does not appear that there is any greater risk of this compli cation after iridencleisis than after tre phining. W . H. Crisp. DINITROPHENOL CATARACT Among many names supposed to in dicate the causation of cataract this one must have a place. It is less than a year since this variety was first mentioned in the literature, but so many cases of this form have been recognized that there can be no doubt as to its causation, nor as to its importance. When Tainter, Stockton, and Cutting presented their paper upon "Dinitrophenol in the treatment of obesity," last year, at the meeting of the Ameri can Medical Association (Section on Pharmacology), it was based upon 170 cases. No mention, however, was made of cataract as a possible effect of dinitrophenol. They had conducted most careful investigations to prove the safe-
which opens the eyeball in the region of t h e iris or ciliary b o d y carries w i t h it an e l e m e n t of risk as to s u b s e q u e n t d e v e l o p m e n t of s y m p a t h e t i c o p h t h a l mia. After skillful p e r f o r m a n c e of in t r a o c u l a r o p e r a t i o n s such as those for removal of c a t a r a c t or for relief of in t r a o c u l a r tension, the e l e m e n t of risk is statistically very r e m o t e , b u t it exists. I n selecting a m e t h o d for either of these p u r p o s e s , t h e q u e s t i o n w h e t h e r such m e t h o d involves u n d u e risk of s y m p a t h e t i c o p h t h a l m i a is of g r e a t impor tance. F e w will d o u b t t h a t the risk of s y m p a t h e t i c o p h t h a l m i a is in close p r o p o r tion to t h e incidence of prolonged uveal inflammation. I r i s prolapse o c c u r r i n g after c a t a r a c t e x t r a c t i o n has a l w a y s been an u n w e l c o m e complication, lead i n g not m e r e l y to delayed h e a l i n g but also to t h e possibility of s y m p a t h e t i c d i s t u r b a n c e . I t w a s largely because of this experience t h a t the proposal to in carcerate the iris in a limbal incision 430
EDITORIALS
for the cure of glaucoma was at first strongly criticized by many surgeons. They felt that the procedure was con trary to good surgical principle. But it is noteworthy that some prominent ophthalmologists who at first rejected iridencleisis (or iridotasis) on this ground were later numbered among its most enthusiastic advocates. In the history of the trephine opera tion, consideration of uveal infection as a late complication has played a very important part. Thus, Wilmer's survey of the literature concerning almost 3,500 trephine operations showed late infection in 1.2 percent. On the other hand, the same author was able to find only 0.38 percent of cases of late infec tion among 517 iris-incarceration opera tions (including Borthen's iridotasis). Gjessing's review of 122 cases in which iridencleisis was performed in the course of twenty years showed no case of late infection, and this author em phasizes the almost complete absence of such a complication in his experience. A similar impression was derived by Pillat from reexamination of about one hundred cases after intervals of from one to seven years. The question why there is less danger of late infection after iridencleisis than after trephining has been discussed by Holth. He points out that in his opera tion (iridencleisis) the fistula is placed farther from the limbus than is the tre phine fistula, and therefore has a thicker conjunctival covering. He makes the in teresting observation that Seidel's fluorescein test is much more frequently positive after trephining than after iri dencleisis. Olsson has just reported a case of sympathetic ophthalmia after iriden cleisis (Acta Ophthalmologica, 1935, volume 13, page 61). His comprehensive review of the literature includes a num ber of the references here mentioned. He was able to find only one case (that of Herbert) in which sympathetic oph thalmia had been directly associated with iridencleisis performed for simple glaucoma. Pillat's case followed per formance of this operation for glau coma secondary to tuberculous cyclitis. Lundsgaard had done a sclerotomy. He
431
subsequently excised and cauterized a resulting fistula, and this secondary op eration was followed by sympathetic ophthalmia fourteen days later. In 1930, Schonenberger gathered from the literature three cases of sym pathetic ophthalmia following the tre phine operation. One of these occurred shortly after the operation, one three years later, and the third five years later. To these three he added three more that had occurred in Vogt's clinic at Zurich. Two of them arose shortly after the operation, the third after two years. Schonenberger raises the question whether this complication of the tre phine operation is really so rare as the literature would indicate; and of course the same question may be asked with regard to iridencleisis. Hoist reported in 1934 (Acta Ophthalmologica, 1934, volume 12, page 348) a case which had occurred in the Oslo clinic in 1931, after iridencleisis. The experience of any single case of sympathetic ophthalmia is so tragic that the surgeon involved is likely to have misgivings as to his operative method. On the other hand, the most faultless technique does not seem to offer safety against this complication. From the evi dence available it does not appear that there is any greater risk of this compli cation after iridencleisis than after tre phining. W . H. Crisp. DINITROPHENOL CATARACT Among many names supposed to in dicate the causation of cataract this one must have a place. It is less than a year since this variety was first mentioned in the literature, but so many cases of this form have been recognized that there can be no doubt as to its causation, nor as to its importance. When Tainter, Stockton, and Cutting presented their paper upon "Dinitrophenol in the treatment of obesity," last year, at the meeting of the Ameri can Medical Association (Section on Pharmacology), it was based upon 170 cases. No mention, however, was made of cataract as a possible effect of dinitrophenol. They had conducted most careful investigations to prove the safe-