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The Medical Society of the District of Columbia
622
K A N S A S CITY S 0 C 1 E T \
year. Both eyes seemed to be affected about equally. There i.s no history of diplopia, no pain. He stated that at first his vision seemed to be better in the evening and worse during the bright part of the day. He disliked the color blue so much that blue ob jects had been removed from his room. Examination: External examina tion of fundi, reflexes and form fields were normal. V . O . D. 10/200, O . S. = 10/200. In the right eye there was a complete loss of the green field, and a central scotoma for red. In the left eye there was a central scotoma for both red and green, but not for blue. This scotoma extended from the macula to a little to the temporal side of blind spot. Blood Wassermann was 4 plus. Kahn test was 4 plus. Spinal fluid Wassermann and cell count were neg ative. There was a questionable vocal cord paralysis. Blood pressure was 160/72. Otherwise physical examina tion was negative, A diagnosis of toxic amblyopia was made in spite of the 4 plus Wasser mann. Diagnosis was made on the cen tral color scotoma with no contrac tion of peripheral fields, also because both eyes became affected at much the same time. After one month of treatment with potassium iodid, and abstinance from tobacco and alcohol, patient's vision returned to 20/30 plus. He is now able to read newspaper print. In toxic amblyopia there is an in volvement of the papillomacular bundle. In optic atrophy of tabes there is a concentric contraction of the field with involvement of this bundle as a late complication. Spasm of Accommodation. D R . J. W . K I M B E R L I N reported a case of a man, aged 32, who came complain ing of headaches and reduced vision. He was wearing —1.50 S. both eyes; prescribed by an optician. His vision was 5/9 plus, both eyes. The usual preliminary examination was made, and he was given a prescription of homatropin hydrobromate 2 % and in structed to put one drop in each eye at bed time and the following morning one drop in each eye every fifteen min
utes for four doses, and to report at the office 45 minutes after the last drop. When he reported the next morning it was found that instead of having both pupils dilated and the near point receding, he could read print up very near to the eye and could not read it beyond 15 cm. and the pupils were pinpoint in size. The distant vision was much reduced, being cleared up only by the use of a —6.00 sphere. T w o drops of 2% homatropin, ten min utes apart, were instilled in one eye and in 20 minutes the pupil dilated to 6 mm. and a —3.00 sphere cleared the vision. The other eye remained the same. Homatropin was instilled in the other eye and a new prescription for homatropin was given him with the directions given on the previous day. Following is the refraction, found the next morning: O. D . — 0.50 S. C — O.SO Cx. 135° V. = 20/20; O. S. — 0.50 S. C — 0.50 Cx. 45° V . = 20/20. Following the instillation of the first prescription the patient had consider able saliva and later vomited. That prescription was filled by a drug store that double checks all prescriptions, but from the symptoms and physical findings he must have used pilocarpin instead of homatropin. On investigation it was found that the bottle that contained the homa tropin was kept in a cabinet on a shelf just beneath an identical bottle con taining the pilocarpin. It is quite evident that the pilocarpin was used by mistake. ALBERT L E M O I N E ,
Reporter. T H E MEDICAL SOCIETY OF T H E DISTRICT OF COLUMBIA. Section on Ophthalmology and OtoLaryngology. February 18, 1927. D R . W . T . D A V I S , Chairman.
Choked Disc with Central Retinitis. D R . O S C A R W I L K I N S O N reported the case of Mr. J . E. K . , who consulted him Dec. 7, 1926, complaining of in ability to see with his right eye during the week preceding. He had had no illness during the past five years, until
SOCIETY PROCEEDINGS
623
about two weeks prior to first visit, at and well defined fullness of the nerve which time he had suffered two at head that causes it to project sharply tacks of very severe headaches not ac into the vitreous cavity, which we have companied by vomiting. One week come to recognize as choked disc. before, he noted his vision was mark Rather in the case under discussion edly reduced in the right eye. was found a wide spread, poorly de fined edema and serous infiltration of The lids, conjunctiva and cornea of the retina, showing in the posterior the right eye were normal. The pupil reacted to light and accommodation, portions large areas of white fatty de but rather sluggishly. The iris was posits, with flakes of hemorrhage scat normal and media clear. Fundus ex tered thruout. Also the involved area amination showed marked choked disc, was not markedly raised above the about three diopters; in the macular level of the surrounding field. region were to be seen brilliant white The fact that the urine was reported streaks radiating from the macula, as normal on one examination was these covering about two disc diam merely an indication for further tests eters, presenting almost a typical pic Even tho this shows nothing abnormal ture of old albuminuric retinitis. The at first, a blood chemistry would surel> veins were much engorged and the demonstrate a high nitrogen retention arteries at places were obscured by in In other words he regarded the con flammatory exudates. There were a dition as one of marked albuminuric number of minute punctate hemor retinitis, and of ominous prognostic rhages on and about the disc, the out import as it demonstrated a high de lines of which were completely obliter gree of kidney dysfunction. The eye ated. Vision was reduced to counting signs were but secondary to and fingers at three feet. The left eye was symptomatic of the general systemic normal in every respect with vision involvement. equal to 6/5. The nose was slightly D R . E . R . GOOKIN said he had seen congested, with no pus or exudates or the patient four or five days before he obstruction. There were badly in consulted Dr. Wilkinson and had fected tonsils. Teeth were in good made the diagnosis of papillitis and condition and roentgen ray showed no renal retinitis. He had suggested a abscesses. Urinalysis revealed no general survey but the patient had sugar but slight traces of albumin. passed from his observation. Blood Wassermann was negative. Polyopia. Blood sugar was normal. D R . E . R . GOOKIN reported the case Tonsillectomy under local anesthe of Miss R. Α., aged 25, stenographer, who complained of having had double sia was performed Dec. 13, 1926. vision since birth. In reading the let Discussion. MAJOR A. G. WILDE said the patient presented by Dr. ters on the Snellen chart she saw two of each of the test letters with one or Wilkinson did not in his history sug gest to him the likelihood of choked the other eye covered. She showed a disc. Choked disc, or papilledema, is mixed astigmatism and had normal known to be a purely mechanical proc central vision with correction. Muscu ess arising from some interference with lar balance normal. the normal venous outflow. It is also Ophthalmoscopic examination was recognized that disturbances of vision negative. Dr. Gookin said the various due to choked disc do not appear ab authors of ophthalmic literature gave ruptly, and when choked disc is pres the following condition as causes of ent even to considerable degree, the polyopia: "Incipient cataract, sub vision may be practically normal. luxation of the lens, luxation of the The patient gave a history of sud lens into the anterior chamber, double den onset with rapid loss of vision. macula in each eye, vitreous opacities, He appeared rather anemic and his glass in vitreous, iridodialysis and mixed astigmatism." He was inclined general weight and health seemed to attribute the polyopia in his case to somewhat below average. Upon examination of the fundus, hysteria. JAMES N . GREEAR, JR., Secretary. there was not found the tortuous veins
K A N S A S CITY S 0 C 1 E T \
year. Both eyes seemed to be affected about equally. There i.s no history of diplopia, no pain. He stated that at first his vision seemed to be better in the evening and worse during the bright part of the day. He disliked the color blue so much that blue ob jects had been removed from his room. Examination: External examina tion of fundi, reflexes and form fields were normal. V . O . D. 10/200, O . S. = 10/200. In the right eye there was a complete loss of the green field, and a central scotoma for red. In the left eye there was a central scotoma for both red and green, but not for blue. This scotoma extended from the macula to a little to the temporal side of blind spot. Blood Wassermann was 4 plus. Kahn test was 4 plus. Spinal fluid Wassermann and cell count were neg ative. There was a questionable vocal cord paralysis. Blood pressure was 160/72. Otherwise physical examina tion was negative, A diagnosis of toxic amblyopia was made in spite of the 4 plus Wasser mann. Diagnosis was made on the cen tral color scotoma with no contrac tion of peripheral fields, also because both eyes became affected at much the same time. After one month of treatment with potassium iodid, and abstinance from tobacco and alcohol, patient's vision returned to 20/30 plus. He is now able to read newspaper print. In toxic amblyopia there is an in volvement of the papillomacular bundle. In optic atrophy of tabes there is a concentric contraction of the field with involvement of this bundle as a late complication. Spasm of Accommodation. D R . J. W . K I M B E R L I N reported a case of a man, aged 32, who came complain ing of headaches and reduced vision. He was wearing —1.50 S. both eyes; prescribed by an optician. His vision was 5/9 plus, both eyes. The usual preliminary examination was made, and he was given a prescription of homatropin hydrobromate 2 % and in structed to put one drop in each eye at bed time and the following morning one drop in each eye every fifteen min
utes for four doses, and to report at the office 45 minutes after the last drop. When he reported the next morning it was found that instead of having both pupils dilated and the near point receding, he could read print up very near to the eye and could not read it beyond 15 cm. and the pupils were pinpoint in size. The distant vision was much reduced, being cleared up only by the use of a —6.00 sphere. T w o drops of 2% homatropin, ten min utes apart, were instilled in one eye and in 20 minutes the pupil dilated to 6 mm. and a —3.00 sphere cleared the vision. The other eye remained the same. Homatropin was instilled in the other eye and a new prescription for homatropin was given him with the directions given on the previous day. Following is the refraction, found the next morning: O. D . — 0.50 S. C — O.SO Cx. 135° V. = 20/20; O. S. — 0.50 S. C — 0.50 Cx. 45° V . = 20/20. Following the instillation of the first prescription the patient had consider able saliva and later vomited. That prescription was filled by a drug store that double checks all prescriptions, but from the symptoms and physical findings he must have used pilocarpin instead of homatropin. On investigation it was found that the bottle that contained the homa tropin was kept in a cabinet on a shelf just beneath an identical bottle con taining the pilocarpin. It is quite evident that the pilocarpin was used by mistake. ALBERT L E M O I N E ,
Reporter. T H E MEDICAL SOCIETY OF T H E DISTRICT OF COLUMBIA. Section on Ophthalmology and OtoLaryngology. February 18, 1927. D R . W . T . D A V I S , Chairman.
Choked Disc with Central Retinitis. D R . O S C A R W I L K I N S O N reported the case of Mr. J . E. K . , who consulted him Dec. 7, 1926, complaining of in ability to see with his right eye during the week preceding. He had had no illness during the past five years, until
SOCIETY PROCEEDINGS
623
about two weeks prior to first visit, at and well defined fullness of the nerve which time he had suffered two at head that causes it to project sharply tacks of very severe headaches not ac into the vitreous cavity, which we have companied by vomiting. One week come to recognize as choked disc. before, he noted his vision was mark Rather in the case under discussion edly reduced in the right eye. was found a wide spread, poorly de fined edema and serous infiltration of The lids, conjunctiva and cornea of the retina, showing in the posterior the right eye were normal. The pupil reacted to light and accommodation, portions large areas of white fatty de but rather sluggishly. The iris was posits, with flakes of hemorrhage scat normal and media clear. Fundus ex tered thruout. Also the involved area amination showed marked choked disc, was not markedly raised above the about three diopters; in the macular level of the surrounding field. region were to be seen brilliant white The fact that the urine was reported streaks radiating from the macula, as normal on one examination was these covering about two disc diam merely an indication for further tests eters, presenting almost a typical pic Even tho this shows nothing abnormal ture of old albuminuric retinitis. The at first, a blood chemistry would surel> veins were much engorged and the demonstrate a high nitrogen retention arteries at places were obscured by in In other words he regarded the con flammatory exudates. There were a dition as one of marked albuminuric number of minute punctate hemor retinitis, and of ominous prognostic rhages on and about the disc, the out import as it demonstrated a high de lines of which were completely obliter gree of kidney dysfunction. The eye ated. Vision was reduced to counting signs were but secondary to and fingers at three feet. The left eye was symptomatic of the general systemic normal in every respect with vision involvement. equal to 6/5. The nose was slightly D R . E . R . GOOKIN said he had seen congested, with no pus or exudates or the patient four or five days before he obstruction. There were badly in consulted Dr. Wilkinson and had fected tonsils. Teeth were in good made the diagnosis of papillitis and condition and roentgen ray showed no renal retinitis. He had suggested a abscesses. Urinalysis revealed no general survey but the patient had sugar but slight traces of albumin. passed from his observation. Blood Wassermann was negative. Polyopia. Blood sugar was normal. D R . E . R . GOOKIN reported the case Tonsillectomy under local anesthe of Miss R. Α., aged 25, stenographer, who complained of having had double sia was performed Dec. 13, 1926. vision since birth. In reading the let Discussion. MAJOR A. G. WILDE said the patient presented by Dr. ters on the Snellen chart she saw two of each of the test letters with one or Wilkinson did not in his history sug gest to him the likelihood of choked the other eye covered. She showed a disc. Choked disc, or papilledema, is mixed astigmatism and had normal known to be a purely mechanical proc central vision with correction. Muscu ess arising from some interference with lar balance normal. the normal venous outflow. It is also Ophthalmoscopic examination was recognized that disturbances of vision negative. Dr. Gookin said the various due to choked disc do not appear ab authors of ophthalmic literature gave ruptly, and when choked disc is pres the following condition as causes of ent even to considerable degree, the polyopia: "Incipient cataract, sub vision may be practically normal. luxation of the lens, luxation of the The patient gave a history of sud lens into the anterior chamber, double den onset with rapid loss of vision. macula in each eye, vitreous opacities, He appeared rather anemic and his glass in vitreous, iridodialysis and mixed astigmatism." He was inclined general weight and health seemed to attribute the polyopia in his case to somewhat below average. Upon examination of the fundus, hysteria. JAMES N . GREEAR, JR., Secretary. there was not found the tortuous veins