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The Ophthalmology of Art
VOL. 79, NO. 3
CORRESPONDENCE
521
CORRESPONDENCE THE OPHTHALMOLOGY OF ART
Editor: It was with great pleasure that I read the delightful article, "Georges de La Tour and the overaction of the superior oblique mus cle" (Am. J. Ophthalmol. 78:999, 1974), by H. Burian. Such an article was a welcome re lief in the midst of case reports and electron micrographs. I would like to pause from the art of ophthalmology and make a few com ments about the ophthalmology of art. For several years, I, too, have enjoyed practicing diagnostic ophthalmology on famous people of the past by observing the paintings and portraits in museums, galleries, and private collections. I suspect a number of ophthalmologists enjoy this pastime. The ocular abnormalities range from the obvious, such as William Dunlap's self-portrait show ing an enucleated right eye, to those of ex treme subtlety, as offered by de La Tour. It Fig. 1 (Wilson). French 1750 portrait showing is not surprising that artists through the ages have depicted many ocular abnormali heterochromia, anisocoria, leukoria, and swelling of the left eyelids. ties before they were understood or described in the ophthalmic literature. Master artists also expressed their powers of observation with subtle color variations particularly in recording the eyes. I have seen such an example in a 1750 French por trait in a private collection. Depicted are heterochromia, anisocoria, leukocoria, and slight swelling of the left eyelids (Figs. 1 and 2). The left eye has a green iris and an irregular, 6-mm pupil with a grayish cast over the temporal half. The right iris is blue and the pupil is 4 mm and round. Several ophthalmic diagnoses might be considered, but I suggest this represents iridocyclitis with a cataract or retinal detach Fig. 2 (Wilson). Detail of Figure 1. ment in the left eye, possibly related to "sharpness of observation." It makes me trauma or an intraocular foreign body. Other portraits by this artist from the same wonder if old master painters were practicing and other collections show normal eyes, con the art of ophthalmology on the side? R. SLOAN WILSON, M.D. firming that these changes are not accidental, Little Rock, Arkansas but as Burian said of de La Tour imply
522
AMERICAN JOURNAL OF OPHTHALMOLOGY
Editor : Bravo! for Dr. Burian's injecting some art appreciation into our scientific journal. I submit, however, that if Dr. Burian had watched the young lady's hands instead of her overacting superior oblique muscle he would have seen her clipping the young man's pendant and indeed her confederate is deftly picking his pocket ! All the nervous eye movements are a re sult of their fear of discovery while the old lady distracts him. The ladies are pretty enough, but obviously a nasty bunch. LEWIS C. GORDONSON,
M.D.
New Hyde Park, New York COMBINED KEHATOPLASTY AND
MARCH, 1975
zonulolysis, and see no reason to discontinue this practice but we would hesitate to recom mend "mechanical" zonulolysis as advocated by Dr. Kaufman; (3) as far as graft di ameter is concerned, corneal opening of 7.3 to 7.5 mm suffices for extraction of the lens provided of course the corneal problem does not require a larger graft. PROF. DR. H. SAUTTER PROF. DR. G. NAUMANN
Hamburg, Germany REFERENCES
1. Sautter, H., Naumann, G., and Démêler B. Über Erfahrungen mit gleichzeitiger perforierender Keratoplastik and Kataraktextraktion. Klin. Monatsbl. Augenheilkd. 163:290,1973. 2. : Proceedings of the 20th International Ophthalmological Congress, Paris 1974. In press.
CATARACT EXTRACTION REPLY
Editor: We read with interest the article, "Com bined keratoplasty and cataract extraction," by H. E. Kaufman (Am. J. Ophthalmol. 77: 824, 1974). Since 1968 we performed 86 simultaneous keratoplasties with intracapsular cataract ex tractions in often complicated eyes of pa tients aged 40 to 82. After at least six months' follow-up we achieved crystal-clear corneal grafts in 90% of cases. A reversible "immunological" clouding occurred in 15% but responded well to corticosteroid therapy. An anterior vitrectomy was performed in five eyes.1·2 In younger patients we routinely use 250 mg of acetazolamide, twice daily postoperatively. General anesthesia is preferred, but local anesthesia is adequate in elderly pa tients. Inasmuch as this has been a satisfac tory procedure for both the patient and sur geon we would like to stress the following: (1) It is not necessary or advantageous to use a simple or double ring if the corneal graft is preplaced with two to three tempo rary sutures below to facilitate closure of the eye immediately after lens extraction; (2) we always inject alpha-chymotrypsin for
Editor: The major point of my article was to in dicate that a modern technique in the hands of experienced surgeons, provides a safe combined corneal graft and cataract extrac tion. The results are approximately as good as those of phakic keratoplasty alone. I at tempted to stress the major aspects of suc cessful surgery, but attempted also to em phasize the many ways to accomplish them. Thus, in our hands, results are most success ful when the lens is removed intracapsularly. Alpha-chymotrypsin makes this possible, as does mechanical zonulolysis. The enzyme has occasionally been associated with unex plained corneal clouding as well as increased inflammation activity. With mechanical zonulolysis the enzyme is not necessary ; con versely, it does not present a serious hazard, can be supplemented by zonulolysis, and helps to accomplish the major goal of removing the lens in its capsule. Similarly, vitreous loss must be prevented, or if it occurs must be adequately handled by removing vitreous fluid from the wound. The use of a double ring is rapid, does not delay the operation, gives good support for
CORRESPONDENCE
521
CORRESPONDENCE THE OPHTHALMOLOGY OF ART
Editor: It was with great pleasure that I read the delightful article, "Georges de La Tour and the overaction of the superior oblique mus cle" (Am. J. Ophthalmol. 78:999, 1974), by H. Burian. Such an article was a welcome re lief in the midst of case reports and electron micrographs. I would like to pause from the art of ophthalmology and make a few com ments about the ophthalmology of art. For several years, I, too, have enjoyed practicing diagnostic ophthalmology on famous people of the past by observing the paintings and portraits in museums, galleries, and private collections. I suspect a number of ophthalmologists enjoy this pastime. The ocular abnormalities range from the obvious, such as William Dunlap's self-portrait show ing an enucleated right eye, to those of ex treme subtlety, as offered by de La Tour. It Fig. 1 (Wilson). French 1750 portrait showing is not surprising that artists through the ages have depicted many ocular abnormali heterochromia, anisocoria, leukoria, and swelling of the left eyelids. ties before they were understood or described in the ophthalmic literature. Master artists also expressed their powers of observation with subtle color variations particularly in recording the eyes. I have seen such an example in a 1750 French por trait in a private collection. Depicted are heterochromia, anisocoria, leukocoria, and slight swelling of the left eyelids (Figs. 1 and 2). The left eye has a green iris and an irregular, 6-mm pupil with a grayish cast over the temporal half. The right iris is blue and the pupil is 4 mm and round. Several ophthalmic diagnoses might be considered, but I suggest this represents iridocyclitis with a cataract or retinal detach Fig. 2 (Wilson). Detail of Figure 1. ment in the left eye, possibly related to "sharpness of observation." It makes me trauma or an intraocular foreign body. Other portraits by this artist from the same wonder if old master painters were practicing and other collections show normal eyes, con the art of ophthalmology on the side? R. SLOAN WILSON, M.D. firming that these changes are not accidental, Little Rock, Arkansas but as Burian said of de La Tour imply
522
AMERICAN JOURNAL OF OPHTHALMOLOGY
Editor : Bravo! for Dr. Burian's injecting some art appreciation into our scientific journal. I submit, however, that if Dr. Burian had watched the young lady's hands instead of her overacting superior oblique muscle he would have seen her clipping the young man's pendant and indeed her confederate is deftly picking his pocket ! All the nervous eye movements are a re sult of their fear of discovery while the old lady distracts him. The ladies are pretty enough, but obviously a nasty bunch. LEWIS C. GORDONSON,
M.D.
New Hyde Park, New York COMBINED KEHATOPLASTY AND
MARCH, 1975
zonulolysis, and see no reason to discontinue this practice but we would hesitate to recom mend "mechanical" zonulolysis as advocated by Dr. Kaufman; (3) as far as graft di ameter is concerned, corneal opening of 7.3 to 7.5 mm suffices for extraction of the lens provided of course the corneal problem does not require a larger graft. PROF. DR. H. SAUTTER PROF. DR. G. NAUMANN
Hamburg, Germany REFERENCES
1. Sautter, H., Naumann, G., and Démêler B. Über Erfahrungen mit gleichzeitiger perforierender Keratoplastik and Kataraktextraktion. Klin. Monatsbl. Augenheilkd. 163:290,1973. 2. : Proceedings of the 20th International Ophthalmological Congress, Paris 1974. In press.
CATARACT EXTRACTION REPLY
Editor: We read with interest the article, "Com bined keratoplasty and cataract extraction," by H. E. Kaufman (Am. J. Ophthalmol. 77: 824, 1974). Since 1968 we performed 86 simultaneous keratoplasties with intracapsular cataract ex tractions in often complicated eyes of pa tients aged 40 to 82. After at least six months' follow-up we achieved crystal-clear corneal grafts in 90% of cases. A reversible "immunological" clouding occurred in 15% but responded well to corticosteroid therapy. An anterior vitrectomy was performed in five eyes.1·2 In younger patients we routinely use 250 mg of acetazolamide, twice daily postoperatively. General anesthesia is preferred, but local anesthesia is adequate in elderly pa tients. Inasmuch as this has been a satisfac tory procedure for both the patient and sur geon we would like to stress the following: (1) It is not necessary or advantageous to use a simple or double ring if the corneal graft is preplaced with two to three tempo rary sutures below to facilitate closure of the eye immediately after lens extraction; (2) we always inject alpha-chymotrypsin for
Editor: The major point of my article was to in dicate that a modern technique in the hands of experienced surgeons, provides a safe combined corneal graft and cataract extrac tion. The results are approximately as good as those of phakic keratoplasty alone. I at tempted to stress the major aspects of suc cessful surgery, but attempted also to em phasize the many ways to accomplish them. Thus, in our hands, results are most success ful when the lens is removed intracapsularly. Alpha-chymotrypsin makes this possible, as does mechanical zonulolysis. The enzyme has occasionally been associated with unex plained corneal clouding as well as increased inflammation activity. With mechanical zonulolysis the enzyme is not necessary ; con versely, it does not present a serious hazard, can be supplemented by zonulolysis, and helps to accomplish the major goal of removing the lens in its capsule. Similarly, vitreous loss must be prevented, or if it occurs must be adequately handled by removing vitreous fluid from the wound. The use of a double ring is rapid, does not delay the operation, gives good support for