- Email: [email protected]
Transposition of Tendons
EDITORIALS
840
TREATMENT OF OCULAR INFECTION* Since the introduction of sulfonamides and antibiotics the frequency of visual dam age resulting from superficial infections of the eye has been much reduced. This is per haps most clearly evident from the gratify ing response to treatment of hypopyon ulcer. Sensitivity of the infecting organism is usu ally readily apparent from reduction of the ocular injection; and, in corneal lesions especially, this is often a more useful guide to progress than bactériologie examination. Suppression of the inflammatory reaction by topical application of steroid preparations may produce whitening of the eye similar to that seen during recovery, and in certain cases—for example, interstitial keratitis, where the reaction occurs from an allergic type of response in the absence of corneal organisms—this may be entirely beneficial. Where active infection exists, however, such whitening is often deceptive: the infection, although apparently ameliorated, pursues a protracted course, deeper invasion of the ocular tissues is encouraged and serious complications are not unusual. Such sequelae have been recognized as hazards of steroid therapy since the earliest trials of topical cortisone in this country, and it is remarkable that they continue to be seen in apparently undiminishing num bers. They result more commonly from the use of preparations of a steroid combined with an antibiotic or sulfonamide, than from the use of steroids alone. A further reminder of this peril comes from the United States, in respect to mycotic infections. Gingrich* re ports 10 cases of mycotic corneal ulcer in which the fungi were identified either from the conjunctival discharge or from corneal scrapings. In most of these cases there were deep ulcers, and four of these perforated into the anterior chamber. Descemetoceles »Reprinted from The Lancet, July 21, 1962, pages 137 and 138. t Gingrich, W. D.: J.A.M.A., 179:602, 1962.
were seen in a further three, and in four there was hypopyon ; in two, secondary cata racts developed, and in all but two (which were detected in an early stage) the visual effects were severe. Seven of these cases had previously been treated with preparations containing steroids, some of them for weeks, and this treatment is thought by Gingrich to have contributed materially to the ultimate damage resulting from the infection. In all but two cases minor trauma had also oc curred; and thus the steroid, through its known effect of discouraging corneal epi thelial healing, had played a further part in the disastrous course of the condition. Of the many species of saprophytic fungi which have been identified as causes of keratomycosis, only seven were encountered in this series. Gingrich recommends a form of combined sulfacetamide-thimersal therapy applied by iontophoresis, as generally the the most effective where a fungus is the in fecting organism. Specific antimycotic treat ment will no doubt in time be devised; but it is greatly to be hoped that, meanwhile, the advocacy of preparations of steroid com bined with antibiotic or sulfonamide will be curtailed, and the use of steroids avoided where the corneal epithelium is not known to be intact.
CORRESPONDENCE TRANSPOSITION OF TENDONS
Editor, American Journal of Ophthalmology: Dr. Bloomgarden and Dr. Jampel in their paper in the August, 1963, issue of T H E AMERICAN JOURNAL OF OPHTHALMOLOGY,
conclude from their experiments on mon keys, that transposition of the tendons of two extraocular muscles, quickly if not im mediately, causes interchange of the func tions of these muscles. Probably few oph thalmologists can accept this conclusion, cer tainly I cannot. To me it seems completely
CORRESPONDENCE
841
impossible that it could be true. In 1942, I terested to know that angioid streaks were brought forward in T H E AMERICAN JOUR previously reported in a patient with acro NAL OF OPHTHALMOLOGY, a more than rea megaly by Dr. T. B. Holloway in 1927.1 Dr. sonable explanation of the phenomenon in Holloway's patient was a 52-year-old man question, and the paper of Dr. Bloomgarden whose pituitary disease dated from the age and Dr. Jampel does not cause me to doubt of 27 years. The peripapillary slate-colored or change this explanation. These authors streaks progressed in the seven-year interval refer to my explanation but do not refute that the patient was followed. it. Obviously, it must be refuted before their An additional example of angioid streaks conclusion can be accepted. with acromegaly was examined by me in De In their experiments, after the tendons of cember, 1960, and has not been previously the right superior rectus muscle and the reported. This is a 64-year-old Negress with right external rectus muscle were trans a 30-year history of acromegaly, who was posed, they found that when the left eye examined at the Wilmer Institute on referral moved to the right so also to some extent did from the Medical Department for the pur the right eye. They assumed that this out pose of routine visual field studies. The pa ward movement of the right eye was due to tient herself had no ocular complaints and contraction of the superior rectus muscle. I with a +1.5D. sph. had 20/20 vision bi maintain that it was due to contraction of laterally. Positive eye findings were limited the external rectus muscle because this mus to fundus examination. There was bilateral cle was still able to pull the eye outward in chorioretinal degeneration in a starlike pat spite of its displaced tendon. But the su tern around the optic discs. In this atrophie perior rectus and internal rectus muscles, area and at its margins dark-gray, narrow, because of reciprocal innervation, became circumferential and radial angioid streaks longer, so that the superior rectus muscle were present in each eye. The maculas ap took no part in the outward pull on the right peared normal and there were no hemor eye. The authors do not state exactly how rhages or exudates. limited was the outward movement of the In addition to very advanced changes of right eye but, from what they say, evidently acromegaly, it is notable that the patient had this movement was much less than it would calcified varices in the lower extremities, have been if the superior rectus had actually calcification of the ear cartilages and calci assisted in this motion. fied patellar tendons. The patient's fam ily history and physical examination were (Signed) F. H. Verhoeff, M.D., entirely negative for pseudoxanthoma elasti252 Pleasant Street, cum. Skin biopsy was not obtained and fur Marblehead, Massachusetts. ther examinations have not been possible. However, with inactive acromegaly, current calcium and phosphorus blood studies would ANGIOID STREAKS AND ACROMEGALY presumably be normal. Editor, On the basis of pathologic material re American Journal of Ophthalmology: ported in the literature and additional cases In the July, 1963, issue of T H E AMERI examined by me, there seems no question CAN JOURNAL OF OPHTHALMOLOGY (56:137- that angioid streaks are clinical manifesta 139), Dr. George M. Howard reported the tions of cracks in a brittle and relatively occurrence of angioid streaks in a patient opaque Bruch's membrane, as postulated by with acromegaly. The author and other per Kofler in 1917. sons concerned with the relationship of an The relationship of angioid streaks to vari gioid streaks to various diseases may be in ous disease entities has recently received ex-
840
TREATMENT OF OCULAR INFECTION* Since the introduction of sulfonamides and antibiotics the frequency of visual dam age resulting from superficial infections of the eye has been much reduced. This is per haps most clearly evident from the gratify ing response to treatment of hypopyon ulcer. Sensitivity of the infecting organism is usu ally readily apparent from reduction of the ocular injection; and, in corneal lesions especially, this is often a more useful guide to progress than bactériologie examination. Suppression of the inflammatory reaction by topical application of steroid preparations may produce whitening of the eye similar to that seen during recovery, and in certain cases—for example, interstitial keratitis, where the reaction occurs from an allergic type of response in the absence of corneal organisms—this may be entirely beneficial. Where active infection exists, however, such whitening is often deceptive: the infection, although apparently ameliorated, pursues a protracted course, deeper invasion of the ocular tissues is encouraged and serious complications are not unusual. Such sequelae have been recognized as hazards of steroid therapy since the earliest trials of topical cortisone in this country, and it is remarkable that they continue to be seen in apparently undiminishing num bers. They result more commonly from the use of preparations of a steroid combined with an antibiotic or sulfonamide, than from the use of steroids alone. A further reminder of this peril comes from the United States, in respect to mycotic infections. Gingrich* re ports 10 cases of mycotic corneal ulcer in which the fungi were identified either from the conjunctival discharge or from corneal scrapings. In most of these cases there were deep ulcers, and four of these perforated into the anterior chamber. Descemetoceles »Reprinted from The Lancet, July 21, 1962, pages 137 and 138. t Gingrich, W. D.: J.A.M.A., 179:602, 1962.
were seen in a further three, and in four there was hypopyon ; in two, secondary cata racts developed, and in all but two (which were detected in an early stage) the visual effects were severe. Seven of these cases had previously been treated with preparations containing steroids, some of them for weeks, and this treatment is thought by Gingrich to have contributed materially to the ultimate damage resulting from the infection. In all but two cases minor trauma had also oc curred; and thus the steroid, through its known effect of discouraging corneal epi thelial healing, had played a further part in the disastrous course of the condition. Of the many species of saprophytic fungi which have been identified as causes of keratomycosis, only seven were encountered in this series. Gingrich recommends a form of combined sulfacetamide-thimersal therapy applied by iontophoresis, as generally the the most effective where a fungus is the in fecting organism. Specific antimycotic treat ment will no doubt in time be devised; but it is greatly to be hoped that, meanwhile, the advocacy of preparations of steroid com bined with antibiotic or sulfonamide will be curtailed, and the use of steroids avoided where the corneal epithelium is not known to be intact.
CORRESPONDENCE TRANSPOSITION OF TENDONS
Editor, American Journal of Ophthalmology: Dr. Bloomgarden and Dr. Jampel in their paper in the August, 1963, issue of T H E AMERICAN JOURNAL OF OPHTHALMOLOGY,
conclude from their experiments on mon keys, that transposition of the tendons of two extraocular muscles, quickly if not im mediately, causes interchange of the func tions of these muscles. Probably few oph thalmologists can accept this conclusion, cer tainly I cannot. To me it seems completely
CORRESPONDENCE
841
impossible that it could be true. In 1942, I terested to know that angioid streaks were brought forward in T H E AMERICAN JOUR previously reported in a patient with acro NAL OF OPHTHALMOLOGY, a more than rea megaly by Dr. T. B. Holloway in 1927.1 Dr. sonable explanation of the phenomenon in Holloway's patient was a 52-year-old man question, and the paper of Dr. Bloomgarden whose pituitary disease dated from the age and Dr. Jampel does not cause me to doubt of 27 years. The peripapillary slate-colored or change this explanation. These authors streaks progressed in the seven-year interval refer to my explanation but do not refute that the patient was followed. it. Obviously, it must be refuted before their An additional example of angioid streaks conclusion can be accepted. with acromegaly was examined by me in De In their experiments, after the tendons of cember, 1960, and has not been previously the right superior rectus muscle and the reported. This is a 64-year-old Negress with right external rectus muscle were trans a 30-year history of acromegaly, who was posed, they found that when the left eye examined at the Wilmer Institute on referral moved to the right so also to some extent did from the Medical Department for the pur the right eye. They assumed that this out pose of routine visual field studies. The pa ward movement of the right eye was due to tient herself had no ocular complaints and contraction of the superior rectus muscle. I with a +1.5D. sph. had 20/20 vision bi maintain that it was due to contraction of laterally. Positive eye findings were limited the external rectus muscle because this mus to fundus examination. There was bilateral cle was still able to pull the eye outward in chorioretinal degeneration in a starlike pat spite of its displaced tendon. But the su tern around the optic discs. In this atrophie perior rectus and internal rectus muscles, area and at its margins dark-gray, narrow, because of reciprocal innervation, became circumferential and radial angioid streaks longer, so that the superior rectus muscle were present in each eye. The maculas ap took no part in the outward pull on the right peared normal and there were no hemor eye. The authors do not state exactly how rhages or exudates. limited was the outward movement of the In addition to very advanced changes of right eye but, from what they say, evidently acromegaly, it is notable that the patient had this movement was much less than it would calcified varices in the lower extremities, have been if the superior rectus had actually calcification of the ear cartilages and calci assisted in this motion. fied patellar tendons. The patient's fam ily history and physical examination were (Signed) F. H. Verhoeff, M.D., entirely negative for pseudoxanthoma elasti252 Pleasant Street, cum. Skin biopsy was not obtained and fur Marblehead, Massachusetts. ther examinations have not been possible. However, with inactive acromegaly, current calcium and phosphorus blood studies would ANGIOID STREAKS AND ACROMEGALY presumably be normal. Editor, On the basis of pathologic material re American Journal of Ophthalmology: ported in the literature and additional cases In the July, 1963, issue of T H E AMERI examined by me, there seems no question CAN JOURNAL OF OPHTHALMOLOGY (56:137- that angioid streaks are clinical manifesta 139), Dr. George M. Howard reported the tions of cracks in a brittle and relatively occurrence of angioid streaks in a patient opaque Bruch's membrane, as postulated by with acromegaly. The author and other per Kofler in 1917. sons concerned with the relationship of an The relationship of angioid streaks to vari gioid streaks to various diseases may be in ous disease entities has recently received ex-