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Treatment of Traumatic Catatropia
NOTES, CASES, INSTRUMENTS TREATMENT OF TRAUMATIC CATATROPIA Major
H. THORNE, M.D., F.A.C.S.
FREDERIC
CRISTOBAL, C.Z.
Mr. E. R., aged 43 years, was in jured in January, 1926, by the explosion of a priming cap. A portion of the cop per jacket pierced the right upper lid, near the inner canthus, entered the or bit and lodged near the optic nerve. On the fourth day following the ac cident a slight infection developed in the wound. An attempt was made im mediately to extract the foreign body. The attempt was unsuccessful and an other was made the following day un der ether anesthesia. This attempt was unsuccessful as well and during the operation the superior rectus and the levator muscle of the lid were injured or completely severed. Three subse quent attempts were made to extract the foreign body, but each ended in fail ure. The infection subsided in a few days. During the following few months two operations were performed on the up per lid, for correction of the ptosis, and one on the inferior rectus muscle for re lief of the existing catatropia. Eventual ly prisms were prescribed, beginning with a strength of two diopters. The strength of these was increased until diplopia was overcome. The patient came under the observa tion of the writer in 1932, at which time he presented the following: a marked ptosis of the right upper lid, twentyseven diopters catatropia, right, faint central opacity of the posterior lens capsule, left. The fusion sense was nor mal. He was wearing the following cor rection : O.D. + 1.00 cyl. ax. 90° =C= 12 diopter prism base u p ; vision was 20/50 + 3 ; O.S. + 1.00 D. sph. O + 0.25 cyl. ax. 115° =0= 12 diopter prism base down, vision 2 0 / 3 0 — 1 . Without correction a vertical diplo pia was present. The patient, however, stated that upon arising in the morning binocular single vision could be main
tained for a short time. Then tilting of the head backward was necessary to maintain such vision. After a short time binocular single vision could not be at tained in any case. Binocular single vision, without correction, was not found at any time by the writer. Ocular movements of the left eye were normal. The movements of the right eye were normal except in the field of the principal action of the su perior rectus. Fixation with this eye could be maintained horizontally, with head erect, but this required conscious effort. Comfortable fixation, with head erect could be maintained without con scious effort at four degrees below the horizontal or primary position. With considerable effort fixation could be raised eight degrees above the hori zontal giving a range, from comfortable fixation to the extreme upper limit, of twelve degrees. Greater effort than normal was re quired to accomplish the limited verti cal rotation of the right eye. The nerv ous energy being equally distributed between the two superior recti muscles resulted in an excessive vertical rota tion of the left eye, while maintaining the right eye at comfortable fixation. The patient objected to wearing prisms and was extremely anxious to have his ocular defects corrected. The loss of action of the superior rectus and the levator palpebral muscles, together with the surgery already performed, made further efforts to raise the globe, surgically, inadvisable; there seemed to be little or nothing upon which to work. However, after a study of his ocular movements an improvement, at least, seemed possible. The factors considered as being in favor of improvement were: (a) his comfortable fixation point of four de grees below the horizontal; (b) the ability to fix eight degrees above the horizontal (range of twelve degrees) ; (c) the strong fusion sense; (d) the ability to attain binocular single vision, without correction, upon arising in the morning.
248
NOTES, CASES AND INSTRUMENTS
If the action of the sound superior rectus were weakened, less vertical ro tation would occur with the same innervation. It should then be possible for fusion to bridge the gap remaining be tween the visual lines, making binocu lar single vision possible, in so far as the defective eye could be rotated. A fascia lata hammock-operation was performed on the right upper lid for correction of the ptosis. The lid was ele vated until its palpebral margin crossed the cornea in the same position as that of the left with the eyes open in the primary position. Because of the twen ty-seven diopters of catatropia, this level left the lid slightly lower than its fellow. This surgical correction was successful. The eyes were then refracted under homatropine and the following correc tion prescribed: O.D. + 0.25 D. sph. =C= + 1.00 cyl. ax. 115°, vision was 20/20; O.S. + 0.50 D. sph. =C= + 0.50 cyl. ax. 180°, vision was 20/20 — 4. Seven months after correction of the ptosis a 5 mm. recession of the left su perior rectus muscle was performed. The eyes were covered for four days. Dressings were then removed and the above correction worn constantly. Conjunctival sutures were removed on the fifth day and the recession sutures on the eighth day. Prisms have not been worn since the operation. Binocular fixation is com fortable in the primary position and can be maintained, for a time, eight degrees above this point. When gazing higher the head must be tilted to maintain binocular single vision. There has been no discomfort and the results are en tirely satisfactory to the patient. The foreign body, the primary cause of all his trouble, remains in the orbit but causes no symptoms. Colon Hospital. ARTERIOVENOUS ANEURYSM RESULTING FROM PECULIAR E Y E ACCIDENT EDWIN B. D U N P H Y , BOSTON
M.D.
Mr. E. M. a farmer, aged thirty-five years, was first seen by me on October
249
6, 1932. One month previously a threetined haying-fork fell from a hay rick just as the patient looked up, and one of the tines entered the right orbit at the outer canthus. There was a gush of blood and considerable pain. He fainted and was taken to a local hospi tal, where the conjunctival wound was sutured. The following day the eye pro truded considerably. This protrusion increased daily and in about one week the patient was conscious of a blowing noise in his ears, present only when he assumed a recumbent position. He was never able to see with the eye after the accident. Examination showed a greatly proptosed eye with a corneal ulceration from lagophthalmus. No pulsation was felt. There was a great mass of chemotic conjunctiva protruding from below the globe. Ocular motions were abolished. The pupil was dilated and fixed. The fundus showed a dirty-white atrophic disc with blurred margins; the retinal veins were dilated; vision was nil. X-rays of orbit and sinuses were entire ly negative. A loud bruit was heard all over the head. This could be stopped by pressure over the right carotid artery. A diagnosis of arteriovenous aneurysm was made. The tine of the haying fork must have entered the orbit at the outer canthus, traveled along its outer wall, passed through the great sphenoidal fissure, and then penetrated the cavernous sinus and internal carotid artery. It was ex traordinary that the direction of the tine should have conformed so closely to the slope of the outer orbital wall that this was not fractured. The optic nerve was undoubtedly injured at the apex of the orbit thus accounting for the immediate loss of vision. An attempt was made to ligate the internal carotid artery, but due to the patient's condition under the anesthetic, had to be given up. The eyeball had to be removed because of the necrotic cornea and for cosmetic reasons. Fol lowing enucleation, a brisk hemorrhage occurred, which was easily controlled by packing the cavity and making pres sure. After all dressings were re moved there was an unsightly mass of
H. THORNE, M.D., F.A.C.S.
FREDERIC
CRISTOBAL, C.Z.
Mr. E. R., aged 43 years, was in jured in January, 1926, by the explosion of a priming cap. A portion of the cop per jacket pierced the right upper lid, near the inner canthus, entered the or bit and lodged near the optic nerve. On the fourth day following the ac cident a slight infection developed in the wound. An attempt was made im mediately to extract the foreign body. The attempt was unsuccessful and an other was made the following day un der ether anesthesia. This attempt was unsuccessful as well and during the operation the superior rectus and the levator muscle of the lid were injured or completely severed. Three subse quent attempts were made to extract the foreign body, but each ended in fail ure. The infection subsided in a few days. During the following few months two operations were performed on the up per lid, for correction of the ptosis, and one on the inferior rectus muscle for re lief of the existing catatropia. Eventual ly prisms were prescribed, beginning with a strength of two diopters. The strength of these was increased until diplopia was overcome. The patient came under the observa tion of the writer in 1932, at which time he presented the following: a marked ptosis of the right upper lid, twentyseven diopters catatropia, right, faint central opacity of the posterior lens capsule, left. The fusion sense was nor mal. He was wearing the following cor rection : O.D. + 1.00 cyl. ax. 90° =C= 12 diopter prism base u p ; vision was 20/50 + 3 ; O.S. + 1.00 D. sph. O + 0.25 cyl. ax. 115° =0= 12 diopter prism base down, vision 2 0 / 3 0 — 1 . Without correction a vertical diplo pia was present. The patient, however, stated that upon arising in the morning binocular single vision could be main
tained for a short time. Then tilting of the head backward was necessary to maintain such vision. After a short time binocular single vision could not be at tained in any case. Binocular single vision, without correction, was not found at any time by the writer. Ocular movements of the left eye were normal. The movements of the right eye were normal except in the field of the principal action of the su perior rectus. Fixation with this eye could be maintained horizontally, with head erect, but this required conscious effort. Comfortable fixation, with head erect could be maintained without con scious effort at four degrees below the horizontal or primary position. With considerable effort fixation could be raised eight degrees above the hori zontal giving a range, from comfortable fixation to the extreme upper limit, of twelve degrees. Greater effort than normal was re quired to accomplish the limited verti cal rotation of the right eye. The nerv ous energy being equally distributed between the two superior recti muscles resulted in an excessive vertical rota tion of the left eye, while maintaining the right eye at comfortable fixation. The patient objected to wearing prisms and was extremely anxious to have his ocular defects corrected. The loss of action of the superior rectus and the levator palpebral muscles, together with the surgery already performed, made further efforts to raise the globe, surgically, inadvisable; there seemed to be little or nothing upon which to work. However, after a study of his ocular movements an improvement, at least, seemed possible. The factors considered as being in favor of improvement were: (a) his comfortable fixation point of four de grees below the horizontal; (b) the ability to fix eight degrees above the horizontal (range of twelve degrees) ; (c) the strong fusion sense; (d) the ability to attain binocular single vision, without correction, upon arising in the morning.
248
NOTES, CASES AND INSTRUMENTS
If the action of the sound superior rectus were weakened, less vertical ro tation would occur with the same innervation. It should then be possible for fusion to bridge the gap remaining be tween the visual lines, making binocu lar single vision possible, in so far as the defective eye could be rotated. A fascia lata hammock-operation was performed on the right upper lid for correction of the ptosis. The lid was ele vated until its palpebral margin crossed the cornea in the same position as that of the left with the eyes open in the primary position. Because of the twen ty-seven diopters of catatropia, this level left the lid slightly lower than its fellow. This surgical correction was successful. The eyes were then refracted under homatropine and the following correc tion prescribed: O.D. + 0.25 D. sph. =C= + 1.00 cyl. ax. 115°, vision was 20/20; O.S. + 0.50 D. sph. =C= + 0.50 cyl. ax. 180°, vision was 20/20 — 4. Seven months after correction of the ptosis a 5 mm. recession of the left su perior rectus muscle was performed. The eyes were covered for four days. Dressings were then removed and the above correction worn constantly. Conjunctival sutures were removed on the fifth day and the recession sutures on the eighth day. Prisms have not been worn since the operation. Binocular fixation is com fortable in the primary position and can be maintained, for a time, eight degrees above this point. When gazing higher the head must be tilted to maintain binocular single vision. There has been no discomfort and the results are en tirely satisfactory to the patient. The foreign body, the primary cause of all his trouble, remains in the orbit but causes no symptoms. Colon Hospital. ARTERIOVENOUS ANEURYSM RESULTING FROM PECULIAR E Y E ACCIDENT EDWIN B. D U N P H Y , BOSTON
M.D.
Mr. E. M. a farmer, aged thirty-five years, was first seen by me on October
249
6, 1932. One month previously a threetined haying-fork fell from a hay rick just as the patient looked up, and one of the tines entered the right orbit at the outer canthus. There was a gush of blood and considerable pain. He fainted and was taken to a local hospi tal, where the conjunctival wound was sutured. The following day the eye pro truded considerably. This protrusion increased daily and in about one week the patient was conscious of a blowing noise in his ears, present only when he assumed a recumbent position. He was never able to see with the eye after the accident. Examination showed a greatly proptosed eye with a corneal ulceration from lagophthalmus. No pulsation was felt. There was a great mass of chemotic conjunctiva protruding from below the globe. Ocular motions were abolished. The pupil was dilated and fixed. The fundus showed a dirty-white atrophic disc with blurred margins; the retinal veins were dilated; vision was nil. X-rays of orbit and sinuses were entire ly negative. A loud bruit was heard all over the head. This could be stopped by pressure over the right carotid artery. A diagnosis of arteriovenous aneurysm was made. The tine of the haying fork must have entered the orbit at the outer canthus, traveled along its outer wall, passed through the great sphenoidal fissure, and then penetrated the cavernous sinus and internal carotid artery. It was ex traordinary that the direction of the tine should have conformed so closely to the slope of the outer orbital wall that this was not fractured. The optic nerve was undoubtedly injured at the apex of the orbit thus accounting for the immediate loss of vision. An attempt was made to ligate the internal carotid artery, but due to the patient's condition under the anesthetic, had to be given up. The eyeball had to be removed because of the necrotic cornea and for cosmetic reasons. Fol lowing enucleation, a brisk hemorrhage occurred, which was easily controlled by packing the cavity and making pres sure. After all dressings were re moved there was an unsightly mass of