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Visual Disturbances Due to the Use of Digitalis and Similar Preparations
1438
NOTES, CASES, INSTRUMENTS
VISUAL DISTURBANCES DUE TO T H E USE O F DIGITALIS AND SIMILAR PREPARATIONS JOSEPH
V. M. Ross, M.D.
Berwick, Pennsylvania
Much has appeared in ophthalmic litera ture about visual disturbances due to digitalis and similar preparations. Gillette's* article is an excellent review of visual symptoms of digitalis intoxication and his bibliography is extensive. Gillette makes no reference to digitoxin but other papers concerning this drug have appeared since 1946. From all the writings, the fact emerges that visual disturbances following digitalis and digitalislike preparations are not uncom mon. The expressions, however, are variable and the exact mechanism or mechanisms of action are unknown, even though the symp toms were recognized and reported by With ering himself. One of the problems discussed is the pres ence or absence of diplopia as part of the visual symptom complex. Herewith are reported three cases all of which were characterized by diplopia and all of which were believed due to digitalis or digitoxin intoxication. CASE REPORTS CASE 1
This patient was a white woman, aged 58 years. Her only visual complaint was diplo pia. Her vision was 20/30, O.U., correctible to normal for near and far. All ophthalmic studies revealed normal findings except for her extraocular muscle status. This patient had had her right kidney re moved in 1943 but her remaining one was functioning properly. There was no hyper tension but she had an annoying heart ir regularity for which digitoxin had been given. She had taken 5.0 mg. of this drug before the sudden onset of diplopia. There were 6A of right hyperphoria in straight * Tr. Am. Ophth. Soc, 44: 156-165, 1946.
gaze. Further muscle and prism studies re vealed a paresis of the right superior oblique muscle. Upon withdrawal of the digitoxin, all findings were normal after two weeks. When digitoxin was given again, the paresis re appeared. It again disappeared in two weeks after cessation of the drug. CASE 2
This patient, a white woman, aged 73 years, had had high blood pressure for years. When first seen, corrected vision was: 20/ 40, O.U., for near and far. She presented a bilateral hypertensive retinopathy, Grade 3, with hemorrhages, both superficial and deep, and retinal transudates. A few months later, after having ingested 84 gr. of digitalis, the patient complained of a right ptosis and diplopia—the former due to levator paresis; the latter, to a paresis of her right superior rectus muscle. Blood pres sure was approximately 160/100 mm. Hg throughout her course. She also complained of all the usual symptoms of digitalis intoxi cation as anorexia, nausea, vomiting, slight diarrhea, fatigue, alterations in cardiac rhythm and rate, and chromatopsia (which she described as blue smoke rings before her eyes surrounding objects that looked whiter than usual). Vision was reduced to 20/70, O.U., for near and far. Central field studies at one meter with a one-mm. white test object re vealed bilateral small pericentral scotomas. However, from these studies it is not clear if such field findings indicated a prechiasmal syndrome or retinal disease undetectable ophthalmoscopically. Digitalis was stopped and vitamin B-complex with vitamin C was given parenterally every other day. There was a recovery of vision to 20/40, O.U., for near and far, in three weeks, and normal fields and muscle action in seven weeks. The possibility of a vascular basis for the paresis of the superior branch of the third cranial nerve must be considered.
1439
NOTES, CASES, INSTRUMENTS CASE 3
This patient, a white man, aged 65 years, had these complaints: (1) Staggering when he walks, (2) headaches, worse on the left side, (3) diplopia. He stated that eight weeks ago he experi enced weakness, dyspnea, and swelling of his legs. His blood pressure was, is, and always has been, normal. For the past two weeks he has been taking digitoxin and his total in take had been 7.4 mg. His symptoms had appeared rather suddenly several days ago. He presented normal vision with lenses for far and near, but showed 10A of right hyperphoria, straight ahead. Further muscle and prism investigations revealed a paresis of the right superior oblique. With with drawal of digitoxin and giving of one cc. of benadryl intravenously and one cc. of depropanex intramuscularly every other day, re covery was rapid in one week. However, 4A of right hyperphoria remains to this day and prisms are worn with comfort. DISCUSSION
Only the salient features of these case re ports are mentioned; however, many studies were done. In only one case was specificity of the drug's action tested, and here with re turn of drug intake, symptoms recurred. Admittedly, the unilaterality in these cases is hard to explain (although one case did show bilateral scotomas). Attempts to elimi nate other causative factors, however, seemed to substantiate the belief that drug intoxication was involved. The response to benadryl, an antihistaminic, and depropanex, a vasodilator, in one case was dramatic. In an unreported case exhibiting a prechiasmal syndrome with bilateral cecocentral scotomas following digitoxin administration, the re sponse to benadryl and depropanex was equally dramatic, although the drug was not withdrawn. This suggests that the toxicity may be re lated to vasospasm and/or allergic phenome na of increased capillary permeability and
excessive irritability of smooth musculature. It would seem that digitoxin might have a special affinity for the papillomacular bun dle but also that it (and other digitalis prepa rations) must have neurotoxic properties not so localized which may be related to acetylcholine inactivation. 321 East Front Street.
CORRUGATED SILVER W I R E FOR SEVERING PTERYGIUM FROM T H E CORNEA PAUL TOWER,
M.D.
Los Angeles, California
Various surgical procedures have been proposed for the treatment of pterygium and, depending on the technique mainly em ployed for correction of that condition, the operative methods may be arranged into five groups:. (1) Ablation, that is, removal of the thickened membrane through excision or curettement; (2) ligation; (3) electrosurgery, that is, electrocoagulation, fulguration, desiccation, or diathermy; (4) separation of the head of the pterygium from the cornea, followed by rotation and implantation be neath the bulbar conjunctiva, in a direction deviating from its original line of growth; (5) insertion of a skin or mucosal graft beneath the conjunctiva. While it is not intended to enter into a comparative evaluation of the various pro cedures for the management of pterygium, there remains little doubt, even after an in complete survey of the literature, that the transplantation method, as originally de scribed by McReynold,1 is favored by the majority of authors. In my experience, the McReynold operation has proved satisfac tory in almost 100 percent of all cases. REMOVAL OF APEX OF GROWTH
The most essential part of any surgical procedure for the management of pterygium is the removal of the apex of the growth
NOTES, CASES, INSTRUMENTS
VISUAL DISTURBANCES DUE TO T H E USE O F DIGITALIS AND SIMILAR PREPARATIONS JOSEPH
V. M. Ross, M.D.
Berwick, Pennsylvania
Much has appeared in ophthalmic litera ture about visual disturbances due to digitalis and similar preparations. Gillette's* article is an excellent review of visual symptoms of digitalis intoxication and his bibliography is extensive. Gillette makes no reference to digitoxin but other papers concerning this drug have appeared since 1946. From all the writings, the fact emerges that visual disturbances following digitalis and digitalislike preparations are not uncom mon. The expressions, however, are variable and the exact mechanism or mechanisms of action are unknown, even though the symp toms were recognized and reported by With ering himself. One of the problems discussed is the pres ence or absence of diplopia as part of the visual symptom complex. Herewith are reported three cases all of which were characterized by diplopia and all of which were believed due to digitalis or digitoxin intoxication. CASE REPORTS CASE 1
This patient was a white woman, aged 58 years. Her only visual complaint was diplo pia. Her vision was 20/30, O.U., correctible to normal for near and far. All ophthalmic studies revealed normal findings except for her extraocular muscle status. This patient had had her right kidney re moved in 1943 but her remaining one was functioning properly. There was no hyper tension but she had an annoying heart ir regularity for which digitoxin had been given. She had taken 5.0 mg. of this drug before the sudden onset of diplopia. There were 6A of right hyperphoria in straight * Tr. Am. Ophth. Soc, 44: 156-165, 1946.
gaze. Further muscle and prism studies re vealed a paresis of the right superior oblique muscle. Upon withdrawal of the digitoxin, all findings were normal after two weeks. When digitoxin was given again, the paresis re appeared. It again disappeared in two weeks after cessation of the drug. CASE 2
This patient, a white woman, aged 73 years, had had high blood pressure for years. When first seen, corrected vision was: 20/ 40, O.U., for near and far. She presented a bilateral hypertensive retinopathy, Grade 3, with hemorrhages, both superficial and deep, and retinal transudates. A few months later, after having ingested 84 gr. of digitalis, the patient complained of a right ptosis and diplopia—the former due to levator paresis; the latter, to a paresis of her right superior rectus muscle. Blood pres sure was approximately 160/100 mm. Hg throughout her course. She also complained of all the usual symptoms of digitalis intoxi cation as anorexia, nausea, vomiting, slight diarrhea, fatigue, alterations in cardiac rhythm and rate, and chromatopsia (which she described as blue smoke rings before her eyes surrounding objects that looked whiter than usual). Vision was reduced to 20/70, O.U., for near and far. Central field studies at one meter with a one-mm. white test object re vealed bilateral small pericentral scotomas. However, from these studies it is not clear if such field findings indicated a prechiasmal syndrome or retinal disease undetectable ophthalmoscopically. Digitalis was stopped and vitamin B-complex with vitamin C was given parenterally every other day. There was a recovery of vision to 20/40, O.U., for near and far, in three weeks, and normal fields and muscle action in seven weeks. The possibility of a vascular basis for the paresis of the superior branch of the third cranial nerve must be considered.
1439
NOTES, CASES, INSTRUMENTS CASE 3
This patient, a white man, aged 65 years, had these complaints: (1) Staggering when he walks, (2) headaches, worse on the left side, (3) diplopia. He stated that eight weeks ago he experi enced weakness, dyspnea, and swelling of his legs. His blood pressure was, is, and always has been, normal. For the past two weeks he has been taking digitoxin and his total in take had been 7.4 mg. His symptoms had appeared rather suddenly several days ago. He presented normal vision with lenses for far and near, but showed 10A of right hyperphoria, straight ahead. Further muscle and prism investigations revealed a paresis of the right superior oblique. With with drawal of digitoxin and giving of one cc. of benadryl intravenously and one cc. of depropanex intramuscularly every other day, re covery was rapid in one week. However, 4A of right hyperphoria remains to this day and prisms are worn with comfort. DISCUSSION
Only the salient features of these case re ports are mentioned; however, many studies were done. In only one case was specificity of the drug's action tested, and here with re turn of drug intake, symptoms recurred. Admittedly, the unilaterality in these cases is hard to explain (although one case did show bilateral scotomas). Attempts to elimi nate other causative factors, however, seemed to substantiate the belief that drug intoxication was involved. The response to benadryl, an antihistaminic, and depropanex, a vasodilator, in one case was dramatic. In an unreported case exhibiting a prechiasmal syndrome with bilateral cecocentral scotomas following digitoxin administration, the re sponse to benadryl and depropanex was equally dramatic, although the drug was not withdrawn. This suggests that the toxicity may be re lated to vasospasm and/or allergic phenome na of increased capillary permeability and
excessive irritability of smooth musculature. It would seem that digitoxin might have a special affinity for the papillomacular bun dle but also that it (and other digitalis prepa rations) must have neurotoxic properties not so localized which may be related to acetylcholine inactivation. 321 East Front Street.
CORRUGATED SILVER W I R E FOR SEVERING PTERYGIUM FROM T H E CORNEA PAUL TOWER,
M.D.
Los Angeles, California
Various surgical procedures have been proposed for the treatment of pterygium and, depending on the technique mainly em ployed for correction of that condition, the operative methods may be arranged into five groups:. (1) Ablation, that is, removal of the thickened membrane through excision or curettement; (2) ligation; (3) electrosurgery, that is, electrocoagulation, fulguration, desiccation, or diathermy; (4) separation of the head of the pterygium from the cornea, followed by rotation and implantation be neath the bulbar conjunctiva, in a direction deviating from its original line of growth; (5) insertion of a skin or mucosal graft beneath the conjunctiva. While it is not intended to enter into a comparative evaluation of the various pro cedures for the management of pterygium, there remains little doubt, even after an in complete survey of the literature, that the transplantation method, as originally de scribed by McReynold,1 is favored by the majority of authors. In my experience, the McReynold operation has proved satisfac tory in almost 100 percent of all cases. REMOVAL OF APEX OF GROWTH
The most essential part of any surgical procedure for the management of pterygium is the removal of the apex of the growth