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Visual Loss Associated with Oral Contraceptives
874
AMERICAN JOURNAL OF OPHTHALMOLOGY
four main groups classified as dysenteria, flexneri, boydi and sonnei, or groups A through D. The organism we cultured was sonnei, Group D. It is differentiated from the other groups because it ferments lactose and is indole negative. Man is the major car rier, along with other primates, especially monkeys and apes.3 The number of unidenti fied asymptomatic human carriers, as com pared to symptomatic carriers, is estimated to be nine to one.4 In our case, the source of the organism is unknown. Evidently at the time of trauma, the patient contaminated his injury site with the sonnei strain of the or ganism. A classic sign of human infection is dys entery. Isolated cases of shigellemia are re ported without dysentery.5 In our patient, stool cultures were negative, as were cultures of immediate family members. Serum anti body studies did not indicate a recent sys temic infection. However, the serum anti body titer is a poor diagnostic aid in making a diagnosis of Shigella. It is not surprising that the combination of sulfasoxazole and Neopolycin drops were an effective treatment for Staphylococcal aureus and Shigella sonnei. However, there are new modes of treatment for Shigella infec tions. Since Hardy's 6 work, sulfadiazine has been the treatment of choice for Shigella in fection. Garfinkel7 found that over 1400 cases of shigellosis in veterans of the Ko rean war were treated successfully with oxytetracycline. Haltalin and Nelson,8 and Haltalin,9 tested 300 stains of Shigella for sus ceptibility to sulfadiazine by dilution tech niques; 59% of Shigella sonnei were sulfadiazine-resistent, whereas only 8% ^ " 8 ^ r é sistent to ampicillin; 2% to colymycin; and 1% to kanamycin and neomycin. Haltalin concluded that ampicillin, kanamycin, and colymycin are the antibiotics of choice for Shigella infections. Since kanamycin and ampicillin are not usually prepared for topi cal administration, an effective treatment re gimen for Shigella corneal ulcer would con sist of neomycin and colymycin drops.
MAY, 1970
SUMMARY
A case of Shigella sonnei corneal ulcer is reported. The clinical appearance was not specific. The ulcer responded well to anti biotics. Neomycin and colymycin would be excellent antibiotics to use for ocular Shi gella infections. REFERENCES
1. Duke-Elder, S. : System of Ophthalmology, vol. 8. London, Kimpton, 1966, p. 187. 2. Maxwell, E. M., and Walter, H. P.: Iritis and cyclitis in dysentery. Brit. J. Ophth. 2:71, 1918. 3. Schneider, I. : Enteric bactériologie studies in a large colony of primates. Ann. New York Acad. Sei. 85:93S, 1960. 4. Watt, J., and Hardy, A. V.: Studies of the acute diarrhea diseases : Cultural surveys of normal population groups. Publ. Hlth. Rep. 60:261, 1945. 5. Graber, C. D., Browning, D., and Davis, J. S. : Shigellemia without shigella diarrhea. Am. J. Clin. Path. 46:221, 1966. 6. Hardy, A. V. : Studies of acute diarrheal dis eases : Sulfonamides in shigellosis. Publ. Hlth. Rep. 6:8S7, 1941. 7. Garfinkel, B. T. : Antibiotics in acute bacillary dysentery. J.A.M.A. 51:1157, 1953. 8. Haltalin, K. C, and Nelson, J. D. : In vitro susceptibility of shigella to sodium sulfadiazine and to eight antibiotics. J.A.M.A. 193 :705, 1965. 9. Haltalin, K. C. : Double blind treatment study of shigellosis comparing Ampicillin sulfadiazine and placebo. J. Pediat. 70:970, 1967.
VISUAL LOSS ASSOCIATED W I T H ORAL CONTRACEPTIVES MARGARET S. S M I T H ,
M.D.
AND ALLAN KREIGER,
M.D.
Torrance, California
Oral contraceptives have been implicated in a variety of isolated ocular abnormalities. Goren1 reported two cases of retinal edema, which were reversible upon withdrawal of the oral contraceptive drug. Flynn and Esterly2 reported a case of bilateral retinal From the Department of Surgery, Division of Ophthalmology, Harbor General Hospital, Tor rance, California, and the UCLA School of Medi cine. Reprint requests to Allan Kreiger, M.D., Harbor General Hospital, 1000 West Carson Street, Tor rance, California 90509.
VOL. 69, NO. S
NOTES, CASES, INSTRUMENTS
VA. 2 0 / 2 0 2/1000 WHITE
875
VA 2 0 / 5 0 2/1000 WHITE 5/1000 WHITE
Fig. 1 (Smith and Kreiger). Five degree absolute central scotoma with normal blind spot and full peripheral field, RE.
edema and periphlebitis, which also cleared when the drug was discontinued. In his review of the subject, Walsh 3 de scribed several cases of optic neuritis and retrobulbar neuritis occurring in young women taking these medications, but although the clinical course in his series strongly suggests an association between the drug and the dis ease, definite evidence is lacking. In the following case, a close relationship between the use of an oral contraceptive and visual loss was observed on two occasions. CASE REPORT
A 16-year-old Caucasian girl presented with a seven-day history of painless, progressive decrease in vision in the right eye and intermittent right temporal headache. There was no antecedent injury and her general health was good. She had taken an oral contraceptive (Norlestrin*) for the previous 14 days and otherwise used no medication. * Norlestrin (norethindrone acetate, 1 mg, ethinyl estradiol, 0.05 mg).
Visual acuity was RE :20/50, and LE :20/20. Pu pillary reactions, motility, and slit lamp examination of the anterior segment were normal. Applanation tension was 15 in both eyes. Ophthalmoscopy, in cluding contact lens examination, revealed no reti nal abnormalities, or changes in the disks, maculae, or vessels. Tangent screen testing, using 2-mm and 5-mm test objects demonstrated an absolute central sco toma of five degrees in the right eye, with normal blind spot and peripheral field (Fig. 1). Left vi sual field was normal. Loss of the right central pat tern was also evident on the Amsler grid, although the patient was unable to accurately define the lim its of the defect. Complete neurologic examination was otherwise negative. Laboratory studies, including complete blood count and sedimentation rate, were normal. X-ray films of the skull and orbital foramina were negative. The drug was discontinued. One week later vi sual acuity was 20/20 in both eyes and visual fields were normal. The oral contraceptive was resumed at that time, and discontinued in two days when she again developed loss of central vision in the right eye. Right visual acuity was 20/40 and tangent screen examination demonstrated an absolute cen tral scotoma of approximately two degrees (Fig. 2). In two weeks the visual acuity had once more
876
AMERICAN JOURNAL OF OPHTHALMOLOGY
MAY, 1970
Right
VA. 2 0 / 2 0 2/1000 WHITE
V.A. 2 0 / 4 0 2/1000 WHITE 5/1000 WHITE
Fig. 2 ( Smith and Kreiger). Two degree absolute central scotoma with normal blind spot and full peripheral field, RE. improved to 20/20, and ophthalmoscopy and visual fields were normal. A three-month followup exami nation was also normal. DISCUSSION
This case demonstrates a reproducible, probable cause and effect relationship be tween an oral contraceptive drug and the de velopment of a central scotoma. In view of the normal ophthalmoscopic findings and lack of peripheral field loss, the central sco toma is probably best explained by a retrobulbar neuritis. The patient was in good health, had taken no other medications, and was not specifi cally treated in any way other than by dis
continuing the drug. The time sequences are short and the examinations well documented. SUMMARY
A case of a central scotoma apparently re lated to the use of an oral contraceptive drug is presented. REFERENCES
1. Goren, S. B. : Retinal edema secondary to oral contraceptives. Am. J. Ophth. 64:447, 1967. 2. Flynn, M. A., and Esterly, D. B. : Ocular manifestations after Enovid. Am. J. Ophth., 61:907, 1966. 3. Walsh, F. B., Clark, D. B., Thompson, R. S., and Nicholson, D. J. : Oral contraceptives and neuro-ophthalmologic interest. Arch. Ophth. 74:628, 1965.
AMERICAN JOURNAL OF OPHTHALMOLOGY
four main groups classified as dysenteria, flexneri, boydi and sonnei, or groups A through D. The organism we cultured was sonnei, Group D. It is differentiated from the other groups because it ferments lactose and is indole negative. Man is the major car rier, along with other primates, especially monkeys and apes.3 The number of unidenti fied asymptomatic human carriers, as com pared to symptomatic carriers, is estimated to be nine to one.4 In our case, the source of the organism is unknown. Evidently at the time of trauma, the patient contaminated his injury site with the sonnei strain of the or ganism. A classic sign of human infection is dys entery. Isolated cases of shigellemia are re ported without dysentery.5 In our patient, stool cultures were negative, as were cultures of immediate family members. Serum anti body studies did not indicate a recent sys temic infection. However, the serum anti body titer is a poor diagnostic aid in making a diagnosis of Shigella. It is not surprising that the combination of sulfasoxazole and Neopolycin drops were an effective treatment for Staphylococcal aureus and Shigella sonnei. However, there are new modes of treatment for Shigella infec tions. Since Hardy's 6 work, sulfadiazine has been the treatment of choice for Shigella in fection. Garfinkel7 found that over 1400 cases of shigellosis in veterans of the Ko rean war were treated successfully with oxytetracycline. Haltalin and Nelson,8 and Haltalin,9 tested 300 stains of Shigella for sus ceptibility to sulfadiazine by dilution tech niques; 59% of Shigella sonnei were sulfadiazine-resistent, whereas only 8% ^ " 8 ^ r é sistent to ampicillin; 2% to colymycin; and 1% to kanamycin and neomycin. Haltalin concluded that ampicillin, kanamycin, and colymycin are the antibiotics of choice for Shigella infections. Since kanamycin and ampicillin are not usually prepared for topi cal administration, an effective treatment re gimen for Shigella corneal ulcer would con sist of neomycin and colymycin drops.
MAY, 1970
SUMMARY
A case of Shigella sonnei corneal ulcer is reported. The clinical appearance was not specific. The ulcer responded well to anti biotics. Neomycin and colymycin would be excellent antibiotics to use for ocular Shi gella infections. REFERENCES
1. Duke-Elder, S. : System of Ophthalmology, vol. 8. London, Kimpton, 1966, p. 187. 2. Maxwell, E. M., and Walter, H. P.: Iritis and cyclitis in dysentery. Brit. J. Ophth. 2:71, 1918. 3. Schneider, I. : Enteric bactériologie studies in a large colony of primates. Ann. New York Acad. Sei. 85:93S, 1960. 4. Watt, J., and Hardy, A. V.: Studies of the acute diarrhea diseases : Cultural surveys of normal population groups. Publ. Hlth. Rep. 60:261, 1945. 5. Graber, C. D., Browning, D., and Davis, J. S. : Shigellemia without shigella diarrhea. Am. J. Clin. Path. 46:221, 1966. 6. Hardy, A. V. : Studies of acute diarrheal dis eases : Sulfonamides in shigellosis. Publ. Hlth. Rep. 6:8S7, 1941. 7. Garfinkel, B. T. : Antibiotics in acute bacillary dysentery. J.A.M.A. 51:1157, 1953. 8. Haltalin, K. C, and Nelson, J. D. : In vitro susceptibility of shigella to sodium sulfadiazine and to eight antibiotics. J.A.M.A. 193 :705, 1965. 9. Haltalin, K. C. : Double blind treatment study of shigellosis comparing Ampicillin sulfadiazine and placebo. J. Pediat. 70:970, 1967.
VISUAL LOSS ASSOCIATED W I T H ORAL CONTRACEPTIVES MARGARET S. S M I T H ,
M.D.
AND ALLAN KREIGER,
M.D.
Torrance, California
Oral contraceptives have been implicated in a variety of isolated ocular abnormalities. Goren1 reported two cases of retinal edema, which were reversible upon withdrawal of the oral contraceptive drug. Flynn and Esterly2 reported a case of bilateral retinal From the Department of Surgery, Division of Ophthalmology, Harbor General Hospital, Tor rance, California, and the UCLA School of Medi cine. Reprint requests to Allan Kreiger, M.D., Harbor General Hospital, 1000 West Carson Street, Tor rance, California 90509.
VOL. 69, NO. S
NOTES, CASES, INSTRUMENTS
VA. 2 0 / 2 0 2/1000 WHITE
875
VA 2 0 / 5 0 2/1000 WHITE 5/1000 WHITE
Fig. 1 (Smith and Kreiger). Five degree absolute central scotoma with normal blind spot and full peripheral field, RE.
edema and periphlebitis, which also cleared when the drug was discontinued. In his review of the subject, Walsh 3 de scribed several cases of optic neuritis and retrobulbar neuritis occurring in young women taking these medications, but although the clinical course in his series strongly suggests an association between the drug and the dis ease, definite evidence is lacking. In the following case, a close relationship between the use of an oral contraceptive and visual loss was observed on two occasions. CASE REPORT
A 16-year-old Caucasian girl presented with a seven-day history of painless, progressive decrease in vision in the right eye and intermittent right temporal headache. There was no antecedent injury and her general health was good. She had taken an oral contraceptive (Norlestrin*) for the previous 14 days and otherwise used no medication. * Norlestrin (norethindrone acetate, 1 mg, ethinyl estradiol, 0.05 mg).
Visual acuity was RE :20/50, and LE :20/20. Pu pillary reactions, motility, and slit lamp examination of the anterior segment were normal. Applanation tension was 15 in both eyes. Ophthalmoscopy, in cluding contact lens examination, revealed no reti nal abnormalities, or changes in the disks, maculae, or vessels. Tangent screen testing, using 2-mm and 5-mm test objects demonstrated an absolute central sco toma of five degrees in the right eye, with normal blind spot and peripheral field (Fig. 1). Left vi sual field was normal. Loss of the right central pat tern was also evident on the Amsler grid, although the patient was unable to accurately define the lim its of the defect. Complete neurologic examination was otherwise negative. Laboratory studies, including complete blood count and sedimentation rate, were normal. X-ray films of the skull and orbital foramina were negative. The drug was discontinued. One week later vi sual acuity was 20/20 in both eyes and visual fields were normal. The oral contraceptive was resumed at that time, and discontinued in two days when she again developed loss of central vision in the right eye. Right visual acuity was 20/40 and tangent screen examination demonstrated an absolute cen tral scotoma of approximately two degrees (Fig. 2). In two weeks the visual acuity had once more
876
AMERICAN JOURNAL OF OPHTHALMOLOGY
MAY, 1970
Right
VA. 2 0 / 2 0 2/1000 WHITE
V.A. 2 0 / 4 0 2/1000 WHITE 5/1000 WHITE
Fig. 2 ( Smith and Kreiger). Two degree absolute central scotoma with normal blind spot and full peripheral field, RE. improved to 20/20, and ophthalmoscopy and visual fields were normal. A three-month followup exami nation was also normal. DISCUSSION
This case demonstrates a reproducible, probable cause and effect relationship be tween an oral contraceptive drug and the de velopment of a central scotoma. In view of the normal ophthalmoscopic findings and lack of peripheral field loss, the central sco toma is probably best explained by a retrobulbar neuritis. The patient was in good health, had taken no other medications, and was not specifi cally treated in any way other than by dis
continuing the drug. The time sequences are short and the examinations well documented. SUMMARY
A case of a central scotoma apparently re lated to the use of an oral contraceptive drug is presented. REFERENCES
1. Goren, S. B. : Retinal edema secondary to oral contraceptives. Am. J. Ophth. 64:447, 1967. 2. Flynn, M. A., and Esterly, D. B. : Ocular manifestations after Enovid. Am. J. Ophth., 61:907, 1966. 3. Walsh, F. B., Clark, D. B., Thompson, R. S., and Nicholson, D. J. : Oral contraceptives and neuro-ophthalmologic interest. Arch. Ophth. 74:628, 1965.