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Visual Toxic Symptoms from Digitalis†
400
NOTES, CASES, INSTRUMENTS
taken to provide enough scissors-space with in the initial limbal groove. This can be ac complished in three ways: First, the initial limbal groove should be placed astride the limbus. As the flap of the conjunctiva and Tenon's fascia are reflected toward the cornea, a dark zone of about one mm. in width comes into view. This is the limbus of the cornea. The anterior border of the limbus appears to merge imperceptibly with the clear cornea, but the posterior border can usually be seen as a sharp white line, marking the anterior termination of the sclera. The initial groove is begun three-fourths mm. posterior to this white line and continued for another threefourths mm. in front of it, into the limbus itself. The cut must be boldly and cleanly made, avoiding "scratching," and should extend to about one-third of the thickness of the lim bus with the first incision. A sharp No. 15 Bard-Parker blade is preferred by most surgeons for this purpose. The direction of the groove is at an oblique angle of about 45 degrees with the limbus. It is important that the upper half of the limbus be thoroughly freed of loose episcleral tissue and all oozing of blood stopped before the suture is inserted. If one prefers to enter the anterior cham ber between the loops of the suture, the tip of the keratome should not follow the oblique direction at the groove but be directed to ward the anterior pole of the lens instead, to avoid an intralamellar incision. If, however, the surgeon prefers to enter the anterior chamber between the sutures, an initial limbal groove, at the 12-o'clock posi tion but this time perpendicular to the lim bus, facilitates the smoother passage of the keratome and avoids its sudden jerky en trance into the anterior chamber. The obliquity of the initial grooves provides am ple space for the corneal scissors and does not interfere with the onward progress of the needle through the corneal lip of the groove.
Second, still more space is obtained if the limbal bites are taken closer to the base of the triangular groove and farther away from its apex. The suture is well anchored if a generous but superficial intrascleral bite is taken, emerging just at the edge of the scleral lip of the groove.* Third, still more space is provided for the maneuverability of the corneal scissors with proper retraction of the suture loops. When the corneal section is being enlarged, the as sistant usually retracts the lower loops while the surgeon fixates the upper loops and flap. If one must work without a trained assistant, a small serafine clamp attached to the lower loops effectively retracts them out of the way of the advancing scissors. SUMMARY
A method for the repair of an accidentally cut McLean suture is suggested. Some safe guards against such a mishap are reviewed. 185 North Wabash Avenue (2). VISUAL TOXIC SYMPTOMS FROM DIGITALIS+ CHARLES A. TURTZ,
M.D.
New York
Toxic symptoms from digitalis can result from a single large dose, or from cumula tive effects of smaller doses, after a long period of time. In addition to the usual toxic symptoms, such as slowing of the heart beat, headaches, nausea, vomiting and diarrhea, suppression of urine, delirium, convulsions and coma, there were also reported cases of bizarre visual hallucinations, such as yellow vision (xanthopsia) or objects outdoors ap pear as if covered with snow. Cases have been reported in which objects appeared colored red or brown. Flickering of lights and transient scotomas may also be present. A case has been reported of a child, aged * Hughes, W. F., Jr., and Owens, W. C.: Post operative complications of cataract extraction. Arch. Ophth., 28:577 (Nov.) 1947. + From the New York Medical College.
401
NOTES, CASES, INSTRUMENTS nine years, who showed oscillatory move ments of the eyeballs. Some patients have reported seeing tiny spots like goldfish, others have seen bright floating spots. All these symptoms disappeared when the drug was withdrawn. Wagener, Smith, and Nickerson reported a case of digitalis poisoning which produced retrobulbar neuritis. Vision was badly im paired (10/200). The fundi appeared nor mal and a central scotoma was present. The vision returned to normal five weeks after the drug was withdrawn. Mydriasis is present in the majority of cases; occasionally, miosis (de Schweinitz) with rapid and irregular pulse has been re ported. Langdon and Mulberger claim that the visual phenomena are due to the involvement of the visual cortex rather than the retina. Carroll believes normal dosage might pro duce visual symptoms with little or no evidence of drug intoxication. There have been no reports of toxic amblyopia follow ing digitalis poisoning. CASE REPORTS
I have recently seen two cases of visual hallucination following the administration of digitalis. CASE 1
Mr. M. L., a cardiac patient, aged 55 years, short, obese, with a florid complexion, did not appear ill. He gave a history of digi talis medication for five months, and con sulted me on April 5, 1952, because he had blurred vision for the past three weeks, and objects appeared as if covered with snow. An examination revealed visual acuity to be: R.E., with correction, 20/70; L.E., 20/40+. The cornea and lenses were clear. An examination of the fundi revealed an ovoid disc of good color and well defined. The right disc appeared injected, the retinal vessels were slightly sclerotic. The arteries appeared thinned and the retinal veins were full. The proportion was 1 to 4 (instead of
the normal 2 to 3). There were no exudates or hemorrhages present. The peripheral fields were normal and the central field revealed a paracentral scotoma. Tension was well within normal limits. A diagnosis of digitalis poisoning was made. The drug was discontinued and, in three weeks, the visual hallucination had en tirely cleared up. The central scotoma in the right eye disappeared and vision, with cor rection, in each eye returned to 20/25 — CASE 2
Mrs. A. J., aged 65 years, a short and stocky woman, consulted me on November 10, 1952, and gave a history of headaches and blurred vision which steadily increased for two weeks. There also was flickering of light and yellowish tinge of objects, espe cially outdoors. Visual acuity in the right eye, with correc tion, was 20/40; in the left eye, 20/50. The cornea was clear and the lenses showed early sclerosis. Fundus examination revealed round, welldefined discs that appeared slightly injected. The retinal vessels showed nothing remark able except slight sclerotic changes in the smaller arterioles. In the right fundus to ward the periphery, there were pinpoint specks of choroidal atrophy (senile changes). The peripheral fields, taken on the perimeter, were well within normal limits, and the central field taken on the tangent screen showed no scotoma. The diagnosis of digitalis poisoning was made and the drug was withdrawn. Five weeks later the bizarre symptoms had cleared up and vision in the right eye returned to 20/30+ ; in the left eye, 20/25—. SUMMARY
Two cases of digitalis poisoning which produced bizarre visual symptoms are re ported. Three weeks after digitalis was dis continued, these symptoms cleared up com pletely without any permanent impairment of vision. 65 Central Park West.
NOTES, CASES, INSTRUMENTS
taken to provide enough scissors-space with in the initial limbal groove. This can be ac complished in three ways: First, the initial limbal groove should be placed astride the limbus. As the flap of the conjunctiva and Tenon's fascia are reflected toward the cornea, a dark zone of about one mm. in width comes into view. This is the limbus of the cornea. The anterior border of the limbus appears to merge imperceptibly with the clear cornea, but the posterior border can usually be seen as a sharp white line, marking the anterior termination of the sclera. The initial groove is begun three-fourths mm. posterior to this white line and continued for another threefourths mm. in front of it, into the limbus itself. The cut must be boldly and cleanly made, avoiding "scratching," and should extend to about one-third of the thickness of the lim bus with the first incision. A sharp No. 15 Bard-Parker blade is preferred by most surgeons for this purpose. The direction of the groove is at an oblique angle of about 45 degrees with the limbus. It is important that the upper half of the limbus be thoroughly freed of loose episcleral tissue and all oozing of blood stopped before the suture is inserted. If one prefers to enter the anterior cham ber between the loops of the suture, the tip of the keratome should not follow the oblique direction at the groove but be directed to ward the anterior pole of the lens instead, to avoid an intralamellar incision. If, however, the surgeon prefers to enter the anterior chamber between the sutures, an initial limbal groove, at the 12-o'clock posi tion but this time perpendicular to the lim bus, facilitates the smoother passage of the keratome and avoids its sudden jerky en trance into the anterior chamber. The obliquity of the initial grooves provides am ple space for the corneal scissors and does not interfere with the onward progress of the needle through the corneal lip of the groove.
Second, still more space is obtained if the limbal bites are taken closer to the base of the triangular groove and farther away from its apex. The suture is well anchored if a generous but superficial intrascleral bite is taken, emerging just at the edge of the scleral lip of the groove.* Third, still more space is provided for the maneuverability of the corneal scissors with proper retraction of the suture loops. When the corneal section is being enlarged, the as sistant usually retracts the lower loops while the surgeon fixates the upper loops and flap. If one must work without a trained assistant, a small serafine clamp attached to the lower loops effectively retracts them out of the way of the advancing scissors. SUMMARY
A method for the repair of an accidentally cut McLean suture is suggested. Some safe guards against such a mishap are reviewed. 185 North Wabash Avenue (2). VISUAL TOXIC SYMPTOMS FROM DIGITALIS+ CHARLES A. TURTZ,
M.D.
New York
Toxic symptoms from digitalis can result from a single large dose, or from cumula tive effects of smaller doses, after a long period of time. In addition to the usual toxic symptoms, such as slowing of the heart beat, headaches, nausea, vomiting and diarrhea, suppression of urine, delirium, convulsions and coma, there were also reported cases of bizarre visual hallucinations, such as yellow vision (xanthopsia) or objects outdoors ap pear as if covered with snow. Cases have been reported in which objects appeared colored red or brown. Flickering of lights and transient scotomas may also be present. A case has been reported of a child, aged * Hughes, W. F., Jr., and Owens, W. C.: Post operative complications of cataract extraction. Arch. Ophth., 28:577 (Nov.) 1947. + From the New York Medical College.
401
NOTES, CASES, INSTRUMENTS nine years, who showed oscillatory move ments of the eyeballs. Some patients have reported seeing tiny spots like goldfish, others have seen bright floating spots. All these symptoms disappeared when the drug was withdrawn. Wagener, Smith, and Nickerson reported a case of digitalis poisoning which produced retrobulbar neuritis. Vision was badly im paired (10/200). The fundi appeared nor mal and a central scotoma was present. The vision returned to normal five weeks after the drug was withdrawn. Mydriasis is present in the majority of cases; occasionally, miosis (de Schweinitz) with rapid and irregular pulse has been re ported. Langdon and Mulberger claim that the visual phenomena are due to the involvement of the visual cortex rather than the retina. Carroll believes normal dosage might pro duce visual symptoms with little or no evidence of drug intoxication. There have been no reports of toxic amblyopia follow ing digitalis poisoning. CASE REPORTS
I have recently seen two cases of visual hallucination following the administration of digitalis. CASE 1
Mr. M. L., a cardiac patient, aged 55 years, short, obese, with a florid complexion, did not appear ill. He gave a history of digi talis medication for five months, and con sulted me on April 5, 1952, because he had blurred vision for the past three weeks, and objects appeared as if covered with snow. An examination revealed visual acuity to be: R.E., with correction, 20/70; L.E., 20/40+. The cornea and lenses were clear. An examination of the fundi revealed an ovoid disc of good color and well defined. The right disc appeared injected, the retinal vessels were slightly sclerotic. The arteries appeared thinned and the retinal veins were full. The proportion was 1 to 4 (instead of
the normal 2 to 3). There were no exudates or hemorrhages present. The peripheral fields were normal and the central field revealed a paracentral scotoma. Tension was well within normal limits. A diagnosis of digitalis poisoning was made. The drug was discontinued and, in three weeks, the visual hallucination had en tirely cleared up. The central scotoma in the right eye disappeared and vision, with cor rection, in each eye returned to 20/25 — CASE 2
Mrs. A. J., aged 65 years, a short and stocky woman, consulted me on November 10, 1952, and gave a history of headaches and blurred vision which steadily increased for two weeks. There also was flickering of light and yellowish tinge of objects, espe cially outdoors. Visual acuity in the right eye, with correc tion, was 20/40; in the left eye, 20/50. The cornea was clear and the lenses showed early sclerosis. Fundus examination revealed round, welldefined discs that appeared slightly injected. The retinal vessels showed nothing remark able except slight sclerotic changes in the smaller arterioles. In the right fundus to ward the periphery, there were pinpoint specks of choroidal atrophy (senile changes). The peripheral fields, taken on the perimeter, were well within normal limits, and the central field taken on the tangent screen showed no scotoma. The diagnosis of digitalis poisoning was made and the drug was withdrawn. Five weeks later the bizarre symptoms had cleared up and vision in the right eye returned to 20/30+ ; in the left eye, 20/25—. SUMMARY
Two cases of digitalis poisoning which produced bizarre visual symptoms are re ported. Three weeks after digitalis was dis continued, these symptoms cleared up com pletely without any permanent impairment of vision. 65 Central Park West.