Lymphomatous Tumors of Eye and Its Adnexa _Lantern Demonstra

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					                         SOCIETY      TRANSACTIONS                      859

The   Ophthalmologist's     Place in the Prevention of Traffic Accidents.
      Dr. Lowell S.      Selling, Detroit.
    This article was published in full, with discussion, in the Sept. 26,
1942 issue of The Journal of the American Medical Association, page

Lymphomatous Tumors of Eye and Its Adnexa (Lantern Demonstra¬
    tion). Dr. John S. McGavic, New York.
   This article will be published in full in a later issue of the Archives.

Ocular Changes in Young Diabetic Patients (Lantern Demonstration).
     Dr. Cecil S. O'Brien and Dr. J. H. Allen, Iowa City.
   This article was published in full, with discussion, in the Sept. 19,
1942 issue of The Journal of the American Medical Association, page

Ochronosis of the Sclera and Cornea Complicating Alkaptonuria :
    Review of the Literature and Report of Four Cases (Lantern
    Demonstration). Dr. James W. Smith, New York.
   This article was published in full, with discussion, in the Dec. 19.
1942 issue of The Journal of the American Medical Association, page

              DETROIT      OPHTHALMOLOGICAL                SOCIETY

                      Howell Begle, M.D., President
                  Edmond L. Cooper, M.D., Recorder
                                 Nov. 19, 1942

Pitfalls in  Ophthalmic Surgery. Dr. Lawrence T. Post. St. Louis.
    Complications are bound to occur in ophthalmic operations, but the
incidence can be greatly reduced by proper preparation of both the
surgeon and the patient. Adequate anesthesia is important. I have
always used a subconjunctival injection of 1 per cent cocaine hydro¬
chloride dissolved in 1:1,000 epinephrine hydrochloride solution just
prior to intraocular operations. This renders insensitive the terminal
branches of the anterior ciliary nerves and will prevent sudden move¬
ment due to pain on the part of the patient. Injection of 1 to 2 cc. of
2 per cent procaine hydrochloride solution retrobulbarly in the region
of the ciliary ganglion is performed prior to all intracapsular cataract
extractions. Full local anesthesia induced before the removal of sutures
will preventsqueezing of the lids and other reactions to pain, which may
result in hemorrhage from the iris into the anterior chamber. I have
found pentothal sodium a valuable anesthetic for some patients, since it

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permits  intraocular operations to be clone safely on patients who, owing
to  worry or anxiety, are not good operative risks if operated on under
local anesthesia. There is some danger, especially of anoxemia, con¬
nected with its use, however, and it should be administered only by a
competent anesthetist.
    Postoperative prolapse of the iris or the vitreous can be prevented in
most cases by the use of corneoscleral sutures. Recently I have found
the McLean suture to be very satisfactory. It provides almost an air¬
tight closure of the wound and does not tend to cause postoperative
astigmatism due to corneal irregularity. When a large prolapse of the
iris does occur it is treated by excision of the prolapsed tissues and
covering of the wound with a conjunctival flap. When the prolapse
is small the daily application of concentrated trichloroacetic acid to the
prolapse is often satisfactory.
    Postoperative infections are best combated before surgical interven¬
tion is attempted. All foci of infection should be removed. I advocate
thorough treatment of young syphilitic patients prior to operation, but
I feel that old patients who have a positive serologie reaction but no
other evidence of syphilis may be safely operated on without treatment.
    Every one in the operating room should be free from colds and other
infections. The patient's face should be free of acne or other infective

                    Howell Begle, M.D., President
                   Edmond L. Cooper, M.D., Recorder

                                  Dec. 2, 1942

Physiology    and Anatomy of the Extraocular Muscles. Dr. Harold
      F. Falls, Ann Arbor, Mich.
     The individual actions of the extraocular muscles in the primary
position were reviewed. It was pointed out that with the exception of
the external, the rectus muscles are adductors. The superior and inferior
oblique muscles are abductors. The action of the superior and inferior
rectus muscles and the superior and inferior oblique muscles when the
eye is in adduction or abduction was discussed.
     It was recalled that the purpose of ocular movements is to extend the
field of vision and that the fusion faculty exerts a supreme control over
these movements.
    The surface anatomy of the eyeball was reviewed, especial emphasis
being placed on the distance from the limbus, in millimeters, of the
insertions of the tendons of the four rectus muscles, as well as on the
length of the tendons themselves. It was pointed out, in this regard,
that recession of a muscle is limited by the distance between the original
insertion and the equator of the eyeball, while resection of a tendon is
limited by the length of the tendon.

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                          SOCIETY       TRANSACTIONS                         861

Diagnosis       of Concomitant Strabismus.          Dr.   John    G. Beall, Ann
     Arbor, Mich.
    Concomitant strabismus is characterized by the fact that the two
eyes are equally involved in a muscular imbalance without loss of func¬
tion on the part of any single muscle. Several facts help differentiate
this type of squint from paralytic squint. In concomitant squint the
angle of deviation is the same in any direction of gaze and. the primary
and secondary deviations are the same. There is no limitation of ocular
movement in concomitant squint except when the condition is of long
standing, when organic shortening of a muscle may occur, resulting in
limitation of movement.
    Concomitant strabismus may be either alternating or monocular.
Alternating convergent strabismus is usually due to absence or extreme
weakness of the fusion faculty. Alternating divergent strabismus is due
usually to weakness of the fusion faculty or to weakness of accommoda¬
tion. Monocular strabismus is more often due to refractive errors (more
commonly hypermetropia), especially a difference in refractive error
in the two eyes (anisometropia).
    Proper treatment of concomitant squint is dependent on accurate
diagnosis. Careful study of each case of strabismus should include
 (1) history, including age of the patient at onset, and constancy of the
squint; (2) heredity; (3) central vision with and without correcting
lenses; (4) fixation; (5) measurement of the angle kappa; (6) char¬
acter of the squint; (7) measurement of the angle of deviation with
and without correcting lenses; (8) refractive error, and (9) fusion
Surgical  Treatment of Strabismus. Dr. F. B. Fralick, Ann Arbor,
    A consideration of the surgical treatment of strabismus should deal
largely with the determination and evaluation of the preoperative find¬
ings. Surgical intervention should not be considered until the following
data are available : ( 1 ) the refractive error determined during atropine
cycloplegia; (2) the visual acuity with the correction determined during
cycloplegia; (3) the presence or absence of the fusion faculty and its
degree; (4) the presence or absence of diplopia; (5) the deviation, with
and without cycloplegic correction, at 6 meters and 33 cm. and in the
six cardinal directions of gaze ; (6) the near point of convergence, and
 (7) the ocular movements in the six cardinal directions of gaze in the
cover   test.
    If the accommodative element is absent when tested by measure¬
ment of the angle of squint with and without glasses, glasses should
not be prescribed for the squint alone, since the angle of squint will not
be lessened by the glasses. The purely accommodative type of squint
does not require surgical correction, but the patient should be referred
to an orthoptic technician, if available, so that an attempt may be made
to break up the convergence-accommodation association. When the
squint is partly accommodative and partly mechanical, the mechanical
portion should be corrected surgically, largely by a strengthening opera¬
tion on the external rectus muscle, supplemented when necessary by a
central tenotomy or a minimal recession of the internal rectus muscle.
Every effort should be made to conserve the power of convergence.

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862                   ARCHIVES OF OPHTHALMOLOGY

   As far as possible, one should determine whether the squint is a
convergence anomaly (excess or insufficiency) according to Duane's
classification,   a   divergence anomaly (excess    or   insufficiency)    or a com¬
bination of the two.        There will then be little doubt        as   to whether   a
strengthening operation (resection, cinch, etc.)          or a   weakening
tion (recession, guarded tenotomy, etc.) is indicated. The selection
of the external muscle or the internal muscle to be operated on may be
 influenced by the screen test with the eyes in the six cardinal directions
of gaze. By this study a paretic muscle may be uncovered.
      Brown and White have demonstrated the poor results obtained by
 the use of glasses, orthoptic training and surgical intervention in the treat¬
ment of convergent strabismus complicated by a vertical imbalance unless
the vertical anomaly is corrected. Generally, the vertical deviation should
be corrected first, but in the higher degrees of lateral deviation it is often
necessary to correct a part of the horizontal deviation in order to study
the vertical deviation accurately. In such cases the surgical correction
should be confined to the external muscle.
     In esotropia, the surgical correction should be such that a near point
of convergence of around 90 mm. is maintained or developed. A weak¬
ening of the internal muscle is more necessary in cases in which there
is spasmodic in-shooting than in other cases. In cases of esotropia in
which the near point is 90 mm. or over, the surgical correction should
be accomplished primarily by shortening the external muscle, and in
cases of exotropia, it should be
                                    accomplished by shortening the internal
     The optimum time for operation is when no progress in reduction
of the squint is being achieved with nonoperative measures. The earlier
the nonsurgical measures are carried out, the more likely that one will
he able to obtain a functional result by surgical correction if it is needed.

       NEW        YORK     ACADEMY OF MEDICINE,                    SECTION
                           OF OPHTHALMOLOGY

                          Daniel B. Kirby, Chairman
                         R. Townley Paton, Secretary

                                   Dec. 21, 1942

Unsuccessful Cataract Extractions.            Dr. Theodore L. Terry             (by
    The lesions present after unsuccessful cataract extractions, as
revealed chiefly in enucleated eyes, are more or less unrelated and of
varied importance. A brief analysis shows that they can be divided into
five general groups.
    1. Lesions arising through failure to remove the lens or part of the
lens, such as the nucleus, capsule or cortex, with proliferation of new
abnormal lens fibers.

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