NOTES, CASES, INSTRUMENTS COLOBOMA OF THE OPTIC

NERVE. J. Ε . JENNINGS , Μ . D . ,

ST. LOUIS.

Mrs. W . M., aged 48, consulted me March 28, 1924, to have her eyes ex­amined for reading glasses. She stated that the vision of the right eye was very defective.

V i s i o n : O . D . 6 - 1 0 0 ; with - 0 . 7 5 sph. 6 - 6 0 . O . S. 6 - 7 . 5 ; with - 0 . 3 7 cyl. ax. 165 6—6.

T h e fundus of the left eye is normal.

Fig. 1.—Coloboma of optic nerve.

The site of the optic disc of the right eye is occupied by a grayish white fun­nel shaped cavity about three times the diameter of the normal disc. T h e rim of the cavity is covered at places with masses of black pigment. T h e retinal vessels on the nasal side disappear abruptly at the edge, while those on the temporal side can be fo l lowed some distance d o w n into the cavity, when they are lost to view. T h e field of vision is normal except that the blind spot extends from the fixation point outwards 20 degrees.

MEDIAL CONGENITAL ANKY­LOBLEPHARON.

CONGENITAL ABSENCE OF CARUNCLES.

E. H . OPPENHEIMER, M . D . ,

NEW YORK CITY.

Mrs . N., Spanish, aged 66, was re­ferred to the E y e Department of the

L e n o x Hill Hospital , June 14th, 1924. She had been treated in the Skin D e ­partment of the Hospital , for sores of the mouth, presumably pemphigus due to plates and dating back seven years.

T h e patient complained that the left eye occasional ly become red ; very lit­tle tearing, no actual pain. A s a child her eyes were sometimes red, but never seriously aft'ected. She had never been i l l ; four normal children. She used glasses.

Examinat ion showed a small w o m a n of rather cachect ic appearance. Vis ion , fundus, moti l i ty normal. Loca l in­flammation of left bulbar conjunctiva due to the presence of t w o delicate in­verted misplaced lashes of the lower lid, a condit ion sometimes met with in old and debilitated patients. As ide from this slight irritation both eyes appeared perfectly normal.

T h e palpebral condit ion is nor­mal without follicles or scars. Ever­sion of both upper and lower lids, however , reveals a slight Symble­pharon, a fold which reaches nasally to both borders of the lids. Thep l i casemi -lunaris and the caruncle are missing or both sides; and a web like bridge oi true skin extends from one cana.liculus to the other above where the lacus lacrimalis and caruncle ought to be. If stretched, this br idge or membrane appears thinner, paler and more trans­parent in the middle part so that, were there a caruncle beneath, it wou ld be visible thru it. N o scar whatever can be seen. T h e puncta are smaller than usual and hard to detect. T h e y are properly located and the canaliculi pa­tent, but extremely narrowed. Can­not syringe thru to the nose.

U p o n closer inspection the eyes look strange, evidently due to the fact that the angle of the lids is circular ( see sketch 2 ) or nearly so (sketch 1 ) .

Diagnosis. That neither traumatism nor inflammation or other disease is the cause is proved by the lateral o c ­currence and the symmetry , the ab­sence of scars, the lack of semilunar folds, the missing caruncles, and also the history. T rachoma is out of the question. It therefore is a congenital malformation.

788

NOTES, CASES A N D INSTRUMENTS 789

Remarks. Similar cases are not, so far as I could find out, on record. I have never seen one in m y private prac-

J (

Fig. 1.—Congenital absence of caruncle, right eye.

tice. In 1908 I reported a rare case of ankyloblepharon filiforme a d η a t u m ( A r c h . f. Augenh . , v. 6 1 ) . O n l y five other cases had hitherto been published.

ΤΤΤΠΤΤ

Fig. 2.—Congenital absence of caruncle, left eye.

A t that time I concluded: "I venture to state that anomalies of this kind prob­ably occur oftener than it seems, for many colleagues have not the time, nor do they trouble to report on all curious cases they meet with in their private practice, provided they present only casuistically interesting features."

Perhaps some of m y readers may k n o w of similar cases from their rec­ords.

A N E W L I D E L E V A T O R .

A . S. GREEN, M . D . ,

L . D . GREEN, M . D . ,

SAN FRANCISCO, CALIF.

There are three distinct methods for control l ing the lids dur ing a cat­aract operat ion; first a speculum of some kind, second a hook , and third the fingers. T h e object of each method is to proper ly expose the field of oper­ation and to control the lids. T h e de­gree of safety with which this is done varies with the method used. T h e

speculum, whi le g iv ing the largest and mos t accessible field, is the mos t dan­gerous , because the blade may act as a fulcrum, and if the patient squeezes, it may cause a great loss of vitreous. T o avoid this s o m e operators dispense with the speculum entirely and use the thumb or fingers to retract the lids. Th i s method is undoubtedly safer than with the average speculum but is sadly deficient in certain types, the squeezers and patients with prominent eyes.

RIGHT

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Fig. 1.—Green's new lid elevator. Complete instru­ment right and left blades front and below in section.

Undoubted ly the safest method for these and all other cases is the lid hook as advocated and used b y Col . Henry Smith. W i t h a hook one may fre­quently cause the cornea to drop to­wards the lens after the section, dem­onstrating the negative pressure; whereas a speculum, b y resting on the g lobe , causes a positive pressure and thus increases the liability to loss of vitreous. T h e lid hook has a serious disadvantage in that it greatly inter­feres with the manipulation of the operator and does not g ive an adequate operative field.

F o r about e ight years the writers have used an instrument that embodied