746 CASE REPORTS

marked reactions; but the process looks more like an anaphylactic stage of the system both to the drug and the toxins liberated by it in the eye, which in this case was likely the weakest spot. No other cases of a similar na­ture have been reported to my know­ledge and no exact cause assigned to such a condition thus far.

CHRONIC SIMPLE GLAUCOMA. IRIDOTASIS.

W M . F. HOLZER, M. D.

WORCESTER, MASS.

Theodore H., Age 64, English, mar­ried, carpet weaver, come to the office July 10, 1920, complaining of indistinct and failing vision past three years, par­ticularly the right eye, which failed about one year before the left. There had never been any pain associated with the failure of vision, no neuralgic headaches, nor rainbow halos.

Examination: O. D. Vision ?? of light perception. Anterior chamber was very shallow. Pupil measured 4 x 5 mm. oval, axis 90°, very sluggish. Media clear. Deep total pathologic ex­cavation of the nerve head, with engor­ged veins bending sharply over the edge and pulsating at the base of ex­cavation. The nerve was atropic, pale greenish color, lamina cribrosa very distinct. Arteries not unusual, veins markedly distended and moderately tortuous. Tension 52 mm. mercury (McLean).

O. S. Vision 5/60. Anterior chamber not quite as shallow as O. D. Pupil 3 mm. irregular in outline, slightly more active than fellow. Media clear. Deep glaucomatous excavation, en­gorged veins bending sharply over edge. No pulsation, except upon pres­sure on globe. Nerve more normal tint than fellow. Veins moderately distended and tortuous. Tension 46 (McLean). Field much contracted.

Immediate operation was advised to attempt to arrest destruction of the left optic nerve. Pilocarpin hydro-chlorid 4 gr. to the ounce, four times

daily, and eserin sulphate 2 gr. to the ounce, at night were prescribed.

July 14, 1920. Iridotasis at City Hospital, record No. A 15596. Tension O. D. 48, O. S. 40.

Operation: Left eye. At 8:00 A. M. patient was given 34 Sr- rnorphin sul-phat and 1/200 gr. hyoscin hydrobro-mat subcutaneously. At 8:30 one drop of atropin sulphat 1% was instilled. At 9:00 o'clock after four instillations of 4% cocain hydrochlorat and 1-1000 adrenalin chlorid (separate solutions) at intervals of two minutes, the con-junctival sac was flushed with a warm 1:8000 mercury chloride solution, and a Clark (Weiss) speculum was intro­duced. The patient was directed to look down and the ocular conjunctiva was grasped with fixation forceps 10 mm. above the limbus at 12 o'clock and opened transversely 10 mm. The sub-conjunctival tissues were opened and carefully dissected free from the sclera down to the limbus. A Jaeger (Weiss) curved keratome was passed thru the sclera beginning 2 mm. above the limbus and emerging into the an­terior chamber thru the angle. The keratome was introduced far enough to make the scleral incision 4 mm. in length. Fine curved iris forceps were introduced and the free border of the iris grasped at 12 o'clock and pulled gently into the wound,—the posterior surface of the iris then facing anterior­ly. The conjunctiva was then pulled up in place, speculum removed, and the lids gently closed. A sterile dressing was applied, the eye bandaged, and protected by a Ring mask.

July 15, 1920. There was slight conjunctival injection at the wound. Anterior chamber was reestablished and deeper. There was a hernia of the iris thru the scleral wound, elevated 1 mm. and measuring 2 mm. broad. Roller bandage applied.

July 16, 1920. Eye dressed. Out of bed.

July 18, 1920. No injection. Band­age removed. Dark glasses.

July 24, 1920. Discharged from hos­pital Globe white. Hernia of iris same as last noted. Using myotics in right.

CASE REPORTS 747

July 27, 1920. At office. Vision 5/15. August 13, 1920. Field showed slight

enlargement. Vision 5/15 with + 1.25 -f .50 x 180 = 5/10 less 2 letters. Ten­sion O. D. 44. O. S. 22. Using my-otics in right.

August 28, 1920. Tension O. D. 40. O. S. 24. Vision 5/15 with + 1.25 -f .50 x 180 == 5/10 ordered.

October 11, 1920. Vision same. Field practically same as August 13. Tension O. D. 44. O. S. 22. Using pil-ocarpin in right.

The question arose as to the choice of operation in this particular case, tre­phine, iridectomy or iridotasis. Here was a man possessing only one seeing eye, in which the field of vision was markedly contracted. Having seen two late infections following tre­phine, and noted contraction of the vi­sual field and occasional severe hemor­rhage following iridectomy, I decided upon iridotasis, because of its simpli­city, and ease and dispatch with which the operation can be performed; assets when the patient has but one seeing eye. The adrenalin controls hemor­rhage from the conjunctiva, and the at-ropin dilates the pupil so that the sphincter of the iris does not pull the incarcerated portion away from the scleral wound.

ENUCLEATION; FAT IMPLAN­TATION.

WILLIAM W. LEWIS, M. D.

ST. PAUL, MINN.

J. S., aged 16, was first seen at the City and County Hospital, in the ser­vice of the writer, March 1st, 1921. A working girl. Previous history nega­tive, except "sore eyes" in infancy, leaving a blind deformed eye, an un­sightly protruding eye, scarcely cover­ed by eyelids. General appearance, un­dersized, undernourished girl.

The right eye was apparently normal as to exterior, except nystagmus. Face asymmetric, oscillating nystagmus. In the left eye protruding staphyloma of the cornea. The left lids scarcely cov­ers a misshapen globe. Anterior cham­

ber obliterated, iris adherent to cornea at centrally located scar. No pupil opening visible. Tension about nor­mal. Fixation (cover test) oscillation. Movements unrestricted. Vision R. 1/10; L. light and shadows.

Ophthalmoscope: Right media clear; optic nerve head, deep inferior conus. Macula and periphery normal.

Treatment: March 3rd. Brow and lashes clipped. General anesthesia. Irrigation of conjunctival sac with boric solution. Conjunctiva snipped at the limbus, continued around the cornea; each of the four recti success­ively hooked and divided close to in­sertion in the sclera and the ends held with clamps. Optic nerve cut 1 cm. be­hind the globe. Obliques and remain­ing shreds freed. Globe removed. Hot normal salt pack applied while belly wall was opened. Belly wall, median line, opened and a small piece of fat dissected out. Opening in belly wall closed by encircling sutures to obliter­ate space. Piece of fat immersed in 95% alcohol and inserted into Tenon's capsule which was closed with a puck­er string of catgut. Ends of oblique muscles sutured across stump. The conjunctival sac was closed with 40-day catgut. Pad dry dressing and bandage.

Mar. 4. Ice bag ordered to be applied continuously to hold down reaction which was considerable. Lids much swollen, some pain.

March 4. Tremendous reaction, dis­coloration ; ice bag.

March 6. Lids almost black, tremen­dous reaction. .Hot applications.

March 7. Lids look almost as if they would slough.

March 8. Reaction subsiding, con­siderable mucous secretion.

March 9 to 12. Reaction subsiding gradually.

March 12 to 18. Lids discolored but swelling of lids almost gone. Consider­able secretion.

March 20. Considerable secretion, purulent.

April 1. Comes to the office. Styes on the lower lid. Stump looks good.