CARDIAC ARREST 427

the units are millimicromoles of acetylcho-line hydrolyzed per minute per gram dry weight of red cells at 37°C (normal is 18-20).

C O M M E N T

The plasma pseudocholinesterase returned to normal levels in about one month. As-suming a lifespan of 120 days per erythro-cyte, the red blood cell acetylcholinesterase was recovering at the expected rate until the end of March. Thereafter, recovery was inexplicably more rapid.

This patient exhibited some of the usual systemic side-effects of anticholinesterase drugs. In addition, she had a cardiac arrest. It is suggested that the patient was in a pre-cariously compensated asymptomatic state of cholinesterase inhibition. The additive effect of sinus-auricular node depression due to a reflex increase in vagal tone secon-

TABLE 1 DETERMINATION OF ACETYLCHOLINESTERASE AND PSEUDOCHOLINESTERASE IN PREOPERATIVE AND

POSTOPERATIVE BLOOD SAMPLES

Date Pseudocholines-esterase

Acetylcholin-esterase

25/2/64 2/3/64 9/3/64 31/3/64 21/4/64 8/6/64

38 66 88 143 185 199.4

0.37 1.50 1.70 5.11 15.13 15.9

dary to colonie stimulation, probably tipped the balance in favor of decompensation re-sulting in the ensuing symptoms and signs.

Banting Institute 100 College Street (5).

ACKNOWLEDGMENT

We wish to thank Dr. W. Kalow of the Depart-ment of Pharmacology, University of Toronto, for his assistance in the preparation of this case report.

REFERENCES

1. Krishna, N., Mann, M. J., and Leopold, I. H. : Blood cholinesterase of normal and glaucomatous subjects. Am. J. Ophth., 52:242, 1961.

2 Dienstbier, E. : The cholinesterase activity of erythrocytes in patients with glaucoma (in Czech). Csl. Oftal., 14:321-326, 1958.

3. Leopold, I. H., Krishna, N., and Lehman, R. : Effects of anticholinesterase agents on blood cholines-terase in normal and glaucomatous subjects. Tr. Am. Ophth. Soc, 57:63-86, 1959.

4. Humphreys, J., and Holmes, J. : Systemic effects produced by echothiophate iodide in the treat-ment of glaucoma. Arch. Ophth.,, 69:737 (June) 1963.

5. Drance, S. M. : Phospholine Iodide and Demecarium Bromide in the management of glaucoma. Am. J. Ophth., 50 :270, 1960.

6. Leopold, I. H. : Ocular cholinesterase and cholinesterase inhibitors (Friedenwald Memorial Lec-ture). Am. J. Ophth. 51:885 (May) 1961.

E L E C T R O N M I C R O S C O P I C S T U D Y O F T R A B E C U L A R M E S H W O R K *

I N CLINICAL AND EXPERIMENTAL GLAUCOMA W I T H ANTERIOR

CHAMBER HEMORRHAGE

T S U Y O S H I Y A M A S H I T A ^ M.D., AND DAVID A. R O S E N , M.D.

Kingston, Canada

With very few exceptions the various forms of primary and secondary glaucoma

* From the Department of Ophthalmology, Fac-ulty of Medicine, Queen's University. This study was assisted by funds provided by grant 605-7-169 of the National Health Grants Program.

t Present address : Section of Ophthalmology

are considered to occur against the back-ground of reduced outflow of aqueous from the eye. The precise pathogenesis of the aqueous outflow impediment and the site of

Department of Surgery, School of Medicine, Uni-versity of Missouri, Columbia.

428 TSUYOS'HI YAMASHITA AND DAVID A. ROSEN

ENDOTHEUftL MESHWORK PATHOLOÎY

M t i . o n - « A R H i Q

" ■ I I I i ' ^ ' L - S A L I N E f «

IN VIVO EXPERIMENT PERFUSION STUDY

Fig. 4 (Yamashita and Rosen). Obstruction of aqueous outflow by anterior chamber injection of autogenous blood. Course of the experiment and results of perfusion of monkeys 6310 and 6311.

resistance to outflow in many forms of glau-coma have received intensive study. The studies to date have been more successful in raising questions than in providing answers. Thickening of the beams of the uveal and sclerocorneal portions of the trabecular meshwork, as well as degeneration of the endothelial meshwork, have been demon-strated in eyes with chronic simple and iron-induced secondary glaucoma.1"3 There is increasing evidence to suggest that the en-dothelial meshwork may play a salient role in the regulation of aqueous flow in normal-ity and in glaucoma.4"6

The present study consists of a correlated histologie and electron microscopic study of a group of eyes which share in common the feature of anterior chamber hemorrhage as-sociated with reduced facility of aqueous outflow.

MATERIALS AND M E T H O D S

Two previously normal human eyes de-veloped recurrent anterior chamber hemor-rhages with secondary glaucoma following blunt injuries. The glaucoma failed to re-spond to treatment and enucleation was nec-essary to relieve pain.

Six rhesus monkeys ranging from 3.9 to 10 kg received anterior chamber injections of 0.15 ml of autogenous arterial blood on three separate occasions. Their intraocular pressure was measured with a Goldmann ap-planation tonometer. Tonography was per-formed with a Mueller tonographer. Perfu-

sion was performed by a method described by Bârâny.4 All the experiments were per-formed under intraperitoneal Nembutal anes-thesia.

The eyes were fixed in osmic acid im-mediately after removal or after earlier fixa-tion in buffered 2 % trioxymethylene solu-tion. The trabecular meshwork was embed-ecl in epon resin 812 (Shel l) , cut one mi-cron thick and stained with toluidine blue or Prussian blue. Thin sections for electron microscopy were stained with uranyl acetate before viewing with an RCA-111 unit.

RESULTS

a. Two human eyes with open-angle glau-coma secondary to anterior chamber hemor-rhage.

One eye has thickened trabecular beams in the sclerocorneal meshwork and widely open intertrabecular spaces containing eryth-rocytes. The endothelial meshwork is mark-edly condensed and the pores are absent (fig. 1) . In the deeper portion of the endothelial meshwork, the cells are increased in number and size. Some contain osmiophilic granules and many show vacuolar degeneration of the cytoplasm, indistinct cytoplasmic membranes and pyknotic nuclei. The interendothelial spaces are obliterated (fig. 2 ) .

The second eye appears similar to the first in light microscopy but shows more ad-vanced cellular degeneration of the endothe-lial meshwork in electron micrographs. The cells lining the inner wall of Schlemm's canal are flattened and degenerated and the pores traversing these cells are obliterated. The interendothelial spaces are completely occupied by thick homogeneous material, cellular debris and intact or disintegrated erythrocytes. In the deeper portion of the endothelial meshwork, cells are markedly degenerated and in places are adherent en-closing capillarylike spaces (fig. 3 ) .

b. Monkey eyes injected zvith autogenous blood.

Of the six eyes which had received re-

TRABECUÏ .AR MES1ÏWORK IN GLAUCOMA 42<J

:·.·.α·-** "2.'' '^ -*- ."--* .«η , ί ' ' ί ' ' ""-!'_ V '," "'

' • f i ia b-*Af

A C

*. .... .. ? Kig. 1 ( Yaniasliita and Kosen). Traheenlar niesliwork obtained from eye of 73-year-old patient who

had developed open-angle glaucoma sccondarx lo anterior chamber hemorrhages following blunt injury with intraciilar pressure of 40 mm I Ig and up ( χ240 ) .

Eig. 2 (Yaniasliita and Rosen). Electron micrograph of the endothelial niesliwork of the same trabecula shown in Figure 1.

430 T S l ' Y O S U l YAMASIIT'I'A AXT) DAVIT) A. ROSKX

I-'isi. 3 (Yamasliiin and Rosen)· Tin- endothelial meshwork of eye oi a 71-vcar-o!d patienl wlio liad developed traumatic anterior ehainlier hemorrba.m's with intraocular pressure" 65 mm I k and retinal delaelmient. (CLS) ('apillarylikc spare.

>ν * * » * · » * ■

l'iy. .i (. Yamashita and Rosen). Traheeular mesliuork ol monkev 6300. Transient rise of intraocular pres-sure ii]) to 40 nun HK was recorded and ontllow facility before enueleation was 0.07 ( χ 2 4 ϋ ) .

T R A B E C U L A k MF.SHVVORK IN GLAUCOMA 431

Fig-, 6 (Yaniasliita and Rosen). Electron micrograph of eiidothelial mcshwork of same trabecula shown in Figure 5.

432 "SUYOSHI Y A M A S H I T A A N D DAVID A. R O S E N

FIR. 7 ( Yamasinta and Rosen). Serial sections showing the "pore" of the endolhelral meshwork lining the inner wall of Sehlenmi's canal ( S C ) . ( P ) Port·. ( A M P ) Acid nuicopolysaccharide.

TRABECULAR MESHWORK IN GLAUCOMA 433

TABLE 1* OBSTRUCTION OF AQUEOUS OUTFLOW BY ANTERIOR CHAMBER INJECTION OF AUTOGENOUS BLOOD

Left eye control

Right eye experi-mental

Case

C

C

Monkey 6309

0.34 (T)

0.07 (T)

Monkey 6308

0.33 (T)

0.15 (T)

Monkey 6310

0.39 (P)

0.12 (P)

Monkey 6307

0.35 (P)

0.20 (P)

Monkey 6306

0.48 (P)

0.39 (P)

Monkey 6311

0.24 (P)

0.22 (P)

Endothelial Meshwork Pathology

Superior + Nasal + + Inferior + + + + Temporal + +

+ + + + + +

+ + +

+ + + + +

+ + + +

+ +

+

(T) by tonography. (P) converted from perfusion study. * Eyes with decreased outflow facility (C) demonstrated more marked pathology in the endothelial

meshwork.

peated anterior chamber injections of blood, two developed a transient rise of intraocular pressure up to 40 mm Hg . In no instance was there a sustained elevation of pressure and the trend in the latter part of the exper-iment was toward hypotony. Nevertheless, there was a striking reduction in the facility of aqueous outflow as determined both by tonography and perfusion in four eyes out of six (table 1, fig. 4 ) . The morphologic study reveals the angles to be open and the uveal and sclerocorneal portions of the meshwork to be normal. The pathology is confined to the endothelial meshwork where there is an impressive increase in the num-ber and size of endothelial cells which con-tain iron-positive granules (fig. 5 ) . Electron microscopically, these granules are os-miophilic and are found in the cytoplasm of swollen endothelial cells. The inter endothe-lial spaces are markedly narrowed (fig. 6 ) . The severity of pathology in the endothelial meshwork correlates well with extent of de-crease in facility of outflow (table 1, fig. 4 ) .

DISCUSSION

The feature shared by these eyes is pathol-ogy of the endothelial portion of the trabec-ular meshwork which appears to be compat-ible with reduced facility of aqueous outflow. This pathology includes obliteration of the pores which characterize the inner

wall of Schlemm's canal in both human and monkey eyes in normality (figs. 7 and 8 ) , an increase in the size and number of endothe-lial cells, various forms of cytoplasmic and nuclear degeneration and the accumulation of dense amorphous material between en-dothelial cells. These changes in all in-stances overshadowed the pathologic fea-tures in the sclerocorneal and uveal portions of the trabecular meshwork. The similarity of the findings in all eyes studied makes it likely that the pathology in the endothelial meshwork was an effect of the hemorrhage and was of paramount importance in pro-ducing the intractable painful glaucoma as-

UnderLyincj cell

Fig. 8 (Yamashita and Rosen). Schematic drawing of "pore."

434 T S U Y O S H I Y A M A S H I T A A N D DAVID A. R O S E N

sociated with it in the human eyes and in leading to obstruction of aqueous outflow in the monkey eyes.

SUMMARY

Electron microscopic studies of two human eyes with open-angle glaucoma sec-ondary to anterior chamber hemorrhage

The present status of our knowledge of the A and V patterns in horizontal strabis-mus was summarized by an authoritative panel during the 1963 meeting of the Academy.4 According to this panel, vertical incomitancy occurred in 25% of all patients with strabismus. The high incidence empha-sizes the clinical significance of this entity. Careful diagnosis and good surgical judg-ment are essential to obtain beneficial re-sults. The primary aim should be correction of the deviation in functionally important directions of gaze, such as the straight-ahead and downward positions.

A great number of surgical procedures have been suggested by various schools of

* From the Wilmer Institute of Ophthalmol-ogy, The Johns Hopkins Hospital. This study was supported in part by grant NB-05147-01 from the National Institute of Neurological Diseases and Blindness, Beihesda, Maryland.

demonstrated marked pathology in the en-dothelial meshwork which may account for the impaired aqueous outflow. Obstruction of aqueous outflow and similar pathology were achieved in the eyes of rhesus mon-keys which had received anterior chamber in-jection of autogenous blood.

Queen's University.

thought, the type of surgery depending on the view of each author regarding etiology of the defect. Much remains to be learned before it can be determined how best to handle these patients surgically. In this paper we will attempt to outline some diag-nostic features which we consider impor-tant, and report on the surgical results ob-tained at the Wilmer Institute in patients with A and V patterns.

DIAGNOSIS

In order to be able to compare the efficacy of various surgical approaches, it is essential that pre- and postoperative mea-surements are obtained under similar condi-tions. The Academy panel4 recommended that measurements be taken at 25 degrees of up-ward gaze and 25 degrees of downward gaze. Breinin2 pointed out that, when the eyes are rotated to extremes, the effects of check liga-

R E F E R E N C E S

1. Teng. C. C , Paton, R. T., and Katzin, H. M. : Primary degaieration in the vicinity of the chamber angle. Am. J. Ophth., 40:619-631, 1955.

2. Becker, B., and Yamashita, T. : Histopathological and histochemical studies of the chronic simple glaucoma. Tr. Glaucoma Symp., J. Macy Foundation Publication, 1960, pp. 223-228.

3. Yamashita, T., Becker, B., and Johnston, G. : Histologie and clinical studies of glaucoma secondary to retained intraocular iron foreign body. Am. J. Ophth., 50:169, 1960.

4. Bäräny, E. H. : Physiologic and pharmacologie factors influencing the resistance to aqueous outflow. Tr. Glaucoma Symp., J. Macy Foundation Publication, 1955, pp. 123-221.

5. Speakman, J. S. : Glaucoma Research Conference. Am. J. Ophth., 55 :821-823, 1963. 6. Grant, W. M. : Experimental aqueous perfusion in enucleated human eyes. Arch. Ophth., 69 :783-801.

1963.

DIAGNOSIS AND SURGICAL MANAGEMENT OF VERTICALLY INCOMITANT HORIZONTAL STRABISMUS*

GUNTER K. VON NOORDEN, M.D., AND CLYDE L. OLSON, M.D. Baltimore, Maryland