1446 NOTES, CASES, INSTRUMENTS

I attribute the lack of infection at the hands of the older operators to the fact that they were careful not to touch the tips of their instruments, and that they used fewer instruments; consequently, each one could be laid back carefully, so that its tip was not touching anything that might cause contamination.

NOTES, CASES, VENOUS PULSATION AS A SYMP-

TOM OF EARLY GLAUCOMA*

SAMUEL ENGEL, M.D. San Francisco

The phenomenon of pulsation of the retinal vessels is usually looked upon as only a curiosity without much clinical significance. Arterial pulsation is present in glaucoma at a pressure of about 60 mm. Hg (Schijftz). The artery is com-pressed in diastole, while the vessel is still able to fill in systole, at which time the arterial pressure is slightly higher than the intraocular pressure. Among medical diseases, arterial pulsation is found in aortic insufficiency as a manifestation of the increased pulse-volume, and in Graves's disease.

Venous pulsation as a physiologic phenomenon can be seen in a considerable number of patients, particularly in chil-dren. It is due to the fact that the venous pressure is about equal to the intraocular pressure, and the increased filling of the choroidal arteries in systole raises the intraocular pressure just enough to com-press the vein, which dilates again in diastole. The appearance of venous pulsa-tion depends, therefore, on the intraoc-ular pressure and on pressure in the vein. In the majority of patients, it can be brought about by increasing the intraoc-

* From the Department of Ophthalmology, Stanford University Medical School.

As to Dr. Adler's remarks, I would say that I have read merely an abstract of my paper. In the complete paper, air sterilization by triethylene glycocoll and ultraviolet is discussed, and ways sug-gested in which they may be used with safety. Much has still to be done on that subject before the answer is known.

INSTRUMENTS ular pressure by pressing slightly on the eyeball. When the pressure is further in-creased, venous pulsation may be present even together with arterial pulsation.

Increased intracranial pressure, by compressing the vein in the subarachnoid space surrounding the optic nerve, causes stasis in the retinal veins and so raises the pressure in the veins. Absence of venous pulsation is, therefore, an early sign of papilledema. Manz (1874) and Laqueur (1877) observed that venous pulsation is usually lacking in "inflamma-tion of the meninges" with marked venous hyperemia of the retina (cited by Leber1). In neurologic patients suspected of cerebral disease, I am inclined to re-gard the presence of venous pulsation as a sign which makes increased intracranial tension highly improbable, a fact also stressed by Baurmann.2

While examining several patients for refraction or because of slight discom-fort, I was impressed to observe marked venous pulsation in one eye which was not, or only to a lesser degree, present in the other eye. The pulsation had a slightly different character from the type usually seen. It was more "jumpy;" the constriction was more marked; and the filling more rapid. When taking the ten-sion of such an eye, I found an increased intraocular pressure in many cases. Physiologic variations in the appearance of the venous pulsation were present, and

NOTES, CASES, INSTRUMENTS 1447

I did not find increased tension in all suspected cases. However, those which showed an increase in tension might have been overlooked if my attention had not been attracted by the pulse phenomenon.

CASE REPORTS

Short reports of three histories follow: Case 1. Dr. S. K. D., aged 60 years,

came to me in February, 1943, because he felt a slight pain in the right eye when coming from the light into the dark, also after lighting a match in the dark. Ex-amination showed vision to be: O.D., with a +1.25D. sph., 20/15; O.S., with a + 1.50D. sph., 20/25. The left eye had al-ways been the poorer eye. The pupil of the right eye was slightly larger than that of the left; the anterior chamber deep. There were two tiny precipitates on Descemet's membrane. The discs were normal, but showed a marked venous pul-sation, with the aforedescribed "jumping" characteristics in the right eye. There was a slight venous pulsation in the left eye. The intraocular pressure was 40 mm. Hg (Schi^tz) in the right eye; 20 mm. in the left.

A diagnosis of serous iridocyclitis, with increased intraocular pressure, was made, and the right eye treated with mild my-driatic drops. The tension dropped slowly to 23 mm., and the pulse phenomenon decreased in intensity until it was the same as in the left eye.

When the patient had a similar attack in October, 1943, the degree of venous pulsation made it possible to assume ap-proximately a rise or fall in tension, which was confirmed by the tonometer.

Case 2. Mr. A. W. E., aged 72 years, was seen in October, 1944, for refrac-tion. Examination disclosed vision to be: O.D., with a -1 .00D. sph. C 1-50D. cyl. ax. 15°, 20/40; O.S., with a 1.25D. cyl. ax. 165°, 20/15. (Vision in the right eye

had always been impaired.) The iris of the right eye showed a small peripheral coloboma at the 5-o'clock position and some fine posterior pigment synechiae. Gonioscopy revealed that a small tissue stump had been left peripheral to the coloboma and that there were anterior peripheral synechiae on both sides of the coloboma. As the patient had never had his eyes operated on, this condition was assumed to be a coloboma after early in-flammation of the iris.

The pupils reacted to light, although slightly irregularly in the right eye. The discs were normal. The vessels of the right eye showed slight bending, which could have been regarded as within phy-siologic limits. But the central vein of the right eye had a strongly accentuated pul-sation, whereas the pulsation in the left eye was just visible. The tonometer regis-tered a tension of 33 mm. Hg (Schip'tz) in the right eye; 23 mm., in the left.

Under treatment (2-percent solution of pilocarpine), the tension of the right eye dropped to normal, and the difference of pulsation between the two eyes disap-peared.

Case 3. Mr. W. L., aged 42 years, on a visit to California, came to see me in October, 1945. The day before he had had an attack of cloudiness over the right eye after an afternoon's exposure to sun-light. For the past year, he had experi-enced similar attacks, but of lesser degree, two or three times monthly. Ten years before, holelike changes of oval form in both maculas (from solar radiation?) had been observed. This had impaired his vision as follows: O.D., with a —4.00D. sph. C -0 .50D. cyl. ax. 90°, 20/25; O.S., with a -0 .50D. cyl. ax. 90°, 20/30.

The right eye, whose anterior chamber was deep, showed neither corneal edema nor precipitates. Both discs were normal. A venous pulsation, "jumpy" in char-

1448 NOTES, CASES, INSTRUMENTS

acter, corresponded to a tension of 42 mm. Hg (Schio'tz), which decreased to 26 mm. under pilocarpine treatment. Ten-sion in the left eye had always been normal.

On a search through the literature only one reference was found, that of Tron-coso, who mentioned, as an ophthalmo-scopic symptom of glaucoma, that: "the veins frequently show spontaneous pul-

CORNEAL INSULT FROM PODOPHYLLIN

ROBERT S. ROSNER, M.D. Cleveland

Ophthalmologists must constantly ad-vise doctors against treating skin condi-tions around the eye as they would else-where on the body. The following case points out that doctors have yet to learn this simple dictum.

A practitioner of medicine treated a pa-tient for "warts around the left eye" with a 25-percent solution of oleoresin po-dophyllin in mineral oil. He stated that this medication was used for the removal of warts in other regions of the body with good results.

REPORT OF A CASE

A white man aged 52 years, in good general health except for a rectal condi-tion for which he consulted his doctor, was advised by the same doctor to have some warts removed from the region of his left eye for cosmetic reasons. The patient was given a prescription for 25-percent oleoresin podophyllin in mineral

sation." It would, therefore, seem worth-while to draw attention to the fact that a difference of venous pulsation in the two eyes, particularly if "jumpy" in character, may be a sign of an early glaucoma that does not yet show marked clinical symp-toms and should induce the physician, if for no other reason, to test ocular ten-sion.

350 Post Street (8).

oil to be applied nightly with a glass rod to the affected parts. On January 27, 1946, the patient applied this medication to the areas as instructed. No ill effects resulted from the first application. The following night his son applied the medi-cine to the parts with a glass rod. The patient went to bed soon after, and, dur-ing the night, his nose "ran like water," and his left eye smarted and itched. He said that he had not been conscious of any seepage of the medication into the eye but felt that this must have occurred while he slept. Twice during that night he awak-ened because of some discomfort around the left eye. The next morning the left eye was "all red and puffed up." Some discomfort was present, but no severe pain. He was able to stay on his job by squinting and keeping the left eye closed. When the eye was opened, he felt some pain. He consulted the practitioner on January 29th, because the pain grew pro-gressively worse. An analgesic ointment was instilled, and the eye bandaged. The doctor instilled more ointment on the fol-lowing morning. The patient then became aware that vision in the involved eye was

REFERENCES

* Leber, Th. Die Zirkulations- und Ernaehrungsverhaeltnisse des Auges. Leipzig, 1903. ' Baurtnann, M. Ueber die Entstehung und klinische Bedeutung des Netzhautvenenpulses.

Deutsche Ophth. Gesell., 1925, p. 53. 1 Troncoso, M. U. Internal diseases of the eye. Philadelphia, 1942, p. 252.