PREFACE Crile General Hospital feels honored in having been act as host to the recent Military Ophthalmological Meeting on 26, 29 and 30 November 19450 The Ophthalmological Staff of Crile General Hospital wishes to thank Col0 Gouverneur Vo Emerson, Commanding Officer, Crile General Hospital, and Col0 Clifford VQ Morgan, Executive Officer, Crile General Hospital, for their invaluable assistance in making this meeting a success and the publication of this volume possible0 Most grateful appreciation is also extended to Lt0 Col0 Mo E, Randolph and Lto Colo Trygve Gunderson, the Ophthalmological Consultants for the Surgeon General’s Office, Washington, D0C0, and to Lto Colo Ro Po McDonald, Executive Medical Service Branch, Air Surgeon’s Office, Professional Division,.Washington, D0C0, and to Lto Col0 NornaaDo Hall, Chief.of the Surgical Service, Crile General Hospital, for their many services, enthusiasm and unlimited cooperation during the preliminary and active phases of this prograir.o GILBERT Cc STRQBLE, Lt„ Colo, MoC0, Chief, Eye Surgical Center, Crile General Hospital, Cleveland 9, 0hioo TABLE OF CONTENTS Page Wednesday Morning Session November 28, 1945 Welcome Colo Go Vo Emerson » . o • . • , . . . . « , , . . . 1 Lt o Colo N o Do Ra11 00,00.0000,000000 1 Symposium on Orbital Reconstruction "The Use of Tantalum and The Ruedemann Eye Implant in Orbital Reconstruction" Lto Col, Gilbert C, Struble , , » , e <> , • , „ 2./ "The Use of Orbital Tracings as an Aid in Recon- structive Surgery of the Orbit" Lto Colo Ec Lo Shiflett « e « . , . , o , . , e 5 Discussion on the Use of Tantalum and the Implant Eye in Orbital Reconstruction Dr o iio Do Ruedemann « . 0 , , . . . , « • . • . 8 "The Processing of the Ruedemann Implant Eye" Capto James Clifford, D,C, „ , , , , « » o . « . 12 Discussion , , « o , o «, , , « , o » , • , » , 13 Wednesday Afternoon Session November 28, 1945 "The New Orbital Implant" Lto Col, N0 L, Cutler . . • * . . . , • . . • . . 17 "Orbital and Ocular Injuries Produced by Modern War Missiles" Major A© I o Kref t 0000,00000,00,0 13 "The Use of Dermal Instead of Fat Implant in Deep Sockets" Major G0 L, Witter . . , . . • * . . « • . . « 20 Discussion . . . • , . • . . . . . . « • . • . 21 Page 'Wednesday afternoon Session (continued) "Elevation of Orbital Contents with Plastic Plates" Capto Bo F0 Souders , * « . . . . . . . , . . « o 28 Discussion 0 • . . . • . . . « . • . . . . . c • . 31 "The Use of Fascia Lata in Retro-tarsal Atrophy Following Enucleation" Major Go L0 Witter » . . . . • . . . . . . . « 0 36 Discussion , , , . , 0 . . . . . . . . . . . . , . 39 "TheEvaluation of Recent Ophthalmic Concepts as Related to the Fabrication of Plastic Artificial Eyes and Implant Devices" Major Victor Ho Deitz 0 <> • • . . 0 • . . « 0 e 43 Discussion 0 0 0 » 0 » « 0 » » » » « 0 0 o » « 0 o 48 Thursday Morning Session November 29, 1945 "Rehabilitation of the Blind" Lto Colo Mo £o Randolph 0 . . . . . . . . . . e 0 49 Discussion 0 0 o . . . . . » . . . . „ . . . . . 0 52 "The Vossious Ring Phenomena" Major Trygve Gunderson . . * « . « o , e . • o o 52 DiSCUSSiOn ooooooo o o ooooooooooo 56 "End Results in the Treatment of Retinal Detachment at Crile General Hospital" Major L0 J» Groll » » • • . . « . . • • . . . . 0 56 DISCUSSlOn OOOOO o 0 ooooooo o o o o o o 61 "Visual Disturbances Associated with Head Injuries" Capt o John Sc McGavic 0 <> • . . . • . . • « . . 0 66 Discussion . , „ . . • . * . . . . . • • . . . 0 . 72 Page Thursday Afternoon Session November 29, 1945 "Testing of Night Vision" Lt. Col. P, H. McDonald . 74 The Etiology and Treatment of Blepharitis - A Study in Military Personnel" Lt. Col. Phillips Thygeson 80 Discussion 95 "Dendritic Keratitis" Major J. H. Allen 99 Discussion 102 "Ocular Muscle Balance in Flying Personnel" Capt. Richard G. Scobee 105 "The Development of Goggles" Lt. Col. John L. Matthews 106 Remarks by Major W, P. Chamberlain ......... Ill "Ocular Changes in Scrub Typhus" Major H. G. Scheie ................ 112 Discussion ......... ....... 112 Friday Morning Session November 50, 1945 "Correction of Large Notching Defect of Upper Lid" Lt. Col. N, L. Cutler . 117 "Repair of Lid Margin Deformities" Lt, Col. So A. Fox o 119 "Choice of Procedure in Ophthalmic Plastic Surgery" Gapto A, E. Sherman 121 IV Page. Friday Morning Session (continued) "Ophthalmic Plastic Surgery" Capt o Alston Callahan c • . • . . > » • • • « « 123 Discussion « • • • » • * » • » . . . . . . • 1126 Friday Afternoon Session November 30, 1945 "Transplantation of Vitreous” Lto Colo No L0 Cutler e . » » » » o » o » o . » 134 Discussion » » o . » 0 „ » . » » e » <> » ° » 145 "An Alternate Method of Eyelash Transplant" Major George A0 Filmer 0 0 » <>. 0 « » o 0 „ <. o 147 "Myositis of Extra-ocular Muscles Causing Unilateral Exophthalmos" Major George A0 Filmer 6 « <> » . . o c <. . . . 148 "Relaxation Deformities of the Eyelids and Socket Following Enucleation" Major George A. Filmer 0 <> » o o o „ 0 o o „ -> 152 Symposium on Intra-ocular Foreign Bodies "Removal of Intra-ocular Foreign Bodies" Lto Colo M, Ho Riwchun 0 ■> <> 0 c « » o o <. o o 154 "Oxygen Injection of Tenon’s Capsule as an Aid in Localization of Intra-ocular Metallic Foreign Bodies" Major Ho Go Scheie „ » * o <> o « o » » o 0 0 o 156 "The Use of the Berman Locator in The Evaluation of Intra-ocular Foreign Bodies" Major Albert Abbott 00oooooooooo 156 Page Friday Afternoon Session (continued) "Technical Refinements in the Removal of Magnetic Intra-ocular Foreign Bodies from the Posterior Segment of the Eye" Lto Colo Gilbert Ce Struble . . , 0 . . . 0 0 « 164 Discussion <. 0 • • o e . . . » » » . • * „ , 164 WEDNESDAY MORNING SESSION November 28, 1945 The first session of the Military Ophthalmologies! Meeting convened at the Crile General Hospital, Cleveland, Ohio, at nine~ten o’clock, Lto Cole Gilbert G0 Struble, Chief, Eye Surgical Center, Crile General Hospital, presidingc CHAIRMAN STRUBLE; The meeting wil] come to order Gentlemen; I should like to introduce Colonel Go Vo Emerson, the Commanding Officer of Crile General Hospital, who will, speak to us at this time0 Colonel Emerson^ COLo Go Vo EMERSON; Colonel Struble, Members of the Staff and Visitors; I just want to take a brief amount of time to extend greet- ings and hearty welcome to the visitors at this meetingo We feel very fortunate that you have selected Crile for this important conference and a very fine program has been preparedo I feel that it will be an important contribution to the work done on surgery of the eye and it will be a valuable addition to the history of the Medical Department when this session has been compiledo We trust that your stay here will be pleasant and that we will have the pleasure of meeting all of you individually as time goes on„ CHAIRMAN STRUBLE; Thank you, Colonel Emerson At this time, gentlemen, I should like to introduce Lt„ Col0 No Do Hall, Chief of the Surgical Service, who has been instrumental in assisting us in many ways in making this meeting possible„ Colonel Hall£ (Applause) LTo COLo No Do HaLL; On behalf of the Surgical Service, I wish to extend a sincere and hearty welcome to all of you0 We at Crile feel honored that this meeting is being held here and we are proud of our Eye Section0 With such an illustrious group gathered and so much talent, I know that your meeting is going to be most interestingo If there is anything that we can do to make your stay here more pleasant, we shall bo glad to do it 0 ooo Announcements o0O CHAIRMAN STRUBLE; I think it would be more interesting if we have a different chairman presiding at each session, and with your permission, gentlemen, I should like to name Colonel Cutler the chairman for the afternoon; Colonel Randolph for tomorrow morning’s session; Colonel McDonald for the afternoon session tomorrow; Colonel Fox for Friday morning; and Colonel Burch for the afternoon session on Fridaye ooo Introduction of members present 0o0 ooo Colonel Struble then read his prepared paper on "The Use of Tantalum and The Ruedemann Eye Implant in Orbital Reconstruction with Presentation of Cases,," In June of this year, Colonel Derrick T<, Vail, the Ophthalniological Consultant for the Surgeon General3s Off ice, became interested in the Ruedemann type eye implant, particularly for the correction of severe orbital injuries0 He named Dr. Ruedemann as the civilian eye consultant in this Eye Surgical Center to assist in this worko Dr0 Ruedemann has donated a great deal of his own time, as a matter of fact approximately one day each week, for the past two months0 He has furnished all the tantalum used and is responsible for the development of the tantalum mesh, paddles, sutures, wool and of the implant eye. We wish to give Dr, Ruedemann the entire credit for this development and to thank him for his excellent cooperation and for the many courtesies he has extended this departmento The implant eyes used by us have been developed from models worked out and perfected by Drc Ruedemann who will later discuss this matter personallyo Our eyes have been processed by Captain James Clifford, Chief of our Acrylic Eye Department, who will demonstrate the technique to those of you who are interested0 It was apparent at once that many problems confronted us in this work, which were not present in civilian patients., The chief of these factors was some way by which we could previously determine orbital measurements and orbital volume in those cases requiring correction,, This fact was brought home to us early in those first cases where an implant eye was placed in the usual manner. In a few of these cases, the implant globe dropped down and back and almost disappeared except for the visible anterior segment„ On two occasions in which a glass ball implant had been previously placed in tenon0s capsule with little or no benefit - later X-ray studies showed these implants to have dropped below the level of the orbital floor and to be lying in the maxillary sinus and pterygoid fossa,, This problem was discussed with Lt a Colo Emory Lo Shiflett, Chief of the X-ray Service here. Colo Shiflett has developed a method of orbital tracings and measurements so that it is now possible to tell in advance exactly how much increase in the orbital diameter in any meridian is present0 These tracings are now performed routinely on every patient prior to operation and we feel we are now in position to approach these cases surgically with confidence0 The value of these tracings and measurements was particularly brought out in one case which to superficial examination appeared idealy suited to this procedure,, Colo Shiflett, however, demonstrated to us that, owing to a complete loss of the posterior orbit and of a part of the squamous portion of the temporal bone, brain tissue was lying directly under the conjunctiva,, Obviously, operation in this case would have been disastrous Colo Shiflett will discuss this work later in the program0 I wish to take this opportunity of thanking him for his splendid cooperation in this and other work associated with our department, and to state that without his cooperation, this work could not have been developedo 2 At first , ¥1/ 0 believsd it might be possible to adjust for the increased or decreased orbital volume by using a larger or smaller sized implant eye( In two cases, an eye 27 mm., long was used to correct a severe depressed deformity0 In both instances, the eye appeared proptosed after operation. In another instance9 where it appeared a shallow eye was necessary, an eye 22 mm- deep was used, and we ended up with an enophthalmos„ It appears, at the present time, that with few exceptions, a standard eye 24 mm0 in diameter and 24 mnu long, slightly tapered posteriorly and beveled at the upper and lovjer margins is probably the correct size0 In cases where a mistake has been made in the size of the eye used, it is a relatively simple matter to remove this globe and to insert another of the proper sizec The appearance of the socket dur- ing the exchange of eyes proved very interesting to us* The inside of tenon0s capsule, in which the globe rests, becomes smoothly lined with what appears to be pseudo-mucous membrane throughout its entirety Dr0 Ruedemann has previously called attention to this fact and on microscopic section has demonstrated this lining to consist of endo thellal cellso It was the suggestion of Dro Ruedemann that the element tanta lum be used to make up the difference in volume where the orbital diameter was increased and to thus elevate the implant eye to its normal position and relationship with the other eye0 In our early series, we used tantalum wool for this purposee At the present time, we are using tantalum mesh which we feel is even more satisfactory This preparation developed by Johnson and Johnson to Drc Ruedemann0s specifications, lends itself extremely well to this worko Strips of this metal mesh can be cut to any desired size at the time of surgery, rolled up and placed in the floor or lateral aspect of the orbit to bridge over and correct any defects present0 These materials in our expedience have been extremely well tolerated„ In many instances, the post operative reaction, where tantalum packing has been utilized, has been less than that following sane ordinary enucleationso Many of these eyes require adjustment after insertion In fact, I would say it is the rule rather than the exception0 For this reason, we have developed implant eyes with two paddle holes, one in front of the other, to facilitate the advancement or recession of any of the four rectus muscle slips should this be required0 This is a very minor surgical procedure which can be performed under local anesthesiao We feel this is a worthwhile procedure in those cases of moder- ate to severe orbital deformity for the following reasons;: L It is a procedure strictly for the ophthalmologist0 2o It can be used in cases of contracted sockets where there is a deficiency of conjunctiva and thus save the patient the necessity for extensive mucous membrane grafts to the socket0 A conjunctival lining of the upper and lower lids is still necessary and there must also be sufficient conjunctiva in addition to be pulled over the ends of the muscle insertions to prevent exposure of the external and internal paddles. 3o Good movement of the prosthesis is possible if the muscle has not been too severely traumatized or the nerve innervation destroyedo 4o Secretion and discharge is reduced and may be definitely less marked than in those cases where the ordinary glass or acrylic prosthesis is wom0 I am unable to definitely explain this but it may be a result of the fact that there is no dead space between the prosthesis and the conjunctiva to collect secretions and possibly because the prosthesis does not move or rotate around in the socket and, thereby, produce irritation and drain ageQ 50 Sagging of the lower lid and the depressed sulcus of the upper lid is greatly diminished or preventing entirely by restoration of the normal orbital volume3 In our present series of approximately 20 cases, all except one have been performed on sockets in which the eye had been enucleated or eviscer- ated previously.. In most instances* many months had elapsed since the original enucleation„ In those cases where a stump of eyeball remained* it was* of course* removed both as a safety factor and to facilitate the insertion of the implant eye,, In our early series* we performed these operations under pentothal anesthesiac We now feel this is unwise and that intratracheal ether is the anesthesis of choice„ Most of these cases have fractures through the floor of the orbit and* during the orbital reconstruction* the leakage of blood into the antrum* nose .and larynx* is apt to produce a severe laryngo- spasm if pentothal is used. We are applying a snug pressure dressing for about ten days after the operation,, These patients have all received 200*000 units of penicillin in divided doses each 24 hours by intra-muscular injection for a period of from three to seven days depending upon the post- operation react iono Up to the present time* we have found three cases out of 22 who do not tolerate the acrylic implant eye. In these three instances* the implant eye was extruded after various periods of time up to three months* In such a case* it is a very simple procedure to remove the implant eye and immediately fit the patient with a standard reform eye* If desired* Tenon’s capsule can be reopened and a glassball implant placed in the usual manner* 4 Some deficiency of conjunctiva may be noted in such a case due to absorption or atrophy of the margins of the conjunctiva around the implant o If the pseudo-mucosa, which foms around the implant, is utilized, adequate space is present in the socket for the placing of a standard refrom eye in these cases„ If the conjunctiva is again approximated, some traction on the upper and lower cul de sacs may be expected and a mucous membrane graft may be required to restore the size of the socket before a standard prosthesis can be worn* 14 January 1946* Since the above report was submitted, 6 more of the implant eyes have been removed because of extrusion or because of increasing general irritation due to sensitivity to the acrylic eye Because of this high incidence of irritation to the acrylic implant, the author believes that this procedure should be limited only to those cases where other standard procedures have failedo Dr* Ruedemann, in a personal communication on this subject two days ago, informs the author that since he has been covering the posterior portion of the implant eye with tantalum mesh, he has, in large part, avoided these complications0 ooo Lto Colo E, L Shiflott, Chief, Department of Radiology, Crile General Hospital, presented a paper on "The Use of Orbital Tracings as an Aid in Reconstructive Surgery of the Orbit/’ as follows I We have a number of patients with badly comminuted fractures of the orbital and facial bones who are undergoing reconstructive surgery of the orbit and being fitted with the implant eye0 Successful reconstructive surgery and proper fitting of the implant eye depend to a large extent upon restoration of the orbit, either by replacement of fragments, removal of fragments, or sub - stituting tissue or material for lost bone tissue0 The correct total diagnosis of bony deformities is shared by the radiologist and often is dependent upon him almost entirely* The surgeon is often handicapped in the operating room by having only flat X-ray films on a view box available for reference* These are inadequate to guide him unless he has a clear and fixed mental impression of the deformities from previous stereoscopic studies of these films0 There are also individuals who suffer ex- tensive damage to the internal orbit from high explosive fragments without evidence of fracture of the external orbital wall* Unless this is appreciated and all cases X-rayed pre-operatively to deter- mine the presence or absence of this damage, the proper fitting of a prosthesis is probably doomed to failure, because of increased orbital volume* Colo Struble stated some of these difficulties to the Radiologi- cal service and asked if there was any way by which the total extent of damage to the orbit might be portrayed in the interest of better reconstruction and a more adequate fitting of the implant eyc0 We considered many ways of attempting this and finally chose the simplest way which suggested a practical and workable solution to the problem,, and began orbital tracingss and were surprised and pleased with the efficiency and workable accuracy of such a simple procedure0 Stereoscopic postero-anterior films in chin-nose position,, the nose and chin resting heavily on filmc and steroscopic lateral*,, injured side down,, are made , Films are processed in the usual way« They are studied stereoscopicaily and pseudo-scopically and under stereoscopic vision the normal and abnormal bone structure is traced on the film with an indelible pencil„ using the normal orbit as a guide0 After all fractures are identified;, defects in orbit created by the fractures noted and traced on the film, the right sided film as the individual faces the stereoscope if the left- sided film if left-handed„ the film with tracing is removed and placed upon an ordinary view box0 Upon this is superimposed a piece of clear transparent paper,, and the tracing is recopied on the papero We find architectural blue print tracing paper the best because of its great transparency and durability. This may be done with pencil or inkc. We find the ordinary tracing pen and India ink quite satisfactoryo Enough of the face is included to permit the appreciation of facial symmetry or asymmetry, The vertical and horizontal meridians of the normal orbit are measured and noted and compared with increased or decreased dimensions of the involved orbit„ The combined anteroposterior and lateral tracings convey to the surgeon the three dimensional defects which can be appreciated by verbal consultation or by a short descrip' ■ tive reporto The graphic and written report are sent combinedo It can then be taken to surgery for refresher reference at any time needed0 After reconstructive surgery, the procedure is again performed without reference to the pre operative tracing for checking of accuracyu It i»0 indeed,, gratifying how nearly the two tracings duplicate each other,, which speaks well for its accuracy and for accuracy of evaluation of the injured orbit by the radiologist0 It might be said that the radiologist benefits from this procedure for it demands accurate study9 and probably results in a more accurate report than the written description of findings. In complicated frac- tures,, it is sometimes necessary to make the original film tracing with different colored pencils to indicate the different depthsP planes and relationships of fragments0 Colo Struble also mentioned that in some individuals difficulty was encountered in fitting the superior paddle by reason of impinge- ment of paddle and prosthesis against the superior orbital wallo We undertook a study of the orbit in the lateral planes in an effort to determine if possible the cause of this difficuly. Fifty unselected cases on which Sweet localizations had been done were used for this investigationo The globe was reconstructed in the orbit by using the 6 horizontal plane of the cornea and the anterior position of the cornea as fixed planes, as established by the first Sweet exposure of the localizing film in which ball and cone are superimposed0 a sphere with 25 mmo diameter is constructed, so that the anterior surface is exactly 10 mm0 from the ball and the diameter corresponds to the projected horizontal plane , as established by the Sweet apparatus,, All other planes in reference to facial and orbital physicgomy are construed from the horizontal axis of the globe0 We feel that this establishes a workable accurate relationship of globe to orbit and bones of the face which enter into surgical relationship to orbital reconstruction., We have founds so far, that orbits fall into three typess One the anoph> thalmic eye in which the vertical plane of the summit of the cornea lies well posterior to the orbital floors and constitutes 42$; the exophthalmic type in which the summit of the cornea lies on an average of 4 mm, to the anterior surface of the orbital floors constituting 22$; and a third type in which the summit and anterior margin of orbital floor are flush, a type we have not so far designated. The types are definite, unmistakable and subject to wide variables. The anophthalmic eye is subject to the largest variables of its orbit and appears to be placed in the largest orbits. The supra-’global space, that is the distance from the crest of the globe to the roof of the orbit, in the averages, vary little, but this space in the anophthal- mia eye varies from 2,5-12,5 mra,8 while that in the other types is considerably less, being 4 and 5 mm. It might be that the clinical application of these criterea might prove of value if used cons is tently pre-operatively in all cases. The study emphasizes to us that, although there may be averages of the orbit, the variable in individ- uals is great and the only approximate normal is the opposite orbit0 These studies also suggest to us that a defect in the orbital floor2 irregardless of location, will affect the position of the globe or an implant by reason of periglobal tissue prolapsing through defect and pulling globe with it. thus disturbing the planes of the globe or implant. We do not claim the accuracy of this as axiomatic. We do feel, however, that this gives sufficient accuracy to be used as a surgical guide. We do not offer these findings as definite opinions, but wish to point out that definite possibilities of importance to the reconstructive surgeon are promised. These studies are simple to perform, require little extra time, and can be performed by any radiologist and, given the films, by the surgeon himself. We now show you one of the tracings, and since they will be shown with each case this morning, you can determine whether or not they will be of value to you. The other study is demonstrated in the exhibit booth. Time does not allow for further description. ooo Presentation of cases by Ltc Col0 and Lt„ .Col Shiflett ooo 7 DISCUSSION ON THE USE OF TANTALUM AND THE IMPLnNT EYE IN ORBITAL RECONSTRUCTION DRo A. Do RUEDEMANN (Chief„ Department of Ophthalmology's, Cleveland Clinic Hospital and Civilian Eye Consultant;, Grile General Hospital)? I would like to make a few remarks in regard to the development of this acrylic eye0 In the first place„ I am like a hen with a bunch of ducklings0 These ducklings have gotten away from mep In that they have marched out from under me here*, and Shiflett with his tracings of these orbits,, and Struble and Scheie and Croll and the rest of them used to take me for a ride out here0 I was glad to get out from under themQ The first day I would come out,, I would work on the first patient,, and that always would be the worst oneD Then we re-arranged it„ I thought I would take the second patient,, and then that was the worst one0 I found out they had a system with the anesthetists8 where it wasnH always the same patient on schedule0 We started with this acrylic eye some two years agoQ We got a lot of industrial work in which the eyes and orbits were burned out by acid and alkalis and by hot metals» In attempting to reconstruct these with mucous membrane grafts and skin& one finds that they are most unsatisfactoryo I started by using acrylic implants with tissue over them and putting them in the orbit, and leaving them in there as long as we couldo Sometimes we would leave them in for a period of threep four or five weeks0 We found that most orbits tolerated acrylics0 That is not true of every orbit0 Acrylics are all plastics of the same typec. They now have some two thousand formulas for plastic material0 One hardly knows which of these formulas one is getting in the eyes at the present time0 As a matter of fact„ in the eyes that they are making for us D they now use four different types of plastic in one eyeD So you see if you say9 "Well,, you must neutralize the substance of which this plastic is mades" you may be leading yourself astrayo The truth of the matter is that 80 per cent of the orbits will tolerate plastic„ and another 10 per cent will tolerate the plastic if it is boiled a long while,, as Captain Clifford is doing here0 A dental surgeon told me that when he was making plastic teeths he soaked all his teeth in vinegar for 48 hours0 Since we have used this maneuver,, we have had no acrylics that were intolerable0 I donct believe that is going to be 100 per cent true,, hovfevero We might as well face the issue that all people will not tolerate acrylic implants,, nor will they all tolerate reformed eyes made out of plastics nor do all people tolerate glass eyes0 So you are not going to get 100 per cent results on this or any other method0 8 I am sure that this is not the final story in the business of putting in acrylic prosthesesc I think we are going to get a better way out of this and that we will get better results„ After all, we have only been doing it for two years» If you talked about putting these things in permanently, you probably would run into some difficulty- later on by slow extrusion from the socket perhaps0 If one takes this business of orbital prostheses and divides it into three parts, one finds that in the first group are the simple enucleation group, and I have a movie on that, so I won®t talk about ito The second group is of those with the reform eye where they lose acuity, by virtue of the fact that the upper lid is constantly press- ing down on the reform eye, and presses the lid out0 You can go into these sockets and pick them up, take tenon®s capsule, and by opening up, make four muscle slits, and plant one of these implant eyes inside tenon®s capsule„ You require very little muscle to get good muscle movemento As a matter of fact, if the patient moves about ten degrees with the other eye, directly with the other eye, not lagging, it will require very little more movement to get the entire appearanceQ You must remember, when you are doing orbital plastic work, that the result that you desire is not always the result that the patient desireso You may not be satisfied with ito It is sometimes advis~ able not to talk too much in front of the patient about how that eye lookso It is not always wise to say to your associate, "It looks like hell to me/1 because it may look perfectly all right to the individual who has to have ito I have a case in point of a chap who had his orbit burned out with hot metalo We planted an implant eye in there and it did not looksatisfactorily to me„ I wouldn°t have it around for ten minutes, but I tried to talk him into another operation and he said, "What®s the matter with it? Aren®t you satisfied with it?" Of course, I had to back out very fast, because we were having a terrible Job to get the thing in, in the first place, and to get it to stay in, in the second place0 So with prostheses you have to be ready to let the patient set the standard by which you are going to goc Often monkeying with them and trying to make yourself satisfied with them will spoil your end result0 The third group is the group Colonel Struble showed here this morning => those in which you have orbital de struct ion 0 If you remember your cases of exophthalmos, enophthalmos is exactly the opposite0 In exophthalmos, only two things can happen to the orbit, diminution in the orb it®s size or increase in orbit volumeo There are no muscles or tissues in the orbit that push the eye ups back or down , If you have diminution in size or increase in volumea you have exophthalmos. The eye has no place else to move but forward. In enophthalmos,, you have just the opposite You have increase in size of the orbit or diminution in orbital volume or orbital tissues and then you get enophthalmos. In this last group, we had enophthalmos or we had an increase in orbital volume by virtue of both loss of tissue and increase in orbital size0 If you remember back, in all your cases9 we have tried to replace orbital volume You cannot replace orbital volume just by merely replacing the volume in the eyeball itself„ We have tried thato 1 have with me three different sizes of eyes that we have evolvedo If you want to do an orbital implant on someone who had his eye taken out as a youngster,, then you must use an eye that is smaller than the opposite eye, or they will not match up. The orbit is definitely smallo That is where Colonel Shiflett°s work has come in so prominently for mes in that we did not realize in our simple enucleations or simple replacement of the eye,, that the orbital volume may be definitely smaller by virtue of the fact that the individual had the eye removed earlier in life0 We have a case in point out there now. where we had to go back and definitely put in a smaller eye0 In regard to the eyeball shifting I feel that most of our shifts are due to the fact that the orbit is beginning to diminish in size0 It may be advisable that we review this group0 We are now trying to place a tantalum sleeve or tantalum covering on the back of our implants in order to allow the tissue to grow to the implant and hold the implant in place without the use of tantalum paddles^ This is another change in the process, but I think for the type of eye that we are showing here this morning, the tantalum plates with the tantalum wire and the tantalum mesh make the best procedure0 It is not possible that all of us have these patients and all of them get good results, They are difficult to do a Colonel St ruble did not tell you this.. They are difficult to do.. They require a tre - mendous amount of patience and a lot of study beforehand0 If I may suggest one thing, it Is that you get rid of your remorse by knowing what you are doing before you do them5 because they are a terrible headache afterwards if the eye is out of place or if you have to go back in the socket th-o second time0 1 can assure you that I have spent hours and hours*, both here and at home y trying to put these eyes where they belongs and I for one am not satisfied that this is the final story in these acrylic implants0 I think that we can do a better jobc, and I am sure that out of a meeting like this all of us will learn a great deal*, and I may find out that we are entirely wrong0 Dr0 Ruedemann passed out samples of tantalum mesh and acrylic eyes ooo A motion picture on Operative Technique was shown, and the following are a few of the comments made by Drc Ruedemann during the showings I have a couple of little stunts0 One that I don°t know where I picked up, is to buttonhole the conjunctiva and then with an old Stilling knife go around and cut the conjunctiva, then put a pinchers clamp on and again, with the Stilling knife, cut off the muscles, because you get a much better cut with the Stilling knife0 Now, these muscle plates are attached by merely sewing through and through to the under side of the musclea The wires are attached to the muscle plates, first, before operation; and merely by going through the muscle and out, one attaches the muscle plate to the under side of the muscle, gaging it so that the anterior portion of the plate will be covered by part of the pendulum0 The last stitch that goes through is locked0 We have changed this technique so many times that the artist has refused to make any changes until we are finally settled on one methodo You will notice that this will be locked„ I don°t know why, except that it keeps the wire fastened0 This wire is hard to handleQ It is very brittle, but once it is put in, you can depend on its staying theree You must bury the endSo The ends are sharp and have sharp pointsQ The original cords were put on to hold the eyeQ After the plate is attached, the paddle tip is turned over and put into the paddle hole, and then the wires are passed through the holes that are made in the acrylic eye„ If you work with tantalum wire, you will find that you have to tie it close to the knoto The wires will break off as they did four or five times yesterday0 Then you braid the wire and with the braided edge, you turn the braided end down into the hole0 You bring tenon0s capsule over, and then you bring the conjunctiva over tenon0sD It isn°t always possible to bring tenon0s capsule up over the muscleo It isn°t so easy to dissect it outo There is one thing to remember, the more dissection you do with tenon0s capsule, the more likely you are to get poor balance of the levator muscle„ We do very little dissection0 Interestingly enough, we found out from this procedure that the levator muscle actually is a muscle that is divided into three planeso One plane goes on to the eyeball„ One plane goes to the tarsal cartilage, with its superior aspect, and one plane goes to the skiEo If you approach the levator by going to the outside, you may only get the levator fibers going to the skinQ You must approach the levator muscle by going through from underneath„ If you do a recession of the levator in the case of exophthalmos, we have found out you have to go to the eye fibers in order to get a decent reeession0 Otherwise, the lid wom°t come down0 Art Coller has bee®, working on the same prosthesis in the Navy and insists that the oblique should be attaehedo I cam tell you it is a terrible jobp in the first place0 to put the attachments on0 and in the second place9 we had most of our trouble in those cases in which we did the obliqueso To come back and pick them up is not easy, After aUp the thing is enough of a headache without building up any more worries0 We can now build a tantalum mesh and put it on these plastic eyes and sew the muscle directly to the tantalum mesh, X think that procedure will eliminate the paddles eventually and allow for better placing of the muscles on the acrylic eyeG It will eliminate about 10 or 15 per cent that are now sensitive to the acrylic0 I am not sure that soaking them in vinegar is going to be the answer9 and I am trying to figure out in advance what is going to happen to it. As I said beforep these eyes are not 100 per cent satisfactory0 We have now a little over 100 of them put in the socketsp and only seven of them have had to be kept out permanently0 Of those sevenp two were in recurrence of orbital tumors0 I thinkp perhapsp in our ©nthusiasm2 we put one in9 ia one case where we should not havec In the other easep we went into an eye that had been enucleated seven years beforep a very disagreeable looking socket0 We went into that socketp opened it upp and put one of our implants in0 A short while afterward„ in a period of a monthp the ey© was being extruded and h© had a recurrence of his tumoro I would not be a bit surprised if we stimulated a re- growth by going in there and putting the implant ln0 If I may say just a few words in regard to this againp first„ I think that the problem of their staying in the orbit is more or less solved. They will stay in0 The positioning of then I think is not going to be as serious,, because you must correct it0 at presentp before you put your acrylic eye inp especiallyp if you have a divergent eye. I think that when the people from the Army release their eyes to the civiliansp the eyes will be better than the ones that we are dealing with. They will look better and probably \«onct fade as mueho We are just now getting over our difficulty with fading, (Applause) o,o The paper by Captain James Cliffordp D,C0p Chief„ Acrylic Eye Laboratoryp Crile General Hospital, on "The Processing of the Ruedemann Implant Eye" was not reads but Captain Clifford explained his display ,oo The display depicts the procedure employed in the complete fabri- cation of the Ruedemann Implant Eyep Beginning with the processed iris buttonp followed by the wax model with the button attaehedo The most commonly used mold 24x24 mm0 made by investing the wax model in stone and coating the same with tin -foil is the next step displayedo The processed sclera and body of the ©ye. Including the iris buttonp or the rough ey©9 is next displayedo The following steps carry up to the finished eye9 excluding the attachment receptacles? Velning with rayon fibres9 modifying colors using 10jo monopoly solution of different colorsn and9 lastly9 the conjunctiva coat which is a clear layer of plastic mm0 in thick- ness processed over the entire cornea and sclerao The highly-polished9 completed ey©9 including the tantalum paddle receptacless is the last step of the display0 The large eyes on display are used for display purpose only0 All other eyes are practicalo DISCUSSION LTo COLo No ho CUTLER (Dibble General Hospital)5 I noticed that the implant that was sent around here had two different curvatures on the spheral surface„ I was wondering whether you approximate the spheral curve to the approximate diameter of the eye on the other sidec Also9 I want to ask if the amount of movement in these eyes has been measured in degrees to give us an idea of how the results are running0 About how many of these patients have to have some secondary procedure doneQ They do oft the badly deformed socket9 but on the normal enucleations9 do you have to go in to change either the position of the eye vertically or horizontally or anteropostertally? DRo RUEDEMANNs We get on the average 20 degrees movement nasally and about 25 to 30 degrees temporally0 Superiorlyp we hardly ever get more than 15 degrees9 and inferiority 9 it doosn°t make any difference0 It runs about 10 or 12 degrees by actual measurement 0 As I said if the initial movement is made at the same time with the ether eye9 with the reform eya9 the initial movement has a tendency to lag, and it is that lagging that gives the appearance of staringo If the initial movement is initiated at the same time0 it doesn°t take as much movement as it would with a reform where the eye doesn°t approach the same position It is the lateral move- ment that counts mostly0 The rest of the movement9 the movement up and downf) is covered by the lids very materially9 so you don°t notice that much9 but the movement to the siden into the extreme outside,, is the most important and movement less than 20 degrees is very noticeable0 The eye has to move better than 20 degrees in order to get an appearance like the other ona0 13 Surprisingly enough9 you can go back into these old sockets and pick up old muscle stumps and attach the acrylic eye to those old muscle stumps and get nearly as good movement as you do in the primary enucleation0 It doesnH change that story a great dealo I meant to say one other thing but I forgot it0 That was on the conjunctivao Remember just one thing about the and that is that it is no goodo Don°t depend on it for anything0 It won°t stay in positiono It is the mucous membrane that cannot be used9 and if you try to cover plastic eyes with it or try to cover metal with it0 or any- thing else9 it is sure to wear away very quickly and be of no value to youo So you must plan in all of these operationsB as far as the con- junctiva is concernedD to exclude it and do without it as far as possible0 We had in our original plastic eyes the conjunctiva attached by a purse string around the cornea9 and I frankly say that the first eye we put in is still in and looks all right„ but the second and third one did not look all right because the conjunctiva pulled away from the cornea„ and with the sensitivity apparently of the conjunctiva to the acrylicD it pulled away so far that you can see the holes that we put in to attach the conjunctiva to the ey®0 So you should not depend on itp as these eyes are all mad© with an acrylic front0 We could not use them if they were shaped exactly like the eye with the conjunctiva pulled over them0 The other question was as to how often it uas necessary to make secondary changes We never did any experimental work by planting these eyes in animals0 We started planting them right in humans from the start o Our total number of changes would amount to 30 per cent of the patients in our series of 1C1 people0 Some of these changes were for fading of the plastic0 Some of them were because the eye was too smallo Our original ©yes were far too smallo We had an idea that we could take the muscles and slip them through holes and turn them back on themselves and that would act as a clamp0 but they were too deep set0 DRo RICIitRi) Go SCOBEE |Sto LcniSp Missouri)£ I would like to ask Dr0 Ruedamann if all the suture material was catgmtp or did they use some silk* . DRo RUEDEMANNr We started out by using silko Then we found it was unsatisfactory and that0 due to the tissue fluid0 the muscles would come looseo At leastp we blamed the early failures on silko Then we went to nylon which uvas just as bad as silko Then we went to eatgut9 which is practically no good at all for this procedure0 So w© had to look around for another0 The trouble with both the tissue sutures was that they did not hold the muscle long enough„ It takes at least two weeks0 These eyes should be covered for at least two weeksP and most of the suture material is not effective over a two -week period of time0 With our tantalum we are going back to attaching the muscles to the tantalum mesh with catgut9 in the belief that the muscle will grow to the tantalum mesh within the two week period of time that the catgut is effecttv©0 Silk and nylon were of no value to us at alio They softened up and almost disintegrated in eight to ten days5 time0 DEL SCOBEEs Do you use catgut on Tenon0s capsules too? DRo RUEDEMANNg Yesp we do not use tantalum wire to close Tenon0s capsuleo All the tantalum should be buried 0 When you get exposure of the end of the tantalum., you get discharge., due to one of two things? Either faulty position of the wires of the tantalum plate or sensitivity t© the acryliCo MAJOR TRYGVE GUNDERSON (Eye Consultant,, Surgeon General0s Office)? I am very curious to know exactly what happens between the acrylic implant and the socket itself„ whether you get a type of epithelium growing around it or whether you have a granulated tissuep or whether it becomes a fibrous capsule that is intimately connected to the acrylic it*elf0 If you probe the edge of the conjunctiva of Tenon0s capsule between that and the acrylic„ what is the situation there9 Dr0 Ruedemann? I am very curious to know0 DRa RUEDEMANNs One thing that worried us most,, to start withp was what would happen in the orbit if we got infection in the orbit and got meningitis if we had a direct pathway. Fortunately s we had only two infections in our series of casesp and one we probably should not have operated on at all0 The man had infection to start with9 and we didnct take it into consideration enough when we put in the implanto The other case was a late infection., coming nine months after acrylic implant had been placed. He developed cellulitis0 We didn°t do anything with the acrylic eye, W© treated with some deep heatp penicillin., and let him goc He still retains his acrylic without any change at alio We were surprised to find that this was more like endothelium lining than epithelium. It isn°t epithelium tissue, It takes eleven or twelve days before the tissue forms around the aciylic eye0 It does not grow into ito The tantalum plates and the tantalum wire will grow right into the tissue0 The tissue will grow directly around 15 It and will accept it0 It will not accept the acrylic eye as it does the tant alum o In some of the early onesB where we attached the conjunctiva directly around the cornea„ the conjunctiva in two or three instances grew up over the front of the plastic and gave the appearance of a keratitis0 That was a rarity rather than the usual condition0 In most instances„ the tissue does not tolerate acrylic as well as it does the tantaluBio It is a pseude-end©thelium lining and it forms rapidly around the eye0 If the socket is not tolerating the plastic,, this lining becomes very heavy in connective tissue and forms between the muscles and foms a bridge between them, and that is where the extrusion takes place0 With the constant pulling back on the muscles and the tightening up of the endothelial liningP the eye is gradually forced forward and pulls the tantalum out from its attachments„ but the tantalum itself grows into the muscle or the muscle tissue grows around it0 CAPTAIN Ao E0 SHERMAN (0°Reilly General Hospital)s I would like to ask Colonel Struble a quest ion0 When you are putting in the tantalum wall -that isp the filling material -as I underit#£d you put it in at the same time you put in the acrylic eye0 LTo COLo STRUBLEs That is correct0 CAPTAIN Ao Eo SHERMANs Hew do you approach that? Do you work back through the muscle tone„ put it along where you want it? In the case that you showed„ I wondered if a very satisfactory result would not have been obtained by simply using filling materialo As I understood„ you said he had plenty of room in his socketo In factp he had quite a large socket„ so it is more a matter of filling the orbit than anything else0 I notice that the end result was not too satisfac- tory and he had practically no movemente I wondered„ in cases of that type„ if it would not be just as well t® use filling material of one kind or another to build up that socket and simply fit them with ordinary cork eye or glass eyeQ LTo COLo STRUBLE? In response to your last question0 I think we could have used ordinary material, such as cartilage or possibly bone0 CAPTAIN SHERMAN? I didn°t mean the materialo I meant simply fill the orbit where you want t© fill it out„ and use the implant along the fl@or or any way you wanted to do ito Wouldn°t it be a good enough socket so he could wear a pretty good ordinary orbit? LTo COLo STRUBLE? Without some type of restoration of the floor and back of the orbitp I don9t think he could have worn any type of eye „ As a matter of factp Captain Clifford saw this man and couldn°t make any kind of eye for hiiu I see no reason why he could not have been reconstructed 16 with something other than tantalum just as well0 On the other quest ion 9 as to how we place the materialP we open the conjunctiva t© the midlinej, dissect the conjunctiva down if the deformity is in the floor9 or laterally if it is laterally,, raise Tenoncs capsulev free up the area underneatha and just place the tantalum underneath0 That is alio It is very simple„ The tantalum is almost like screen0 It is cut in strips and you can roll it up to any desired size0 WEDNESDAY AFTERNOON SESSION Lt o Colo No Lo Dibble General Hospital,, presiding THE NEW ORBITAL IMPLANT ooo Lto Colonel Cutler showed a motion picture LTo COLo CUTLER? There are two or three things about these cases that I might tell you. I think we have don© 22 of them so farc We have t© learn on human patients* and all the men on the service have done them. Of these 22B we had to take tw® out because we used catgut sutures and they didnct hold* and we had to take tw© more out because we didn°t have a firm enough bite on Tenon5s capsule0 That is important0 Twelve of them have been fitted with artificial eyes to dateu The minimum lateral movement is 65 degrees„ and the maximum is approximately 75 to 80p and the average is 700 Seventy degrees takes in the lateral movement between the edges of a pair of spectacles on an average person0 The vertical movement has been consistently 65 degrees £ that is* we have measured them on the perimetero Of these 12 patients that have been fitted with artificial eyes* none has had any significant sinking-in of the upper lid to dateQ Whether that will remain so or not„ we do not knowc You want to bear in mind* of coursep that these are not abnormal socketso They are normal sockets0 There is no tendency for the lower lid to droop from the weight of the prosthesis, since the prosthesis does not rest on the fornixo In fact, the prosthesis is made as small as it can possibly be and still stay inside the lids0 Of course, the eye has to be properly centered by the artificial eye maker„ The dentist who is making our eyes was making the ordinary reform eye or styloform, as we call it0 He was making a larger diameter than the normal diameter of the eye0 After a little bit of argument (you know how these dentists are) I got him to make them approximately 25 mm, in diameter, and in some cases we had him make them a little less, and in some cases a little more* It is a matter of j udgment 0 We are going to have these implants made out of chrome alloy throughout, and we think they can be made up more quickly0 You can adjust the position of the artificial eye in all directions* The implant is not always exactly facing straight aheado Where that is the cases it can be taken care of in the fitting of the prosthesis„ ooo Major Ao Jo Kraft, M0C„, Billings General Hospital, presented his paper oh "Orbital and Ocular Injuries Produced by MoaWrn War MissilesoM (Applause) This paper will be published in complete form by the Journal of War Medicine in an early issue0 Major Kreft discussed factors which influence eye wounds in modern warfare. He gave a classification of war injuries of the eyes and visual pathv/ays, stressing particularly indirect ocular war injurieso LaGranges Law was discussed0 The ballistics of modern high velocity war missiles were presented as an explanation of the types of orbital and ocular injuries under discussion0 The following conclusions are taken from this paper lo Serious eye frequently macular in can be produced by blast concussion alone9 without perforation of body tissues by missiles or other foreign bodies* 20 Equally serious indirect ocular lesions can be produced by the orbital penetration of even minute shrapnel fragments traveling at extremely high velocities without touching the glob e o 3o To date9 we have seen no instances in which severe traumas of the mandible alone have resulted in ocular injuries* It is possible that the temporo-mandibular joint may absorb some of the concussion or at least direct the concussion away from the globe0 4o In our present series of cases of ocular injury,, resulting from severe unilateral w ounds of the facial boneSj, the eye injury has always been on the same side as the facial injury9 and in all cases9 the eye of the opposite side has been unaffected0 5c LaGranges Law holds for facial injuries produced in World War II as in World War L 6c All persons who have been exposed to severe blast or who have incurred war wounds of the head are entitled to a most thorough and painstaking examination of the eyes and visual pathways © (a) This should include a careful examination of the ocular fundus through dilated pupils, Particular care slhould be exercised so that a minute rupture in the foveaperi foveal retinal or choroidal degeneration or a disinsert ion of the retina at the ora serrata is not overlooked, All cases should have careful field studies made, to be certain no defect has been missed, We have found it worthwhile to check the patients carefully for evidence of micropsia or macropsia by having them look at a dot placed in the center of a staff of parallel lines0 Using this simple test,, we have been able to determine the localization of a very minute perlfoveal lesion which was almost invisible with the white light of the ophthalmoscopeo 70 All cases enumerated above should have a complete radiological examination of the skull facial bones both orbits and optic foraminas for evidence of fracture or foreign body. In indicated casesp soft tissue radiograms of the orbits for evidence of very small and practically non radio opaque foreign bodies should be made,, so that these tiny particles frequently overlooked on routine flirasa will not be missed0 LTo COLo STRIBLE? I realize that we wandered a little far afield on this0 The reason I ran it in on the program here was because I thought it would explain some of these severe orbital traumas that we are encountering and that we are talking about todayo It certainly was an eye opener to me to know that the horsepowera moving effect„ of a bullet,, for instance9 is over 10P000 horsepower, The weight of that mass of the missile is not the important thing0 It is the velocity with which the missile transmits its force to the tissue„ and when you realize that these little particles flying off high explosive shells sometimes come with a velocity of two or three times that of the initial velocity of a bullet from a rifle„ we may have a wounding effect up to over horsepower0 That I think explains why we find a severe damage in the orbit„ such as Colonel Shiflett has demonstrated to you thismorning a 19 severe damage to the tissuesP and yet on X ray study of these orbits9 we may only find a little tiny particle in this orbit0 THE USE OF DERMAL INSTEAD OF FAT IMPLANTS IN DEEP SOCKETS MAJOR Go Lo WITTER (Dibble General Hospital) % Certainly., we all have had problems that are in common„ and I think that it is fitting that at this time we just discuss briefly another type of implant which can be inserted in a very deep eye socket to minimize its deptho The problem of the deep eye socket you are all familiar withP the boys we have had come to us wearing prosthesis that are extremely in fact, so large that it is almost difficult to deliver them a pros- thesis,, The artificial eye maker is unable to make a sightly arti- ficial eye for a deep socket0 The real object in our attack is that we minimize the depth of the socket 9 create again a superior and inferior fornix, provide a flat <, or even better9 a slightly convex posterior wall of the socket which will have a more positive contact with the prosthesis* In so doing, we eliminate the need for a large prosthesis0 We eliminate a great deal of irritation which comes from such a large prosthesis0 Major Witter showed slides illustrating eases O*o You have all tried fat and found it very unstable0 You may have tried cartilage or bone , You may have tried many other things* We feel that foreign abjects placed in the eye socket are very apt to be involved by new fibroblastic tissue and eventually a very fibrous capsule will be formed about them,, to which the adhesive bands connect and con- tract and cause these foreign bodies to migrate* We have not had a long time to observe these men,, but it is not likelyp as we see the problem, that the de-epithelialized skin will be connected to bands which, when they contract„ will cause it to migrate0 This is an extremely simple procedure* A portion of the bodys, particularly the abdomen., the lateral portion of the abdomen,, even the anterior chest wall., may be the site that you can take the skin from* You de-epithelialize the skin by using a Blair knife or Paget°s derma totome* The simplest instrument is the one to use* We use the Blair knifeo From that de-epitheliallzed areap an ellipse is obtained and is placed in warm saline solution until you have closed the abdominal wound* Following this, you prepare the socket for implantation0 20 We have been making a horizontal incision in the conjunctiva and a vertical incision in the Tenon0s in order not to have the suture lines lying directly above one anotherc After the incision is made in the conjunctiva. it is elevated well to the fornices and toward the canthi. Then the vertical incision is made in Tenon0s capsule and it likewise is well elevatedo You then have a large piece of de -epithelialized skin„ about 40 mm0 by 20 mnios, which you may utilize to place in this socket in a quantity that will give you the amount of filling that you desire0 As we see its it is one of the features that should be emphasized and that should speak well for skin as an implant. The previous pre- parations of bone and cartilage and metal and glass and acrylic require considerable thought and time9 and very frequently turn out to be a bit too big or too smalls The fact that the skin is so easily obtained;, and you can cut the amount that you want and place itp seem to us two very marked factors in its favor. The amount of skin that you put in is definitely determined by how far forward you v;ant the socket to comec You naturally want it to fill the lids to as nearly as possible the amount that an eye would fill the lidSo The way the skin is put in matters very little„ It has been placed in9 in layers, one layer on top of another One rather long piece of skin has been rolled and placed beneath .Tenon0sp or one layer in itself has been found sufficient to do the job0 It is well to fill Tenon0s out as well as possible that is , towards the frontices and toward the canthio The Tenon0si capaule is closed by using mattress sutures and slightly overlapping,. The conjunctiva is closed by c ont inuous suture © The compression bandage is applied for a matter of four or five days9 at which time the black silk sutures are removed0 We have had only one instance where the skin was not accepted well., That patient had a marked scarring of the lower half of his socket„ and in looking back on it was not an ideal case at that time to have attempted to open Tenon0So The scar was adherent to the inferior of the orbit<> There is no reaction to the skin0 There is very little serious discharge following the implantation0 Thank you veiy much. (Applause) DISCUSSION LTo COLo Mo Eo RANDOLPHS I would like to ask Major Witter If this method is used because the usual methods of bona or glass balls were not found to be practical. We haven0t had any particular difficulty in inserting glass balls,, particularly boneg as a secondary implant,, at alio I think that is a fine additional method 9 but I donH see the ad vantage of it0 LIaJOR To CAVANAUGH (Cushing General Hospital) s Have any pictures been taken of the subjects flanks or chest wall or abdomen following the surgery? That is certainly gilding the lily£, as far as I am con- cerned o CAPTAIN Bo Ro SAKLER (Wakeman General Hospital)? At Wakeman Hospital,, we have used the so-called grafts for retracted lids follow- ing enucleation0 I found that in using that type of graft., we got very nice results in filling up the upper lids0 We never used the implants in the sockets9 but the upper fold was filled out veiy satisfactorily following the enucleated eyeQ By the ways we took the skin not from the abdomen or chest wall but from inside the armQ MAJOR WITTER? To answer Colonel Randolph„ about whether we were satisfied with other types,, that was just something that we thought wre would try9 and it seemed to work out very well so we con tinned using it in twelve cases0 Howeverp it has been stated by many,, and it has been our experience9 that occasionally the foimed implants do move0 As far as taking skin from the individuals9 we have had no com- plaints from the boys on whom we have done itc Furthermore0 it is rather interesting that the skin is simply closed by using subcutaneous foririo The scars are at a minimum0 In regard to the reform implantp many men whom we respect very highlya and one in particulars, gave up after three years of trying to make acrylic fit the prosthesis0 Others besides Dr. Greaar have expressed their opinion in the literature that reform implants do have a tendency to migratec I am sure that they do not all migrate0 It is very fortunate that they do not* because a great many of them have been used in the paste Let us put it another wayQ That this is another medium of minimizing an abnormally deep eye that if it is done with ease it does not cause any reaction in the conjunctiva or Tenon0s? that there is a lot of it available0 and borrowing it from the patient does him no harm.. When you have it in your hand at the tablep you can use the amount you wanto Often that is where we lose out in placing reform implants in sockets0 One question that has not been asked*, which probably should bej, isg What happens to hair follicles? As the Captain mentioned*, the plastic surgeon has used it in a reas where there is movement for a long time* He has never worried about ito In the three months that we have observed our patientsp we have seen no difficulty in the socketso 22 CAPTAIN SHERMANs I think possibly you are misquoting Dr0 Greear°s art id© o The only one I know of was the art id© in whi«h he pr©« posed using grooved glass spheres as implants0 and in that he said that the ordinary spherical implants and spheres would occasionally migrate0 I don°t think he wrote anywhere that the grooved glass spheres had much tendency to migrate5 occasionallyp yes9 but I think very rarelyG The grooved glass spheres that are on the market at present are somewhat a far cry from the original grooved glass spheres*, and some that we have obtained have had very shallow grooves0 They might just as well have none0 I think when you use a grooved glass sphere as a laid implant0 with fairly deep in it*, there is very little chance of its migrating out of the muscle coato By the wayD also in that operation of his*, he said that he usually went right through Tenon0s capsule0 Usually in those cases*, it is impossible to reopen Tenon°s capsule*, so actually I think you are putting the implant within the muscle0 We tried using acrylic implants before we could obtain the glass ones0 and we were able to make those large grooves0 As far as the dermal graft goes*, there has been occasional trouble with it8 I am sure0 1 remember Drc Wheeler0s saying that he knew of also had tried it himself there was a late formation of cysts from sebaceous glands and so forth0 There has been a fair amount of work done on that by Peer,, of Newark*, in which he buried dermal grafts and examined them microscopically as long as a year and a half laterp and usually the epithelial elements that remain do undergo degeneration and are replaced by giant cells9 fibroblasts*, and finally end up as a mass of fiber tissue0 MAJOR WITTERS I would like to say that Captain Sherman0© remarks are well takenD I wish he and Colonel Cutler would get togethero I did read the article which was referred to 0 LTo COLc CUTLERYou have me confused with Dr0 Greeaffo Probably what you had in mind was that we have seen Wheeler0s grooved spheres not in the place he put themo He never wrote a postscript to that article to that effect„ However,, I think that it probably is necessary to use whatever method you think is going to work with the equipment you have and the material you haveQ As to the abdomen*, there has been no problem0 We have not felt there was going to be any later disadvantage0 The matter of using a person0s own tissue*, whether you use fascia or derma or cartilage 23 or bone is9 of a problem to bring up additional procedure on patient o MAJOR CAVANAUGH? How soon do you expect to change the size of the prosthesis that you have used on these fellows? Would you be willing to estimate the time? LTo COLo CUTLHR? You mean for the final prosthesis? MAJOR WITTER; About two weeks<, In that particular the eyes had been shaped out ten days after surgery0 MAJOR CAVANAUGH? I meany when are you going to enlarge them,, not take them down? LTo COLo CUTLER? The socket hasn°t changed in four months so that we could change the prosthesis. The muscle coat is gone and so is Tenon°s capsulQo You just have some ill sorted scar tissue present0 1 don°t think you have in many of these cases a definite space in which to put something with some certainty„ MAJOR CAVANAUGH? That brings up an interesting point I had two fellows that were enucleated when they were children One soldier lost his eye when he was seven years of age. He is twenty-four now. I wanted to find out whether you could put an acrylic implant in that type of individual. I told him I didn°t think it would work but to my amaze ment. it split easily., went in easily, and slid up easily, and worked perfectly wello If most of our patients are of the type that have had just a straight enucleation overseas and have come back without an implant permanently, I feel the only implant to use is an acrylic, unless you are going to use this new system0 LT. COL. CUTLER? The cases I have in mind are those where there has been severe laceration and I have gone in and found the Tenon5s space in some cases but certainly not good enough to find it on quite a few of them, ■ MAJOR CAVANAUGH? I mean just a clean-cut enucleation LTo COLo CUTLER? On a clean cut enucleation. I agree with you. We have only felt we would use this type of procedure in cases where you just don°t have any you just have a mass of scar tissue and a lot of that. We haven°t been able to isolate Tenon0s space in those cases, nor have we felt we were in the muscle coat any more than the general position of the muscle coato MAJOR GUNDERSON? I think it might be apropos at this time to mention one reason why glass balls do migrateQ 1 believe it is a hangover from several articles that were written on implantation, one notably by Dr. Jersey and one by Dr. Verhoeff. 24 In their original descriptions* they placed sutures in the ends of the four rectus muscles and actually drew them over the front of a 16 to 20 millimeter glass sphere0 If you place such a large sphere in the Tenon0 s capsule and draw the four rectus muscles over that and sew them tightly* they are bound to be under some tensiono I know that both of these gentlemen gave up that operat ion and failed to rewrite it0 In my travels around this country and in the Mediterranean Theater* I found a great many eye surgeons were still attemp ting to draw the four rectus muscles over the glass ball which they were implantingo If you do that* I am perfectly sure that a great number of them are going to slip out between the four rectus muscles and become dislocatedo The obvious correction of it is to pay no attention to the rectus muscles at all* but simply to sew the free edge of the Tenon0s capsule over the glass ball so that it lies with no tension whatever* either over lapping it or in one single thick layer0 I am perfectly sure that in my own experience* since I have given up this first operation which I described* I have had no glass balls migrate If we can correct that misconception by these few words* I think itis worthwhileo MAJOR CAVANAUGHS For Major Gunderson0s information* in February of 1917* Dr0 Verhoeff wrote an article* telling how he did give up suturing the four rectus muscles and used the envelope flap he is using at the present t ime o LTo GOLo CUTLERs There is just one further comment on it* that is* that these cases in which this skin has been used have not been cases in which we felt there was a Tenon0s space in which to implant something* and they did not have a ball in there or any implantation at alio There was apparent lacerationo ooo Colonel Gtruble asked Dr0 Ruedemann to make some comment on Lto Colo Cutler0s presentation 000 DR0 RUEDEMANN; All I can say is that it looks very good to me0 The only question that arises is whether you replace the ©rbital volume or note The trouble with the implant may start about at the end of two or three months0 Regarding extrusions* our eyes have all been retained for the first two or three months0 I think this is an (excellent method* and for primary enucleation* I think it is equal to the method we use* or perhaps better than the method we use* I caaH say I haven01 tried it 0 The movement is absolute ly excellento I think he is to be complimented on it because it offers one thing that we would have difficulty with * and that is the placement of the eye* if you have a tendency to retraction of the single muscle0 The procedure is logical and you just accept it 0 It looks like one of those things that ought to worko If I may say one word about implants in general„ over a period of some years we have tried every type of implant and have taken out all these various types of implants to put in these acrylic eyes0 I don°t know of any that doesn°t work at one time or another0 We have taken out glass balls„ gold balls0 bonea and the restf) and it seems to me that they are all tolerated by certain individuals at one time or another and that some of them are not tolerated at alio It seems apparently an idiosyn- cracy that the patients who will tolerate a gold ball won°t take a glass ballo The glass balls., to be surep are the ones that have holes in some of them,, and are ruptured within the eye socket by secretions getting in to themp and we have them explode in the socket„ So we have planted acrylic eyesg clear acrylics9 within the socket and had the socket opened up so that you could look through the acrylic eye and see what was going on in the back of it and retain it in the socket for a year with a clear opening in there so we could watch what was going on within the socket0 We have done the same thing inside of the scleraP using what was known as Burch evisceration9 and taken off the cornea and put a clear acrylic inside the sclera and watched the eyec You could watch the tissue form on the optic nerve and arresto These are all tolerated in certain individuals9 and in others they are not0 In contradiction to Major Gunderson0s thought on not sewing muscle across the front of these, I don°t think that makes a lot of difference0 I think it is the way you finally close over in front of the implant„ whether it is going to be retained or notp how much reaction that individual has to the implant0 and how much connective tissue forms between the muscles, whether it is extruded or not» We have done them both ways0 We still sew some muscles over some of themp because the ones you sew the muscles over give you the best move- ment o Going back to Drc Cutler0s implantj, the only thing about, the implants Dr0 Cutler and I are doing is that we have gone one step further than this other implant p and some of them will stay in and some of them will not o It isn°t going to make a great deal of difference how you put them in there or what you do as long as they stay in0 I think he is to be compli- mented on this implanto LTC COLo So Ao FOX (Newton D0.Baker General Hospital)s We have been using the acrylic implant now for about 160 cases9 with the round ball with small indentations like the bone ballo This is hard to believe9 and I don°t believe it myselfp but we have had no extrusionso We use the ordinary two-suture cross closure of Tenon0s and an ordinary running suture0 I wouldn°t vouch for the movement and I wouldn°t vouch for how long they are going to stay inp but we have had no extrusionso. I don°t know how to explain it except perhaps that we use the 26 snare in cases of enucleation instead of incisions,, I am under the impression that we get less hemorrhage after the enucleation,, We use a tight pressure bandage for five daysc DRa RUEDEMAMo I would like to ask one quest ion 0 There must be some men here who do not put any implants in at alio Someone cam© to visit me and said*, "Why do you put anything in at all? Why not close it over? You get just as much movement without it as you do with ito" I think somebody must have some experience with thato LTo COLo CUTLERt I might say one things Dr0 Ruedemann0 We used a different type of implant in about lOO-odd oases0 on which I sent a paper in awhile ago*, called a bastard implant0 We put in a hollow acrylic implant and pulled Tenon0s capsule inside, so that eventually you had a socket which had a depression in the middle of the implant and completely covered over0 Then I had a stud on the back of that which fitted into this hollow spacep and w© got an improvement on the movementp but when you draw the conjunctiva over your implant you have lessened the normal amount of space in the fornices and that puts actual limitations on the movement of the prosthesis„ We found that in some of those cases9 because of the shape of the implant*, we could get almost as good movement with a steel reform eye*, because when that turned, that shortened the fornix on one side and deepened it on the otherc It has been my impression*, speaking of sockets without any im plant at all* that the socket sometimes had a surprising amount of movemento If I remember correctly„ Joe Friedanwald doesnct use one or didn°t use to0 I have also seen patients who had an implant put inside the slcera and had a movement which was practically the same as a nomal eye so far as the stump was concerned*, but it was not transmitted to the prosthesis to any degree at alio The problem always seemed to me a question of transmitting the movement of the stump to the prosthesis without regard to whether you had an implant or note We just evolved this method as being a method of actual mechanical transmission of movement0 DRo JOHN KEYES (Inactive)2 Dro Ruedemann goes back into my ophthalmol ogle a 1 history a little bit*, in the days when we just used to take out the eye*, periedo Incidentallys, I saw a practitioner do that same thing last year0 He just removed the eye„ sewed the conjunctiva and quite I followed the case and when the prosthesis was I was surprised to see that the movement was not too bade Ip howeverB believe,, from quite a few years of experience with spherical implants„ that the patient should be given the advantage of the implant until such time as the present methods of Dr0 Ruedemann and Dr Cutler are available to us in civilian life0 27 I am very much interested to see how tolerant the socket is to dental acrylic material0 I became interested in plastic material as demonstrated back in 1923 by Colo Sowers„ and I was interested in using dental acrylic material in the sockets and in the prosthesis0 You recollect that at that time a letter from the Consulting Surgeon was sent around to the eye centers o They were not quite the same ones that are functioning now.. This letter described the work done in Europe by oculists and by dentists on prostheseso That stimulated us and we started in on ito At about that timej, a patient came from North Africa with a hard spherical mass in the floor of the orbit0 We were surprised to find a large acrylic marble9 and to note that there was no prosthetic reaction beyond that acrylic marble0 It was a very large onep and that was apparently the reason it had dropped out of Tenon9s capsule0 We decided If it could stay down on the floor of the orbit for several months and not get any more reaction than that9 we would try some spherical implantSo We got some marbles and had a dentist run us off some spherical implantSo Some were smooth and some were recessed0 During the time I was with B we used them with great satis fact iono We had decidedly the impression that it is better to put in a little too small implant than a full or large onec The work of Colo Cutler has interested me very muctu I don°t see why those of us in private practice cannot use that type of implant with great success when the material is available0 I have seen Dr0 Ruedemann operate 0 Dr» Ruederaann has an uncanny skill in operating on all these cases0 A lot of us are not going to be able to duplicate his work until it becomes more simplifiedo His eyes do look beautiful and work wello I have enjoyed the meeting very much so faro COMMANDER F0 Mo MORRISON |USNHP Annapolisp When I came home and practiced with ny father;, he had tried implants and decided to leave them offo He had given up entirely0 To me that was careless0 I used bon© im- plants and he used simple enucleation0 I don9t know whether it involves my operative technique or not*, but his results were just as good as mine0 ELEVATION OF ORBITAL CONTENTS WITH PLASTIC PLATES CAPTAIN Bo Fo SOUDERS (Dibble General HospitalGentlemen-. During the past year or more at Dibble,, we have encountered a number of traumatic defects of the orbital floor which are quite similar to those which we saw this morningo Many of them were not quite as severe„ but some of them were quite comparableo We found eventually that the usual transplant material9 such as cartilage or bone9 fasciap were inadequate in a number of scores0 We were 28 principally a little wary of cartilage because the transplants were done by the plastic service and they always lived in constant mortal fear that we might do something following the cartilage transplant that would sacrifice that transplant0 Also I might add that we used fascia lata with not too encouraging results0 Considering these facts* we entertained a thought of using a plate or wedge of methyl-methacrylate to build up the defects in the floor of the orbit0 We arbitrarily decided on a wedge-shaped structure0 The first ones were solid9 but we very soon decided that perhaps it might be a good idea to place large perforations in the plate in order to allow for the ingrowth of fibrous tissue in order to secure the imbedded plate0 The smaller perforations were made even later t© accommodate the suture whichwas used to secure the plate in the early post operative phasec The plates were made of methyl methacrylate which an ordinary- dental technician can do in any dental laboratory„ Within the past three weeks we have considered the use of barium as an im- pregnating medium in order to make these plates more or less radio opaque„ We feel that this type of implant offers definite advantages0 as I have said,, it is very simple to procure, It is easy to in 5 sert and can be varied from time to time if the effect is not that which is desiredo Alterations can be made. The plate can be im- pressed further back into the socket if we find it is too far anterior0 Additional plates can be added if the correction has not been adequateG The plate can even be removed with ease if indicated So far we have not had any that we felt it was necessary to remove in the cases we have hadu Considering these advantages9 we have used this implant material on 11 eases since September 27 „ and we feel that the result has been quite gratifyingo The technic of its insertion is simplicity itself0 We obtain some idea of the defect of the orbit floor by stereoscopic orbital instrumentSo We look at them ourselves and determine just how large the defect isc It is a qualitative estimation we admits but it gives us some notion as to the size of the defects and,, therefore p it gives us some idea as to the size of the plates we are going to use o We usually have a fair number of these plates on the operating table ,, so that if we did have a miss in our judgment „ we could make the ib cossary adjustment We have found in some instances we wanted to alter the shape or size of the plate„ The plates vary from 15 to 30 millimeters in their depth and width and they are from 3 to 5 millimeters thick If we find that the plate is too large or the shape isn°t just what it ought to bep the dental technician is 29 consulted and he can vary the shape of the plate in a short period of time0 It merely entails a wait of fifteen or twenty minuts while it is being re-shaped and re sterilized„ We make a curved linear incision in the lower lid„just at the expected position of the infra -orbital margino That is carried down to the depths of the orbito In some instances,, the infra orbital margin is not there0 It is depressed down on the cheek,, but we try to make the incision over the point where it should be© By sharp dissect ion„ we create a bed at the floor of the orb it9 and the dissection is of such extent that the plate will bridge the bony defecto In other words9 this dimension will have covered the bony defect in the socket0 We find that it will create a satisfactory infra orbital ridge and it will also elevate the orbital contents quite satisfactorily. The subcutaneous tissue is closed with interrupted sutures0 You may use 40 chromic catgut or perhaps 6-0 deknatol© The skin is closed with several interrupted silk sutures» An adhesive compression dressing is placed over the operated eyep and removed in three or four days,, at which time the skin sutures may be removed and another compression dressing may be allowed to remain another two or three days0 We haven0t seen any noted reaction following the procedure0 There has been some necrosis and in one case a small hematomas but in other ways there has been nothing of note seen postoperatively0 A technique has been described for the reconstruction of traumatie defects of the orbital floor with plates fabricated from methyl- methacrylate o The procedure has been used in eleven (11) cases and appears to be a satisfactory means of (1) elevating the orbital contents9 (2) restoring a substantial barrier between antrum and orbit and (3) restoring the contour of the infra orbital margin© A number of advantages of the present procedure over bone,, cartilage or fascia lata transplantations are apparent„ These are its simplicity of technique9 ease of subsequent alteration if necessary, and satisfactory tolerance to additional plastic surgical procedures to the eyelids and socketo The presentation is illustrated with lantern slides© o Showing of cases with lantern slides ©©© In giving this presentation today, I want to emphasize that it is a preliminary report0 We have done these procedures since September.273 of this year9 and in spite of that fact*, we feel that the results are couraging enough to date that the procedure can be done0 We feel that it is effective to elevate the orbital contents to create a barrier between the antrum and the orbit as well as to reconstruct the inflow of the infra orbital margins if the defect is not too greato LTo COLo CUTLERs I might add that we do not feel that this is the answer to all of our problems of fracture of the floor of the orbit© 30 Although we are not reporting on itp we started using tantalum plates made up of the mold to reconstruct the orbital rinp and in connection with thatp using derma to fill in the depressed areas on the side0 Our plastic surgeons have always been using that on the face9 although they have been using dermal plastic grafts and we bave just been using dermao DISCUSSION CAPTAIN Ao E, SHERMAN (0°Reilly General Hospital)s Our dental officer who made the acrylic prosthesis was having some difficulty in fitting cases that came back from overseas having surgical evis cerationp and those that had had a simple enucleation but who had a fairly full socket below with a rather marked retraction of the upper part of their socket9 with a drawing back of the levator and skin below the brows causing that unsightly depression and also causing a rather wide open eye with any eye prosthesis that he could make „ About six. months ago0 we got together and made some acrylic wedges shaped a little differently from this, of which I will show a picture on mainly with the idea of elevating the orbital, contents and trying to get rid of the depression below the brow in retraction of the upper lid* We were very satisfied with the resultSo Wto* w® first did themp we used a rather simple approach and went through the conjunctiva in the back portion of the socket and almost down into the lower fornix and put our wedge in placeo W® used dissection to get down in the floor of the orb itp not under the peri orbit, put our wedge in placeP closed the deeper tissues with catgut and closed the conjunctiva0 We found the implants would tend to ride forward and we could feel them right on the lower orbital nm> I remember only about one case where you could actually see a little bulge there that was hardly noticeabl«0 After that we decided it would be better procedure to put them in the same way plastic surgeons have used cartilage to fill in the floor in fractured floor*, so we went in through the skinp through the orbital margin, cut the peri-orbita on the bone and elevate ito It elevates very easilye We elevated far enough back so we could put in our wedge shaped acrylic0 We used the larger portion of the wedge posteriorlyr the idea being to try to elevate the orbital contents as much as possible in the posterior portion of the socket 0 We also used the acrylic wedges in similar cases to those of CaptainS ouderSp who had fractures of the floor of the orbit with depression of the globe„ resultSo Again we have been very satisfied with those Captain Souders didn°t say. but I assume he puts these under the peri -orb its o Possibly he doesn0t„ I notice he used them also to regain a lost orbital margin0 We donc’t do that© There is another way in which we differo At O0ReillyP the plastic service has gone through the tantalum plate stage for defects surrounding the orbit and given it up in favor of cancellus bone from the illume We ourselves prefer to use cancellus bone from the ilium to build a lower orbital lateral orbital region and even extending lower0 If it gets too far from the orbit„ we turn them over to the general plastic surgeon0 Of course, our neurosurgeons continue to use tantalum plates for pulsating above the orbit9 which includes the orbital rim0 They usually get nice results as far as contour goes, and so on„ CAPTAIN Bo F0 In answer to that question;, we do not ordinarily make an incision of the peri-orbitao In most casesp we have done this procedure,, As I said before „ the orbital floor has been pushed out of its own positiono I don°t believe you gain much by going down to its level and putting your plate beneath the periostic peri orbitaQ I also neglected to mention that we secure the plate to the smaller portion that you see in the plate with catgut, usually 20 chromic catgut0 We take a bit of periosteum, any that is available at the margin where the plate is to be inserted„ and we try to get the plate back fairly far because we notice the same tendency that Captain Sherman spoke of for the plate to protrude«, We feel if it is placed a little behind the normal position and secured with catgut, in a short time fibrosis will take over and will secure the plate to the position that we desire to haveQ LTo COLo E„ Lo SHIFLETT (Crile General Hospital)s I feel that a radiologist talking about reconstructive surgery is like a boy out of school0 I look upon this problem from a little different aspect„ that maybe you don°t emphasize sometimes0 In adopting the physiological functions of the muscles of the eye to the form of the body, you have to consider the f act that you are dealing not only with the physiological function of tissues but you are dealing with a mechanical foreign body and there is a certain amount of mechanics that enter into the worko I noticed in the illustrations there is always a tendency to build up the floor too little0 If you will use a method that we have used here, I think you will find that the average growth of the eye lies much higher in the orbit than you usually believe it doesQ These films are easy to obtain,, All you have to do is make a lateral with your first three films and you can reconstruct the size of these orbits by using the opposite one as normal„ Of course, if he has no globe 32 in one side, it is very easy to make one on the opposite side0 There is one thing here that maybe you thought about and maybe you didn0to I notice that even though these plates are different shapes9 the breadth and the length are more or less proportional in all of themo Reconstructing the floor of the orbit and the roof of the antrum gives you a pretty good idea that those plates are going to have to be made, some short, some long, some thick, some thin in front and some thin behind, I would think because if you study these orbits closely enough you will find that the floor of the orbit slopes from forward upward and backward to the cone at the posterior margin, and if this is allowed for in the mechanical reconstruction of this orbit, I think you may get your corner of elevation farther back. It would be higher farther back than it would be in front„ Those things I think must be consideredo I think it is one of the problems in which we can help you, particularly in getting too thin a plate skino I believe if you study these carefully and compare with the opposite side,, using your measurements, you probably won9t have to go back and put in these plates0 Another disadvantage of going back and putting in another plate is that you have left those holes for the fibrous tissue to grow into and you have to destroy that0 I believe that if the radiologist applies himself, he can help you out a great deal in some of these little problems that will influence the resultso LTo COLo CUTLERs I was going to say, Colonel Shiflett, that I think the points that you and Colonel Struble have made about the orbit are very useful to us, and we intend to make use of themc We haven0t known just how to go about it before0 CAPTAIN SAKLSRs We have done several of these cases in patients who had seeing eyes0 There we utilized a little trick, using the Maddox rod with the light„ We don°t inject the globe at all in the orbitj just superficial injection of novocain, which doesn°t affect the extra-orbital muscle, and we get a pretty good idea of the amount of cartilage to put in0 DRo JOHN KEYESs I want to ask Captain Souders whether any symptoms were met showing evidencs of dysesthesia of the fifth cranial nerve before or after operation*. CAPTAIN SOUDERSs I expected that question would be askedo Sur- prisingly enough, there weren°t any0 Several have had anesthesia, which they had due to their original injury, but we have seen nothing of that kindo 33 CAPTAIN SHERMANs When you put them in along the peri- orb it a*, you are likely to get some disturbance of sensation*, but I have seen none that had a loss of sensation0 They recover normal sensation0 MAJOR VICTOR Ho DEITZs There is one feature I would like to bring out that was not touched upon yet„ That is relative to the opacifying agent used in the acrylic materialo I have worked with barium sulphate and incorporated it in the methyl- methacrylate„ and I have found that it requires as much as 25 to 50 per cent of the loading of the material in order to opacify accurately in shooting the X -ray through the skull0 That iss howeverB on a thickness of o0&lp about a millimeter and a halfo That must be computed for the thicknesses that Captain Souders uses0 I believe *, however*, when we compare our element 73 tantalum*, it assumes a very strategic position in the periodic table. One observer probably back in 1890*> in his original experiment in the autodynamic effect of metals„ trying to disprove the various theories in metal therapy at that time, worked with spirogyra. His experiments were placing this particular botanical specimen in water*, and tried to inhibit its growth by the introduction of various metals0 He came to the conclusion that probably the metal which is completely unionizable*, such as tantalum probably is*, would be most ideal0 When we compare the barium sulphate*, it admittedly is less ionizable than silicon dioxide glass at a pH of 7D2P which we may expect to find. Granted that this is true*, we might expect little ionization to occur from those particles that in processing are found on the exterior of the plastic. These however,, are in contact with the various tissues and if slipped under the peri-orbitas they will come in contact with the various tissue enzymes0 There is one feature about the use of barium sulphate. It is all right when given in the methods used in radiographic diagnosis9 but the barium sulphate seems to be somewhat anti-histogenic in its action. For that reason*, if I should want to opacify acrylic*, I would prefer by far to incorporate tantalum dust*, and there is another possibility that tantalum dust will in the course of time be given off to the tissues. That must be done by technical process whereby it is reduced with corbor- undum stones and put through about 120 mesh sieve. If that is done* it will take out the particles of the carborondum usually given to the materialo Then again*, it may be done by using an iron file*, whereby you will have to resort to washing with hydrochloric acid to precipitate the iron*, leaving the free tantalum which is unaffected by those particular acids o The tantalum may also bo used in little pieces9 perhaps some two or three millimeters in length9 cut very expediently from tantalum mesh. It works very well. It bonds well. Although I am not in position to quote my results at this time*, I have found that it actually seems to stimulate histogenesis5 particularly fibrogenesis0 As Dr, Ruedemann has pointed out*, it is quite evident that it does so. Now if those particles are on the exterior*, there is a possibility that there will be a fibrotic union that will occur right on the surface of those acrylic wedges when inserted in thisD LTo COLo CUTLERs In regard to the use of we have bean impressed with some of the neurosurgeons0 reconstruction of the orbital rim in connection with skull plates0 With that idea in minds we have started to try this outQ I am wondering why the plastic service gave up the use of tantalum around the orbital rimu CAPTAIN SHERMANs I think probably it was because the orbital rim itself usually involved the malar area or pretemporal area0 I believe too often the final results did not give them the contour over that area that they had hoped fors even though they were careful I believe in the dental department in the reform plate , When they switched to the iliac bone, they found it was so much easier around the operating table and also gave them a good solid filling material and became very firmly unitedo Otherwise9 you have some exposed bone at either endo Also I believe that at times they were a little afraid that the collection of serum or blood clot betv;een the tantalum plate caused trouble,, requiring drainage afterward and also the possibility of infection 0 One other thing 1 am reminded of is that apparently the boys were complaining of temperature changes when they would go out in the cold with these things0 LTi COLo CUTLERs We are not prepared to comment on this thing really5 because we lon°t know anything about it0 but from what little we have dones which is practically nothing, the change in the contour of the tantalum plate at the operating table is one of the easiest things in the ?/orldo CAPTAIN SHERMAN,: It is if you use thin finished tantalum and again you don°t have much filling material underneath the tantalum LTo COLo CUTLER;; We don°t fill underneath0 We bore holes in the plateo It is not a castings It is an outside shell and the shape is made up from a mass,, shaped and reshaped at the table„ It looks good in the early stage0 CAPTAIN SHERMANs Some of them d® and dome of them don3to LTo COLo CUTLERs I was interested to know what the trouble was CAPTAIN SHERMANs Do you suture with the bone? LTo COLo CUTLSRs We use wire and screws CAPTAIN SHERMANs That is what I mean 35 DR0 RUEDEMANNj I think that you are talking about something that is necessary0 Donct use tantalum plate at all, but the tantalum mesho You can mold it two or three times and cut it any way you want and mold it at table and it will stay the way you put it- The tissue grows through it0 Don3t use tantalum plate0 It acts like almost any other metallic it is smooth and the tissue does not grow through it0 With the tantalum mesh, the tissue grows to it , and if you want to take it out, you have to cut yie tissueo CAPTAIN SHERMAN2 I think the use of tantalum tissue is a good suggest iono I don°t believe anyone out our way has been using it for any thing,, Have you used it for orbital rims and things like that? DR0 RUEDEMAHN2 Yes, we have tried taking the tantalum mesh and re- constructing the entire socketo You can fold it over any number of'times you wish, and then you must fasten it because it does have a tendency to migrateo We have attached it to the peri-orbita with the tantalum wireQ If you reconstruct the orbit with the tantalum mesh, you can attach your acrylic eye to that, or if you use it as an inferior plate of the orbit, go through the anterior as suggested by Captain 3ouders, and again use it in any number of thicknesses you desire0 LTo C0Lo CUTLER? It sounds excellent-, Do you reform that over a mask or not? DR., RUEDEMaNNs Not at alio You can form it as you go along. It shapes itself very readily0 Colonel Shiflett has brought up the point that we have had the same difficulty that Captain Souders has, that we have always been a little bit low on the eye sideQ We were a little bit too conservative rather than the other wayQ THE USE OF FASCIA LATA IN RETRO -TARSAL ATROPHY FOLLOWING ENUCLEATION MAJOR Go Lo WITTER (Dibble General HospitalI would like to report to you the results of 138 cases in each of which we have trans- ferred a strip of fascia lata from the thigh to correct what is probably better known as orbital atrophy of the lid rather than retro tarsal0 You are all familiar with it0 Captain Sherman just mentioned that this depression is frequently corrected when they elevate the orbital contents, and certainly we have noted that, too0 This is « means of correcting the depression which occurs just beneath the brow in the upper lid, in anophthalmia individuals who other- wise have a normal ey® socketo 36 The fascia lata is easily obtained,, We use a fascial stripped If you use a fascial be sure to keep well above the knee and you will not meet the cross fibers that are there,, and considerable subtissue and fat is adherent0 A strip of fascia approximately 12 cent meters by 1-g- centimeters in size is obtained and is placed in warm saline until the brow is ready for its insert ion0 These are done usually under local anesthesia.. If one chooses to do them under general anesthesia,, it is wise to infiltrate beneath the orbicularis oculi and in front of the septum prior to making the incisions c- An incision is made over the rim of the orbit at approximately the external angular process or on the surface beginning in the superior tarsal furrow,, and coming out parallel to the external angular ligament0 through skin,, and through the f ibers of the orbicularis at that point0 Then using Stevens0 keratotomy one begins to tunnel and tunnel in curved fashion, keeping just immediately beneath the hair in the brow0 I think that is very important,, and the previously recorded suggestions in the literature, that that be carried deep into the orbit,, I think ought to be corrected,, chiefly because if we keep in front of the orbital septum and beneath the obicularis ocullp the fascia will remain inside without migration and will not interfere with elevation or depression of the lid with function of the levator muscle,, nor will it disappear into the orbit as it would be very likely to do if we carried it beyond the orbital septumo The tunneling is carried to a point selected by you or your patlent9 to match the point where the fold in the upper lid normally is seen to stop on his normal side0 That may be opposite the superior orbital notch However, you select that point by previously having examined the patient to determine where the fold does end nasally on him,, on his normal side0 Then by opening the lids with the scissors a stab wound is made through skin muscle into a tunnel that you have made and the scissor points then are brought outo An aneurysm needle is inserted through in the opposite direction from which you just went Two sutures are carried through ito The needle is then threaded and it now contains the two sutures„ We have one black and the other white so we can keep tab on them more easily0 They are strong cotton or silk sutures„ This is brought through from the direction in which you just went in making the tunnel8 and back out in the original or initial incisiono At this point9 the fascia is usually divided into two sections by cutting it in half or by incising it lengthwise, Ordinarilyy however., it is cut in half because the usual length between these two points is rarely over two inches and it is approximately four centimeters„ to be more exact 0 A claxnp catches the fascia9 which has been thoroughly cleansed of all subfascia tissues„ so it glistens as you look at it and it is allowed to hang in this fashion0 Then taking the pointed barb part of the knife9 it is shreddedo We feel it is quite essential to shred fasciae It has been done without being shredded„ but it seems to mold better and form a smoother insert if it is done0 This is laid over the white suture9 or Suture No? lo That suture is drawn through the preformed tunnel,, and this group of fascia pressed here0 Then„ if it is necessary and a considerable amount of filling is desiredy the second strip of fascia,, treated in similar fashion as indicated there„ is also drawn througho The amount of fascia which one needs is determined likewise at the time that the operation is doneQ It is quite essential at this point that cne beyel the fascia so a knob does not exist at the initial or the final extremity of the in- serted stripo Following that,, one plain catgut 4-0 suture is used to close muscle„ and usually two black silk sutures„ 6-0 „ to close the skin in this position,, We then insert the conformer the patient is wearing at the time and apply pressure dressing„ This dressing is maintained for a period of two days9 at which time the black silk sutures are removed„ and very frequentlys but not necessarily„ a% pressure is maintained again for a period of 24 to 48 hours0 We feel that fascia lata is a relatively stable substance to insert in the upper lid to reform its contour and suggest it as one means by which this can be donec The oldest case that we have been able to ob- serve has been in sight now for a year and a half0 Summary of 138 cases in each of which a strip of fascia lata was used to redevelop a normal orbital contour in an eyelid where a dis- figuring depression had occurred due to atrophy or sinking of orbital content., secondary to enucleation of the eyeball0 Pre-operative and post-operative pictures of 4 cases are shown0 That the inserted fascia is well-tolerated„ without reaction and is known to persist for one and one-half years is emphasized„ The technical procedure is described with diagrammatic; illustrations,, The only reference to this procedure is in "Textbook of Ophthalmic Surgery0" ooo Showing of lantern slides of cases Ooo We have had only two individuals of the 138 who have gotten any infection and have thereby lost the fascia or had to have it removed„ but we have had two other patients who,, for a long period of time following the insertion of the fascia9 had a rather pinkish red swelling of the lid 38 and the skin was rather shiny, suggesting that there was a very low- grade type of infect iono In each of those, at the suggestion of Colonel Cutler, we merely injected penicillin with a little novocain and the inflammatory reaction cleared quickly and without any re currence of infection in those two individualso In summary, we present these diagrams and pictures to show what we have done in 128 cases,, We feel that fascia is a stable substance, that is readily obtained and is easily molded to reform the depression in the browQ Regarding the legD in case it comes up. as did the shin before„ I would like to say that when you take fascia lata,, you very fre- quently have a bulging of the lateral femoris group of muscles through the gap that has been caused in the fascia lata itself0 That disturbed me very much when we first did ito I kept these boys in bed for a period of two and sometimes three weeks, with tight binders and so forth, to see if it would minimize the appearance of this protruding muscle, and it did note So now we do not ask them to stay in bed any longer than necessary to allow complete healing of the skin wound., approximately five to seven days. The sutures are removed in five days, and it is not consistently true that any remarkable amount of bulging takes place» The ortho-pods and the general, surgeons who have used fascia for many reasons and take great quantities of it, assure us there is no weakening of the limb when one removes fascia latao I have watched this thing and of the patients we have had, not one has complained about his limb0 In anesthetizing fascia lata, it might be wise, to some of you who have not used the procedure, to say that you must go beneath the fascia lata to obtain anesthesia, and a great quantity of anesthesia above the fascia lata is of little value,.. It should be just enough to obtain skin* Anesthesia of the sensory nerves that perforate from beneath fascia lata is sufficient to obtain all the anesthesia necessaryo DISCUSSION LTo COLo FOX; In regard to the fascia lata site, we have used this procedure and found it excellent„ If you take a long narrow strip of fascia lata, certainly not wider than an inch, and if you let your patient up and about much earlier than usual— we let them up in forty-eight hours--you will find the tendency is to minimize the bulge „ CAPTAIN SAKLER* We use quite a bit of fascia latao We have been taking it in conjunction with the lower and middle third, rather than taking the upper0 In not taking too wide a strip, we try to invert the gap by some subcutaneous sutures, and it works out pretty- well for uso We haven01 had any trouble in that way at alio 39 LTo COL* CUTLSRs Do you use the stripper? CAPTAIN SAKIERs We strip upward rather than downward. We come right down the fascia lata by doing so, and don°t have to gc through subcutaneous tissue and fat0 LTo COLo Mo Eo RANDOLPH {Valley Forge General Hospital)i That is a fine operation. We have used it at Valley Forge with a good deal of success. I would like to ask you how many of those cases that you have done had secondary implants or had implants0 CAPTAIN SHERMAN" Do you feel that the operation that I use at times, using derma to fill out the back of the socket9 also helps take care of this retro-tarsal depression? MAJOR WITTERS To answer Colonel Randolphs question;, I do not recall anyone in particular who had a secondary implant„ Some of these boys already had implants,, in the shape of spherical implants in Tenon9sG None of them had any secondary implants in the eye socket0 In regard to whether or not derma will do the whole job-°that is, minimize the depth of the eye socket, in an extremely deep socket „ and also fill out the sunken or depressed area in the orbital depression of the lid- it has not b een our experience that it does, but we have done very few de-epithelialized skin implants. 1 think probably the men who have had more experience in doing implants in the floor or the orbit might better discuss that than one trying to minimize the depth of the eye socket0 It is true that when you examine boys on the ward, if you press at the inferior orbital rim, if they have an implant 9 very frequently you will find that your depressed area In the orbital portion of the lid above disappears0 That is the impression that has been given by Captain Sherman and also CaptainS ouders. Captain Souders mentioned it many times at our hospital. CAPTAIN SHERMAN;: I guess Captain S ouders has not tried tie use of acrylic forms or wedges on the floor of the orbit. In cases with enophthalmus;, with small implant—you haven°t tried that? CAPTAIN SOUDERSs No. It alleviates but does not obliterate that impression. LT. COL. CUTLER2 I did a rough check one time on our enucleation cases. We used to have a ward of about 69 or 70 patients, and the two times I ran a check, it ran about 30 per cent with some evidence of depression of the upper lid. It was present in patients who had ball implants as well as in patients who did not. We do not have any statistics as to the actual but cer- tainly in the cases where we have filled out the orbits by putting in any material, whether it has been to put just back in the orbit or whether it is in the floor of the orbit, the tendency has been to over- come thato In some casess it has completely overcome that, and in others it has not, In one of these cases where we put some plates ins one fellow whose eye was way down still had that depression of his upper lid, but it was much less noticeable0 The question comes up as to the ordinary enucleations where you do have an implant and where it does occur in civilian practice, whether one would put something in the upper lid or something in the floor of the orbit o I don°t know the answer, I would be inclined to put in fascia lata at the present time0 CAPTAIN SHERMAN; My impression, from what I have heard here and from our experience, is that most of the boys from overseas, who have not had implants undergo considerable retraction of their socket over a period of about three months 0 I have watched some of them© They come in, and you have to give then a furlough 0 In fact, there was one time when we were told to give them ninety-day furloughs, that we couldn°t work on them that way, just to make room for other patientSo It is surprising how much re- traction they would undergo during that second third and fourth month, you might say, after they were wounded0 Most of them did not come to us un til at least a month after they were originally hit© I feel that the way I would handle them is to put in a late implant„ Use dermis, if you wish, but I still prefer the crude glass spheres if they have roots in them, If you still have too much depression sinking in below the brow, put in a wedge and implant along the floor under the peri orbita, where it is firmly anchored there© We never did make holes in our acrylic „ Possibly if we had in the ones that we put in by the conjunctival route, they would have stayed a little better where we wanted themQ By putting them under the peri-orbita, I am sure that, except in very extreme cases, we give them a very good looking upper lid—that is, under the brow the re 0 There have been occasional ones, very bad ones, those I think with fractured floor too, in which we have done all three things,, At least I remember one in particular where before we used the acrylic we had already put an acrylic groove sphere and we used preserved cartilage along the floor of the orbit and elevated his orbital contents very satisfactorily, at least as much as we could. We put in two pretty good sized pieces of preserved cartilages, and then at a later date, we filled in the upper lid with fascia lata, too. We did all three things and it still doesn01 look too goodo MAJOR Lo Jo CROLL (Fletcher General Hospital) & We have seen several of these cases. Essentially they have been cases which had no implant whatsoever. When we did a secondary implant usually we corrected it so we were fairly satisfied with the result and so was thepatient. When we werenH, we asked the plastic department to fill out the upper part of that plastic prosthesis, That3 toop would help considerably in this effect© MAJOR GAVANAUGHo I would like to hear what the other men are usings but I feel if you can use an 18 mm0 diameter acrylic implant ? you usually get away with the problem by just putting in that size implant0 I think if you use a smaller implant, you may have a tendency to need further surgeryo I would like to know whether I am using a small ball or a large ballo I will speak to one man and he will .say, "Fourteen is enough; that is plenty,," Another man will want 16„ I have gone to 18 and stayed there9 feeling that was the answer to the problem in most cases0 LTo COL© CUTLER? How about the custom of using an 18 mm0 sphere? What do you use at Valley Forge? LTo COL© RANDOLPH: Eighteen millimeter© LTo COL© CUTLER? What has your experience been on the upper lid? LTo COLo RANDOLPH? Usually quite satisfactory0 In most cases of secondary implants9 the use of a large implant has served the purpose quite adequatelyo Captain SAKLER? We use 16 to 16 mm0 Sometimes you just can°t get the 18 mm0 in and we use 160 We try to use as large as possible© I should say„ Colonel Cutler,, that your observation is conservative© We had a lot of those cases show retraction of the lids two or three months later© They were in the hospital for other things© There seems to be no particular relation© LTo COL© CUTLER? The length of time following the enucleation probably has some relation to it© What it iss I don9t know© The patients I ran the checks on were not overseas cases© That was the time we were getting E©ToP©So boys in© when they heard about the plastic eyes© They were all civilian cases© We were not impressed with the fact that simple enucleation had caused these retract ions„ but it could well have been so because we didnst keep any statistics on it© I don°t know how long it takes for this retraction to take place© Apparently in civilian practice9 the men in San Francisco to whom I have talkeds all of whom put in implantss but I don°t know the size,, consider that it is quite a problem© Whether they are using 18 or not „ I don9t know© MAJOR CAVANAUGH? It must be that the size of the implant has some- thing to do with it because if you take a youngster and remove the eye at six years of age and don9t put an implant ins and you see that person at twenty years of age„ the facial bones have not formed on the side of the enucleation and you have a depression in your orbital rims© I think it is very important to get a very large implant in, even though you may feel that it may pop out© Personally,, I would take a chance on its popping out „ just figuring the development of the facial contour in years to come© I agree with the Captain that the time element in the format ion of this fold might be anywhere from two weeks to three months, but it certainly is very rap id 0 I think the tine element has nothing to do with the correction of it either,, I really feel that if you put in a large implant„ you have solved the problem in at least ninety per cent of the caseso DHo JOHN KEYESs Just to confuse the record, I want to state that I distinctly have the impression that large implants are veiy bade Why? Because they are difficult to holdD In my experience, more of them extrude than the small onesQ Based on bitter experiences of my own and other ophthalmologistsp I feel that the small implant is much more preferable to the large one0 It seems to me that 12s or 14 mmc is just about righto MaJOR CAVANAUGH? My answer to that is that we all know that the eye fits into a cone, and when Nature or God, whoever made the eye9 put practically 25 mra0 in diameter there,, that is the answer0 DRa KEYES? The socket couldnst stand still LTo COLo CUTLERS Pfeiffer, in a recent article„ reported his observations of some youngsters that had had implants, and it was his conclusion;, as I recall, that putting in an implant did favor the development of the orbit on that side, but there was still some reduced orbital capacity on that side, I think he reported on a case he had observed at least seven years0 THE EVALUATION OF RECENT OPHTHALMIC CONCEPTS AS RELATED TO THE FABRICATION OF PLaSTIC ARTIFICIAL EYES xiND IMPLANT DEVICES MAJOR VICTOR H. DEITZ, D0C0 (Chief;, Plastic Eye Service, Halloran General I must admit that it was not until just yesterday that I was apprised of the fact that 1 had been included in the program„ T had hoped that 1 would not be included0 Some of the work that I have undertaken has been in conjunction with Major DeBow of Hallaron General Hospital, for which he should receive considerable credit, and he has very ably cautioned me not to go unnecessarily awryp as most of us sometimes tend to give vent to a little experimental trends We have tried to hew to the line© I cannot sensationalize what I am to present0 I prefer to remain basically factualo I must admit that I am speaking as the prosthetist and not the ophthalmic surgeonQ I cannot say that I have enucleated an eye, I have only observed itQ I am rather new in this field© I have only tried to observe what happens in various cases rather critically and have hoped to remain completely unbiased in so doingo 43 I remember. just a few things from Wilder0 s Craniometry 5 and I think possibly I can use seme of those principles rather strategically is. applying it to the conditions with which we are confronted*. This is a compromise, perhaps somewhat as Colonel Shiflfttt has mentioned,, between’the Walters and the Caldwell position,, not compensating for the 20 to 23 degrees for the divergence of the orbit anteriorly« It is straight ahead in every respecto If you use that as a standard you can compare from that basis0 I would like to say that this case is one wherein we were confronted with a protruding implant sphere, a glass sphere of exactly 20 mm0 In diametero Ordinarily9 on the cases I find that a vertical line projected, from the infra orbital foramen would normally bisect the implant sphere if it were in its ideal posltion0 This may appear to be alitle bit high, but then again I concur very much with Colonel Shiflett in respect to the so called infraglobal space., when we are concerned with the normal eye,, being about twice that of the supraglcbal space., so if this were simply over some 5 im0s or possibly 4 mm.-,,, it would be in its ideal position from the standpoint of prosthetisto I was able to adduce considerable information by my original work with injection impressions0 That has not worked out wholesale for the routine thesis when prosthesis had to be customized0 It causes a ballooning of the tissues and the tissues of the socket with the eyelids held in juxtaposition;, in such a way that you shoot into the socket and cause a ballooning out of tissues*, It follows a physical law which is actually undesirable in our case*, It is comparable to reducing the physics to Pascal°s principle., where the pressure is equal to all surfaces within the confines of the void upon which the pressure is being impressed*, In this particular cases we had difficulty because we had to include the diametric factor which is 20 mm*, of this glass sphere along with its lateral migrationp giving us a very slight clearance against the lateral wall of the orbit „ Ordinarily we bring the temporal flange of the prosthesis around that and set it in this particular sulcus,, We had difficulty in this case, and it ultimately required considerable technical ingenuity to circumvent that*, The glass implant sphere is, in my opinion*, tried and proved,, and probably in the opinion of other men it undergoes some ionization so that it has to be removed0 That has been observed** However,, there is a possi bility that with the plastic prosthesis some problem will present itself in the futureo We have a friable implant sphere against which a rather com paratively rigid plastic is placed*, From the glass-eye manufacturerss there have been some few cases wherein a blow struck upon the glass eye has frac- tured not only the glass eye but the glass implant sphere as well*, If that happens when the blow is struck against the glass eyes perhaps in the future we will find there will be an increase in the incidence of such an unfortunate condition when we have the friab le structure behind a relatively rigid one0 44 I must say that I concur with the three gentlemen who have stated that the larger the implant sphere that can be used,, the better„ within biologic limits9 obviously,, The 20 millimeter implant sphere posed a considerable technical problem9 but nevertheless in those cases wherein I have observed the larger implant spheres„ there has rarely been any objectionable degree of formation of the upper lid sulcus0 However„ there is no doubt that the 18 might be the critical pointo A 16 mm0 sphere,, if we go into geometry and figure the pi or first power thereof„ we know is of a volume of approximately 205„ but when we take the 18„ because of the rapid geometric progressions, we have a volume of 3o I have determined the volume of some 25 to 40 prostheses— • somewhere in there—made by the Army met hod s the all plastic, and have found them to be actually an average of 2C75 in volume0 For simplicity, let us assume that they are 30 If we take as our premises the fact that the average eye is about 605 cco in volumep when it is enucleated,, we give back to the orbit our 3 GCo We must make up 3-1/2 ccD in the anophthalmic socket0 We have actually two voids by which we intend to effectively obturate the one void in the normal case0 It is not to be presupposed that because we have the greater volume of 24eye„ roughly speaking lit varies a little bit of course) Tenon5s capsule will have the same0 It will be a little less when it is brought togethero So there is no need to go to the extreme and want all the volume in thereQ However,, again,, if the prosthesis be 3„ and the implant sphere be 3, that is 6, but the motility of volume is 6050 That just makes us a little bit shorto Nineteen hits it almost exactly, whereas the 20 mm0 sphere,, because of extremely rapid geometric progression at that point and at its pi or for the first powerB would be as great as 50 Now 5 and 3 would make 8, 1-1/2 over,, but perhaps that would compensate in those cases wherein there is some atrophy of the peri orbital tissues„ and particularly„ as is supposed,, the orbital fat0 It is a matter of concern to all of you I know„ and I would prefer from what I have seen to see a larger prosthesis inserted rather than a smaller one0 I have not evaluated this statistically.. I have tried to remember all these cases„ and it is relatively inexplicable why the anophthalmic socket sometimes shows no orbital sulcus and the unusual degree of motility of the posterior wallo Those are the exception,, howeveru 45 (Slide) In this case. I attempted. as best I could, to bisect the obicularis latuso It is close enough for our purposes9 although I did not have the proper devices« What I wanted to see is just what Colonel Shiflett emphasized. and that was the position0 I don°t quite get what he meant by his Class 1 and Class 2.% however8 from whatl have seens it falls within the line of limbus with the patient looking in distant vis ion 0 ConsequentlyB in this particular case. as in all these‘artificial eyes without exception. there is some degree of exophthalmus0 You can see the infra orbital ridge at this point and what would constitute the anterior pole of the cornea if we quite catch it there at that point0 So it was very interesting that it was emphasized0 It is exactly what I have found„ I cannot use the reading of the exophthalmometer unless I reduce it to a formula that whatever measurement I get on the normal side I can expect a one quarter loss,, and then assume that should be the position of the eye on its anterioposterior plane © This happens to be a glass spherep a 16 mm0 sphere. and it was difficult to palpate it 0 It receded somewhat., and in so doing there appears a somewhat hiatus between the implant at the prosthesis and the implant sphere which in actualitys by technical test9 is more apparent than realo This is a plastic eye© In these cases., in order to evaluate the degree of effective obturation, when we resort to the sphere extension with the curl back glass eye makers refer to it as the Blind Dutchman,, we find it necessary to bring it back so it imposes some stress upon the superior portion of the implant sphere, not an undue stresses w© do not want to depress it „ However,, we have to get an eye in the socket and our meridial plane from the lateral aspect must be in absolute verticalityc Of course. you know the plastic eye is completely radio lucento What we do in this case, and it is most expeditious„ is to take o001 tinfoils adapt it over the eye. adapt it thoroughlyo The increase of the surface o001 of an inch is negligible, but it is adequately opaqu©. so that when you insert it in the socket you can observe the relation- ship of the prosthesis to the socket0 You can determine, if so desired8 the degree of mobility of the prosthesis and actually have roentgeno- graphic evidence of same0 (Slide) Probably this is an evaluation of physiognomy<> It doesn°t look too bade It looks fairly normal0 There is a tendency for the lid from its lateral aspect to diverge toward the medial canthus progressive ly9 and when it is rather taut,, we put ia a prosthesisc We might get a little line0 It gives an impression of canthal foldsp which are obvious ly unwantedo However. I intentionally showed this at this time as sort of a psychological gesture,, Both of these are artificial eyes0 ooo Showing of slides Oo0 46 When you find a flaccidity of the inferior lid„ you find that the eye must be light, because there is a gravitation factor, but when there is no adherent lateral palpebral ligament and this tissue is rather mobilej then we get this little sag right at this point0 We did every- thing to overcome that„ That is as far as we can go by prosthetic means0 Once it is loose from its restraining ligamentous tissues, then it seems to follow the contour of the orbital rim, and, of course,, the orbitae on somewhat of a rhomboidal configurations, down a little bit, and this seems to follow it very well., So from what I can see, once there is a laxity on the part of the tissue you no longer have the support of ligamentous attachment to bone, it will assume that acclivity of the infra- orbital ridgeo There seems to be what I dubbed a monocular phenomenon,, I try to have the individual look straight ahead and invariably he turns a little bito He does it instinctively0 This is the way they put their best foot forwardo They put their best eye forward in this case0 That is some- what psychological because they want the better eye to show a little moreQ They put it forward0 Secondarily, in view of the fact that they have lost 45 degrees of their vision, this eye loses 45 on this side of the 180-degree field„ It is quite possible that they want to turn just a little bit to broaden that vision and compensate and give a little more to this side„ In so doing, we freauently find it is those cases that show a little more sclera from canthus to limbus medially than they do laterally, which we do not find ordinarily in the normal individual0 That is just one of the features that we pick up„ The decent ration of the eye also seems to determine the degree to which the iris itself is decentered one way or another, although we have no definite date on that0 (Slide) This is arcus senilis0 We dealt with the Juvenalis type0 It is very thin* close to the limbus*, incontiniura The arcus presenilis„ not incontinium*, and then a little wider and smaller pupils concomitant with aging*, and the arcus sinilis broader and somewhat irregular in its outline„ We can put pentralie or nevi or anything on the eye0 This can not be done on the painted disk*, This should lie on the plane of the cornea and it is done just that way» It is a fatty degeneration of that particular structure,., so that is where it should lie and it should be assiduously simulatedo (Slide) The use of the split conformsr„ Orthopraxis in ophthalmology 1 suppose is not a new thing, but Captain Callahan and also Major Coe out at Northington General Hospital have very extensively undertaken experiments along this line„ In view of the fact that I realized he was interested in it, I wanted to emphasize this0 We tried a different technic rather than to have the screw device with split conformer that will work in either direction - that is, laterally or medially, or both directions simultan- eously, or have a unilateral action or act both in superior and inferior direction, or act simultaneously0 This calls for adequate lateral sulcus as well as medial sulcus, and to increase the groove within the medial superior quadrant of the sulcus0 This is a rather sharp confomer, well rounded off, attached to a loop with holes for the reception of the wire with screw adjustment,. Ordinarily the socket would be about 28 mm., 28 to 30, internal dimatero On its horizontal plane this was some 16, In order to get it in. It had to expand about 12 to get it up to the 28. This was placed in conjunction with a stabilizing exterior prosthetic device, and with the various guy wires stabilizing this and with our screw adjustment we were able to stretch ito I think it can be very adroitly carried out, very carefully in every respect, with a check-up and removed perhaps every other day. In this case, unfortunately, we did get a little stretching laterally, although there had also been a mucous membrane graft laterally and inferiorly0 Vie can°t effect a stretching day by day. We can get it in this respect in a unilateral direction. It did necessitate the performance of a tarsorrhaphy. Perhaps in some respects there is much to recommend the tarsorrhaphy. I have seen some lid margins which are just a little bit irregularo That might be one objection. We have tried to overcome that by so doing. Nevertheless it didn°t work out entirely to our satisfaction. We got buckling of the upper lid and the punctum slipped under, and it didn9t produce what we wanted in the medial superior quadrant. Never- theless, such a device has possibilities, and I think if a number of men work along the line that something will be accomplished sometime0 DISCUSSION LTo COLo GUTLEHt The only comment I have is that it is our general reaction about a depressed upper lid that it should be corrected by one of the three methods that have been discussed here this afternoon,, and not by putting something on the prosthesis that is really a surgical problejra9 unless there is some reason that the patient or someone else doesn9t want to have it done0 ... The meeting adjourned at five twenty-five o9 clock o.o 48 THURSDAY MORNING SESSION LTo COLo Ua Eo RANDOIPH* Eye Consultant* Surgeon General0 Office* Washington,, D0Co* and Chief of the Department of Ophthalmology* Valley Forge General Hospital,, presidiago LTo COLo Ho Eo RANDOLPHS I am going to take a very few minutes to tell you briefly what the Army has been doing about the rehabili- tation of the blind soldier0 During the last war* we knew we had a number of blinded soldiers* but shortly after Armistice Day* these fellows were all gathered to- gether at a place outside Baltimore,, in Evergreen* and no one seemed to have the faintest idea who was going to take the responsibility for themo Was the Army going to b e responsible* or the Veterans0 Administration* or the Red Cross* or even The iunerlean Legiont The result was that the whole program was pretty much chaos * and from what we have been able to gather,, from the results we have seen in the so-called rehabilitated soldier of the last war* the results have been pretty poor0 Nothing particularly was done about the blinded in this war until after things got under way <> Around the spring of 1943* the Army suddenly woke up to the fact that in training maneuvers and so forth* a number of soldiers were being blinded by training accidents,, land mines,, grenades* and so fortho They were sent to two hospitals* Lebanon on the West Coast and Valley Forge on the East Coasto They were simply sent there with perhaps the casual remark* "Well* her® they areo Do something with them0" Due to the efforts of the staff at Valley Forge at that time* headed by Lto Colo James Greear* a number of workers who had had a great deal of training in civilian life and were in the Army as privates were gathered together and sent to Valley Forge to star! a program o Due to the efforts of these enlisted men - one from Detroit and another from the New York Institute for the Blind - they recruited a civilian staff of Braille teachers and typists* occupa- tional therapists and so forth* and the program got under way0 It so happened that the to the ratio at that time of about 10 to Ip were being sent to Valley Forge0 The program out on the West Coast did not yet become an actuality„ and did npt become so until Dibble was activated as a blind center,, at which time Colonel Cutler took over out there„ and he got a blind rehabili- tation staff together9 and thatp toop has been functioning with a great deal of efficiency0 49 Th® situation went on, and these boys were being given a certain amount of blind trainings but it was decided by the President's Committe President Roosevelt0 the Secretary of tfar„ Secretary of Navy9 Secretary of State,, and Veterans0 Administration - to put out a directive to the effect that all blinded casualties„ after going through what necessary medical and surgical treatment was indicated,, would be sent to a final blind training center,, which at that time had not been located0 It also charged the Army with the social rehabilitation9 not to be confused with the vocational rehabilitation,, which is the responsi- bility of the Veterans0 AdministrationQ So the Surgeon Generali's Office immediately started looking for a likely and satisfactory site which could be the main blind training centero They looked at places throughout Pennsylvania9 the East,, and in Florida-, and for one reason or another,, each place was rejected as being impracticalo Finally„ Avon Old Farmsp a boys0 school outside of Hartford,, was established for the purpose of final social rehabilitat ion0 It was quite a job getting that place started9 because the Army had culled what training personnel was available0 Nevertheless the Army took over on the first of June,, 1944,, and the xkvon Old Farms School,, now called Old Farms Convalescent Hospital Special9 was opened,, and the first group of patients from Valley Forge came there0 In briefp as to the Army°s program for blind rehabilitation,, I will give you just a sketch of what happens to a blind soldier as he comes into either Dibble or Valley Forge„ and take him on through to Avon Old Farmso He comes in, and he has assigned to him an orienting instructorD spoken of as an "orienter," This is an enlisted man who has been trained by the Blind Rehabilitation staff to be this boy0as guide and counselor The boys eften call these fellows their Seeing Eye Dogs0 He is responsible for the main activity of blind training„ and that is orientationo He teaches the boy how to get around the hospital the proper method of handling a cane„ how to go up and down steps,, the various little tricks of the trade which are not the least bit obvious to those of us who are sighted In addition to that „ he is responsible for this boy°s being taught how to eat and how to shave9 how to dress9 how to keep his room clean0 'Those things are terribly important 0 Along with that „ the trainee,, as he is called,, is immediately seen quite soon after he arrives in the hospital by a man who has been through the mill, and in the army it has been a fellow who has been blinded and who has undertaken the Army°s blind training program.,, He actually introduces this boy to blindness„ the psychological aspect0 It is an extremely important interviewo He tells him what it is like to be blind* what the problems are* and what the difficulties are that he will meet* what he can expect and what he cannot expect0 In addition to thats blind counselors are used to interview these boys* to discuss their personal problems These counselors are people who are civilians* who have been in blind work for years0 They may be blind or sighted0 Coincident with the medical and surgical care* this orientation is going on at all times* until the trainee is able to pass satis factorily a very rigid examination which includes the ability to go around the hospital* to go to strategic points within the hospital., and in the case of Valley Forge* the ability to pass a very stiff examination going around the streets of Phoenixville0 In addition to that* the trainee receives instruction in Braille and typing. Practically all of these boys resent Braille* because it is a stigma of blindness0 We are able to talk many of them into it by telling them that it will give them the ability to use their hands* to use their fingers0 Particularly fcr those who want to continue their education* it is impossible for them to do very much about it unless they have some my of taking notes* and Braille is the only way that can be doneQ Typing classes are important in the regime* and most of the boys are very enthusiastic about typing because it gives them a degree of independence0 With that* they have a large reconditioning athletic program These boys can bowl. They have crews at Valley Forge0 They have a crew which regularly gets trimmed by the blind in the Navy Hospital in Philadelphia0 They play golf* archeryo That seems strange for a boy with bilateral enucleation to go on the course at Valley Forge and regularly shoot in the nine holes in a little over 40o He says if he lifts his head up it doesn°t go righto When a trainee has finished his medical and surgical care* he is transferred to Avon or Old Farms o That is pretty much of a finishing school in one respect* and at the same time a sampling school in anothero Here they* of course* have to be reoriented and the same orienter system is in effect the re0 Old Farms is a rather difficult place in which to find one°s way around* because it i8 built like the medieval architecture of Cambridge or Oxford* find they have a great many obstacles that they have to know how to handle and so forth□ Here they are exposed to as many vocations as possible„ To be specific* there are sixty things which are offered these beyso I will give you just a few. There is a large machine shop where they can take down and put up automobiles and so forth; carpentry; woodworking; bookbinding; salesman ship; radio announcing; stand concessions* which is extremely lucrative vocation0 51 At this time,, we are not training these boys for that but we are exposing them to ito The object is to go to a job and pick out some- thing that you want to do in later life,, because we are shooting for one thing,, and that is not to have these boys sit on the back porch and rock and spend their pension for the rest of their lives0 The course at Avon is a little over four months,, eighteen weeks„ after which time they are given the CoD0D0 and transferred to the Veterans9 Administration. Veterans® representatives are at Avon at all timeso They are constantly interviewing these boys and finding out what they would like to do when they are discharged„ The cooperation we have from the veterans gets better all the time„ These boys, after they scatter throughout the country„ are being looked after in a very highly satisfactory manner for the most parto In that covers the Array's blind programo War Department Memorandum 40 40 is a brief outline of what the administrative details ares that is„ sending the blinded casualty as soon as he is able to travel, either to Dibble or to Valley Forge0 Those of you who may have any blind in your hospital can get them off your hands by sending them to one of those hospitals„ depending upon which is nearer his horae0 DISCUSSION CAPTAIN Bo Fo What is the total number of blinded casualties in this war? LT. COLo RANDOLPH? It is roughly about 10500 That includes the Navy blindedp of which there is a small percentage0 Our figures have had to suffer a little bifc because before we really had any blind center,, about 100 fellows were discharged without taking that train ing, and we have not been able to pick those fellows up very well to know for certain how many there were,, but it is roughly 1000 THE V0SSI0US RING PHENOMENA MAJOR TRYGVE GUNDERSON (Eye Consultant., Surgeon General9s Office) The Vossius Ring is the eponyra for a ring which was first described by Vossius in 190550 He made a more extensive report on the same subject three years later at the International Ophthalmologleal Congress in Lisbon It is also called the traumati« annular opacityp and has certain other names which usually signify its location or its cause0 52 1% might he defined as a ring which occur* on the anterior leas capsule9 only in young individual*;, following traumao Vossius0 original concept was that an object would hit the eye and actually indent the cornea far enough to push the iris against the lens with enough force to leave iris pigment behind on the lens capsuleo This was accepted for a number of years9 until another gentle- man raised the following objections? That in order to cause a per° feet ringp tbs object would have to be at all times perpendicular to the cozneal also that it did not explain certain instances that happened from perforating wounds in the back of the orbit D injuries ▼is a tergo9 as it wereo As time went on9 other characteristics were foundo Blood was usually found in the eyeQ It occurred in perforating wounds and non-perforating wounds0 But the general concept of iris pigment was the one which was generally accepted by everyone except a man by the name of Handmann9 who believed that blood was the important thing and that this might be the residual of blood on the front of the lenao The subject aroused my Interest aboufe a year and a half ago9 during the time of the pushover in Italyo It was shortly after the break through at Anzio9 when our hospital was moved up to Rome9 about a week after the fall of that city0 We were set up on the outskirtse and were receiving a great many casualties from the area between Rome and the Amo River« At one time9 we had 2700 freshly wounded in our hospital<> Naturally9 we had a great many eye injurieso At that time9 1 observed four soldiers with Vossius rings in the hospital at the same timeG The thing that struck me was that the rings were all the same size0 regardless of the fact that these individuals were wounded at different timeso Some were blown up by mines at night„ Others were struck by shell fragments in the middle of the dayQ Their pupils were9 in other words9 either dilated or contracted0 I did not see how it could possibly be from the posterior surface of the ipis9 if this were true0 because0 as you know9 the blast wave travels at some 129000 feet per second9 and the shell fragments themselves scatter about half that velocity,, about 6000 feet a second you might say9 and the pupillary reflex is rather slow9 in the magnitude of two -tenths to half a secondo So if a person saw the flash of an exploding shell at night „ the pupil wouldnH possibly have time to contract before the eye would be strucko As time went ons I saw a total of 19 of these Vossius rings8 and in every instance the size was constant0 It varied between 21/4 and 2-3/4 millimeterso This was a simple measurement, but not particularly accurate probablyo I just did it with a transparent millimeter ruler2 which I held before the cornea and made the measurement with the /8 sphere of the ophthalmoscope 0 There were certain other constant features„ It was always well formedo It was never seen in its formative stage, It was always complete when first seen0 I never observed it until about the fourth day after injury9 and this is very important0 You would believe that if the ring were due to a de- pression of the iris left on it at the time of the injury, the ring would be seen immediately, but this has never been reported 0 In fact, I believe the earliest two cases one reported by Dr, Gipner of Rochester - were reported approximately 12 hours after the injury0 It also, as I have said before9 occurs in young individuals, never in senile or preseniles0 In my series, each eye had blood inside it, either in the anterior chamber9 vitreous or retina, very commonly in the subhyaloid region and often far forward0 It is not a permanent damage0 The rings usually disappear in anywhere from two weeks to two months0 Showing of slides One feature on which I have laid a good deal of emphasis is the fact that the inner margin of the ring is very apt to be serrated and disappear into nothing and the outer margin is apt to be quite sharp0 The inner margin is not very apt to be sharp„ If it were an impression of the iris hitting it , you would expect that the free margin of the iris would leave the clear, sharp outline0 That the reverse is true I think is fairly strong evidence that the iris has nothing to do with ito To recapitulate9 we have a ring which occurs on the anterior surface of the lens in young individuals, always the same size, that has this feature of being irregular on the inner side and fairly regular on the outer always occurring with blood in the eye0 In looking for an explanation for this,, it is very interesting.. The closest that I can come to it is searching for the anatomy of the lens capsule, Busacca and Melll, an Italian and a Brazilian, did some interest img work on the lens capsules some years ago and pointed out that it has three layers, as you all know. It has the true capsule or epithelium, single layer of cells, surrounded by the pericapsular membrane, which ex tends all the way around the lens5 and thirdly, we have a membrane called the zonular lamella, which is after all a prolongation of the zonular fibers at the equator. This lamella;, according to Busacca and Melll, does not go completely around the lens but ends somewhere in the region where the Vossius ring begin If this be trueP the lens capsule must be thinner in this areao I think that it is very likely that a great deal of the interchange occurred in this zoneQ Of course*, the lens does require a good deal of nutriment and the interchange of fluids here satisfies that require ment, You may ask why the ring is not in all cases a disc0 ly„ it is but the disc is not the iule0 The absorption of the central area may be due to some other factor0 When I was at Valley Forge with Colonel Randolph*, we had an individual with sympathetic uveitis in one eye,, which he had had for a period of two or three months. At that timey we noticed that he had a definite zone of clearing of the precipitates in exactly the same area in which the Vossius ring phenomenon occurred The precipitates were scattered all over the entire anterior chamber over the iris*, the anterior surface of the lens*, and the entire posterior surface of the cornea,, but over the same disc-like area enclosed by the ring we found a definite zone of clearing This was best seen by the ophthalmoscope since that time I have observed another with Dr Cogan,, and someone told me that he saw a very similar one in a patient with siderosis bulb i o I believe this is additional evidence that there may be an in creased fluid interchange in this central area of the anterior lens capsuleo There are still many things that are not kno\m and that I cannot answer What effect does trauma have? If this be blood*, why doesnct it occur in nontraumatic hyphemia? Trauma always seems necessaryo I might mention one patient of Dr Zentmayer“SD who had the least trauma of any He was operating on a patient in Philadelphia many years ago*, for squint. Apparently the needle went a little deeper than usual and injured the root of the iris He found blood accumu lating in the anterior chamber*, after which time he rapidly finished the operation and put the patient under a double bandage and returned him to his room »Vhen he opened the eye four days later the patient had a well-marked Vossius ring This was confirmed by Dr, Holloway at that time. I repeat that trauma is always necessary in some way0 but exactly what effect it has is something that I cannot speculate about It may be that it actually l®®sens the zonular lamella from the pericapsular membrane*, or it may have some secondary effect that we yet do not under stando DISCUSSION CAPTAIN JOHN S0 McGAVIC (Valley Forge General Hospital)? I would like to ask Major Gunderson if it is not true that force applied to an envelope encasing fluid is equally applied in all parts of the enclosed contents, so that it is not necessarily true that the position will have to be perpen- dicular o Second, I would like to ask if he thinks possibly traction on the zonular membrane might be responsible for the production of the Vos sins ring, since the ring occurs at that pointo MAJOR GUNDERSON? I do not believe I can answer those questions very accuratelyo As far as I know9 fluid0s hypothetic pressure in envelope would be similar in all of its parts9 except that in the eye you do have a special mechanism in the valve action of the iris and lens0 I suspect if the pressure suddenly rose in the anterior chamber it would take an instant before it became equalized in the posterior chambero That brings up a rather interesting point, one that has been disputed im this argument, and that is that the lens has a different specific gravity from the other structures inside the eye, and, therefore, the wave of pressure traveling through would have an unequal hypothetical effect on these membraneso In other words, possibly the lens might have more inertia than the iris and they might be thrown against each other at different velocities,. I think it is a possibility that the sudden contraction might loosen the zonulaf lamella from the capsule0 That is a strong possibility, but that alone would not do it0 In that case, there would have be blood pigments or blood derivatives that would be deposited on this same area for some unknown reason0 LTo GOLo CUTLER? I would like to ask whether any experimental work has been done on animals © MAJOR GUNDERSON? Yes, it has been done by a number of people0 Gipner, in Rochester, is the last one that I know ofQ He did it with bebe shots, which are the most common causative agents in civilian lifeD He stood off at 10 yards from dogs and shot at their eyesc He was not able to produce any, and he tired of it finally0 That has been the experience of others who have tried it0 I think they probably have to go up higher in the animal kingdom in order to do it„ I believe it would be much more fruitful if you were to do that with baboons0 ooo Major Lo Jo Croll, Fletcher General Hospital, read his paper on "End Results in the Treatment of Retinal Detachments at Crile General Hospitalo" The retina as a whole is not involved in retinal detachment, but a 56 cleavage occurs between the two primitive retinal layers9 the pigment epithelium remaining in position attached to Bruch0s membrane9 while the inner retinal layers become separated from ito The retinal pigment epithelium originates from the outer neurectodermal layer of the embryonic optic cup0 The remaining layers of the retina arise from the embryonic inner neurectodermal layer0 Thus,, in retinal separat ion,, the inner layer becomes displaced from the outer layer,, allowing the potential space to become an actual spacea All retinal detachments may be classified as secondary and the cases of Idiopathic detachment are probably caused by inflammatory or degenerative changes0 Dr0 To L0 Terry„ in examining microscopic sections of eyes,, classifies separated retina into four general typess (1) Retinal separation with typical hole in retina,, arising from trauma;, and may be associated with mild uveitisD (2) 'Retinal separa - tion that arises from exudation under the retinae (3) Retinal separa tion„ with uveal melanomas® (4) Retinal separation with myopia0 The types of injuries causing retinal detachments ares (l) Direct injuries to the eye „ including perforating wounds,, intra ocular foreign bodies „ and contusions 0 (2) Indirect injuries to the eye „ as blows and contusions on the head,, and countercoup0 Duke Elder states that the choroid Is more easily ruptured than the healthy retina,, and the normal eye can stand the most severe trauma involving even rupture of the sclera and the loss of vitreous without the occurrence of a detach- mento We have seen a great many more tears of the choroid in War Injuries than tears of the retina0 Severe inflammatory lesions have been recognized as etiological factors in retinal detachment for a long time0 It is only comparatively recently that a mild equatorialP and anterior choroiditis,, has been considered as a precipitation factor in retinal detachment „ In these cases,, the detachment is due either to the formation of exudative subretinal fluid,, or to traction by fibrous tissue,, or to shrinkage of the globe 0 In war injuries,, we have seen severe vitreous hemorrhages„ which produce detachments9 as a late sequelap by contracting fibrous bands0 Gonin9 J0p In his latest papers„ obtained an incidence of 87$ of holes in retinal detachment„ and it was his opinion that retinal holes were almost invariably found in retinal detachments if sufficient time were spent in looking for them0 Duke Elder,, in summing up the significance of retinal holes9 states that the hole itself is not sufficient to cause the detachment 0 Other factors,, such as disease,, degeneration and severe trauma„ play a part in retinal detachment0 The consensus of opinion today is that a retinal hole exists in nearly every case of retinal detachment except those caused by intraocular tumor0 Retinal tears or holes may be single or multiple and of varied form and size0 The types of retinal holes usually seen in retinal detachment ares (1) Crescentic,, horse-shoe-shaped tears „ the convexity is always turned towards the optic nerve and usually occurs in the upper half of globeo (2) Round holes, occurring either singly or in groups„ 57 occurs chiefly in temporal half of the globe,, mainly in the supra temporal quadranto (3) Irregular slits and fine sieve like perforations usually seen near or at the periphery0 (4) Dialysis or disinsert ion at the ora serrata occurs almost always at the lower part of the globe mainly9 in the inferior and inferior temporal quadrants„ Subsequent detachment spreads slowly backward and upward with delayed involvement of the macula and visual disturbance0 In war injuries„ when the patient suffers severep violent traumaj, more than one hole is often found in retinal detachment 0 In several cases9 the retina was lacy9 ripplyp sieve like,, with many holes0 The position of a retinal tear may be localized ophthalmoscopically by estimating the number of disc diameters (ij- mm©) from the tear to the disc or ora0 This is a gross approximate method and easily done Each disc diameter is 1©5 mm© and the ora serrata is considered 8 Mo from the limbus of a globe measuring 24 mm0 on its anterio posterior axiSo Drawing of the fundus with details,, and localizing the retinal hole in relation to retinal blood vessels„ is another helpful method George Stine°s method,, with tables for retinal localization„ is a more accurate method© The patient uses Sehwelgger perimeter at 19 cm© and looks at own eye in mirror or a finger (propiC'Ceptive) if macula damaged. using giant scope to look at tear,, and draw away until beyond range of arc„ rotate arc until it intercepts ophthalmoscopic beam9 and read off arc on perimeter arm„ and angle through which it is turned,, and consult tables for localization of retinal tear on the globe© All the cases of retinal detachment were operated by different members of the eye staff at the Eye Cril© General Hospital;, UoSoAo* The operative procedure consisted of a large conjunctival flap, with good exposure of sclera0 Area of detachment was outlined with methylene blue9 and the scleral area outlined was treated by using a single point insul ated tip electrode8 causing micro punctures0 In many places„ the punctures were enlarged to insure adequate subretinal fluid drainage0 Drainage holes stay open longer and the retina is more likely to fall back into posit ion* when a special current (coagulation and cutting) is used; thus partial drainage is established early in the operative procedure and the retina is more easily caught by the adhesive choroid it is„ Multiple diathermy punctures give adequate drainagep whereas surface coagulation with two or three diathermy punctures may give inadequate subretinal fluid drainage0 In war injuries9 where the retina often is shriveled and has multiple holes8 the entire affected area should be treated„ in an effort to close all the retinal tears and cause adhesions of the retina around th® holes0 * The two scleral resections were done by Lt© Col© Gilbert C© Strublop M© SUMMARY OF CASESs (See chart on next page) 58 NAME AND AGE OF PATIENT j AGE OF i DETACH- ’ MENT PREVIOUS SURGERY ETIOLOGY HOLES I VISION BEFORE SURGERY VISION AFTER SURGERY VISUAL FIELDS . g ; j 19 yrs ! 3 mo none Infla mmatory none 20/100 J-5 20/100 J-5 Improved r-,b; *r~~ • - - - - —■ — — ■ - . • —». - 23 yrs 36 mo none Degenerative Dialysis II M JO 20/100 J-4 • Improved MoJ o 1 *: — 35 yrs , 7 mo . yes Trauma yes , 5/200 J-0 10/200 J-0 Improved BoJ * — ■■ - • 23 yrs . 5 mo > none Inflammatory none 5/200 J-0 5/200 J-0 Improved H,AT' ’ .. — ' 32 yrs , 2 mo., yes . . Trauma ... Dialysis 20/400 J-0 20/400 J-0 Improved r-.z ' ' • Trauma -i- -V w * — - 23 yrs 2 mo , none L.FoD. Dialysis Ijo P o L, P- Improved F M? V ' * ‘ * ' * ■* - * • 24 yirso 10 mo yes Blast none 20/20 J-l 20/20 J-l Improved R., H, ■ • — , • - • - 21 yrs3 11 mo., none Inflammatory yes 20/80 J~1 20/70-3 J-l Improved FoL-“ - C> F/ in 19 yrs > 3 mo yes Trauma yes L 0 P 0 T, field Improved C 0 J/ '' 2G yrs 5 mo, none Trauma Dialysis L0P0 10/400 Improved P’oPV Trauma — 24 yrs 5 mo , none I ,FoB yes L oP 'i L qP y. Improved 59 NAME AND AGE OF PATIENT AGE OF DETACH- LENT PREVIOUS 1 SURGERY ETIOLOGY HOLES VISION BEFORE SURGERY VISION AFTER SURGERY VISUAL FIELDS SoRo ' Sclerectomy 29 yrs> * * -- 2 moo none Trauma Dialysis Poor LoPo Clear LoPo Improved J oE o Trauma Sclerectomy 21 yrs o 26 TTIOp yes IoFoBo Dialysis L oP o 20/l00 J-5* i Improved W Jo*' . - Trauma - - ~ 25 yrso 7 no,. none IoFoBo yes 10/200 J~0 Enucleated EotT o 2 I0F0B0 . ' -.. - 23 jtso 6 days removed Trauma none LoPr> Enucleated 60 Comment s Areas of dialysis were present in s ix cases and peripheral holes in five;, and no hole was seen in four cases0 Extensive barrage was done over the affected area because of the severity of the injuries„ The use of a combination coagulation and cutting currents rather than coagulation currents, is preferred in securing delayed healing of micro-punctures9 thus resulting in adequate drainage9 and reattachment of the retinao In cases of spontaneous reattached retinas in young active recurrent detachment resulted when patient became ambulatory9 necessitating surgery„ Scleral resection was done on two cases of severe retinal detachment with good resultsc Acknowledgement is made to Lt0 Colo Go Co Strubles Major Ho Go Scheie9 Major Jo D„ >Sleight and Capt 0 Hoyt for allowing me to present these cases and to Sgto Helen Hellebo who perforated the visual field studies .and prepared the inclosed field records0 I take this oppor® tunity to express my thanks to Lt0 Col0 Go Co Struble for his advice and assistance in preparing this papero DISCUSSION LTo COLo STRUBLEs At the time the retinal detachment became available to us9 about two years ago8 I will be frank to say that I was a little skeptical„ As a matter of facte, I was afraid to use it9 having had no experience with ito So before I began using it „ I calibrated on animal eyes9 on pigs0 eyesn using the power settings recommended by the company that put it outo I think you will remember that there are three main types in your kito One is the one-point electrode (insulated)0 They recommended a power setting of 30o On the two-point9 they recommended a power setting of 34 on the Schoenberg Hooke On the six-point electrode I insulated)9 they recommended a power setting of 500 I tried all these different settings and variation on pigs0 eyes and then dissected them and found that the power settings recommended weres at least with our voltages, much too higho The retina was simply burned up and the sclera was burned up0 After dissecting a good many of these eyes9 the conclusion that I reached at that time on the one-point type was about 169 or anywhere between 15 and 20„ I think it varies in different places9 in different towns9 depending upon the line voltage„ At Billings 16 worked well0 Our experience here has been that 18 is about correcto We found 22 best for the two-point and 20 for the six-points but we have practically discontinued the two latter types and are using now entirely the one-point electrode0 * POWER SETTINGS POWER SETTINGS RECOMMENDED BY RECOMMENDED BY LIEBLE-FLaRSHEIM CO* EXPERIMENTAL hND CLINICaL work One-point Electrode (Insulated) 30 16 (15-20) Two-point Electrode (Schoenberg Hook) 34 22 Six-point Electrode (Insulated) 50 20 Personnaly, I am quite satisfied with this instrument0 I think there are some things about which we have to be carefulo The field should be dry, and we must be very careful in putting the tip of the electrode on the sclera that it is entirely perpendicular as the point goes througho If you go through at an angle9 you can get a bad tear and bad burn of the sclera and get a'considerable prolapse of the vitreous, if you are not careful-. Just a word about the experience that Major Croll described„ On that one case that you saw9 we used just the surface coagulation and we did get a very severe choroidal effusion, I am quite certain that is what it was„ The next day the detachment was very much worse,, probably because we did not have enough drainage and we had to go back and operate on him later with multiple punctures„ He eventually came out all right except that a portion of his retina involved with this massive choroidal effusion no longer functioned0 so that he incurred a severe and permanent loss of his field,, although his detachment was eventually curedQ I should like to ask if the other members here have had the experience that we have had, that eyes with siderosis do poorly with any kind of surgery0 We had one case of detachment which Major Croll reported with intra-ocular foreign body and siderosis and the eye did poorly We expected it to do poorly, as a matter of fact, but it was relatively quiet before we operated, and even though we got it out, it still went to pot after wardso So when we find siderosis in the eye we feel quite discouraged about the whole situation before we even do anythingo 62 LTo COLo RANDOLPH; I can certainly agree with you on that, This- eyes with siderosls do poorlyo You found also* didn’t you* Colonel Rlwchun* that the power setting.- in the original leaflet put out by the company were far too nig 1 think we went ahead and put a notice in the Bulletin to the effect r.r.at the povrer setting should be in the range that you describe, Co li- st ruble , But didn’t you find it that way? LTo COLo RIWCHUN (Walter Reed General Hospital)i Yes* I agree with Colonel Struble that the power setting is way too high We w.t down to approximately the figures Colonel Struble had.. Witn that, it worked wello MaJOR DeBOW; I would like to ask what the experience of this group is with the injection of air into the vitreous in detached retinaso COLONEL STRUBLEs We have not used the procedure at all am sorrv o LTo COLo RANDOLPH; I had one case where I injected air in the vitreous I fished around for a foreign body* which reacted slightly to the magneto His retina was pretty much all off 1 X went n with a very fine pair of forceps and I think I would have been there yet trying to grab this thing* but I couldn’t get it- I filled him up with air* and strangely enough* the retina has remained iq place* although the foreign body is still present0 la another case where a forceps extraction was used on a p e - of copper* just behind the lens* with the resultant- loss of cons'w- able fluid vitreous so far (it has been about two months now)*the man seems still to be all right LTo CCLo CUTLERS I have injected air in the vitreous ana in the chamber and injected saline* and I haven51 had any bene': n a effects from ito At one time* I had the idea that perhaps grafts of epithelium might be used* but I never got around to doing ito I heard Dr0 Pischel give a sort of symposium on detachment the retina about a month ago in San Francisco* and I was impressed with hxs good result So I am also impressed with the good result* that Major Croll and Colonel Struble have had herac I didn’t bring any statistics on «ur own results,, unfortunate vc There Is one aspect of detachment of retina whiek was mentxo.ue--- aer©* and which Dr0 Pischel himself went over rather offhanded" and that is the matter of preoperative tension , I think that, the matter of preoperative tension is important <, McNamee* in repair.-.tig of detachment of retina a large series of cases, also found it had a definite relation to the prognosiso I think that the postoperatire tension also is significant because I believe that you can get a reduction of tension9 depending on where your areas are put and how you put them,, in that you may pro duce a partial effect of cyclodiathermy„ I know of eyes a number of years ago when we did reduce the tension by doing that in an uncon - trolled glaucomao I also am inclined to think that the condition of the vitreous has a great deal to do with the detachment 9 in the first place 9 and also with prognosis in the second place „ Thatp toos we do not ordinarily study or perhaps pay enough attention to0 It has been demonstrated by a number of people that a shrinkage of the vitreousD with demonstrable adhesive bandss has apparently resulted in tearsp and I am inclined to feel that we are treating a symptom when we treat a tear0 We all know that when we remove foreign bodies that intrude upon the eye without a treatment rather than the hole made9 we do not get detachment0 We have all seen a number of eyes that have foreign bodies in them,, in which the eye is quiet and there is no detachment0 Appar ently s, it must have got in from a holec In some respectss I am amazed that we can re-attach retinasp since we really do not know a great deal about them,, I think., as yetc At our place„ we are always arguing about the pinhole glasses9 since the fellows come from different parts of the country., and we appear to get results with or without pinhole glasses0 Another thing that has impressed us is that in certain types of detachment p at the end of approximately 18 days,, the retina has not been in place9 and a month later it has8 and he has not worn pinhole glasseso I don°t know how to explain thato If he had worn pinhole glasses9 of course 9 we could explain it as being due to pinhole glasses j, but we are at a loss when he does not wear pinhole glasses0 I believe that the condition of the vitreous and the volume of the vitreous is going to have some relationship to our detachment cases and their treatmento I hope that as a result of the experience we are getting, we will get information which will enable us to make a better prognosis0 It is something that we are very .much interested in out in San Franciscoo I am hoping that we will be able to decide whether we should get our patients up the next day after detachment of the retina or keep them 18 days, whether we should have them wear pinhole glasses or whether we shouldn°to 64 Pischel demonstrated, as you probably have seen these flasks, one with gel in it and the other with solo He has a solution —I have forgotten what it is-®which shows how when a tear is present a solution will flow behind the membrane and cause detachment to extend. To me that doesn’t have any significance, because the vitreous is a sol gel, and not a sol or a gelo Why you should use one thing to demonstrate one part of your detachment and another thing to demonstrate another part, I don’t know, but I think you have to con- sider the vitreous as a sol gel0 We know that a certain amount of trauma causes so-called synerisis to take place where the solution tends to separate from the gel and if you have a more fluid vitreous you probably should get an extension of your detachment or perhaps the detachment occurs in the first place0 I believe that in adding air or saline you are further disturb- ing the sol gel relationship and you cannot expect benefit from that type of procedureo It all ends up to the fact that I guess I don’t know very much ahout it o DR, HJEDEMAHNs I might add a word in regard to our civilian side of the retinal detachment story, and that is it is no good. In the first place, when you go from the traumatic side to the idiopathic side, you get a rapid falling off in your end results. On the traumatic side, you get between 70 find 90 per cent good results. On the idiopathic or the infectious side, you drop down to anywhere from 10 to 15 per cento I concur with Dr, Cutler that there is something wrong with the vitreous, I go one step further, in that in most of the so- called idiopathic retinal detachments, in which the patient gets a blurred area and then goes on to almost complete detachment, these people have degenerative eyes and the operation for retinal detachment does not cure the degenerating globe<, We have reviewed our cases in regard to these, and I would hate to tell you our end results, because you would immediately find fault with the method we are using, and that has nothing to do with it. We have used single cautery tip, surface cautery, penetra- ting with the single needle, and we found that neither one was as good as the single Walker pins put through the eye and getting very good drainage0 65 As you go down the scale and get away from eyes that have been in* jured, your results fall off very rapidly0 When we take one group, we get a very good result , but when we include them all, our total results are in the neighborhood of 29 per cent good results0 I am not bragging about it„ 1 am just telling the factso In our results, I think we should talk facts0 We have taken these patients who had a so-called idiopathic or infectious type of retinal detachment and have subjected them to a course of typhoid fever therapy plus deep diathermy for a week or ten days, and then done cauterization of the retma0 Then we go back and give them their bed rest0 They have not been in progress long enough to give the end results„ I might say that it does not look very promisings and the single Walker pin is still the best from our point of view9 unless we operate on some of the traumatic ones early enougho A few of them will get better in spite of surgery„ I mean by that9 that they will get better if no surgery ia done0 I do believe that they should be operated upons and I concur with Colonel Cutler that the hole is not always the ira portent point in the retinal detachment9 although if it is found it should be corrected0 Thank youo 1'AJOR CROLLs I would just ask a question 9 whether anybody else has had any experience with scleral resect ion0 LTo COLc RANDOLPHS I assisted in one9 as did Captain McGaviCj, but that is as far as my experience has goneG It sounds like a fascinating procedure and I think we will look for cases on which to do it© ooa Captain John So McGavic, Valley Forge General Hospital, read his paper on ’’Visual Disturbances Associated with Head Injuries ©.,© The lesions that were studied involve the chiasm, the optic radia- tions and the occipital cortexc The anatomy and physiology of the chiasmal fibers require no discussion„ The geniculo-calcarine pathway lies in the internal capsule behind the sensory fibers and internal to the auditory fibers» Fibers from the upper retinal quadrants lie dorsally while fibers from the lower retinal quadrants lie ventrally0 The macular fibers lie between the latter two bundles„ It is under- stood that the visual cortex occupies the medial surface of the occipi- tal lobes from the occipital pole to the anterior end of the calcarine fissureo Posteriorly the visual area extends a little on to the lateral surface of each occipital lobe0 This area is thouglt to Include repre- sentation of the fixation areac Opinion is divided as to whether or not there is bilateral cortical representation of the macular areas0 The consensus is that each cortical macular center represents half of both maculas, that is the left cortex represents the right half of each fixa- tion area, and vice versa„ This must be so as there is division of the fixation area of the field of both eyes when the entire occipital cortex on one side is damaged„ The so-called "sparing of the macula" is the 66 rule in vascular disease but is less frequent with traumatic lesions0 Sparing of the entire fixation area is less frequently found when the central field is closely studiedo One then finds division of the fixa~ tion area rather frequent0 There are three reasons for sparing of the fixation areas (l) Escape from injury of this area in the cortex<, (2) There are two blood supplies to the occipital cortex5 the calcarine artery and the middle cerebral arteryo (3) Patients may learn to use eccentric vision8 particularly when the fixation area is divided0 In vascular accidents only one of the two arteries is usually occluded0 Hence, sparing of fixation is the ru.lec In traumatic cases, both arteries may be damaged, or the entire cortex destroyed0 The cortical representation of the macula is quite large as compared with the area representing the larger peripheral portions of the retinae This is analogous to the large motor and sensory areas in the parietal cortex representing the finger and thumb as compared with the areas representing the trunk and the extremities0 In the area striata, the periphery of the retina is represented near the anterior end of the calcarine fissureQ Lesions in this area usually include damage to the optic radiations9 and few authentic cases have been recorded where isolated injury to this area was present , The upper portion of each retina is represented on the area above the calcar ine fissure, while the lower portion of the retina is represented in the area below the calcarine fissure0 When the area below the calcarine fissure is injured9 one should see a defect in the upper fields of visiono The explanation for infrequency of such defects is that wounds in this area often result in death because of injury to the cerebellum and large blood vessels0 Traquair states that traumatic lesions of the optic nerve and occipital lobe are frequent while trauma to the chiasm is rare, and that lesions in the genicula pathway are more often vascular than traumatic in origin Twelve cases are reported0 9^eKqQ_Xo 'Wounded by shell fragment Sustained skull fracture in left parieto- occipital region0 The field defect was? Right hononymous hemianopsia, congruous with sparing of the fixation area and sparing of the small portion of the lower portion of the right field adjacent to the midline. Vision was 20/15 OoUo Interpretation? The site of injury, data obtained at operation, X -ray and field defect indicate a lesion of the left occipital cortex0 Sparing of the fixation area is probably due to the dual blood supply by the calcarine artery and the middle cerebral artery0 5iyL§,-JiQ= o Received compound depressed skull fracture with injury to the brain in the right temporo-parietal area8 with retained metallic foreign body in the left occipital lobe of the brain8 end complete hemianes- thesia with no loss of motor function„ Soldier was unconscious for at least two weeks8 when later he found he was totally blind „ He could move his left arm and leg although he had no sense of position8 and that he had loss of sensation over the left side of his bodyQ The field defect is; Left homonymous hemianopsia with division of the fixation areao- The vision at this time wass O.D0 LoP<>; 0oSo 2/200 0 There was no direct injury to either eye» The hemorrhages in the vitreous could be explained by sudden increase in intra-’Cranial pressure andconsequent compression of vaginal space of the optic nerves and bleed- ing from the central veins0 Interpretations Injury to the right occipital and parietal lobes by penetration of foreign body accounts for the left homonymous hemian opsia and left hemianesthesia and mild left hemiplegiao Case NOo 30 Received comminuted fracture of both leaves of the occipital bone withextensive stellate fractures of both parietal bones0 and multiple metallic foreign bodies at a depth of 5 to 6 cm0 in the left parieto occipital areao He was blind for 15 days when he was finally found to have light perception0 He had bilateral papilledemao The field defect is? Right homonymous hemianopsia with division of the fixation areao Visions 0oD„ 20/70; 0oSo 2C/l00o Interpretations The injury to the occipital region with tract of foreign bodies through the occipital and parietal lobes8 with the data obtained at operation9 X-ray examinationp and the field defect indicate damage to the left occipital cortex and deeper tissue of the brain0 Case NOo 4L Comminuted fracture of the left parieto-occipital region with damage to the dura and brain0 The field defect iss Left homonymous hemianopsia with consider- able loss of the right lower quadrant of the field of each eyep marked OoSo9 and with involvement of both fixation areas0 The vision? OoDo 2C/200, OoSo 6/200o Interpretation; The site of injury„ date obtained at operation,, and by X ray examinations, together with the field defects indicate damage to the posterior poles of both occipital lobes9 especially to right5 and the optic radiations on the lefto Case - Ho, a— Compoundp comminuted fracture of the occipital bone9 more xtensive to the right side of the midline0 The field defect is? Left homonymous hemianopsia with involve- ment of both fixation areas and loss of a large portion of the right lower quadrant of the fie Id „ Vision; OoDo Cc.F0 at 3 feet° 0oSo CoFo at 4 feeto Interpretation; The left homonymous hemianopsia is due to damage to the right calcarine areao The damaged area in the left occipital cortex must lie .above the calcarine fissure and involve the tip of the posterior pole to produce a lower field defect with loss of fixation areao fia§§JSsL^ Wounded by sniper’s bullet„ Struck in the posterior portions of the parietal bones and superior port!cn of the occipital bonep chiefly to the left of the midline0 The field defect* is; Complete right homonymous hemianopsia with loss of about half of the lower left field of each eye and involvement of both fixation areas0 There is also loss of the temporal periphery of the temporal field, 0oSo Vision; O.Do Hand movements nasally, 00So Hand movements temporallyo Interpretation0 Location of the defect in the skull plus the field defect indicates damage to the left occipital cortex with lesser damage to the right cortex at the posterior pole and above the level of the calcarine fissure producing the defect in the left lower fields and involvement of the fixation areas0 -Case No o ?,0 Compound.., comminuted fracture of the right parietal region with herniation of brain substance from the woundo The field defect isu Loss of all but a portion of the right lower fields of vision,, with loss of both fixation areas0 Visions OoDo Hand movements at 1 foot; 0oSo Hand movements at 1 foot0 69 Interpretations Bilateral damage to the occipital lobes, greater on the right side,, with damage above the level of the calcarine fissure would explain the field defect a <3ase BJoq, 9 Compounds, comminuted, depressed skull fracture in the mid occipital region just above the lambdoidal suture and several deeply placed metallic foreign bodiesQ Four were near the midline and one was in the right occipital lobe0 The field defect iss Loss of all field of each eye except for re- tention of 2 degrees in each fixation areaQ Vision was nil for a long time after injury„ Ten months after injury the vision was; 0oDo 20/50 and OoSo 20/20 with correct ion0 Interpretation; Bilateral homonymous hemianopsia with sparing of both fixation areas indicates a lesion to both occipital lobes with out destruction of the tip of either occipital lobe where macular vision is represented in the cortex.. Case Noo 90 Compound, depressed fracture of the left leaf of the occipital bone and several foreign bodies in the left frontal lobe0 This caused complete blindness, although both pupils reacted to lighto There was bilateral papilledema0 The field defect is; Loss of all field in each eye except for retention of 1 degree in the fixation areac This patient is able to read only one letter at a time0 Interpretation; Damage to both occipital lobes with fortunate sparing of the cortical areas representing the fixation area of the retina. Damage to the anterior portion of the calcarine area accounts for loss of peripheral field0 Cji.se IjOg^lQ^ Compound, depressed skull fracture in the mid-occipital region with contusion of the right occipital lobe0 The field defect showed a left homonymous hemianopsia with sparing of the fixation area0 Four months later, the field defect was a left homonymous lower quadrant anopsia with the fixation area sparedo Vision on the earlier date was; 0oDo 20/30; 0oSo 20/30„ On the latter date vision was; C0D0 20/15; 0oSo 20/20n Interpretations The left homonymous hemianopsia is explained by damage to the right occipital cortex„ The improvement in the field on second examination four months later can bo explained on the basis of subsidence of edema in the area adjacent to the destroyed cortexo Case No JJU Injury to the occipital region„ Blindness was immediate follow ing the injury 0 The patient became unconscious about twenty minutes later0 Vision returned three days latero The field defect is a large absolute homonymous hemianopic scotomao Vision iss 20/200„ eccentric9 in each eye0 Interpretations The findings indicate damage only to the posterior tip of the cortex of each occipital lobe,, slightly more extensive on the left sideQ Cgse, No 0 Sustained a blunt„ non-penetrating blow in the left frontal regiono The field defect iss On 9 May 1944P the fields showed a clean-cut bitemporal, hemianopsiao On 10 September 1944„ the right eye showed loss of the entire temporal fie Ids loss of the fixation area and the outer f if teen d egrees of the nasal periphery,. The fixation area was involved,. The left eye showed loss of the entire temporal field except for a small area bordering the midline above the fixation area which was not involved,. Vision was? 0oDo 1/200 (eccentric)„ 0oSo 20/20 , Interpretations The lesion must lie in the chiasm,, involving principally the mid-portion with damage to the crossed fibers and sparing of most of the uncrossed fibers„ CONCLUSIONS^ 1© Correlation of visual field defects with definitely known sites and types of head injury,, the findings at and X-ray examination of the skull offers the best method of studying the cortical representation of different areas of the r etinao 71 20 Cortical representation of the fixation area (macula) is similar to cortical representation of the peripheral portions of the retinae The fixation area is represented at the posterior tip of the occipital lobes while the peripheral portions of the retina are represented in the cortex at the anterior end of the calcarine fissure0 Intermediate points of the retina are represented between these two areas of the area striatao 3o Similarly# the upper half of the retina is represented in the cortex above the level of the calcarine fissure9 while the lower half of the retina is represented below the calcarine fissure0 40 Neither the fixation area (macula) nor the peripheral areas of the retinas have duplicate areas of representation„ bo It# therefore9 follows that homonymous hemianopsia8 vertical hemianopsiap and quadrant anopsia can occur in the peripheral field and that the central fields may also show homonymous scotomas which may be lateral or verticals central or para- centralp hemianopic or quadrantic in shape0 Combinations of homonymous hemianopsia and central ocotocias also occur when missiles producing oblique wounds pass through the tip of one occipital lobe and through the occipital lobe or optic radia- tions on the opposite side as shown by Holmes and Lister0 60 Bilateral homonymous hemianopsia with sparing of the fixation areas (cases 8 and 9) represent the antithesis of bilateral central scotomas with normal peripheral fie Ids0 These cases support some of the statements in previously stated conclusions0 70 Bitemporal hemianopsia can occur from damage to the chiasms although it is rarely a "pure” hemianopsia0 The mechanism of this damage to the uncrossed fibers alone is not entirely clear0 Although each lobe represents half of each eye„ the term bilater- al representation of the macula is confusing9 as the points of representation are precise* they are not duplicated and there is9 therefore9 damage to fields of both eyes0 DISCUSSION CAPTAIN ALSTON GALLaHAN (Northington General Hospital)s This does not correlate exactly with the paper, but at Northington we have been running a study of electroencephalography in relation to ophthalmologyo A few years ago there appeared in the Journal of the American Medical Association an article by Mayer* using cases similar to these which have been presented this morning* in studying the electroencephal ©graphic changes from the occipital lobe and testing the preception of light o I am sorry to say that in running a series of 130 cases, we found there was no direct connection between the electroencephalographic response and the visual abilityQ In other words, we found that Mayer°s paper3 while it is true in many cases, is not an absolute way of differentiating true from false bands, because we had some cases in which a normal alpha wave was present which continued without change whether the eyes were open or closed„ You may be familiar with the method of testingo It is simply to have a patient lying down in the room and have the leads from the occipital lobe and have them turn the light on, and have the patient open his eyes0 We also studied to see if there was any help that could be gained with electroencephalography in differentiating different types of eye lesions, and again we found no difference in ito For instance, we have a normal eye on one side and an eye with marked optic atrophy, but not complete, on the other side0 Then we would test each eye alternately„ In those cases, we found the same type of JS0E0D0 changesQ Our findings were almost entirely of a negative nature, but I think they are ini” portant because there is creeping into eye literature the belief that the EoEoDo can be used as a method of telling absolutely whether an eye is blind or not, and our experience shows that it cannot„ CAPTaIN UcGAVIC: I am sorry that I forgot to say that this paper was prepared with the assistance of Lt« Colo Bedford,, The meeting recessed at eleven o°clock 73 THURSDAY AFTERNOON SESSION Lto Colo Po Ro McDonald, Executive, Medical Service Branch, Air Surgeon0s Office, Professional Division, Washington, DcCo, presiding» TESTING OF NIGHT VISION LTo COLo Po Ro MCDONALDs For several years, I have been studying night visionD In the early part of my Army career, 1 did work at the School of Aviation Medicine at Randolph Field» The problem that presented itself was one of first determining what variation we might expect to find in any Individuals that we had in the Air Corpso If you remember, the Battle of Britain was fought mostly at night„ Early in 1940, General Grant went over to England and saw the work that they had been doing in flight vision and came back to this country and insisted that some program be instigated immediately0 The National Defense Research Council of Scientific Research and Development had a Committee on Vision, and -at that time two people, the late Lto Com0 Linn of the Navy and I went to Randolph Field, which was in 19410 The Lieutenant Commander went up to the Do SQ Enterprise and we conducted studies on several hundred Navy pilots and Air Corps pilots We found that it might be expected in a highly selected group of individuals that the variation was very great» Ho we felt that we could go ahead with developing a test of night vision„ We were not too satisfied with the test the British had at that time0 Of course, the aim of tiny test of night vision, as far as the military service is concerned, is to try to reduplicate the conditions that might be encountered in the night operation, providing you can reduplicate these conditions0 We wanted to know what was the reproduced:lity and reliability of our testso Could we expect the same results from time to time? Was there enough spread in the scores that we got so we could classify individuals into good, poor, or very good? The last problem was one of validity„ Does this test mean anything as far as night operation is concerned? To develop a test for the military services, they went back to the original work of Hecht, who did more in this country than anyone else to develop a satisfactory test of night vision0 The Hecht adaptometer was a small instrument to determine the threshold to a flash of light0 Hecht had laid down these five criteria for any satisfactory test at nights lo One should know the time and the intensity of the light adaptation f The reason one had light adaptation before dark adaptation was that everyone would then start from an equal level, and we know the difference when you come in out of sunny day into a dark room or in a dull dayo So everybody was given a bright light uo shine in their eye for a certain period of time and had to know how bright it was0 2o Then, as far as the testing flash was concerned;, it made some difference as to whether the area of the retina you stimulate is nasally,, temporallyg or how far away from thereQ The most sensitive part of the retina is approximately seven or ten degrees on either side of the maculae That is the most sensitive portion to flash the light at threshold levels0 It might interest you to know that in one of the commercial instruments on the market, for sometime in testing one of the eyes, if the object fell on a blind spot., they had neglected to take into consideration that 15 degrees on one side, you had the same fixation point0 30 This criteria is one that has to do with an area of retina to stimulateo In the total area, if one used e. two-degree field or one used the 20 degree field, one would naturally get a much lower threshold with the larger fields 4o To a flash of light one had to know how long the flash was exposedo The flash of a fiftieth of a second had to be much brighter than one of a sixth of a second*, and also that would be brighter than one exposed for one second0 50 You had to know the color of the testing light0 Having these criteria, we did not think that the Hecht adaptometer research instrument was satisfactory for the purpose of the military service, so we reviewed these criteria and decided which we could eliminate to make the test simple0 One thing you could eliminate would be the light adaptation provided you were assured that everybody got an adequate period of dark adaptation The dark adaptation can be obtained by having individuals sitting in rooms completely dark half an hour., having them wear red goggles with 75 transmission only in the deep end of the red in a room of this intensity and spend the last ten minutes in a dark room*, So we did away with the light since we were only considering the threshold and not the total rate of that adaptation*. The first one then can be scratched off the test for military services „ The second one, the retinal location, demands that one have a fixation device on the instrument, for pilots are taught to use scanning under load- ing gauge, and we thought by doing away with the fixation device and reiterating it to the pilot as they take the test, that they should use perifoveaJ vision and move their eyes one way or the other0 They would be simulating the conditions under which they would be flying. We realized that when we took away the fixation point in the night vision test, some individuals would fail the test because they don’t do it correctly as the fovea is essentially a blind spot at night and some would probably look at it in some high threshold and actually the dark adaptation is entirely wrong□ The size of the retinal area stimulated depends to some extent on the size letter one is going to use0 The criteria that was insisted upon was any test of night vision as far as the night service is concerned should use form discrimination, not just threshold to passage of lighto We wanted to reduplicate the visual tasks that they were to perform at nighto Then the argument came up, of course, as it always does, as to what form we would use. The British had a rotating hexagon in which they used airplane, strata ships, processes, and so on, and forms for various sizes and different figures, but we decided we would use just one simple form and go back to use the letter "C” as one does in measuring visual acuity, or the letter "To” The basis for the test to some extent depends upon at what level of illumination you want to conduct the tests„ One flies at night at levels of illuminationo This is equivalent to moonlight at this level of iliuminationo 000 Lto Colo McDonald used the blackboard in explaining his remarks, and also distributed charts 00o 1 may better explain this chart0 This is intensity of the light in value of microlambertSo This is increasing tensity here0 If one uses a four-degree "C" one can see that at a level of illumination just below four*, If one uses a three-degree ”C" it is just a little above0 So actually the size of the letter one is going to use in a test like this depends upon what level of illumination one wants to test the visual acuityQ The Aeromedic Laboratory wanted to test visual acuity to very small letter, one-degree "C”, which gives visual acuity of approximately 2/200o They said that simulated the night operations. Others insisted that if 76 you are interested in studying rod vision, you should test using a larger letter, and consequently a lower level of illuminationo We made measurements on brightness of starlight night and moonlight night to find out just, where the test should be conducted. Theoreti- cally, one could conduct the test in which one had letters varying from 1/2 degree to 4 degrees, and one would test visual acuity over the entire range of sky brightnesse A test of that nature, however9 is very difficult to conduct. It is not hard to construct, but it is very poor correlationo If one tests rod vision* one gets a real good correlation between one or two tests of the same nature, but when one tests cone vision and rod vision* the interval between cone and rod gives very poor correlation tests, and they are not too reliableo do it was decided* as far as the Air Corps was concerned and the instruments they would use, they would use a two-degree "C" which is well within the rod range0 The rod is taken over from about 3 to 5 microlamberts and from 505 on one is using essentially a cone visiono This seems like a very simple little problem but actually bickering went on for a year as to whether one should test at higher levels of illumination or at lover levels of illumination„ The size of the retinal area stimulated depends* of course, upon the size of the letter one uses as a test object- If one uses a two degree ”C" on a two-degree background, one won't see anything but a little break, so one has to use it on a three or four degree back- ground 0 That is, one would have a field exposed to the eye with a two degree in the center. If one used the letter "T” instead of the "C*, one could get a clew as to the position of it by the darker side of the surfaceo So you have to have a background on which the letter is exposed* which is about twice the size of the letter*. We then incorporated the information we had into a practical test and in the Air Corps we have used four different tests of night vision. The first one I will describe is known as the AoAoF0 Eastman Night Vision Tester*. It was developed by the Eastman Kodak Company0 The instrument actually looks like a small coffin In the front surface of the instrument* there is a white piece of opal glass, and on that is the letter "C" at a potential angle of two degrees0 That letter can take any one of eight positions0 The instrument is automatically run, the light comes on, and the front surface is exposed for five or seven seconds. The light goes out and the "C" takes up a new position0 The test is conducted at eight different levels of illumination* which I will describe later in the method of scoring, and all the individual does is sit back at a distance of 20 feeto This is in a 77 completely dark roonio In front of him he has a small box, and on the front of that is a handle, in which the notching corresponds to the letter "C"0 Each time the letter is presented, he turns the notch to the position he thinks it is inG If it is correct, it is automatically recorded on a counter on the back of the instruments So the test was fairly foolproof„ Individuals were told to keep using perifoveal vision, and if they had the correct answer, it automatically scored, and it did away with the individual problem of testing which one always has o This instrument was very expensive,, Although it was very fine , it had a lot of mechanical failures;, and after whiife we had more instruments that werenH working than that 'were working„ Because of the bulkiness of the Instrument, it wassdecided that we should try to make smaller instruments, so Dr0 Roland of Wilmer Institute devised a small portable night vision tester and it consisted up here of a radium plaque with the letter "C”, and around here, with openings, were various density filters0 One rotated the front surface around this increasing density and found out at what density the individual could see the "C,f „ The "C" could be turned by means of a globe at the back into one of four positions0 The instrument was held at 12 inches, with a string around the individual0s neck, and the test returned to "C"s in whatever direction it was taken0 The Aeromedic Research Laboratory developed a night vision tester to some extent on the same principle0 They use the letter "C” again at two degrees and vary the intensity, but instead of changing the filters as the individual was tested, they had another system of arriving at the score0 The last instrument we used, and we didn°t have very many of them, was a Hecht-Slayer adaptometer, a new model that they developed, which, as a matter of fact, is the best instrument of all for individual test- ing, and in the hands of somebody who knows how to test, but it was not too satisfactory to knock around the country because it quickly got out of kiltero The method of scoring on these instruments varied somewhat0 On the AoAoFo Eastman Night Vision Tester, the method of scoring was based on the frequency of seeing curve0 If you have the light bright enough, you will see all of theme (Illustrating on the blackboard)0 If you have the light dim enough you will see none of them0 Bo there must be a place in between where you see them all and where you see none, where your threshold liesc The AoAoFo Night Vision Tester was scored on this principle,. There were eight levels of illumination„ At the first level, there were five presentations made, at the second level five, and so onc So altogether 42 presentations of the letter ”C” were made, and all individuals as a rule saw the first five, and at the last, practically none of the individuals saw themD Sometimes they guessed correctly, but in computing the score allowance was made for guessing^ 78 .-ill individual came up with a score of something over 400 For a while we considered if they got a score of less than 12 they failed thes testo One advantage to a test which is automatically scored and recorded this way is the fact that an enlisted personnel can conduct the test and they don8t need too much training, The test is to a large extent semi-automatic but it has disadvantage in the fact that it did break down mechanically The other two tests were scored on the basis of seeing three out of four at any one intensity0 You gave a person the exposed test object for a period of a second or two, and if you couldn®t see the intensity you had you turned to the next filter and if you saw three out of fours you put that down as the score0 What did \ve find out with all this elaborate work that was done on night vision test? We were, as a matter of fact, rather disappointed in our result0 We had hoped originally to be able to pick out the good ones and send them to night fighter squadrons and eliminate the poor oneso The test was reliable in the fact that there was considerable spread, and one could pick out some that were very good, and one could pick out some that were very poor, but due to administrative difficulties it was usually found that the person who was very good was scheduled to go to two-engine school and the night fighters were single engine ships and so onQ So that didn°t work out too well® As far as eliminating the people with regard to failing the test, we did that for a while. No air crew were allowed to be air crew if they failed the testo We didn°t have much trouble with pilots; bombers and navigators but nobody wanted to be a gunner3 It just took two or three days for them to find out that if they failed the night vision testa they were taken out as gunners, so the percentage of failures in the gunners® school went up to 15 or 20 per cent We finally had to revise the regulations, and the present status of the night vision test, as far as the A,A F is concerned;, is that it will be given to all pilotsy bombers and navigators at the time of their initial examination0 If they fail the test, then they will be given one or two retests with an ophthalmological examination to rule out refractive errors* If' high refractive error is found, they will be eliminated as a result of that examination0 As far as any other personnel are concerned in the air Corps, it is more of a diagnostic aid, and that is what I think it should beo 1 think if one had a satisfactory test of night vision—these are fairly satisfactory—one should have it in every hospital and every individual who comes in complaining of difficulty of seeing at night, you would use that as an adjunct, the same as one might use individual field or electrocardiogram or something else0 79 The Navy have a test with which I am not too familiaro It is a radial plaque which is somewhat, similar 1 think to the Aeromedic Laboratory Testo I do feel that as far as night vision is concerned in the Army as a whole, one would gain much more from night vision training than one would from night vision testingo My own feeling is that probably less than one per cent of the people in the Air Corps have pathologically poor night vis iono It is true that down at the School of Aviation Medicine, as it was progressed, they saw several cases of people with bad night vision that was due to vitaminosis A0 Those cases are fairly rare, and when they are present, you can usually track them down, like the Captain that Captain Scobie told me about, who came from the South and was very fond of his Mother9s cooking and was very well nourished and did very wello They sent him to the Aleutians, and after spending several months in the Aleutians, he got very tired of K rations and practically didn°t eat them at alio He spent most of his time in the P0Xo, drinking milkshakes0 He came back and was sent to Infantry training, and one time led his whole platoon off the cl iffo The doctor in charge decided they had better examine him for his poor night vision, and they found of the whole platoon, the only two night blind were he and his driverQ But those cases are indeed rare0 We have a night vision training program in the army, in the Air Corps, which unfortunately got snarled up with administrative work and was just getting under way as hostilities ceasedo You can take 100 individuals and give them night vision training for a period of one or two hourso You can show them very conclusively that if they will use perifoveal vision, they will do much better at night0 One can take them out and demonstrate to them in the ordinary- practice demonstrationso That is all I have to say about night vision testingo We are not as enthusiastic now about the program as we were three and a half years ae agOo We have learned a lot about ito I think though that we have a good start for any future developments of any testing devices that may be neededo ooo.Lto Colo Phillips Thygeson, AoAoJo, Tampa, Florida, read his paper on "The Etiology and Treatment of Blepharitis - a Study in Military Personnelo" 0o0 Blepharitis is a chronic inflammation of the lid border0 It can be divided into two general types % (1) the squamous type, characterized by hyperemia of the lid border with dry or greasy scales, and (2) the ulcerative type, characterized by the development of small pustules involving the follicles of the cilia and leading to the formation of small ulcerso Conjunctivitis and superficial keratitis commonly accompany both types0 Blepharitis 4s of distinct military importance because the symptoms characteristic of moderate and acute cases, which include burning and smarting, epiphora, photophobia, and asthenopia, interfere definitely with the efficiency of the soldier. These conditions are exaggerated, especially in air crew members, while in high altitude flying. The complications range from internal and external hordeola, meibomitis, and chalazia, to chronic conjunctivitis, marginal corneal ulceration, and, rarely but importantly, trichiasis and entropion„ The determination of etiology is, in most cases, a prerequisite for adequate therapeutic management which in any event requires frequent observation and a judicious rotation of procedures in all but the mildest casesG Blepharitis seems to be definitely increased under tropical conditions0 A survey of the literature reveals that a wide variety of etiologic possibilities have been advanced0 The more significant of these are as follows? (1) Bacteria, including staphylococci, streptococci, and diplobacilli; (2) allergy to various substances0, (3) fungi1, (4) errors of refractions; (5) seborrhea; (6) animal parasites; (7) vitamin deficiencies; (8) endocrine disturbances; and (9) hereditary predis- position o The reports of Burky, Allen, and Thygeson indicated that toxin-producing staphylococci were probably the most important single etiologic feature and that anti-staphylococcic therapy was an improve- ment over older therapeutic measureso Three hundred fifty cases were available for complete etiological analysis but in a number of cases Army transfers interfered with the completion of therapeutic studies0 Not included in the series were cases of marginal blepharitis seen in connection with such dermatological conditions as exfoliative dermatitis, pityriasis rosea, and herpes simplexo As a minor manifes- tation of a generalized disorder, the lid margin involvement in these cases differed from typical marginal blepharitis in being self-limitedo X o Etiology Comprehensive clinical and laboratory studies were made routinely in the search for features which might have etiologic significance„ The clinical survey included examination of the following associated parts? (1) the scalp, for evidences of dandruff; (2) the face, for skin infections such as seborrheic dermatitis, acne rosea, etc0, and for evidence of seborrhea; (3) the external ears, for otitis externa; 81 (4) the tongue, lips, and corneal limbus, for clinical signs of vitamin B complex deficiency; (5) the conjunctiva and cornea*, for Bitot’s spots and keratinization as evidence of vitamin A deficiency; (6) the cornea, with fluorescein, for evidences of catarrhal infiltration or ulceration and punctate epithelial staining of the type characteristic of staphylococcic infection; (7} the meibomian glands, with expression, to determine the existence of hyperactivity or meibomitis; and finally (8) the lid margins9 to determine by means of gross and bioraicroscopic observation the clinical type of the blepharitis (whether ciliary or meibomian, ulcerative or non- ulcerative), the type of scales (whether dry, tenacious, or greasy), and the condition of the cilia (whether infected or otherwise abnormal)0 In addition to this objective examination, the patient was questioned on the following points; (1) duration of the disease, (2) history or presence of known staphylococcic infections such as styes or boils, (3) dietary habits, with particular reference to vitamin deficiency and to the abnormal use of fats and sweets, and (4) history or presence of pruritus or of other allergic manifestation, such as hay fever, urticaria, or eczema, with particular inquiry into the possibility of drug sensitivity0 All cases with abnormal vision or complaining of symptoms of asthenopia were refractedo Laboratory studies included routine scrapings and cultures of the lid margins, and cultures of the conjunctiva when conjunctivitis was a promi- nent feature,, Conjunctival smears were taken when there was conjunctival secretion or when the history suggested the possibility of allergy, When there was complicating meibomitis, expressed meibomian material was studied for cel] content and bacteria If there was excessive itching, the slides were examined for conjunctival eosinophilia,. Other laboratory procedures included the use of special media for fungi and the testing of pathogenic staphylococci for penicillin and sulfonamide sensitivity0 Patch tests were used as an aid in the diagnosis of contact dermatitis. Laboratory Find ings; Table 1 Laboratory Findings in Blepharitis (350 Cases) Mo. Budding yeast forms, Only OOOOOOOOOOOOOOOOOOOOOOOOOO 100 staphylococci, only O o O O O O O O O o o 0 0 0 O O 0 „ , „ , , . , 130 *Coagulase~positive staph0 aureus and stapho albus 82 D 1. p 1 ot) Q.CillioO OOOOOOOOOOOOOOOO 41 Mixed yeast forms and a pathogenic staphylococci 0 o o o o o o o o o o 102 Alpha streptococci ooooooooooooooo 3 Beta streptococci oooooooooooooooo 2 Coliform bacilli oooooooooooooooo 1 Proteus bacilli 0 o 0 0 o o o o 0 o o o o o o o o 2 Normal 1lora oooooooooooooooooo & ■Etiolaglc types of blepharitis; A comparative study of laboratory and clinical findings revealed that only three important etiological types of marginal blepharitis could be distinguished in this series. These were (1) blepharitis due to seborrheic dermatitis, (2) blepharitis due to pathogenic staphylococci, and (3) blepharitis due to the Morax-Axenfeld diplobacillus„ Their characteristics are summarized in Table 2, There is a high incidence of mixed seborrheic and staphylococcic blepharitis0 Table 2 Characteristics of the Three Principal Types of Blepharitis Staphylococcic Blepharitis Seborrheic Blepharitis Morax >Axenfeld (Diplobacillary) Blepharitis lo Seborrhea capitis Occasionally present Always present Occasionally Present 2o Associated dermatoses Acne vulgaris, Rosacea, Impetigo Infectious Eczema- toid Dermatitis, Sycosis Barbae, Boils Sebo deririo ,of brows & - ext o ears frequent Occasionally dermatitis at external nares 3o Bilateral or unilateral Unilateral cases not common Always bilateral Unilateral cases not uncommon 40 Ulcerative or non-ulcerative Frequently ulcerative Never ulcerative Never ulcerative 50 Associated hordeola Frequent Rare or absent Rare or absent 60 Associated conjunctivitis Frequent and often severe Minimal or absent Always Present 70 Associated keratitis Punctate epi- thelial erosions generally present 0 Marginal infil- trates and ulcers common Absent Marginal infiltrates and ulcers common 80 Scales and Crusting Hard tenacious scales removable with difficulty Greasy Scales s easily removed Macerated epithelium with mini- mal scaling 9o Microscopic examin- at ion of lid margin scrapings Staphylococci and leucocytes Budding yeast forms (Pityrosporum ovale) Diplobacilli No leucocytes Blepharitis_of mixed etiologVo Mixed seborrheic and staphylococcic blepharitis was the second most common type found in the present series0 The diagnosis was made on the simultaneous demonstration of pathogenic staphylo- cocci and large numbers of Pityrosporum ovale in the lesionsc Clinically these cases resembled the pure seborrheic form more closely than the pure staphy- lococcic form except that there were usually conjunctival and corneal compli- cations 0 Blepharitis in Associations it hej_ Diseases „ Blepharitis in acne rosacea is a common finding in civilian practice but surprisingly enough only one case was seen at Drew Field in the course of this stddy- This case was complicated by a meibomitis, That the ocular manifestations were due in large part at least to infection with pathogenic staphylococci was indicated by the striking relief obtained from antistaphylococci therapy, The importance of pathogenic staphylococci in blepharitis in rosacea has been stressed by Wise who found that none of the lesions of rosacea were influenceiby riboflavin0 Pediculosis as a cause of blepharitis was considered in two cases of phthirias palpebrarum discovered at Drew Fields but in one the presence of pubic lice and nits on the lashes did not lead to symptoms of blepharitiss and in the other blepharitis was present but cultures revealed pathogenic staphylococci. That the blepharitis was due to the staphylococci rather than to the pediculosis was indicated by the fact that it persisted after the pediculi were eliminated0 Blepharitis is not a manifestation of trachoma as the virus does not attack the lid margins„ It mustj, therefore., be considered a complication caused by superimposed staphylococcic or diplobacillary infect iono No single case of true allergic involvement of the lid margins was observedo Important of Mild. piy^ub-^lJjilgaLBle phar.it is,i. Routine examination of the lid margins with slit-lamp and corneal microscope in all cases of chronic conjunctivitis revealed a very high incidence of lid margin inflammation which would have been missed if gross examination alone had been relied uponQ Biomicroscopically5 howeverp differentiation between normal and pathologic lid margins could be made easily0 Differentiation could also usually be made in this way between pure seborrheic and pure staphylococcic blepharitis since the greasy scales of the seborrheic type look quite different microscopically from the dryr, fibrinous flakes of the staphylococcic type Many of these biomicroscopic or subclinical cases of blepharitis could be recognized under examination with the ordinary loupe once attention had been called to then from slit-lamp study0 It is clear that careful slit-lamp examination of the lid margins in chronic conjunctivitis should be made routinely0 The conjunctiva could be treated indefinitely without result if the primary focus were in the lid margins and ignored0 Secondary. Factors_l£LJlM. Sjb lalogyi o£JBle£ha,riJlsi. Role of the meibojTiian j^landsj; It was noted that infection was rare in the absence of hypersecretion and that when it did occur it was in the form of internal hordeola rather than chronic meibomitis0 In chronic atonic glands were found which had become coverted into "pus pockets0" A number of cases were seen in which isolated infected meibomian glands appeared to constitute foci for the continuance of the staphylococcic blepharitis0 Role of. vitamin de flc±e_n cy In these series of eases* no clinical manifestations of vitamin deficiency were noted., nor any signs which could be attributed with any certainty to vitamin B complex deficiency0 A number of patients reported excessive intake of fats or sweets or both and some of these were grossly overweight. Both excesses were curtailed in these patients0 ouch dietary improvement s however., resulted in no observable change in the blepharitis0 85 Role of refractive error- One hundred ninety cases were refracted. The results are summarized in Table 3* Table 3o Refractive -Error in Blepharitis Analysis of 190 Gases Emmet ropia „ » « <> 0 » 0 « , c « <, o <. <, „ „ O O 0 o o o 44 Lyopia 0000000000000000400 Low 3 Moderate 12 High 7 O 0 O O 0 0 22 Hyperopia ooooooooooooooooo Low 15 Moderate 0 High 0 0 O O 0 o o 15 Hyperopic Astigmatism 0 . . » . . . . . . . Low 11 Moderate 0 High 1 O O O 0 o o 12 Myopic Astigmatism a 0 o . . » . . « „ » . 0 Low 5 Moderate 0 High 0 O 0 O O 0 o 5 Mixed Astigmatism . . 0 . . . = „ . . . 0 . Low 12 Moderate 1 High 0 O O 0 O O o 13 Compound Hyperopic Astigmatism „ „ . Q » « » Low 26 Moderate 12 High 4 0 O 0 O O o 42 'i Compound Myopic Astigmatism » „ 0 <> . . , . Low 15 Moderate 16 High 5 * Low Error ~ less than lo00 diopter Moderate Error “ loOO - 5o00 diopters High Error s 3o00 f diopters 0 O 0 o o o 36 The patients receiving glasses for correction of refractive errors were carefully questioned as to whether or not they felt that the wear- ing of the glasses alleviated their symptoms. While a few claimed that their eyes felt more comfortable with the glasses, the general opinion was that the disease had not been noticeably influenced. Role of personal hygiene, A number of soldiers stated that although the condition had been present from childhood, they never had serious trouble with it until entering military life. The main factor seemed to be the difficulty of maintaining personal cleanliness under field con- ditions which tended to increase staphylococcic infections of the skin generallyo Role of allergyo Allergies appeared to play no role whatever in the etiology of marginal blepharitis in this series although there were a number of cases of allergic involvement of the entire lid area from drug sensitivity and contact dermatitis due to cosmetics. Role of heredity. There appears to be a definite hereditary factor in blepharitis. In a significant number of cases in this series, there was a history of familial occurrence, particularly in parents and grandparents<, The well-known susceptibility of blond skins to blepharitis was observed; however, the disease being relatively rare among brunette and negro troops „ Role of endocrine glands. The role of endocrine factors could not be determined in this series. DISCUSSION In view of the steady advances currently being made in specific therapy of infectious disease, it is increasingly important to determine etiology in ocular disease. Many ocular infections are still of unknown etiology and many are not specific entitieso It is evident from this and other studies that blepharitis is by no means an etiological entity but he3 a varied etiology comparable to that of other infections of mucocutaneous junctions such as perleche. It is also suggested by this study that mixed infections are almost as common in blepharitis as pure infections 0 In the absence of direct lid inoculation experiments with staphylocci, their pathogenic role in blepharitis must be assumed on the basis of our knowledge of the staphylococcic dermatoses. It is well known that staphylococci have a special predilection for the skin and attack this tissue in various ways to produce the clinical pictures of impetigo, infectious eczematoid dermatitis, folliculitis, etc0 These types of skin reaction were seen in staphylococcic blepharitis of this series0' Furthermore, the etiologic relationship of staphylococci to certain types of blepharitis is clearly shown from therapeutic studies in 87 which elininaticn of the organisms resulted in rapid healing of the disease and failure to do so resulted in its persistence0 It is very difficult to draw a clear distinction between pathogenic and pathogenic staphylococci in spite of the numerous studies which have been made on the subject0 The criterion used in this series, ic.e0, the ability of the organianto give a positive coagulase test, is certainly not one hundred per cent reliable0 On clinical grounds, it is suspected that certain coagulase-negative strains of staphylococcus aureus are pathogenic for the lid margins, but further studies will be required to prove or disprove this suspicion0 In the interests of speculating on the origin of the lid margin in- fection, an attempt was made to obtain the history of onset in each case„ While the data secured was not sufficiently reliable to warrant statistical analysis, certain information of value was obtained„ Most patients with staphylococcic blepharitis gave a history of onset in childhood. Certain of these recalled definite onset after measles, impetigo, acute conjuncti- vitis, and hordeolao In the few cases of recent onset, the blepharitis usually followed an attack of styes or of acute conjunctivitis. It is well known that pathogenic staphylococci are found very commonly in the nose and particularly in the external nares0 It is safe to assume that transfer of organisms from this reservoir to the eyelids by way of fingers or handker- chieves frequently occurs0 The etiologic role of seborrheic dermatitis in blepharitis must be assessed on clinical grounds alone since the etiology of the skin disease itself is still in dispute0 The etiologic relationship of the two con- ditions is clinically apparent, however, from the identity of the lid margin lesions with those of seborrheic dermatitis of the scalp and brow0 It seems probable that Pityrosporum ovale will eventually be shown to be the etiologic agent„ It was constantly present in the seborrheic belpharitis of this series and its demonstration in large numbers in lid margin scrapings is advanced as a diagnostic sign in spite of the fact that small numbers are occasionally found on the clinically normal lido In this series, the correlation between laboratory and clinical findings in seborrheic blepharitis was found to be very close0 Diplobacillary blepharitis, which has long been recognized as a disease entity, was surprisingly infrequent in this series considering the fact that it is known to occur commonly in various parts of the countryo Diagnosis is not difficult as the organisms are usually numerous in lid margin scrapings and identifiable on morphological grounds alone so that cultural studies are unnecessaryo The four cases in this series showed the typical involvement of the angles but a few cases of pure staphylococcic origin also displayed this clinical feature so that diagnosis on strictly clinical grounds is not completely reliable0 It is known that diplobacilli also are frequently found in the nose, particularly in the external naresQ It is, therefore, likely as has been presumed for staphylococcic, blepharitis, that many cases of diplobacillary blepharitis arise as a result of transfer of infectious material from the nose0 It is of interest that with but few exceptions a cause could be assigned to every case of blepharitis0 This, of course, does not mean that determination of etiology was accurate in every case but it does indicate the probability that the common causes of blepharitis are limited to a relatively few' agentsD Isolated cases, of course, may well be caused by a variety of agents not found in this series0 It is believed, however, that this study clearly shows that the ordinary ringworm fungi are not commonly concerned in the disease since ringworm was very prevalent among the patients of this series and the tropical conditions of Florida were conducive to spread of the infection,. In spite of this, not a single instance of lid margin infection was noted0 It seems probablf from this study that streptococci, particularly beta hemolytic streptococci, can occasionally produce or contribute to the production of blepharitis but that they do so very rarely0 Demodex folliculorum, an acarus-like parasite often found in the sebaceous follicles of the face, has been suggested as a possible cause of blepharitis but was not recognized in lid margin scrapings or expressed meibomian secretion from any case in this series0 There seems to be no doubt that increased activity of the sebaceous glands of the lid margins predisposes to blepharitis, particularly the seborrheic variety. However, there were a number of clear-cut examples of staphylococcic infection of the lid margins in individuals with normal skins0 This study has emphasized the importance of routine slit damp study of the lid margins in all cases of chronic conjunctivitis0 When the mild, subclinical cases thus uncovered are included, blepharitis with its associated chronic conjunctivitis, becomes the most common external infection of the eye0 Summary and Conclusions lo Blepharitis was the most common external eye infection seen in military personnel at this station.. In addition to constituting a cosmetic blemish, it was an important cause of ocular disability , both in itself and as a source of conjunctivitis, keratitis, and other complications causing irritation., blurring of vision due to increased secretion, epiphora, photophobia;, and eye straino 20 Laboratory and clinical studies of a series of 350 cases indicated that only three important types of blepharitis occurred; namely3 staphylococcic blepharitis, seborrheic blepharitis, and diplobacillary blepharitis0 There were many cases of mixed staphy- lococcic and seborrheic infection Other causes were unimportant0 89 3o The three main etiologic types of blepharitis had distinct clinical characteristics and in their pure forms could be differentiated on clinical grounds alone in all but a few rare cases in which staphy- lococcic blepharitis simulated diplobacillary blepharitiSo 4o Microscopic examination of lid margin scrapings facilitated determination of etiology« The finding of budding yeast forms, be- lieved to be Fityrosporum ovale, was considered a diagnostic sign of seborrheic blepharitis although its etiologic role in seborrheic dermatitis is still unsettled0 b0 Routine biomicroscopic examination of the lid margin in chronic conjunctivitis revealed a high incidence of mild or sub clinical blepharitis which was usually staphylococcica It is suggested that most cases of chronic conjunctivitis have their origin in bleph- aritis which in many instances will escape notice unless magnification is usedo 60 Secondary factors in the etiology of blepharitis were found to be, in order of importance, (1) increased activity of the sebaceous and meibomian glands, (2) poor personal hygiene under field conditions of military life, and (3) tropical climate which predisposes to a high incidence of infectious dermatoses0 There was no evidence to indicate that vitamin deficiency, refractive error, or allergy played signifi- cant roleso II Treatment In this study, it was proposed to test and compare the commonly applied procedures and to evaluate them in relation to etiology as elucidated in Section L In addition it was proposed to test the therapeutic efficiency of the new chemotherapeutic agents, particularly sulfathiazole and sulfadiazine, penicillin and tyrothricino Owing to movements necessarily incident to military personnel, there was a great variation in the time during which treatment could be carried out„ There were two hundred and sixteen cases, however, which were studied therapeutically over a sufficient period of time for conclusions to be drawn from the resultsc As indicated in Section I, only three important etiologic types of blepharitis were found in this series0 These were seborrheic blepharitis, staphylococcic blepharitis, and diplobacillary blepharitis0 In addition, there was a large group of cases of mixed staphylococcic and seborrheic infect ion„ The treatment of each of these four groups will be considered separatelyo 90 The Lid Margin as a Skin Although blepharitis would seem to be fundamentally a dermatologic problem, there are certain characteristics of the skin of the lid margin which set it apart from the skin of other areas of the body and make It a very special therapeutic problem. As is best observed with a slit-lamp and corneal microscope, the lid margin is divided into two zones, an anterior zone containing the cilia, and a posterior zone containing the orifices of Zeiss and Meibomius0 The two zones are separated by a fine gray line. The anterior zone containing the cilia is entirely cutaneous and can be compared with other hairy areas of the body such as the brows or scalp, but the posterior zone forms a transitional area between skin and mucous membrane and differs from all similar transitional areas of the body In that it contains the orifices of the meibomian glands0 These modified sebaceous glands, which are of unusual length, introduce a unique element into the blepharitis problem because of their tendency to secretory derangement and their susceptibility to infection. Furthermore, the fact that the lashes are the only hairs on the body which, because of the irritating effect of soap on the eyes, do not participate in the ordinary soap cleansing of the face and scalp, further differentiates the lid margins from other comparable structures and has a bearing on the treatment of blepharitiSo The proximity of the conjunctiva and cornea, moreover, limits in many respects the type of therapeutic measure which can be employed since many semi-irritant agents well tolerated by the skin are not at all tolerated by the mucous membranes0 Treatment of Seborrheic BlenharitiSo There were 52 cases diagnosed as pure seborrheic blepharitis in this series0 As previously described in the section on etiology, their most important characteristics were dull, dirty, generally greasy, non-adher-■ ent flakes or crusts on the lid margins, with hyperemia and infiltration of the underlying tissues. The condition was never seen without seborrheic dermatitis of the scalp which appeared in all cases to be the primary focus0 The usual dermatological treatment of seborrheic dermatitis, as described in modern textbooks of dermatology, follows four main liness (1) Dietetic treatments avoidance of alcohol and foods rich in fat such as butter, peanut butter, pork products, salad oils, and fried foods„ (2) Endocrine treatments ilmall doses of thyroid extract for overweight individuals with low basal metabolic rates. (3) Local treatment of skin lesions? Chief reliance on resorcin, sulfur, salicylic acid, and the mercurials, especially ammoniated mercury. (4) Local treatment of scalp. An attempt was made to apply these dermatological procedures to the treatment of seborrheic blepharitis. After considerable experimentation, the following routine was worked out? (1) Treatment of scalp infection by biweekly shampoos with tincture of green soap and biweekly applications 91 of an ointment compounded as follows? iUiimoniated mercury 8o0 Salicylic acid 4o0 Cetyl Alcohol base qeSo ad 100o0 (2) Local treatment of the lid margins? Manual expression of the mei- bomian glands © Careful removal twice weekly of scales, sebaceous materialp .and desquamated epithelium by vigorous massage of the lid margins with cotton swabs moistened with boric acid solution or V/o silver nitrate0 application of an ointment;, consisting of 1$ salicylic acid and 1ft yellow oxide of mercury in a petrolatum base* with vigorous massageo If any symptoms of conjunctivitis were presentP a collyrium of a 1 ’5p000 solution of oxycyanide of mercury was prescribed for use two or three times daily0 (3) Dietary habits were investigated and an attempt made to correct excesses or other errors0 A few patients complained of slight irritation from the use of salicylic acid-yellow oxide ointment but in general it was well tolerated. Treatment of the scalp infection seemed to have a very favorable effect on the control of the lid margin disease0 Sulfonamide ointments9 penicillin ointment and tyrothricin ointment were used without effect0 Vitamin B complex was of no value, An attempt to improve dietary habits were not altogether satisfactory owing to the lack of cooperation on the part of some patients and to the difficulty of adjusting diets under military conditions0 Treatment of Staphylococcic Blepharitis0 The non ulcerative form was characterized by dry9 adherent scales on an inflammatory base,, and the ulcerative form by pustules involving the superficial hair follicles and leading to the formation of shallow ulcers0 Complications of hordeola, meibomitis9 conjunctivit is9 and keratitis were comrnono Of these meibomitis was the most persistent and t roublesome to deal witho The therapeutic problem in staphylococcic blepharitis revolves upon the following necessities? (1) To destroy the bacteria in the lesions” (2) to eliminate or treat predisposing causes such as seborrhea; and (3) to eliminate other staphylococcic infections of the skin such as impetigo,, folliculitisr or furunculosis which could serve to reinfect the lid margins„ The main difficulty lies in the destruction of such staphylococci as have gained entrance to the lid margin glands*, particularly the meibomian glands0 The following groups of therapeutic agents were used? Silver nitrate*, yellow oxide of mercury,, ammoniated mercurys bichloride of mercury,, oxycyanide of mercury*> iodine9 salicylic acid9 merthiolate, zinc sulfate*, and quinolaro Dyes were used*, including gentian violet and brilliant green0 Sulfonamide, including sulfathlazole and sulfadiazinea Penicillin and tyrothricin also used0 Vaccine., including staphylococcus toxoid and stock and autogenous vaccines0 A useful procedure „ was the use of silver nitrate 1 or strength to the lid margins., and simultaneously in strength without neutra- lization to the conjunctiva0 The procedure was a silver nitrate application as detailed above twice weekly„ combined with twice daily applications of 1% salicylic acid =1$ yellow oxide of mercury ointment to the lid margins„ preceded by the instillation of 1-59000 oxycyanide of mercury drops into the conjunctival sac0 Tincture of iodine appeared to be very useful,, especially in ulcerative cases0 It was impossible to use tincture of iodine in most cases cont inuously„ however,, due to lid margin irritation,, but weaker dilutions were well toleratedo A 2$ solution of alcoholic gentian violet and 5ft solution of brillian green alcoholic solution,, was found to be valuable in some caseso Tests withes u If at hlazp le, and, sulfadiazine;; These drugs were employed in 5$> concentrations and appeared to be much more effective than ordinary antiseptics and the majority of cases showed satisfactory improvement or healing0 Early in the study9 it was noted that cases without meibomitis responded much more satisfactorily to local sulfonamide therapy than those with ito In the latter event., it was necessary to institute supplementary therapy consisting of manual expression of the glands combined with staphylococcus toxoid or vaccine or botho Although recent cases were always benefited by this treatments cases of long standing were frequently not relieved„ even by repeated meibomian expressions over long periods of time,, In the use of penicillin,, the reason for this failure was shown experimentally in two patients to be due to failure of the drug to penetrate the meibomian glands after it had been applied to the lid margin repeatedly„ Nor could penicillin be demonstrated in expressed meibomian secretion from two patients on full therapeutic dosage by the intramuscular route0 Tests with penicillin and tyrothrlcln0 Penicillin was employed in 87 cases,, The routine method of application was in solution form (500 units per cc0) and ointment form (1„000 units per gram in a vaseline or base)0 The drops were instilled four times daily and the ointment applied night and raomingo In certain test cases,, the ointment alone was used every hour during the waking hourso Penicillin sensitivity tests were performed on each culture,, (Table 40) Table 4 Penicillin Sensitivity of 98 Strains of Pathogenic Staphylococci Strain Sensitivity- in Oxford Units per cCo Inhibited bys 0o005 u/cc 1 OoOl u/cc 2 0o02 u/ee 16 0o04 u/ce 23 0o05 u/ce 3 0 0O8 u/cc 11 0ol5 u/c® 5 0o32 u/ce 5 loO u/®« 5 5o0 u/ee 1 Not inhibited bys 5o0 u/cc 25 500o0 u/cc 1 Penicillin proved to be moderately effective in relieving the symptoms of staphylococci blepharitis but the results still left something to be desired0 In a few instances., clinical cure without relapse was obtained in as short a time as a vaek., but in general relapses were frequent and some cases proved completely resistant0 There were four cases in which sensitivity to penicillin developed during therapy0 Typical contact dermatitis developed and positive patch tests were obtainedo Tyrothricin was employed in only fourteen cases owing to the necessity of purchasing it privately„ The drug was applied in the form of drops (33 mgo per 100 cc) and ointment (50 mgo per 100 gms) exactly as in the case of penicillin.. Six cases showed marked im- provement but the remainder were unchangeda The drug was not irritating to the conjunctiva or lid margins0 This method of treatment deserves further study„ In this series staphylococcic toxoid was administered in 55 cases but in only 27 was the full course given„ It was used as a supplementary treatment only., local treatment being continued in every case., The few patients who showed extensive skin reactions to intradermal injections of the toxoid improved more rapidly than those with minimal or negative skin react ions0 94 Treatment of Diplobac illary Blepharitis >0 The four uncomplicated cases of diplobacillary blepharitis in this series healed rapidly after short periods of treatment with sulfathiazole ointment used four times daily0 No recurrences were noted,, Treatment of Mixed .Seborrheic .and Staphylococcic Blepharitis „ This type formed the most difficult therapeutic problem of the series0 After considerable experimentations, it was found that the seborrheic factor was best treated first® After the slides became negative for Pityrosporum ovale a course of sulfathiazole or penicillin ointment was prescribed and cases in which meibomitis was present were given staphylococcus toxoid„ Under the regime satisfactory clinical improvement was obtained in most cases and clinical cures in a moderate percentage0 The secondary conjunctivitis and keratitis were treated with silver nitrate combined with a collyrium of 1<=>5P000 oxycyanide of mercury used t»B or three times daily„ The use of staphylococcus toxoid was particularly valuable in the treatment of the corneal complications „ especially the superficial keratitis with punctate epithelial erosions0 The conjunctivitis and keratitis were very serious complications,, DISCUSSION The (treatment of blepharitis5 other than the diplobacillary type which is no problemp cannot be said to be wholly satisfactory at the present timeQ Although the majority of cases can be relieved under ideal conditionss there is one inescapable factor which militates against permanent curej treatment with present methods is at best a long drawn-out affair and even on a military post& where cure is free and the time lost in reporting to the clinic is at government expense„ certain patients will not cooperate for the required length of time,, Under civilian failure to complete the course occurs very much more frequently0 It is clear that future control of the disease will depend largely upon the development of measures which will be effective in days or weeks rather than months«, The recent advances in chemotherapy appear to offer only a partial solution to the problem,, From this studyp it is apparent that infection of the Meibomian glands is the greatest single factor which must be overcome,, Meibomitis was present in all cases which were resistant to therapy and methods for treating it were obviously inadequate0 Repeated expressions of the glands was a useful procedure and in some instances resulted in apparent cureso In general,, however expressions were only palliative0 The inability of both general and topical chemotherapy with the sulfonamides and penicillin to affect the condition was also made clear in this series,, In the case of penicillin to affect the condition was also made clear in this serieso In the case of at leastp it was shown 95 experimentally that the drug failed to enter the meibomian secretions in demonstrable amounts after local and intramuscular therapy* and the finding was confirmed clinically by the fact that penicillin-sensitive organisms were cultured from the meibomian secretions during the course of both types of treatment0 In this connection* it is of interest to report a case of internal hordeolum which developed in a patient receiving 100*000 units of penicillin dailyo The strain of staphylo- coccus recovered from the hordeolum was fully sensitive to penicillin0 Hypersecretion of the meibomian glands* with dilatation of their orifices* appeared to be the main factor in their »U8©«pfclbility to infection0 No satisfactory means of reducing this hypersecretion is at present known„ In selected cases in this series reduction of fats in the diet had no noticeable affect upon ito In view of the minimal clinical symptoms incident to pure seborrheic blepharitis* it is apparent that its principal importance lies in its role of providing a suitable soil for the growth of pathogenic staphy- lococci o The chief problem is the matter of recurrence0 The importance of treating the primary focus* the scalp* which is stressed in all text- books of dermatology* was amply confirmed in this study* for although it was impossible to say positively that recurrences were due to rein- fection, the general impression was gained that reinfection from the scalp was common0 Assuming that Pityrosporum ovale is the cause of the disease* the fungicidal effect of all the agents used in this series* including tinc- ture of iodine* silver nitrate* salicylic acid* ammoniated mercury* yellow oxide of mercury* etc0* was evident from the results of lid margin scrapings which were negative for the yeast after treatment0 The failure of penicillin or sulfathiazole to influence the condition is in accord- ance with the known fact that these drugs fail to affect mycotic infec- tions o The recent dermatological literature has been full of reports which have criticized the use of topical applications of the sulfonamide drugs because of the high incidence of allergic reaction„ The danger of sen- sitization has appeared to outweighr. the benefits to be obtained from local therapy0 The results in this series, however* would seem to indicate that sulfathiazole and sulfadiazine can be used for topical application around the eyes with minimal danger since only four sensi- tizations occurred in the group of over 300 cases treated” two of the four* moreover* were clearly related to previous oral use of the drug0 No sensitivities to sulfadiazine developed in any of the 60 cases in which it was employed0 Long continued use of the sulfonamides in blepharitis* however* would seem to be not only unwise but unnecessary for if there is to be any clinical response to the drug it will occur within fifteen days at the longest0 Sensitization to penicillin (or possibly to impurities contained in it) occurred in five cases in a considerably smaller series and in the opinion of the writer was of more significance than the allergic reactions to sulfathiazole0 There is no adequate substitute for peni- 96 cillin at the present time so that sensitization could be a serious matter in the event that general penicillin therapy were later neededo On the other hand*, since cross-sensitization among the sulfonamides is not common, sulfathiazole sensitivity does not necessarily preclude all subsequent sulfonamide therapy. For this reason9 it is recommended that topical penicillin be reserved for those cases that have failed to respond to other medication and that its administration be limited to not more than ten daysc In this seriess the only instances of novertreatment derma- titis” observed were three cases receiving daily applications of 3of iodineo The condition was readily recognized and treatment discontinued. The possibility of the deleterious effect of over- treatment was considered at all times and frequent rest periods as well as rotation of procedures were employed in long drawn-out cases for the purpose of detecting it 0 Several cases of severe keratitis in blepharitis appeared to be related to insufficient closure of the lids while sleeping. It was possible to obtain observations on these patients during sleep and to show that they did not have normal lid closure. There were other blepharitic individuals9 however9 with the same symptom but without keratitis. It seemed probably, therefore, that the keratitis was primarily staphylococcic in origin and aggravated rather than caused by the drying effect of incomplete lid closure. In this seriess patients with well-established blepharitis in general exhibited a genuine desire to be cured and were extraordinarily faithful in reporting to the clinic for treatment0 Careful questioning, howeverP revealed that they were not so faith- ful in the daily use of their medications. As their conditions improved*, they became more and more careless about treating them- selves o The relative efficacy of clinic versus home treatment was well illustrated in a series of lb consecutive cases which were available for daily treatment. Improvement was much ifiore striking than in cases which could be treated only once or txvice a week. Summary and Conclusions lo A large series of blepharitis cases in military personnel were subjected to therapeutic study with the following fire groups of (1) Antiseptic or germicidal drugss including silver nitrate„ zinc yellow oxide of mercury9 tincture of iodine9 salicylic acidp sulfur„ quinolor,, and merthiolate (2) DyeSj, including gentian violet and brilliant green, (3) Sulfo- namide drugs*, including sulfathiazole and sulfadiazine, (4) Anti- biotics*, Including penicillin and tjirothricino (5) Vaccines,, including staphylococcus toxoid*, toxoid combined with vaccine„ and stock and autogenous vaccines0 2o Seborrheic blepharitis responded best to the following treat- ment; (1) Daily mechanical cleansing of the lid margins9 12} frequent expression of the meibomian glands9 (3) applications of silver nitrate solution to the conjunctiva and 1j> silver nitrate to the lid margins twice weeklyv (4) twice daily applications of an ointment con- taining If) yellow oxide of mercury and salicylic acid to the lid margins9 and (5) treatment of associated seborrheic dermatitis of the scalp9 brows9 external earsp etc0 Sulfathiazole and penicillin applied in ointment form were ineffective0 30 Staphylococcic blepharitis responded well to topical treatment with the following preparations9 listed in order of efficacy; sulfathiazole or sulfadiazine9 and mercurials,, including ammoniated mercury and a combination of 1$ yellow oxide of mercury and salicylic acid. Administration of staphylococcus toxoid proved to be an important supplementary procedure<, Other measures of therapeutic value included topical application of tincture of iodinep gentian violetp and brilliant green to the lid margins0 treatment of other staphylococcic infections of the face or scalp was important 0 4o In staphylococcic blepharitis„ a close correlation between the sensitivity of the staphylococcus strain to penicillin and the clinical response of the disease to topical penicillin therapy was notedo 50 Staphylococcic blepharitis complicated by meibomitis was much more resistant to therapy than uncomplicated blepharitis0 60 The four cases of diplobacillary blepharitis which occurred responded completely and rapidly to topical application of sulfathiazole in ointment fom. 7o Mixed seborrheic and staphylococcic blepharitis proved to be more resistant to therapy than either form separately0 It was found best to treat the seborrheic factor first and to give particular attention to expression of the meibomian glands0 After lid margin scrapings had become negative for Pityrosporum ovalep antistaphylococci® treatment with sulfathiazole or penicillin ointment was employed„ Staphylococcus toxoid was a valuable supplementary treatment.. 8o Contact dermatitis as a result of allergy to both penicillin and sulfathiazole was observed but did not occur often enough to prejudice their use0 9o In pure seborrheic conjunctivitis was an infrequent complication and was readily controlled by the use of mild antiseptics; there were no corneal complications0 In pure and mixed staphylococcic blepharitis conjunctivitis and keratitis were serious complications requiring conjunctival treatment with antistaphylococcic agents. The importance of the lid margin infection as the primary focus was obvious in all caseSo 10o While local chemotherapy with the sulfonamides and penicillin constitute a great advance in the treatment of staphylococcic blepharitis;, the results of this series indicate that therapy is still not entirely satisfactory9 especially in cases complicated by meibomitis. 98 11 o Adequate treatment of blepharitis is of distinct military- importance both for the removal of local irritation and for the prevention of serious corneal complications0 I am indebted to Major Alfred Mo M0C0£, Chief of the Laboratory Service? for placing all laboratory facilities at my disposal;, and to Captain Joseph SQ Gotsp SoC0s bacteriologist0 and his technicians for making the culture studies„ I wish also to thank Captain Morris Waismen;, M0C0& Chief of the Dermatology Section9 for dermatological consultations„ and my associates Major S0 Rc Irvine,, M0Cop and Captain Joseph WQ Hallettp M0C0& for their aid in making the clinical studies0 o o o Applause o o o LTo COLo Pc Ro McDONALDs I would like to ask who prepares Vatox? LTo COLo THYGKSONs That is the National Drug Company0 CAPTAIN SOUDKRSs 1 would like to ask what Colonel Thygeson considers the best ointment baseQ LTo COLo THYGiSSONs I am not satisfied that there is any one base that is besto I think ordinary lanolin base is satisfactory<> There may be a change on thato The dermatologists do have different opinions as to the values of a base0 Where you are using a high concentration of the drug anyway9 I don°t believe there is much difficulty in liberation in the vaseline of lanolin base9 one-third lanolinQ I think that is open to some question0 "Dendritic Keratitis9" Major JQ H0 Allen fUniversity Hospital*, Iowa City9 lowajs A series of thirty patients withdentriti® keratitis were treated by daily intravenous injections of two grams of sodium iodideo The affected eye was maintained under cycloplegia until the cornea held9 but there was no other local treatment or general treatment„ The eye was not dressedo Cases of typical dentritic keratitis of one to seven days duration were selected for this series of treatment0 All of these cases were unilateralc Four9 however,, had two to four dentritic ulcers on the affected cornea© There had been no previous attacks in twenty-five of the patients* whereas five cases had had one to four previous attacks* and this was verified by the finding of corneal scarring under a silt lamp and corneal biomicroscopic examinationo The age range of these patients was from nineteen to forty* one patient being forty, three in the early thirties* and the remainder under twenty-nine years of age0 The weight range was from 135 to 200 pounds<> The number of injections varied from one to fifteen* or an average of seven injections for the series0 The cornea healed two to twenty- two days after the first injection of sodium idodide* or an average of eight days for the entire serieso However* upon analyzing the series in relation to the duration of symptoms* there was an interesting correlation with the treatment„ In five patients who reported for treatment within twenty-four hours after the development of symptoms* an average of three injections of sodium iodide was made* and the cornea healed on the third day after the first injection:, In eleven patients who reported between two and four days after the development of symptoms* an average of six injections were given* daily injections* and the cornea healed in seven days after the first injection* on the average0 In seven patients who had symptoms for five days before treatment* an average of nine injections were made and the cornea healed on the average nine days after the first injection In seven patients who had symptoms for seven days before treatment was instituted* an average of ten injections were made and the cornea healed in slightly more than eleven days on the averagec The five patients with recurrent dendritic keratitis responded in accordance with duration of symptoms0 There was no significant deviation from the averages0 In the above discussion the cornea was considered healed when it failed to show staining by fluorescein with examination of the cornea by microscope and slit lamp* You will see it was not entirely healedo Examinations after fluorescein stain were made daily during the treatment amd for one week after the cornea had healed* and then once a week for three months* depending upon the availability of the patientSo However* there was only one patient that was followed for less than two months after the treatment0 100 In no case was there any significant increase in staining of the lesion twenty-four hours after the first injection0 In cases of longer durations the lesion neither increased nor decreased in size for a day or two or threep after the first injection,, and then healing was observed to begin peripherally., the dendrites becoming shorter and shorter until there was only a small da#b df staining and that disappearedo After the cornea failed to take the stain„ a slight superficial opacity was observed in the line of the but this disappeared,, leaving the cornea clear in one to three days0 Probably that figure should be taken for complete corneal healingo The visual acuity at the time of the original examination varied between 20/25 and 20/509 depending largely upon the position of the dendritic ulcer., In the twenty-five patients with initial lesions,, vision returned to 20/20 or better following treatments. In the five cases with recurrent dentritic keratitis the vision returned to the pre- treatment level as best we could determine0 In other words9 the vision was not diminished by this attack as far as we could tel3U Neither recurrences nor dendritic lesions developed in the period of observation; that is„ within three months after the treat- ment had been completed0 But one patient wrote about a year later that he had had a recurrence0 This particular patient had three previous attacks before we treated him for his fourth attacks Iodine and its compounds have been used in the treatment of dendritic keratitis for many years and in various methods0 Perhaps the most common and best has been that described by Gundersonp which consists of the removal of the corneal epithelium around the dendritic ulcer9 followed by the application of strong iodine solution-, Borne individuals leave the eye open after tbit treatment Others use pressure dressings, However9 the number of recurrences following this method of treatment led Noy to suggest the use of iodides in the form of drops as supplementary therapy„ At about that time,, the author was using potassium iodide by mouth„ However,, we encountered a number of cases of iodism and because of it began to use intravenous sodium iodideo In the beginning of our experience with this drug„ sodium iodide was used to supplement the strong iodine treatment0 However,, the results seemed to justify a trial series with sodium iodide alone„ Bodium iodide was selected because it is less toxic than potassium iodide and in the dose that we recommend and uses iodism As rare0 . However;, there are a number of precautions that should be observed in its use0 One of the first and more important is that no patient with active or healed tuberculosis should be treated with sodium iodide„ A second precaution is that the needle should be well and accurately placed within the lumen of the vein before the injection is given„ Otherwise„ a painful phlebitis will develop<. a third precaution is that the drug should be injected slowly0 Other- wise „ the patient will develop a very severe pain in the region of the parotidso This is temporary and apparently causes no great difficulty,, but it is distressing at the moment„ In the series of thirty patients,, two complications„ probably resul- ting from the use of the drug„ were encountered0 In one patient„ a severe pain in both sides of the face developed approximately fifteen minutes after the administration of the drug and persisted for approximately three hours*, then gradually subsidedo This occurred after the second injection of sodium iodideQ Fortunately*, the cornea was healed the following day and no further treatment was necessaryo In one other patient a mild acne form of eruption appeared over the chest*, arras and legs*, after five injections had been madeQ However,, in this case*, five additional injections were made with only a slight increase in the eruption,. These lesions disappeared three days after the last injectiono This incidence of two complications in thirty patients probably is not a true incidence of complications from sodium iodide inasmuch as in 150 patients„ or approximately 150 patients,, in which similar doses of sodium iodide were given for other ophthalmic lesions only one patient developed a mild acne form eruption,, and that was not sufficiently severe to interrupt the course of treatment 0 To summarizep briefly*, a series of thirty patients with dendritic keratitis were treated by daily intravenous injections of two grams of sodium, iodide until the cornea was healed0 Symptoms had been present for one to seven days before treatment was instituted.-, Neither recurrences nor herpetic lesions developed within three months following treatment„ However,, because of the small number of cases in this series,, no definite conclusions can be drawn,, except that the results justify further study„ (Applause) DISCUSSION Colonel Strubl®“ I would like to ask Major -alien if he has used ether on these corneal ulcers0 We have used it* I should say* on over 20 caseso We think that it is far superior to the topical application of iodine0 The success in the use of ether I am certain depends on the thorough removal of all the involved epithelium over the lesion and around the lesion0 102 Our usual procedure is to pos® about a third of a medicine glass full of ether, hold it close to the patient5s eye, and with a loop, a good light and a fine applicator with tight cotton on the end, thoroughly scrub that area with ether9 and to make repeated applications even up to as many as ten or fifteen times, running the ether well into the Bowman5s membrane„ The advantage that I see in the use of ether is that the patient has practically no pain at all afterwards0 My experience with iodine locally has been that the patient has quite severe pain and almost invariably the ulcers will be completely healed by the following morningc Then it is the usual rule in my experience that they will start breaking down maybe on one edge, and treatment may have to be repeated the following day0 Ether has been much more satisfactory in our hands than the local application of iodine0 I mentioned it to find out whether anybody else has been using it0 LTo COLo PHILLIPS THYGESONs I was extremely interested in this series of Major Allen9sG First of all, on theoretical grounds, we do not have an example of chemotherapy of any of the typical virus diseases<> Dendritic keratitis, of course, is caused by one of the typical viruseso So if sodium iodide is of value in the treatment of dendritic keratitis, that is a distinct advantage in chemotherapyo I have always been under the impression that the action of iodine in dendritic keratitis was not specific but only the actual destruction of the virus in the superficial epithelium, where we know the virus is localized predominantly in the epithelium and the iodization does cause local destruction of the virus0 I am familiar with the fact that a number of dermatologists have used intravenous sodium iodide in herpes zoster, which is entirely urelated, but so far as I know, this treatment has not been sufficiently satisfactory to make it generally used0 So after hearing Major Allen8s series, we collected six cases at Drew Field, and we got some results, but not as startling as Major Allen9s series, because in the six cases we had four that improved very muck under the treatment but did not become entirely healed ani it was necessary later to apply local iodine0 In two cases, we didn9t seem to get any effect at alio We had one case of disciformis keratitis, which I believe was on the herpetic basis, although we had no actual proof of it, and the sodium iodide did not seem to affect the course of ito I think this is an extremely interesting observation of Major Allen9s and certainly should lead everyone of us to build up a sufficiently large series so we can make a definite conclusion0 103 MAJOR TRYGVE GUNDERSONs This is extremely interesting I think and certainly it looks as if Major Allen may have influenced the course of dendritic keratitis0 I must say it is hari to know what the power is of dendritic keratitis., It is a strange disease0 Sometimes it gets well spontaneously very rapidly„ I have forgotten on these cases what was the average duration before you started sodium iodide0 MAJOR ALLENs One to seven days0 MAJOR GUNDERSONs That is an average of about four or five days, and you have about eight days on top of that for the average duration? MAJ OR ALLENs Y e s 0 MAJOR GUNDERSON % That means a little over two weeks« I think with the series I studied some years ago I had about 225 cases 9 and 1 had a normal group that were untreated 0 I think it was forty sorae0 I thought that the average duration there was about three weekSo Of coursep some went on for a long period and others got well very quickly„ Your period does seem shorter than thato I don°t remember which ones we chose for normals but I think we probably took an average group0 I don°t see why iodine should helpa but if it does9 that is thato (Laughter)0 I never thought that iodine per se was the reason it got wello I think,, as Colonel Thygeson pointed out9 it is obviously the fact that you remove the virus infections and it doesn°t make much difference how you remove it9 and you change the course of the disease for the bettero I know that Dr0 Wheeler used to take the scalpel and simply scrape off and got very good results0 I certainly know that to take alcohol and rub off all the epi- thelium gets good results. If you kill it all with iodine you get good result So I think the same thing probably is true with ether,, if you rub it hard enough you get the epithelium off where the virus is and you help to cure that,, If you give it a strong enough dose and make the epithelium come off the corneas, the patient will get well, but the important thing is that you have to get rid of the and no antiseptic that does not kill the epithelium itself will cure the diseaseo But there may be some secondary effect that potassium iodide has in the tissues that does affect itc I think it is very interestingc MAJOR ALLEN% I would like to say to Colonel Struble that I have had no experience with ether in treatment0 In regard to Colonel Thygeson0 s discussions, I realize that these patients were early patients and collected them for that purpose0 I have 104 treated patients with longer duration and with numerous recurrences and considerable scarring of the corneap but unfortunately the majority of those cases were seen and treated before we settled on this routine and the therapy which mixed; that is where we are using the sodium iodide as supplementary treatment to the strong iodine treatmento So we could draw no conclusions at all on that group0 We expect to continue this study and include longer cases0 I might mention that we have studied a few other types of virus lesions with the use of sodium iodide and expect to report some of those observations later9 but sodium iodide seems to be effectiveQ MAJOR To CAVANAUGHS To add to what Major Allen just said9 in 19409 the skin resident was using intravenous sodium iodine for herpes simplex0 ’We treated some of the old chronic dendritic scarred patients9 that we just didnJt want to scrub any more„ with intravenous sodium iodide9 and we didn°t have very many cases? but we were under the impression that they did quite wello MAJOR GUNDERSON? I have used sodium iodide drops in the past but haven0t been impressed with ito LTo COLo McDonald? I have seen patients given sodium iodide to take internally, put it in their eyes by mistake0 It cleared up keratitiso ooo Captain Richard G0 Scobee of St0 Louis9 Missourip presented his paper on "Ocular Muscle Balance in Flying Personnels" (This paper was not offered for abstract ion0 It will be published at a later date)0 LTo COLo Po Ro MCDONALD? Those of you who have read the last Archives know there is an article in there by Dr, Adler on "The of Muscleo" He found the same thing that Scobee found when he measured muscle balance,, that there was a shift in the direction of esophoria under anoxia,, I didn°t read the article completelyc I just picked it up before I left,, but he came to the same conclusion I that it is one process of corv ergences either increase or decrease of impulse0 MAJOR DeVOJSg I have never been sure why those standards have been established,, Why does five diopters of exophoria disqualify a man from piloting? Is there any work along that line? 105 CAPTAIN SCOBEEs Of course„ the airplane„ although developed in this country5 was only considered as a toy at first« The British and the Italians and Germans saw a little more in it than a toy and took it over0 Very shortly after that we found part of the world engaged in the first World Wara and it was to the British and to the French and to the Italians that we had to go for information about our own gadget, and when our Air Corps was first started, it was not if a man was fit enough to fly but was he crazy enough to fly, So there was no selection that went on at first o By the same token,, his examination was written up when we went into the last war and presumably done in a hurry„ and has remained un- changed since the last war with very minor exceptions0 The reason for the five diopters of exophoria limit, for example,,- you cannot pin down in the literature,, except for one study, for the comment was a rather vague one„ the conclusion being that people with exophoria seemed to have more trouble flying than people with esophoria,, and so since ten had been seemingly the logical limit for esophoria,, I presume they decided to have that and make the limit for exophoria fiveQ There were no valid studies ever done.. LT* COLc MCDONALDs Colonel Matthews„ who has been head of the Teaching Department in the School of Aviation Medicine for some con- siderable time,, is going to talk to us now for a few minutes on "The Development of Gogglesc" We have been interested in numerous problemso I spoke to you about night vision testing,. We have also been greatly concerned,, of course,, in the protection of the individual from becoming light adapted and maintaining their dark adaptation„ That has involved design,, cockpit illumination., find so on0 One of the problems we haven9t paid as much attention to as we should8 but have done con- siderable work ons is goggles0 Colonel Matthews is familiar with that0 THE DEVELOPMENT OF GOGGLES LTo GOLo JOHN Lo MATTHEWS (AAFS Randolph Field,, Texas) s Gentlemen I I will not bore you with a detailed account of the evolution of our various goggles and sunglasses in the Air Forces0 Much of the evolution you are perhaps already familiar witho You will recall that at the onset of this or the recent conflict9 our airmen„ our fliers, universally were wearing a goggle which con- sisted of two cylindrical lenses held in a metal frame and seated in a rubber cushion,, joined at the nasal bridge by a metallic bridge of varying bridge widtho 106 This is a goggle which had been evolved over a period of years .and at the time represented the best available0 Yet that same goggle was for several reasons very undesirable9 particularly was it undesirable in its limitation of the visual fields« If we consider the monocular fields of vision and realize that each extends temporally 90 degrees or more and nasally 55 or 60 degrees (illustrating on the blackboard) with an overlapping of 110 to 120 degreess we will find that the binocular field of vision then measures more than 110 degrees in the horizontal and it will measure in the vertical the sum9 we will say, of 70 and 50 8 about 120 in the vertical0 This then represents the field of binocular vision*> that area of our visual field in which our eyes are operating jointly0 Now then*, if we place before the eye any type of goggle which will limit our field temporally or nasally„ superiorly or inferiorly, we will find a marked reduction in the monocular fields but far more importantly9 we will find a reduction in the binocular field of visiono That certainly was the case with the B«7 goggle with which we entered the war0 It was found the nasal field measured 23 degrees*, which then reduced our binocular field of vision to one which had a transverse diameter of only 46-- well9 we will say 50 degrees0 Vertically the limitation was not so great0 However*, this horizontal limitation to 50 degrees was a rather serious handicap to an individual learning to fly„ Those who had flown for considerable periods of time had become adjusted to it0 It was not so serious to them*, but unfortunately it was to the beginner*, flying in the open cockpito He put on his goggles when he first started to fly and then continued with them throughout the period of his service with the Air Corps„ In order to avoid this very serious defect and certain other ones in the B-=7 goggle9 it became apparent that a single-lens goggle would be desirableo You recall that early in the war*, the Polaroid Corporation produced what it termed an all-purpose goggle9 subsequently adopted as standard in the armored forces. It was a sponge rubber base with a plastic shieldp a plastic single lens. That was a very desirable gogglep but in the Air Force we had to consider a number of other factors that were not of concern to the ground forces*, particularly the integration of the goggle with the helmet9 the oxygen mask*, and all the gadgets that a modern flier has to hang around him. There was evolved then at the Aero -Medical Laboratory in conjunction with manufacturers8 a goggle which I believe most of you are familiar with0 We term it the B=H Goggle„ similar to that early Polaroid all-purpose9 it consists of a sponge rubber base with vents above and below for ventilation*, lined with chamois to minimize the danger of rubber burns to the face*, a single lens*, a flexible lens9 covering both eyes*, a lens made of a metal acetate rather than nitrate9 again a fire-prevention measure0 107 With this goggle, we find that the visual field is limited, the binocular field is limited only some ten degrees, so we have then approached a very desirable solution in the goggle„ Perhaps in the future that field will be even further broadened0 One little refinement in that goggle is an adaptation for high altitude flights0 Of course, in the 29 it is not so important0 it is a heated plane, but in our 175s operating at altitudes that are very high, extreme cold was encountered.. Any type of goggle lens in those cold atmospheres was apt to fog or to frost» To circumvent that difficulty,, fine wires9 spaced at intervals of about 3/16 of an inch, were imbedded in this acetate lens0 They were hooked into the electrical system of the plane0 The lens was kept warm throughout the flight and fogging was eliminated0 So much for goggles0 They have no particular application to our civilian ophthalmologic practice, but I would like to say a little bit about sunglasses„ You recall that some fifteen or twenty years ago the popular sunglass was an amber lens, Amber with a very high trans- mission in the yellow was a very disagreeable lens0 Psychologically it was not a desirable filter at alio That was replaced in time by the recently popular blue green or yellowish green lenses, the most popular of which are the Ao0o Calabar and the Bausch and Lomb Antiglare or Raybando We have been subjected to considerable advertising propaganda on green lenses0 Usually the statement is made that they are cooling, that they transmit light or that they will interfere very little with our color appreciation, with very little distortion of normal color valueso I think we might better appreciate this if we draw a diagram indicating the spectrum, the visible spectrum:; that is, if we arbi - trarily say it runs between 400 and 700 millimicrons0 As you are familiar in the visible spectrum by day the b Tightest color, by far the most luminous color, is yellow, slightly greenish but on the yellow side0 If we take that then as 100 per cent luminosity, we will find that normally we have a bell-shaped curve very sharply peaked in the center0 At about 555 to 560, we find the most luminous part of the spectrum;; that is, if we take equal amounts of light energy at varying points through the visible spectrum, this will have 100 per cent brilliance, whereas over here at the 400 millimicron wave length, at the extreme red end, we will find that the light is very dullo These Calabar lenses were advertised to us as lenses which trans- mitted light similar to the normal curve0 If we actually plot the transmission at varying wave lengths of the wave bends, we find the curve runs something like this, (Illustrating on the blackboard)0 What the manufacturer says is true. It transmits light to greatest extent in the yellows and greens, but actually I don5t think that is what we desireo In its selective filtration or comparatively greater filtra- 108 tion at the red and at the violet ends of the spectrum* it is acutally producing color distortionQ However* that is the glass which was popular throughout the nation before the war and was adopted by the armed forceso You are all as familiar as I am with the trade marks of the young pilot at the beginning of the war0 The Calabar glasses were just as much a part of his equipment* his necessary equipment* as was the convertible coupe0 Now that glass which was standard had a transmission of 51 per cento That is over all transmission We felt at that time that such a glass was desirable* that lenses* filters of greater density* were dangerouso I think those of you who have served with the Air Forces have noted the characteristics of pilots0 They put these dark glasses on when they get up in the morning and take them off when they go to bed at night0 In midday* certainly 51 per cent transmission or 4-5 per cent absorption is not dangerous* but at dawn and dusk* it might be dangerous* or certainly glasses of greater density would bec So we kept a very faint attempt there„ It was a Calabar C* for those of you who are familiar with the gradations in these filters0 This lens was found to be inadequate in the tropic zones and particularly in the Arctic zones* flying over ice* sand* snow* water and so on» It would seem then that a lens of much greater density would be indicatedo Oddly enough* the old Arctic fliers* fellows like Joe Crossen* when they were consulted concerning sunglasses* expressed a preference for yellow* for the old amberc That seemed oddp Amber seems quite bright0 The reason that has been advanced is that through its selective absorption of blue* amber lenses permitted the man in the air to differentiate better between blue ice* white paint* and a snow field* or between faint blue water and snow0 Through the selective absorption of blue* the glacial ice and the water were made to appear dark* thus drawing a finer line between blue and whiteQ Well* if amber is desirable* certainly it should not be a bright ambero It would seem then that it would be well to combine with the amber lens a neutral density lens* combine the two* make it a very dark amber0 It so happened that the Pittsburgh Glass Company at that time had a batch of glass long on hand0 They had been unable to sell it* but its transmission curves matched almost exactly those which theoretically were desiredo 2>o the rose-smoked glass wus adopted and they used glass originally 21 per cent and later 15 per cent transmission0 It has been standard issue since that time at the ports of embarkation0 Since V«J Day* a lot of that rose-smoked glass has been thrown on the commercial market and you will see them marketed everywhere0 We grant that amber lenses are of decided advantage in the arctic* but I feel that amber still is uncomfortable for routine useD It would seem to me that this rose-smoked glass will have a rather short vogue„ We will all go through ito Our patients will demand it for a while* but it would seem to me it would be much more desirable to get back to a lens such as was used thirty or forty years ago* a smoked lens* one a little bit more 109 scientifically produced than the smoked lenses were thenQ At that time, you will recall, the ordinary smoked lens had a very uneven absorption across the spectrum so that our blues and greens were accentuated and the reds wese greatly absorbed„ The Bausch and Lomb people have produced gray lenses of a fairly even absorption across the spectrum0 I think that very probably we will see these come into the commercial market in time, and it would seem to us at least that it would be a far more desirable lens than previously has been available to usa Early in the war, it became apparent that our bomber pilots were suffering very heavily from enemy fighters attacking from the sun0 A great problem then was to devise some type of goggle which would permit the bomber pilot to see straight ahead and yet would give him some pro~ tection when he was searching the area of the sun0 That problem, of course, is not limited to bombardment type ships0 All sorts of gadgets were tried0 The British had a fairly effective one, a goggle with a black celluloid flipper which could be thrown down in front of the eyes by the pilot when he wanted to search the area of the sun,, but that had its disadvantages, tooQ Perhaps the lens which comes nearest to solving the problem is one which was developed experimentally not so very long before Day and which has not been generally distributed0 However, I think we will see more of it in the and 1 have a feeling that it has a very definite application in our civilian lifeD I have here an ordinary pair of Calabar lenses, an experimental model2 on which has been deposited, in the upper port ion, a chrome nickel alloy. It is so graded that its density opposite the pupil is nil* and its density increases greatly as we rise in the lens., so that it is so dense at the periphery that it is possible to study the sun directlyo Perhaps it should be a little denser than this experimental model which I have hereQ I have worn this pair of glasses in plane* and found them satisfactory there0 I have also worn them on the highway and find they give me very great comfort when driving into the sun0 My own idea of the best sunglass for routine purposes will then be a gray glass of about , say, forty per cent transmission <=■ 40 to 50 per cent - with a top graded chrome nickel density0 I have very hastily sketched a few of the developments in this field, gentlemen.. We at the School of Aviation Medicine have not been responsible for the development of these „ We have been curious in the development, but .the credit for these developments should go to Aero-= Medical Laboratory at Wright Field0 If anyone would care to see these glasses I would be very happy to show themo (Applause) 110 CHAIRMAN McDOKALDt Is there any discussion of Colonel Matthews0 paper? If notp we are going to bring in a ringer this afternoon0 You notice that Colonel Payne is down on the program to speak of "Recent Ophthalmic Problems in the Philippine Islandsc" He got back from a period of temporary duty over there just about two months ago0 Hep howeverp could not get here todayc HoweverP we are very fortunate in having with us Major Wo P0 who has just come back from four years0 service in the South Pacific0 I would like to call on Major Chamberlain at this moment for a brief discussion of some of the ophthalmological problems he ran into in setting up his hospital and how he came out during the long period of time he was over there LTo COLo RANDOLPH? Has anyone done the procedure that Guy reported several years ago, of the raucous membrane over a piece of acrylic or, piece of metal or rubber tubing? That seemed to be quite successful in the case he reported. DR. RUEDEMANs I have been successful in two cases of the canali- culus. In one we put in an ordinary silver tubing with mucous membrane over it, laid in the sulcus below, and stuck in the lacrimal sac, and that took perfectly. Recently, we had another case of one of our fellows in the hospital who had a severe lacerating injury down through both canali- culi, and we opened that one up, put a piece of heavy tantalum wire with some of the mucous membrane over it, and that is functioning all right, tooo You stick them down in and take a piece of tubing, and if you can establish a fistulous tracts it isn°t hard to maintain them0 MAJOR CAVANAUGH: I have had three cases where the patient had a tear between the punctum and the sac. I take a needle and find an opening in the sac and pull the needle right out with the skin and go through the upper portion of the sac0 1 put fish-lines place it along, until finally 1 have nothing but an ordinary straight needle between the punctum and the hole back through the sac0 1 left them in eight or ten days, and all you have to do then is pull back on that portion of the needle. The three cases worked very wello We have had a few diagrams. If you have ever gone fishing and laced a couple of lines together, that is the principle of the thing0 It gives you an opportunity. You have a solid bar there to suture your torn canal into, and then you know if you do suture together that the 128 continuity is going to be maintained ooo Major Cavanaugh spoke from the back of the room arid the reporter could not hear ,,, Major G, L, WITTER (Dibble General Hospital)s I think that we have learned from the general plastic surgeon a great many things not to do0 They bear repeating,, One is that the graft should not be made larger than the defect0 Another is that the graft should be made as thin as possible0 Another is that all subcutaneous tissue should be removed very carefullyo LTo COL, FOXc I agree with that, because unless you remove all the fibrous tissue, you are going to get contraction, and that is probably xvhere we fell down on the mucous membrane0 MOAT OR WITTER? Apropos of making free skin graft, I think Wakeman brought out a nice trick. He prepares his defects, then in- cises in radial, so you get a much larger defect to fill than with your scar tissue. He then places the free skin graft on that prepared area, When that has healed, he rolls it over, by regularly incising the skin and placing the skin gralt suturing down. When it peels you have an edge which is rolled and thickened, but in two or three weeks that all becomes flattened down, and you have a much larger area and much freer lid. It has worked out very nicely, CAPTAIN SHERMANs Someone brought up the question of time of holding these cases. Naturally we have had cases on hand for over a year because, when you have to do seven, eight or nine operations on them, there has to be a waiting period frequently between operations, I don't see how many of them can be put through faster and still get a satisfactory result as we would like, I think that has been one mistake, that very often one tries to do surgery too soon in some of these eases. Nature helps a great deal sometimes in the body healing process, even over a period of several months after surgery. Regarding the time for the lid adhesions, I think that Wheeler's statements about that still hold true, and I think you will find with lid adhesions in place, provided you have had a good bed for your graft, about a month after the graft is put in, it probably looks its It is trying to contract a little. It still sometimes looks rather congested and during the next two months, there is a stretching of the graft and smoothing of it. Possibly massage helps, I have a boy to do it, I don't know whether it makes much difference, I doubt if it does. In about three months time that skin begins to look pretty soft and smooth and has a good color and appears like normal skin, and also you can usually find tlaat by pushing on the opposite lid and having them look up and down, lid adhesions no longer are needed to hold that lid in position. With the upper lid9 very often under proper conditions, two months probably is all that is needed for the lid adhesions„ I would say Usually there is no necessity at all in leaving the lid adhesions in longer than four months» There is one little trick I didn’t mention, that I am sure most of us are familiar with. When putting a graft in the lower lid, it very often helps I think to leave the lid adhesion suture long and run it up through the brow and tie it over, wherever they are, drawing the lid borders up slightly, not too much, using a little larger graft than the defect would be if we didn’t do thato I don’t think there is anything more to say about the lid notches„ I think ordinarily if you can get rid of the scar tissue, whether it be upper lid or lower lid, prcfided your incision is through the tarsus, as they extend from the tarsus do not converge - I think you can get a very satisfactory result, and there shouldn’t be any tendency for the notch to recuro I think it was Colonel Randolph who mentioned reconstructing the lower lid, making an incision a short distance below the margin and doing intermittent tarsorrhaphy there and joining it to the upper lid and using skin graft below. That 1 believe is the way we used to handle those cases before Hughes came along with his procedure. I think I recall his using that once or twice. 1 personnaly think the Hughes procedure is a little better for it„ Regarding Colonel Fox’s remarks about mucous membrane in the lower cul de sac, I think you have to take a pretty large graft there some- times o I also think that the section should not only remove scar tissue in that region but normal conjunctiva above the back part of the socket should be undermined somewhat and the section should go right down through the bone0 When you use your form of dental molding com- pound, it should hold that mucous membrane graft0 Even though it may pull the conjunctiva to the back part of the sac, you undermine a little bit, it should hold that pretty close to the floor of the orbit0 I will admit there is lots of trouble with those grafts about the third weeko They will try to contract, and I have sometimes had to make another mold out of general molding compound, a little bit smaller, so that they will still be put in and out and stay in place properly, but usually if you can struggle past the fourth week with them,I think from then on they don’t try to contract, although they may stretch a little bito I prefer not to shift over to the acrylic for as long a time in there as 1 can„ If I can keep using that general molding compound form, about four weeks, they usually do very well0 130 Colonel Cutler spoke about using a curved piece of plastic„ I have used that in cases where the eye is still present, in which there has been a very bad ectropion, involving practically all of the lower cul-de-sac, and there is not enough conjunctiva available even by sliding flaps to take care of it alio I never used it in anophthalmic caseso I think it is probably a very good suggest ion„ I have used it in cases that had the eye present„ I haven01 dared leave it in longer than the first dressings even though it is down below the corneao The sutures that hold it in place - possibly I have tied them too tight - seem to want to cut into the skin even with pieces of rubber on them, so I have usually taken that out© Regarding the size of the graft, I think that is a very good point0 I think that one should usually undermine the skin surrounding the areao I don°t mean up toward the lid marginQ I don°t think that should be done to speak of, because it interferes with the lid adhesion sutures0 It should be undermined below, so the skin can contract a little and in that way you use a graft about the size of the defect0 I don°t think it is necessary to use it largerc I think the lid will take care of that for youc I don°t exactly like the idea of making those other incisions and trying to use a large piece of skinQ I don°t think it is usually necessary to use more skin, when you remove the scar tissue, especially if you are using good eyelid skin for your grafto I know that the general plastic surgeon always feels he has to do something like that© I think it is a hang-over from some of the older methods, such as Astersion0s and Billy0s, where for some reason they would not use lid adhesions and have to put in more skinQ Regarding Colonel Randolph0s question about canaliculi, we had one officer who had a lower lid that had been torn loose at the medial canaliculus right through the canaliculus, very similar to one case I showed you there0 His upper canaliculus didn°t function well either© It had been tornQ When Major Swift repaired that lid, we cut a piece of gold orthodontia tube? which extended from within his punctum down to the canaliculus, through the tom part over toward the nasal sac, and went on into the sacc We just left it there0 ~fter about two months, we sent him out with it in there0 The tears were running through it0 It so happened that about a year later, he visited us, maybe not quite a year later0 It still looked just the same, and he is perfect- ly happy with it© Since that time, we have actually forced the passage in some of those cases through the scar tissue, where the lid is already up in position but the canaliculi is scarred in that area© We have used a large spinal needle, about 18, and pushed it in the direction of the sac5 through the scar tissue, in the canaliculus, and then we can draw the stilet and determine by irrigation while we are in the sac0 Then we put a piece of heavy tantalum wire through the needle, draw the spinal needle, and pass a piece of this orthodontia tubingo We have different lengths on hand0 We pass it in there so it goes into the sac and comes through the canaliculus just about to the punctum0 131 The main trouble we have had with them is that the ends of them apparently push into the soft tissue and they don°t function too wello Even though we have left them in for two months or even longer than two monthss we take them out and we don9t get a big opening there0 I think possibly that is one solution„ provided we have the den- tist use one of his little grinding drills and make a couple of openings near the end of the tube, so the tears will drain through there o It can be left in place and it doesnH cause any reaction a LT0 COLo FOXs I think I was the one who made the comment9 Captain Sherman, about keeping your patients longo What I meant was that after the last operation,, you said there were one or two that you had a year after your last procedure0 That is what 1 enviedo CAPTAIN SHERMAN? Some of those have gone from our service over to another service„ They had other work on other parts of their bodyQ LTo COLONEL CUTLER? There is one thing that 1 think has not been touched on here0 We have maligned the plastic surgeonss and they are not here to defend themselves„ I think we have a lot to learn from the general plastic surgeons0 I think I have learned a lot„ One thing 1 think the plastic surgeons can show us is the use of skin flapso Properly placed and properly sutured,, they look very good, and they accomplish a result which you cannot get with a thin skin graft o On occasions, I have carried the skin graft too far away from the lidSo Before you get the orbital rim in some cases you are getting into fairly thick skins0 Those conditions where the skin is thicker are better corrected I think by rotating the skin flap, down here on the temporal sidep getting skin of approximately the same thickness.. We have had some large defects where the skin has been thick and we have been encouraged by that procedure0 Another thing is that oftentimes in the lower lid and toward the outera you can get relaxation by pulling a crescent shaped flap more or less along the procedure Wheeler used in reconstructing a part over the lower lido Wheeler has made a very important improvement in that particular procedure9 in that he used tension sutures on this skin.. The type of case which we have had to some extent has been with the outer canthus very far down0 We have been able to rotate the skin of the cheek and bring that canthus up, and in other cases where there has been a scar coming around this region or down this region, we have corrected it» We have made a cross incision„ putting the point of the scars ‘fche point you want to get the greatest elevation, and then overlapping two pennant flaps„ You measure the width of the flaps, $nd you usually have relaxation in this area« We have done a number of cases in that way0 It is better than putting in skin., Oftentimes in the neighboring skin, you have the best •kti you can use0 I think we have been inclined to forget thato I think we have been inclined to use our skin grafts in the upper lid, a little too far away from the lid on occasions0 CAPTAIN ALSTON CALLAHANS I would like to say, in response to Colonel Randolph's question, that we have used in one case a small silver tube, attempting to open a canaliculus, which was not successful, and in three cases we used a tantalum wire completely through, down through, and out through the nose and tied together., These cases had a good deal of cicatricial tissue in the canthus because of the injury from shell fragments, and hoping to correct it, we left it in place for four months in three cases„ We took the tantalum wire out„ The first two or three days, it drained very well0 After that, it didn't drain through any more0 ooo The meeting adjourned at twelve-fifteen o'clock 00o FRIDAY AFTERNOON SESSION Lt0 Colo Edward E0 Burch*, O’Reilly General Hospital, presiding0 TRANSPLANTATION OF VITREOUS LTo GOLo N0 Lo CUTLER (Dibble General Hospital)s I am going to more or less report on this paper that I have submitted to Washington on the "Transplantation of Human Vitreous" as a preliminary report0 I suppose I ought to start out by saying that according to Rindlaub and Fisher, vitreous is a metamorphic sol gel, isodynamical in form in a dynamic state0 I vasn°t going to say that, but after having come to the meeting, I changed my mind.. Put in plain English, it means that it is an unstable colloid which can be shifted from a gel to a sol apparently very easily, and that under the ultra-microscope, it is composed of fibrilla rather than lamellae of unequal length» /(.bout eight or nine years ago, I decided to see if I could trans- plant the vitreous from one eye to the other of rabbits, and this paper was not published, but I think 1 worked with approximately 50 rabbits, and 1 found that I could transplant approximately four-tenth of a cubic centimeter of vitreous by means of a syringe from the eye of one rabbit to the other eye of the same rabbit, or to the eye of another rabbit, and that nothing seemed to happen out of the ordinary„ The eyes quieted down very quickly0 The tension remained normal,. The eye followed the tension o Fundus examination also was unchanged.. There was occasionally a small floater, and 1 had some of the eyes sectioned and the retina and other structures of the eye were normal0 Four-tenths of a cubic centimeter of vitreous in a rabbit is approximately all that can be transplanted„ I had in mind doing some things which being in the Army has offered me an opportunity to do, and that was to do the same procedure on some human eyes on which it appeared to me to be indicated0 I had been unable to find in the literature any reference to any article or description where this had been done on human eyesD However, there were other things that had been done along this line0 They were done with the attempt to provide a clear vitreous in patients who had opacities of the vitreous<, Many of these articles were not very complete in their observations0 In fact, practically all of them were not. How- ever, one of the first times anything of this kind was done was in 1890, 134 when a man by the name of Ford withdrew vitreous from several eyes, the losSjOf being made up by the aqueouss and reported improvement in one case from light perception to 20/60o Deutschmann in 1906 reported on the injection of vitreous from calves and rabbits into human eyes with treatment of the detachment of the retinae Of 67 cases9 26 were purportedly improved and 36 unimprovedo Komoto„ in 19109 reported on the withdrawal of the vitreous and injection of saline, and at the same time Elschnlg reported on the injection of air0 Similar procedures have been reported by a number of authors, particularly between the decade of 1920 to 19200 They all reported improvement in some cases0 Zur Nedden probably is the person who has treated the most cases by withdrawal of vitreous0 He reported on some 300„ In all of these cases, the observations were really I think not complete enough to give you enough assurance to do the procedure„ I decided to try this procedure on patients who had hemorr- hages of the vitreouso I think there is a great deal that we do not know about vitreous„ There is a great deal that we don’t know about hemorrhage in vitreous0 We know that in some injuries, not penetrating but contusions, the patient may have a severe hemorrhage in the vitreous0 The tension may remain normal for"a considerable period of time, and even the light projection will remain good, but the eye will go downhill„ It v/ill become soft, light projection and eventually light perception will be lost, and the eye will look soft 0 In other casess the hemorrhage will absorb over a varying length of time, and a person may get eventually possibly even a normally functioning eye0 In other cases, the hemorrhage may absorb, and you will have - retinitis proliferans evident in the fundus„ In still the absorption of the hemorrhage for some reason is long delayed and apparently in some cases it seems indefinitely delayed□ The light projection will remain,, The tension v/ill remain normalo We have probably all seen hemorrhages that have been present in the vitreous for many months or a year*, and then show evidence of clearing and continue on to where a person will get quite satisfactory vision,, 20/40a or better0 Why this is so, I do not knowo If some of you have some ideas or informations, 1 certainly would be grateful for it 0 The problem of what eyes would be suitable to try this procedure on is not easy to decide, because in the first place you are working in the darko You cannot be sure that you do not have a detachment of retina ands of course, you cannot be sure that there are not bands in the retinao 135 The procedure was fairly simple, and I don°t think that it is entirely satisfactory yeto Wo closed the eyes that had had a hemorrhage in the vitreous which had not absorbed or had any improve-’ ment of vision over a period of several monthsp but in which the tension was normal, and in which, in general, we considered the light projection good, although there was one of these cases where for some reason or other the light projection was not testedo I have done the operation under local and general anesthesiao I don9t think it makes any difference0 It can be done under local quite wello Perhaps I might say that there are a lot of things that I don°t know and I guess that are not known0 There are a lot of things that we are trying to find out„ One of them is how long we can keep the vitreous and still use ito Then, of course, there is another,, We don°t know whether we can make repeated injections or whether we can use injections of mixed vitreous„ but if vitreous is a sol gel, I believe we should be able to keep it under the proper conditions0 However, in these operations we remove the eye of the donor patient and put it in saline at 370° and keep it in an incubator until we are ready to go ahead with the recipients eye 0 Then we make an incision in the equatorial region of the donor0s eye and using a 5 cc syringe, and a No<, 18 needle, we withdraw as much vitreous as we can0 As a rule, that is or 2 cc, The central part of the vitreous is fluid enough to be drawn up into that size needle and the peripheral part of the vitreous is note Then if it is clear, we proceed with the next part of the operation The eyes that we have used have not been ideal. We have used it in eyes which we considered it was probably the only chance, and I think that has probably affected the results,, The reason 1 mention that is there is a problem, of withdrawing vitreous that has had hemorrhage in it« In some cases, we made a ring of diathermy holes in a quadrant in which we were going to withdraw the vitreous approximately two weeks before the operation. However, we have not done that in all caseso The reason for putting those holes in two weeks beforehand is to create the adhesions solidly before we go ahead with the next step o We made a small incision, after exposing the sclera, with the cataract knife in the equatorial region of the recipient0s eye in the quadrant in which we thought the greatest density was or the region in which we thought we could get the vitreous out frouio The incision was made down to the choroid, and then mattress sutures were placed on each side of the incision» 136 I have changed the method of putting these sutures in a number of times, and each time I thought 1 made it a little better„ Some- times some methods of putting it in were discardedo The latest way to have been doing it is to use about a 4-0 nylon suture and pass it through the outer layers of the sclera, approximately a millimeter and a half incision, and then carry it through the edge of the incision, across to the other side, and in the edge of the incision on the other side, and then out about a millimeter and a half on the other side0 I have put a similar suture across that way0 The reason for that is to try to make a watertight joint around itq 1 didn’t have much trouble with rabbits in making the watertight joint, but I have in humans„ Major Gunderson made the suggestion that I have a knife made which would give an incision which would just accommodate the noedleo I think that has some advantagesQ There is one other thing I think will be advantageous, and that is to have a tapered needle, because there is some value in having a water- tight joint, although it is not necessary„ I have used a size 15 needle, specially sharpened, on a 30 cc0 syringe, to withdraw the vitreous0 The reason for that is to give a little more suction than you would get with a 5 cc, syringe„ However, there certainly is a limit to how much suction you should put on, because you probably can cause a detachment of the retina and I don’t think that we have caused one for that reason as yeto The assistant holds both ends of the mattress suture and then the operator inserts the needle toward the center of the eye and, under direct observation of the assistant, withdraws the vitreous if he can0 The needle is very easy to see and if you have some of these very gelantinous clots you can even see it plug up the ends of the needle0 If possible, one and a half cubic centimeters is withdrawn Then the syringe is removed and the smaller syringe which you usually need to have the adaptor to fit the 15 size needle is fitted and the assistant puts traction on the sutures and the vitreous is injectedo The eye, of course, when you have withdrawn 1-1/2 cc0 of vitreous, has pretty much collapsed, like a puckered grape„ It restores, of course, quickly, and normally with the injectiono The needle is withdrawn quickly while the assistant keeps traction on the sutures, so that the wound closes when the needle is withdrawn.. reason as yet 137 I have had some trouble with sutures pulling out on some of themc In that case, I have had to grasp both edges of the wound quickly with the forceps while other sutures were placed0 That hasn3t made any bad effect at all, but the placing of the sutures is a great help*. The postoperative treatment is purely empirical0 I have kept the patients in bed for a number of days, more or less as if they were a cataract patient, given them a pillow and some 1 have kept in for four days, find others I let up a t the end of two days0 There is no post- operative discomfort, raid the patient has no trouble at all, He wants to get out of bed as soon as he can0 I am going to report three cases here, though 1 have done some others , 1 might give you a short summary of these three cases0 Two of them were successful and one was entirely unsuccessful<, The first patient was a colored man who gave a history of "spots" before his left eye with recurrent visual loss over a period of two yearso He wasn3t too bright 0 fie was in the ait Corps*, (Laughter) He got along well, too0 On June 9, 1944, while taking physical training, he noticed some loss of vision in his left eye0 This was at not very far from our place, and Major Howe sent him over to us after ten days0 He was sent on the nineteenth*. On examination, his right eye was normal and his left eye was normal externally, and the fundus showed a completely blank reflection-, A slit lamp examination showed a normal anterior chamber and lens, and the vitreous filled with a number of brown particles suggestive of hemorrhage0 Vision; light perception; projection excellent„ At that time, 1 had not planned on doing anything to him. We surveyed him and, aside from syphilis, which we were not surprised to find, there was nothing else* We,sent the patient back to duty on the ninth of September0 We got him back in again on the 6th of January 0 He had not noticed any change subjectively in that time, and his eye examination was also unchanged0 The tension in each eye was 180 We decided he was a suitable subject for vitreous transplant, and we told him about the procedure and asked him if he wanted to take the chance, and he "allowed as how he would0M We had a donor who was wounded on the 30th of June 1944 by a shell fire, and the eye had a tension of 3/, faulty light projection*, The other eye was normal„ He had staphyloma over the lew er three-fifths0 He was the person who was selected as the donor0 I might say that our diagnosis on this colored fellow was spontan- eous vitreous hemorrhage and his blood type was 0o The blood type of the donor was A.0 138 We operated on the 19th ©f February,, We did it under sodium pentothal and did it according to the procedure which I described0 The vitreous withdrawn from this Negroes eye was straw-colored and quite watery„ I withdrew approximately 2 cca and then 1 replaced that vitreous with the same amount from the donor,, put some atropine in his eye and a binocular dressing, and let him stay in bedo He was not a particularly good patient and didn’t stay quiet,, but he stayed in bedo He stayed,, lying down, I dressed his eye on the third dayc There was very little react ion„ very slight redness, certainly less than you would expect from an iridectomy0 On the 25th of February (he was operated on the 19th)8 we looked in his eye and noticed that the vitreous showed con- siderable clearing and that the disc could now be seen indistinctly0 We could also see the diathermy punctures in the periphery„ His vision had improved to hand movement at two feeto On the 27th of February,, we found the details of the fundus could be made out in the periphery„ well out,, extending from nine to three o’clock,, There was a small retinal hemorrhage on the temporal side at about 2s30o The disc could not be seen there 0 The interesting thing about this fellow is that the injection of this vitreous seemed to have a very beneficial effect on the post-absorbing of some of the other hemorrhages9 because the vitreous showed a gradual clearing0 That was noted on March 2„ The tension of his right eye was 15; the left eye was 110 Fundua unchanged0 On March 7„ it was noted that the vitreous was clearing and apparently the freshly injected vitreous was diluting some of the opaque vitreous and the macular area was visible and there was a small reddish spot in the center which did not look like fresh hemorrhageo It looked like an old macular lesion or an atrophic rather than inflammatory type of thing0 On March 219 the tension was 19 in the right eye and 14 in the lefto Vitreous remained clear0 On May 3 (that would be possibly about six weeks) „ the vision of the left eye was 20/100„ with -lo00 axis 180„ 20/60-lo Tension 17 in each eye0 That I considered as an indication that his eye had returned more or less to a normal state9 which was after about the first eight or nine days9 white„ and there didn’t seem to be any difference of appearance between the two eyes at alio 139 He was sent back to duty on Juie 6y at the same air field0 I saw him again on September 280 At that timep the tension was 17 in each eye; both eyes white and quiet» Ophthalmoscopic examination of the left eye showed some floaters but not more than ©n the previous examination0 DiscP vessels and macular area were distincto Periphery was clear except below where some old vitreous hemorrhage was still present o Vision was 20/100;, and corrected with -loOO axis 180 20/60 =lo Judging by the appearance of the vitre©us and the appearance of his macula8 I felt that his vision would have been better if his macula had been in better condition I haven9t seen this man sincep but there has not been any change from February 19 to September 280 I don9t think there is anything fur- ther to comment on that particular casec The second case was blood type 0P a boy twenty-three5 who was involved in a fight on December 25 9 1944., and was struck on the left eye and lost consciousness.. Examination at overseas hospital on December 29P.1944. revealed visions Right eye 20/20; Left qye - light perception with proptosis and hemorrhage into the anterior chambero Tension was elevatedc While he was under treatment9 hemorrhage of the anterior chamber absorbed revealing a remaining hemorrhage in the vitreouso Patient was examined by me on February 179 19450 at that time2 the vitreous was normal„ The left eye showed black reflexp and there was a large amount of mobile blood pigment in the vitreous o It was very dense 0 Vision ms light perception „ Tension 15 and 16 o Ho foreign body.. There was appearance of a slight amount of hemorrhage which might have been fairly recent in the extreme periphery below0 That was noted on the 8th of March0 For some reason or other8 the notes on this man do not contain reference to light projection, but I feel that the projection was probably normal because it was something I paid attention t®0 We decided to do a transplant on him. Our donor eye was type 0o That is the.same as the recipiento He had been hit with a B B shot at the age of nine and later lost the sight of his eyec At the time of the examination the cornea in his left eye was thick and somewhat opaqueG Anterior chamber very shallow with dense pupillary membrane0 Tactile tension - normal* Vision: Right eye 20/20; left eye - light percept ion„ faulty project ion0 That man was operated on0 We put one in one operating room and the other in another„ We operated on March 9S and 1 went through the usual procedures but I could not withdraw vitreous through the needle0 Something seemed to plug up the needle0 I think my reaction is that 140 the retina and possibly the choroid plugged it up, because when we took the needle out we lost quite a good amount of clear vitreous from the eyea I think that he must have had a detachment of the retina from the way it behaved, although I don°t know0 I did inject 105 cc0 of clear vitreousp and I think I may have injected it back of either the retina or the choroid, possibly back of the retinao I don°t think I got into the vitreous chamber, because it was very dense with hemorrhage and the vitreous that came out was transparento That was on March 9o I dressed him on March 12, and we noticed a small amodnt of fresh hemorrhage on the lower border of the pupilo Tactile tension felt normal„ At that time I could see a vessel of the fundus in the temporal side, and it was suggestive of a detachment of the retinao On March 21, the tension was 17 in the right eye and 20 in the left eyec The vitreous still had this large hemorrhage in it0 The vision was hand movements at six feet, The projection was poor on the temporal side0 He had also a little tinting of the iris, suggestive of fresh hemorrhage„ The tension remained normal0 The iris resumed the normal coloro He got no improvement in the eye whatsoever, and he was finally discharged from the hospital on August 260 The third case was a young white man , age 27, blood type Ao This fellow was on our blind He stepped on a land mine on August 29, 1944 and was injured in both eyes, legs, right arm and chest„ The right eye was enucleated shortly after injuryo It was noted at the overseas hospital on September 2 that there was some red blood in the vitreous chamber of the left eye0 The patient was examined at Dibble General Hospital on November 17, 19440 The examination at that time showed ophthalmosteresis in the right eye, and vision in the left eye 20/300 uncorrectible0 Small corneal maculae and foreign bodies0 Corneal scar at 2 o°clock with some imbedded debris0 There was a complete iridectomy in the upper temporal quadrant0 Anterior chamber was of normal deptho Iris pattern vias well preservedo Pupil reacted to light and there was a slight capsular opacity of the lens posteriorly<, Ophthalmoscopic examination showed there was a dense vitreous opacity occupying all but the extreme upper periphery of the fundus0 Wolf, in his ’’Pathology” speaks about cyst in the vitreous» Other people say you can°t have a cyst in the vitreous0 141 The upper border of this hemorrhage was curved and it seemed to be well outlinedo You couldn’t see anything below that curve, and above that you could see retinal vessels0 This boy was ready to go to Avon0 His home is in New Yorkp near Albany. I told him, "If you want to take a furlough and come back); we will try this procedure on you. if you want to take a chance0" He said he dido As a matter of fact, I told him that before 1 operated on these other two patientSp so he took a furlough,, and then came back for the operation,. The donor had blood type 0o He had penetrating wound of the left eye,, lacerations of the lidsp marked leucorca of tlie corneap with a dis- organized lens adhering to it. Vision with hand movements at one footp projection poor0 This patient was operated on April 12b 1945D and 2 cc0 of vitreous was withdrawn through an incision at the temporal sidec and a like amount was injected from the donor eye. Postoperatively- he showed the slight ciliary flush that these others had shown# and nothing more. On April 8 9 he had a good red reflex visible over the upper one-half to two thirds of the fundus and the retinal vessels could be clearly seen in the macular area and on one-half of the disco The tension was low0 On April 209 the notes are pretty much the same0 There was a large vitreous floater which temporarily obscured the vision as the patient moved his eye0 During the following three weeks the eye became entirely white and the tension gradually improved„ and the upper half of the fundus became clearly visible0 On May 12 the tension was 120 On May 31 the tension was 13o I took him in about the 27th of May to test his vision and he had about 20/400o I thought his eye looked pretty good. I sent him back to the ward and decided I would give up my practice of ophthalmology and do something else0 He came back three days later,, and he talked to me 0 He is a funny fellowo He has caused a lot of trouble 0 He was always getting into trouble. He said, "I want to tell you something0" I saidp "What°s the matter?" He saidp "You know,, the other day when you examined my eyess I didn°t tell you what my vision really wasQ" 142 The California sun came right out, and things looked hettero I said , "What? s the idea?" He said, "Well, you know, I was afraid I would lose my pension if I told you I could see better,," I said, "You will probably be all right that way0 Letps check your vision,," So I tested his vision It was 20/40, and with the -loOO it was 20/20-20 There was considerable cloudy vitreous in the lower two-fifths of the fundus0 During the ensuing weeks, the fundus details in the upper two- thirds became quite clearly visible up to the periphery and opacity tended to settle down* I was bothered by these opacities that were tending to float past his vision if he moved his eye quickly0 However, he read his mail and wrote letters home, but he didn°t feel he could drive a car,, As a matter of facts, he went around with a WAG and finally married her0 'We discharged him from the hospital on August 60 His tension was normalo Visions 20/40 with °0o50 =0o60 axis 155 “ 20/20o His visual field was good except for the opacity in the periphery below0 Not included in this report, I have done a total of nine patients, and 1 haven"t lost any eyes0 The blood types apparently made no difference„ In some the vitreous appeared to be more fluid than in others„ In some it apparently does not give the appearance of being unusually fluid0 Of these nine, four are 100 per cent successful in my opinion; four are improved; and the one that I report here is entirely unsuccessful0 of the cases that are improved were cases that had a dense, almost a clot possiblyp a hemorrhagic right eye vitreous in the center, and when we tried to get it out we could see it plug up the needle so it wouldnH come out, and all we have been able to do is to dislodge it and then wait to see if we could get some further improvement in the vision0 I think that we have been inclined to treat the vitreous with a great deal of respect possibly, more than we need to0 I don°t knowo Certainly I think that the loss of vitreous which one might have with the cataract operation and consider as somewhat a serious complication is a hangover from the days when extra- capsular extractions were done0 I know it was the opinion of many men that loss of vitreous in intracapsular operations is not necessarily a serious complication at alio Certainly in operations 143 for the detachment of the retina, we reduce the vitreous volume a great deal0 The following are my observations on these cases; From 1.5 to 2 cc. is the maximum amount of vitreous that can be withdrawn through the size needles that are usedo The blood type is.not significant. There was a decided reduction in the vitreous opacity in all except the one entirely unsuccessful case, and I think that was because we didn’t get enough. The pathological vitreous in some cases appeared to be more fluid and in some cases the transplanted vitreous appeared to be more fluid than normal. There was a very moderate reaction following this procedure but no evidence of foreign protein reaction was noted. The tension in all three cases returned to normal within a reasonable period of time and remained normal« I feel that this procedure holds possibilities in vitreous hemorrhage, and it may be that the time to do it is possibly within a couple of weeks after a severe vitreous hemorrhage, when the severity can be evaluated* rather than waiting until that hemorrhage becomes organized or until the retinitis proliferans have formed. It may be that some of these eyes which have gone on to degen- eration might be healed. Certainly a rupture in the choroid is not necessarily a reason for the loss of the eye. We have all seen eyes that have had ruptures in the choroid. The other situation in which I think that this procedure may have value is in operations for detachment of the retina. It has been observed by a number of people that in some cases there is adhesion of the vitreous or shrinkage of the vitreous and adhesion to the retina which causes the retina to tear and pull off. Certainly any operation we do nowfor detachment of the retina reduces the volume of the vitreous. It may be that the tear is a symptom of the detachment and not a cause. I might say that while you treat the hoi® and you can cure the detachment, you may not be treating just the hole. You may be treating the adhesions. Hither directly or indirectly, you may be creating a stronger adhesion opposite the point at which your adhesion is present. Certainly the recurrence of the retinal detachment indicates that you haven’t eliminated the cause. I did treat one case of detachment of the retina, that I ms not going to report at this time because it is only one case, and one swallow doesn’t make the spring, and so on0 We are planning on operating on some cases of 'detachment of: the retina, but probably this question will come up, and I'may as well tell you what we have done at this point, just for what it is worth« I cannot give you the exact data on this patient because I didn’t plan on including it, and it has bden about two'and one-half‘months since we operated on himQ He had spontaneous detachment overseas and was operated on twice there0 He was operated on once at our place,"and all three operations were unsuccessful„ The retina was, 1 guess, approximately two°thirds off; however, the tension remained normal and so we decided*that we would operate on hiiru By the time we got hold of a fellow who had some good vitreous, the rest of his retina came off, and while there was a piece, just a little narrow strip I suppose, maybe five per cent of it was on one quadranto We went ahead and made a couple of rows of diathermy punctures around one-half of his globe„ We didn’t see a hole and we didn’t look for a hole. We didn’t treat any hole„ In fact, we are not very good at finding holes0 Although we are pretty close to Pischel, the influence doesn’t seem to benefit us0 We made most of these diathermy holes deep and through the sclerao We were able, fortunately, to get a tight closure around the needle, and injected this vitreous in there „ This fluid of the retina came out like water through a sieve0 In fact, it blew the tension of that eye up to about 30 or 40 with the needle in there0 It was not anywhere near that high when we took the needle out0 as a matter of fact, there was a small opacity floater in the vitreous I had taken out of the fellow’s eyec I wasn’t intending to inject it, but got interested or excited or something, and injected the opacity too0 We closed it up, and the retina went back in place, and it is all back in place todayo What that means I don’t know, but 1 feel that we are just on the edge, and that is about all'I have to say about it„ Thank youQ (Applause) DISCU3310N DR0 JOHN KEYiiS (Inactive)s 1 would like to ask the colonel a question, Would he care to comment on normal vitreous from an anthrapoid, such as the chimpanzee, as a possible source of vitreous for transplanting? LT, COL, CUTLER: I forgot to mention some heterotransplants that Air Commodore Livingston made., I don’t know whether air Commodore Livingston came through your place or not. He is head of the Ophthal- mological section of the Royal Force, He ms quite an entertaining gentleman, When he was out at our hospital, he said he was interested in this. "As a matter of fact," he said, "I was interested in that myself a number of years ago," I said, "I remember now," I looked up this thing I had written up, and here I had a note about that time that he was boot captain or something else in the Air Corps, and he had done some pure transplants from dogs and pigs and goats or something like that, and only one was successful. He didn’t do many, about six. He said that he felt that the heterotransplant (I think it was in the dog and I have forgotten what the other animal was) seemed to be all right, ‘-Transplants have been done from rabbits to human eyes without success. No one has done anything about the anthropoids„ 1 have felt that as far as the source of supply is concerned, vitreous should be reasonably easy to get if we need it, and I have a feeling that it should be possible to keep it. Surely there wouldn’t be any objection to getting vitreous from a freshly deceased person. It certainly should be a lot easier to get than cornea, for instance. With the exception of this one, observation of Livingston, hetero- transplants have not been successful, I think it is something to look into yet, LT, COL, BURCH: Do you feel that this procedure would be contra- indicated in the case of arteriosclerosis, hypertension, diabetes, or some of the things that are apt to produce vitreous hemorrhage? LT, COL, CUTLER: The only thing 1 can say is that where there has been retinal hemorrhage, as there was in this colored fellow, what- ever the cause was, he had a spontaneous hemmorhage in the first place. It certainly has not had any ill effect on that condition. We have had a case or two of Eales’ disease, and I am anxious to have a patient to do a transplant on him, I believe that vitreous is a nonspecific protein as far as human beings are concerned, as far as my observation goes, and I don’t know what the answer is to that question, but I wouldn’t think it would be contra-indicated. oo* Major George a, Filmer, Beaumont General Hospital, read three papers2 "An Alternate Method of Eyelash Transplant“ "Myositis of Extraocular Muscles Causing Unilateral Exophthalmos" "Relaxation Deformities of the Eyelids and Socket Following Enucleation" AN ALTERNATE METHOD OF EYELASH TRANSPLANT Although a variety of methods of replacing eyelashes have been suggested and employed*, the one which is most readily handled is free transplant of eilia-bearing skin from the eyebrowe The usual location of donor site in this transplant is the inferior border of the nasal end of the brow0 Here*, in most individuals, the cilia are directed largely upwards as well as slightly laterallyo Thus*, when transplanted to the new location in the lid margin, the graft can be placed so that the cilia are directed to curve upwards in the upper eyelid and downward in the lower*, corresponding to the direction of the normal lashes0 In some individuals„ it is not practical to take the graft from this location for any one of several reasons0 Many normal persons do not have the upward growth of cilia at the nasal end, all cilia main- taining a temporal direction throughout the entire length of the browo In other cases*, the inner end of the brow may be involved in scarring from healed wounds, or perhaps may have been used for previous lash transplantso In these cases, an alternate donor site for the graft has been found practical0 In this method*, a vertical segment of the eyebrow is taken from almost anywhere along its course0 frequently the brow widens near the outer end and allows a longer segment to be obtainedo The course of the cilia is directed temporally in the brow, and it is only necessary to rotate the segment 90 degrees either way*, depending on whether it is to be used in the upper or lower lid0 This method is most practical where relatively shorter areas in the lid margin have to be filled in, but two or more segments can be taken and placed end to end if necessaryQ The recipient site is prepared in the usual manner, a trough being made in the lash line of the lid. Then a site is selected along the course of the eyebrow where the growth of cilia is sufficiently luxuriant and a vertical segment removed,, This extends the entire width of the brow, is wide enough to include three or four rows of cilia, and is deep enough to include a thin layer of sub- cutaneous fato If excessive fat remains on the under surface of the graft, it may be trimmed off until the black dots of the hair follicles are just visible, care being taken not to injure the follicles0 When making the parallel incisions for the segment, the ends are converged to form points so that closure of the wound is facilitated,. The brow 147 wound is closed carefully to insure a hairline scar. The ends of the graft are trimmed off enough to allow it to fit accurately into the trough in the lash line, and the segment is sutured into its bed. Atraumatic sutures are preferred; as few as possible should be employed, and with as little trauma to the graft as possible. The sutures are removed on the fifth day* Frequently all the cilia in the graft fall out following the surgical procedure, and commonly the marginal rows do not regenerate. The more central row or rows,however, begin to grow out again after a month or so if the transplant is successful. These new cilia some- times grow out longer than the normal lashes and it is necessary to trim them periodically. The scar in the eyebrow gradually fades, and is almost indistinguishable after a few months. MYOSITIS OF EXTRAOCULAR MUSCLES CAUSING UNILATERAL EXOPHTHALMOS The problem of unilateral exophthalmos always challenges the diagnostic prowess of the ophthalmologist, and on frequent occasions, even after exhaustive clinical and laboratory investigation, the basic etiology eludes discovery, In the present discussion, two cases are reportedo In the first, pathologic examination of biopsied tissue established the diagnosis as granulomatous inflammation of extraocular muscleo The second case manifested certain points of similarity with the first, but no definite diagnosis was made0 lo The first patient {J,S0), a 24-year-old soldier, had been in good health prior to the onset of his eye condition,, He had had diphtheria at the age of four years without complication or sequelae0 His father had mild diabetes, but otherwise there was no history of significant familial disease0 He had been a machinist in civilian life, and worked as an airplane mechanic in the military service „ On the morning of 25 June 1945, he awakened with a headache over the entire right side of his head from the frontal to the occipital region• He received some relief by taking aspirin; but three days later the ache became localized above and behind the right eye and he began seeing double0 During the next week, he developed a sense of pressure behind the eye, noted prominence of the eye and swelling of the eyelids, and became photophobic, He kept the eye shot to atolio light and diplopia. He was admitted to his station hospital on 10 July 1945, and shortly thereafter was transferred to an aAF regional hospital where further clinical examination and X-ray studies failed to reveal any cause for the condition. Although no real evidence of inflammatory reaction was noted, he was given penicillin as an empirical measure, but without effect,.. He was transferred to William Beaumont General Hospital on 21 July 1945o On admission, the patient still complained of severe right frontal headache, only partially relieved by aspirin and codein, and of constant diplopia in ail directions of gaze0 Physical examination was normal with the exception of the region of the right eyeo There was=slight redness and swelling of the upper and lower eyelids and moderate ptosis of the upper lid, with apparent slight paresis of the levator muscle* The eye was proptosed approximately 6 mm* as compared with the left, and there was moderate congestion of the. conjunctival blood vessels,, intraocular motions were markedly limited in all directions, external rotation being somewhat better than other motions0 The cornea was clear and there ms no slit lamp evidence of intraeeular inflammation,. The pupil was equal in size to the left, was regular, and reacted promptly to light and accommo- dation o The vitreous was clear and the fundus appeared normal with the exception of questionable slight fulness of the retinal veins» The disc appeared of normal color and was well outlinedo Vision was 20/20 in each eye, and the visual fields were full and normal,, Color vision was normalo The blood, Kahn and urine were normalo White blood cells were elevated to 13,300 with 72jo neutrophiles, 22/o lymphocytes, bp monocytes, and Ip eosinophiles, but a later count two weeks later was 9,500,, The red blood cell count and hemoglobin were within normal limits„ At no time was the body temperature elevated above the normal level0 Clinical examination of the nose and throat was normal, and X-rays of the para-nasal sinuses indicated no pathology,, X-rays of the skull and orbit were normal, and special laminagraphic studies of the right orbit revealed no bony or soft tissue abnormalityo Chest X-ray was reported as essentially negative, although a group of calcifications in the right hilar region was notedo The pulmonary consultant attached no practical significance to these calcifications and gave clearance for any chest pathology0 Skin patch tests to tuberculin in dilutions of Is 100,000 and Is 10,000 were negative,, A BtiR was calculated as /11>, within normal limits0 General neurologic examination revealed no significant findings0 On 30 July 1945, during the course of the clinical and laboratory investigations, the patient noted that the vision in the affected eye had become blurred for the first time« Ophthal- moscopic examination revealed no change from that on admission, the fundus appearing essentially within normal limits, but the vision had decreased to 20/200* Peripheral fields were full, but tangent-screen examination revealed tne central scotoma and loss of red-green perception characteristic of retrobulbar neuritiso He was placed on high doses of thiamin0 149 Since ao etiology had been established and since there had been no spontaneous improvement in the condition it was decided to surgically explore the orbit, This was accomplished on 7 August 1945„ Under general anesthesia of sodium pentothal, an incision was made over almost the entire length of the inferior orbital margin and the orbit was enteredo The orbital fat appeared grossly normal, but a portion was removed for biopsy to rule out changes found in pseudo«tumor, The orbit was probed with a blunt metal probe without encountering any particular resistance, but on insertion of the little finger as far as possible, a small mass was found inferior to the globe0 On investigation, this proved to be the inferior oblique muscle, which was enlarged and thick- ened in its entire extent from origin to insertion, and had a rubbery consistencyo The entire muscle was excised for biopsy0 The pathologist reported the orbital fat as normalo The muscle was reported as film and delicately encapsulated, with a longitudinal groove present along one surface, Cut surface revealed a pale grayish- white relatively homogenious central portion, with an Imperfectly demarcated peripheral rim of deeper tan color0 Within the central portion there were a few very faint white streaks, but the specimen did not resemble muscle tissue in the gross,, Microscopic examination revealed striated muscle fibers, largely replaced by a granulomatous inf lairjiatory reaction , Central areas of necrosis were bordered by a rim of radially arranged epithelioid cells0 Numerous small discrete granulomata within the central necrosis showed multinucleated giant cells and the appearance of tubercles, with extensive lymphocytic infiltration, Acid-fast stains failed to reveal the presence of bacterial organisms0 A pathologic diagnosis of granulomatous inflam- mation, probably tuberculous, of inferior oblique muscle, was mado0 On recovery from the general anesthetic following the operation, the patient stated that his headache had been relieved, A mild pressure dressing was left on, and was first changed on the fourth post-operative day. At that time, it was noted that the proptosis had receded somewhat, but there was a complete paralytic ptosis of the upper eyelid, and the eyeball was almost completely fixed except for slight external rotation. During the following two weeks, there was marked improvement from every standpoint. The proptosis completely receded, the levator muscle com- pletely recovered its action, and the function of the other extraocular muscles improved. Vision improved to 20/50, with a residual relative central scotoma.. On 9 September, it was thought advisable to allow the patient to go on furlough pending further observation. One month later, on 9 October, he returned from furlough with only few residual findings. There was paresis of the superior and medial recti, but other ocular motions were full. Vision had improved to 20/30-2, and a slight pallor of the paplllo-macular bundle area of the optic disc was becoming apparent. There was diplopia in the primary position and to the left, but single vision could be obtained on looking to the right. 150 Because of the diplopia, the patient was discharged from the Army on 1 November 1945, with the expectation that further gradual improve- ment would take place, 2c The second patient (WoM«), a 25-year-old white soldier, was stationed in India and had been in good health prior to the onset of his illnesso On 11 July 1945, he awoke in the morning with a severe left frontal headache, and was conscious of blurring of vision and spots before the left eye. He reported on sick call, where the medical officer noted a proptosis of the left eye» The proptosis was measured as about 9 mm, as compared to the right eye, and congestion of the conjunctival vessels was notedc The fundus was normal except for fulness of the retinal veins. Vision was recorded as 20/?0, and the visual fields were reported as normal. General physical examination was normal, as were the blood counts and urinalysis. The blood Kahn was negative. Blood smears for malaria and relapsing fever were negative, Stools were negative for ova and parasites, and skin tests for trichiniasis were negative8 X-rays of the orbit, para-nasal sinuses, and chest were normal® During the few days following admission to the hospital, the the vision became more blurred, and was finally reduced to light per- ception, On the seventh day of the disease, the patient developed a fever of 102°, following which the headache and pain in the eye were largely relieved, and one week later enlargement of the pre-auricular gland was noted. On the tenth day of the disease, it was apparent that the external rectus muscle was almost completely paralyzed. On the 24th day, 400,000 units of penicillin were given, followed in the next few days by recession of the proptosis, improvement in vision, and improvement in function of the external rectus. He was returned to the United states, arriving at William Beaumont General Hospital on 4 November 1945, By this time, all signs and symptoms had cleared up except a slight residual paresis of the external rectus with diplopia on looking to the extreme left. Vision had improved to 20/20 with correction of a minor amount of astigmatism. The f irst case was proven by biopsy to have a myositis of the inferior oblique and by inference from the clinical findings, one can assume a similar affection of other muscles within the orbit. Apparently the orbital fat was not involved, as indicated by biopsy of this tissue, but the optic nerve suffered an associated inflammatory reaction. Why the process should subside following surgical exploration of the orbit is a matter for speculation. The second case cannot be labeled with a definite etiologic diagnosis, but bears a number of points of similarity with the first. The proptosis, optic neuritis, and paresis of extra-ocular muscle, with eventual recovery or improve- ment, were common to both. However, the second showed evidence of an acute inflammatory process, with apparent favorable response to penicillin therapy. It is possible that this may fall within the group of cases given the diagnosis of pseudo-tumor*, RELAXATION DEFORMITIES OF THE EYELIDS AND SOCKET FOLLOWING ENUCLEATION Deformities of the eyelids following enucleation are commonly of the cicatricial variety, resulting from wounds which also injured the eye and necessitated its removal. These are corrected by skin graft, pedicle flap, ”Z" plasty, or other appropriate procedure, and it will not be within t.he province of this paper to discuss these0 Following simple enucleation of the eye, where no injury to the eyelids has occured, it is occasionally found that cosmetic deformity of the upper or lowsr lid is present after the prosthesis has been fittedo This may be due to relaxation, retraction, or atrophy of the lid tissueso There may be ptosis or recession of the upper lid, excessive deepness of the upper fornix, shallowness of the lower fornix, sagging of the lower lid, or a subluxation of the entire socket and eyelids,, Consideration of corrective measures for these conditions will be discussed„ A mild ptosis of the upper eyelid is occasionally encountered which cannot be satisfactorily corrected by enlarging or modifying the prosthesis, Unusually very little elevation of the lid is necessary to adjust it to the level of that of the other eye, and this can be accomplished by such procedures as the Blascovicz or Everbusch operations„ The Hildreth modification of the Everbusch operation has proven very satisfactory, as it effectively shortens the levator muscle any desired amount, and the amount of shortening can be readily controlled,, Recession of the upper lid immediately beneath the brow is a rather unsightly deformity, particularly after some time has elapsed following the enucleation„ This is apparently due to atrophy of fatty tissue in the anterior superior orbit, but filling this out with trans- planted fatty tissue from the abdominal wall or elsewhere is usually unsuccessful due to further atrophy of the transplanted fat„ The use of fascia lata and muscle tissue have also been advocated, but a relatively simple and satisfactory method is a dermal graft from the abdominal wall„ This fills out the depression without interfering with the action of the lido The graft decreases 10 to 20j> in bulk in a few months, find occasionally develops sebaceous cysts„ Atrophy of the anterior superior orbital tissue may also result in excessive deepness of the superior fornix of the socket„ This is of no consequence in itself, but may produce a secondary effect on the lower eyelid through the prosthesis„ a prosthesis made to fit this type of socket of necessity has a large backward extension on its 152 upper port ion, and the pressure of the superior tissues of the upper fornix on this extension may force the lower lid downward. If this effect is slight, a simple external canthal tarsorrhaphy may suffice.. However, it is usually more satisfactory to correct the basic cause and fill in the deep upper fornix., This is accomplished by incising the conjunctiva just above the upper border of the tarsus, dissecting the conjunctiva from the entire upper fornix, and filling in the deeper fornix tissues with mattress sutures of catgut,. By this procedure, the heavy upper extension on the prosthesis is eliminated, and the downward pressure on the lower fornix and lid is relievedo Relaxation and sagging of the lower lid is rather commonly encountered, and the corrective measure employed is determined by the degree of sagging0 The simplest treatment for mild to moderate amounts is external canthal tarsorrphaphy, Any technic which spares the lashes is to be preferred, since the cosmetic effect of shorten- ing of the palpebral aperture is largely avoided0 The sutures are left in for one week, end the prosthesis is left in for another week if possible to prevent tearing of the tarsorrhaphy adhesion.. If the amount of sagging of the lower lid is too great to be corrected by canthal tarsorrhaphy, the Szymanowski or Kuhnt-Szyman- owski procedures may be satisfactorily employed to add tension to the lid tissueso In any case of relaxed lower lid, there may also be an accompanying situation of excessive shallowness of the lower fornixo In these cases, the addition of two Snellen type sutures in the depths of the lower fornix is usually effective0 These sutures may be of dermal, double-arm, and tied over small buttons on the cheeko The sutures are tightened a little every day and finally removed in about a week0 The scar tissue formed along the tracts of the sutures deepen the lower fornix find allow the pros- thesis to be retained., If the sagging of the lower lid is extreme, none of these procedures may be effective in raising the lid and adding tension.. In this case, a transplant of a strip of fascia lata into the lower lid near the margin is used0 The strip of fascia is obtained in the usual manner from the lateral side of the thigh, and should be at least six inches long and about 3/8 to 1/4 inch wide0 One end is sutured to the periosteum of the inner end of the inferior orbital margin, the strip is passed along the lower lid margin beneath the skin, around the outer canthus, and upward to where the other end is sutured to the temporal fasciae The loy/er end should be attached inferior to the course of the lower lacrimal canali- culus to avoid interference with lacrimal drainage0 Finally, there are a few cases where the entire socket and lids are luxated downward to a level noticeably lower than the other eye. Mild degrees of this are not objectionable, as many normal individuals show a measurable difference in the levels of the two eyes. If the socket is low enough to warrant corrective measures, building up the floor of the orbit by implantation of a layer of cartilage through an incision in the lower lid may be performed« This provides a higher support for the lower fornix and elevates the prosthesis to the desired new level. The new acrylic prosthesis has aided greatly in minimizing many of these deformities because, unlike glass, it can be modified after it has been made. A defer technician can build up the upper portion to elevate a ptosis somewhat, or can thin it out generally to relieve down- ward pressure by weight on a lower lid. However, if a cosmetic deformity still persists after maximum adjustment of the prosthesis, then the previously discussed surgical measures may be undertaken. o.. Applause ... ... No discussion on Major Filmsr3s presentations ... symposium on intra.~qgular fqrktgn bodies REMOVAL OF INTRA-OCULAR foreign bodies LT. COL. RIWCHUN (Walter Reed General Hospital)? Mr. Chairman, Members and Guests? In view of the excellent presentations that have preceded on this program, up to now, it is with considerable humility and timidity that 1 present the following. The foreign bodies that were seen at Walter Reed were in the main metallic, magnetic and so on. In some cases, actual siderosis had occurred. I might add that in the pre-operative technique in preparation, we always made sure that the patient has had tetanus toxoid. If he hasn5t had an injection of toxoid in six months, he is given another cubic centimeter0 We were using sulfa, starting 24 hours prior to surgery, but we switched to penicillin when penicillin became quite available. We are fortunate that at Reed, we have the new work of Cabinal Mansy in using penicillin, and a mixture of oil and beeswax, and we can give one in- jection a day, starting twelve hours prior to surgery. We give one injection which has 100,000 units, and give injection the next day, and if there is any post-operative inflammation or suspicion of any infection, we continue the penicillin until there is no sign of infection. We give them sodium amytal, three grains, two hours prior to surgery. The method which we are going to talk about is the pars plana approach, which was originally described by Verheoff, and which he used initially back in 1935 I believe. In 1941, Barr and. Fralich, at Ann Arbor, refined the technique by using a trephine opening instead of incision, through the pars planao eoo Showing of a motion picture film during which Ltc Colo Riwchun made the following remarks^ You place an episceral suture. As a rule, when the hand magnet is applied, the foreign body will come right through without having to incise it, but in this case that we report here we couldn’t get it without incising, and then we had to use a giant magnet because the hand method wouldn’t touch ito In the closure, this can be closed separately, or if the incision is 12 millimeters away, the conjunctiva can be closed at that area. We use the Van Lint Akinesia. The O’Brien can be used for those who like the O’Brien. Then the Atkinson injection, 2.5 cc. The traction suture is put in0 1 won’t say anything about the Berman locator because I understand there is a paper on that this afternoon, but Colonel Carney from Boston has been telling me about a locator that he has, which I think I should like very much to have him say a few words about. We first mark the trephine area and then put in the episcleral suture on either side of where your hinged flap is going to be0 LTo COL. RANDOLPH; Is that an automatic trephine? LT. COL. RIWCHUN; That is electric, operated by hand batteries. Then we finish the trephine. You can go in at an angle to leave a flap so you can fold it over in this manner. This shows your uveal tissues in the pars plana area. Ordinarily, most foreign bodies at this point will come right out when you apply the hand magnet. Just because we wanted it to in this case, it wouldn’t. Bo we made a meridonal incision and then followed with the giant magnet. We inject penicillin, 500 units per cubic centimeter sub- conjunct ivally in the region of the incision. The remarkable thing about these eyes is to see the reaction the next day. There is practically none. 155 I have a film on retinal detachment that was hooked on here., Rather than take if off, I thought we would run through it, ,,, Showing of film on retinal detachment , * , We have used the six-point electrode not for penetration, for surface coagulation, and we laid down a barrage outlining area of the detachment. We are using Walker pins here to wall off a hole. We always like to use the Walker pin where there is a hole. In addition to that, we use the multiple single puncture, and in this case there was quite a billowing with a lot of fluid. Recently we have been using rubber suction over these holes to suck out as much of the subnetinal fluid as we can. You have to be careful with it because it can produce a lot of pressure. The advantage of the pars plana method of removal is that there is very little danger of hemorrhage. There is practically no danger of sympathetic ophthalmia, and practically no danger of retinal detachment, because, as you recall, your retina is firmly attached at the ora serrata and at the disc. It is the only two points it is attached, and by using this method, where it is applicable, we feel it is the ideal approach for removal of the foreign body. Thank you, (Applause) ,,o Major Ho Go Scheie, Crile General Hospital, read his paper on "Oxygen Injection of Tenon’s Capsule as an Aid in Localization of Intra- ocular Metallic Foreign Bodies,” (Applause) Major Scheie’s paper was illustrated by a moving picture, showing the technique in detail. He advocates the injection of oxygen into Tenon's capsule followed by radiographic studies of the orbits. The oxygen ring thus demonstrated above the globe is especially valuable in ruling borderline metallic fragments in or out of the globe. This paper has been submitted for publication and will be available for thorough study at an early dateD In the absence of Major Albert J, Abbott, Valley Forge General Hospital, Captain John S, McGavic read the paper prepared by Major Abbott on "The Use of the Berman Locator in the Evaluation of Intra-ocular Foreign Bodies," and demonstrated the Berman locator. THE USE OF THE BERMAN LOCATOR IN THE EVALUATION OF INTRA-OCULAR FOREIGN BODIES A review of the recent literature pertaining to the various problems encountered in the diagnosis end treatment of intra-ocular foreign bodies reveals that the subject is in .a remarkable state of confusion., any globe which has sustained a penetrating wound with a retained foreign body is seriously injured and the ultimate outcome is in doubto The prognosis is grave but not necessarily hopeless, and, unless the eye has been hopelessly traumatized at the time of injury, it should be considered a potentially sighted eyee The cases that have been seen at the Valley Forge General Hospital have practically all been the so-called War Injuries0 They have been seen relatively late and the time interval since the injury has often been weeks or months„ Many of the soldiers have either had one eye enucleated or so severely damaged that there was no hope of salvaging any vision in this globe„ In a number of instances,, a previous attempt has been made to remove a foreign body„ Surgical treatment had often been performed in an attempt to save the eye0 In many cases, there were multiple penetrating wounds and retained foreign bodies involving the tissues about the globe - lids, forehead;, nose, face, conjunctiva, or episclera, as well as one or more intra-ocular fragments0 The locator was devised to locate retained metallic foreign bodies and utilizes the principles of magnetism.. (1, 2) It operates in the following manner; "In a diagnostic rod is placed the equivalent of two trans- formers - one in the handle and the other at the tip, which is used to search for the foreign body0 The primary coils are connected in series to a source of alternating current„ Also in series, the secondary coils are connected through an amplifying unit to a volt- meter o When an alternating current is sent through the primary coils, a current is produced in the secondary coils by induction0 The instrument has a means of equalizing (balancing the voltages in the secondary coils so that the needle of the voltmeter will read approximately zero, since no current flows between them., Now, if the coil in the tip of the rod approaches a magnetic metal (the foreign body), the balance inductance is disturbed and a difference in potential takes place in the secondary circuit, which results in a flow of currento The amount of this current, shown by the deflection of the needle in the voltmeter, varies with the size of the metallic particle and with its distance from the tipo At the greatest point of deflection, therefore, the tip of the locator is immediately over the foreign boay0 Conversely, as the locator travels away from the foreign body, the deflection of the needle is lessened., One can estimate the depth of a foreign body in addition, if its size and composition are 157 known, by determining the distance necessary to give the same reading, with the controls unchanged, in approaching a similar piece of metal. The instrument responds best to iron and steel, and less effectively to copper, brass, silver, aluminum, lead and their combinationThe differentiation of a non-magnetic foreign-body from a magnetic one is easily made when the needle of the voltmeter does not move at all*" (3) The locator gives both a visual response on the dial indicator and an auditory response on the sound attachment when the probe is brought within range of a magnetic foreign body. The large probe is sensitive that it will give a response to an iron particle 1 mm* in diameter at a distance of about 10 mn0 The type of intervening tissue is of no importance as there are no known magnetic insulators. The search coil (inductance) in the tip of the probe contains two poles ijjs-" apart, each a center of sensitivity» (4) (Hhow slide - Fig, 5) Pole A at the distal tip of the probe is the important one in localization., The sensitivity of the probe is greatest when it is parallel to the surface or at a slight angle„ (4) The probe when held perpendicular to the surface is less sensitive but more accurate in ability to localize <> The localizer should be set at its highest sensitivity for purposes of detection,, This permits the detection of smaller particles at maximum distances0 The instrument for purposes of localization should be set so that the peak response is under 10 on the dial. This may or may not require a reduction of the sensitivity of the Instrument» When two foreign bodies are present, the instrument set at high sensitivity may respond to both of them,, However, by cutting down the sensitivity it may be possible to tune the instrument so that it will respond to each foreign body separately« The final localization at the time of surgery should be determined with the shield removed from the probe and the element covered only by its rubber glove„ Contact with the eyeball but without pressure is required., With the instrument accurately adjusted and the probe per- pendicular to the eyeball, the peak response will be obtained over the magnetic particle* (The sensitive pole may be considered at the tip)„ Pressure of any degree on the element may give a false reading and is to be avoidedo The response of the instrument is influence by the following: lo The character of the foreign body - magnetic, non-magnetic, or weakly magnetic. 158 20 The size and shape of she foreign body ~ globular or elongatedo 3o The distance between the sensitive pole and the foreign body o These factors must all be considered in using the locator for the evaluation of the foreign body0 Information obtained from the,clinical examination and X-ray localization must be weighed in the interpretation of the locator responses0 Procedures The lids, forehead and tissues adjacent to the eye are explored first, following which the globe is examined0 The ideal situation pertains whan there are no foreign bodies in the surrounding tissues to interfere and only one in the globe0 If a positive response is obtained over a lid, the point of maximum response is determined and the probe held in that position» The patient is then instructed to rotate his eye0 If there is no change in the indicator, one may assume that the foreign body is in the lid or in tissue which does not move when the globe is rotated,, A foreign body at tbs center of rotation of the globe, however, would not alter the signalo The lid is then moved in various directions and alterations in the signal place the metal in the lidc Magnetic foreign bodies in the conjunctiva or episclera will give positive responses0 They will interfere with the study of an intra-ocular foreign body unless one can get beyond their fields of influence0 It is wiser to remove these prior to final evaluation of the intra-ocular fragment and removal may be absolutely necessary before an accurate reading is possible0 It is possible to scan well the anterior half of the globe without surgical exposure0 The entire exposed surface of the globe is explored*, Assume a positive response in the 12 6 meridian inferiorly with eyes in primary position,, If the foreign body is in the lid, pulling the lid away from the probe will decrease the responseo If this does not alter the response, the patient is instructed to move the eye in various directions0 If, on movement of t he eye, the response alters, the foreign body is either (1) outside the globe but in tissue which moves on motion of the globe, (2) intra-mural, or (3) intra-ocular0 The foreign body is known to magnetic, else it would not have excited the locator„ If the foreign body is far enough anterior, the localization may be satisfactory but should be rechecked at the time of operatiorio If one cannot get the probe far enough posterior, it will be necessary to wait until better exposure is obtained at the time of surgery0 159 If X-ray has placed a fragment in the globe find no response is obtained, the particle is either non magnetic or beyond the field of the pole© If the foreign body is known to be anterior and In a position to excite the locator, no response indicates it is non-magnetic© The metal too far posterior will have to wait until surgical exposure is obtained for evaluation© The foreign bodies located at the most posterior portion of the globe are the most difficult to examine© The probe should be used with the shield removed© A very small foreign body near the optic nerve may escape detection© If a possitive response is obtained, the peak response occurs when the tip of the probe is opposite the fragment© One cannot be certain that the localization is as accurate as in the case of the more anteriorly located metallic fragments© CONCLUSIONS lo The Berman Locator will determine whether or not the foreign body is magnetic© 2© When the exposure is such as to permit adequate manipulation of the instruments, localization can be accurately performed© 3o The data obtained by the use of the locator when correlated with the history;, clinical findings;, X-ray localization and diagnostic application of the magnet, gives the ophthalmologist additional evidence on which to evaluate an intra-ocular foreign body problem© 40 The use of the instrument is simple and rapid and provides a quick means of checking the position of a foreign body after application of the magnet© 50 Foreign bodies located near the posterior pole of the eyeball and themselves less well to the use of the locator than those more anteriorly located0 60 Multiple magnetic fragments in the orbit or in the tissues adjacent to the globe may prevent satisfactory use of the instrument© Six case reports were given describing the value of this Berman locator© The first case, J© S„, age 26, incurred multiple penetrating wounds, involving both eyes, face, and right shoulder, when his tank destroyer was struck by a bazooka shell© The left eye was enucleated the following day© Two small metallic-looking foreign bodies were seen in the superior nasal vitreous anteriorly© There was a questionable foreign body posterior to these two© A foreign body was localized 7 mm© back of the cornea, 4 mm© above the horizontal plane and 8 mm© nasal to the vertical plane© The locator was not available at that time© There was no movement of the visible foreign bodies upon appli- cation of the magnet© of the magnet« Later the locator was used to evaluate the soldier’s condition and the number and position of the foreign bodies., In the meantime the eye began to develop early signs of siderosis0 5ince the visible foreign bodies did not respond to the magnet and did not appear to be bound down, the locator evidence indicated another foreign body, magnetic in character;, in the region of the ciliary body, The eye was operated on9 and the incision was carried anteriorly towards the ciliarjr body. There the magnet produced bulging of the ciliary body but no foreign body was obtained. Apparently scar tissue was holding the foreign body and preventing its delivery from the eye0 The foreign body was finally grasped with forceps and dissected free0 The proper evaluation of this multiple foreign body problem was dependent on the following; Visible intra-ocular metallic fragments that did not respond to the magnet, clinical evidence of siderosis9 X-ray localization and information obtained from the use of the locator, M, L« Mo - age 21, The soldier was wounded in Luzon by fragments of a high explosive shell0 The left eye had been enucleated. X-ray elsewhere had been negative for an intra-ocular foreign body. There were several areas somewhat suggestive in the eye of a foreign body, but not positively identified as such. The locator was positive in the 9; 130 meridian* the peak response being about 10 mm, from the limbus. X-ray localization then showed a foreign body 15 mm, back of the cornea, 3 mm, above the horizontal plane and 10 mm, temporal to the vertical plane. Surgery was advised and after exposure of the sclera, the locator was used and the peak response obtained 11 mm, from the limbus in the 9;30 o’clock meridian. The magnet caused a slight movement of the sclera at one side of the incision. The incision was converted to a "T” over the site of the scleral motion. The magnet again applied and the foreign body on delivery was cloaked in a dense incapsulating band which was severed. The original incision had been made within a millimeter of the foreign body. The locator in this case was of definite help in selecting the site of the incision, A, L0 F, - age 28 This soldier had a penetrating wound through the cornea, 4,0 mm, from the limbus at 2;30 o’clock, caused from a piece of steel* while chiseling off a bead of welding of a car bumper. Upon examination, a questionable foreign body was seen in the mid vitreous. This damage was to the right eye. The locator was positive over the superior nasal portion of the sclera. The X-ray placed the foreign body 18 mm. back of the cornea, Z mm, above the horizontal plane and 8 mm* nasal to the vertical plane, The foreign body, after a few examinations was lost and the locator was again used and the peak response was found to be in the 4 o’clock meridian about 12 min, from the limbus. An incision was made over the pars plana and the foreign body immediately delivered upon the use of the magnet. This case illustrates the use of the locator for repeated localizations and for following a foreign body after application of the magnet, H, C, ~ age 36, * Injured when a rifle grenade exploded, injuring the globe on the right side, Vision: No light perception. The locator was used in this case and it gave positive response over both lids. Over the globe, a peak response could be obtained between 6 and 8 o’clock but the probe could not be moved far enough posterior to be certain of the antero-posterior localization. Under pentothal anesthesia, the sclera was exposed and the locator was used with the shield removed and the tip covered with the sterile rubber jacket. The sensitivity was cut down to tune out the foreign bodies in the lids. The peak response was obtained 16 mn. from the limbus in the 7:30 meridian. It was definite and sfinarp. Incision was made in the sclera, the mid point of the incision being over the site of the peak response. The foreign body was readily obtained upon application of the magneto In this case, the site for the incision was made entirely on the locator findings, £,Bo PfCo Soldier injured when he tripped a mine, in Alsace-Lorain©, Multiple penetrating wounds of both eyes. The left eye was enucleated on 4 December 1944, Only counts fingers with the right eye, X=>ray localization showed a wire, however, there was no response to the locator. It was decided that the foreign body was non-magnetic, In this case locator confirmed the opinion that the foreign body was non-magnetic and that an attempted magnet extraction was not indicated. AailoSo - age 25 Injured when a land mine exploded in France,, The right glebe was proptosed and was enucleated• Progressive loss of vision in the left eye e , Siderotic changes occurred later in this case0 No foreign bodies could be seen upon ophthalmologic examination. The locator gave a peak response 8 mm0 from the limbus between 7 and 8 o’clock when the magnet was applied pre-operatively„ X-ray examination reported one cuestienable foreign body 15 mm. back of the cornea, 5 mm. below horizontal plane and 10 mm. temporal to the vertical plane, and a second foreign body 6 mm. back of the cornea, 9 mm. below horizontal plane, and 6 ran, nasal to the vertical plane. An incision was made over the pars plana and the foreign body was immediately obtained on application of the magnet» X-ray following examination following surgery was negative for intra-ocular foreign body and no response was obtained with the locatoro The locator in this case enabled the operator to place the scleral incision with sufficient accuracy to obtain the foreign body o L0s0 - age 28 Injured when a Jap detonator cap exploded. Penetrating wound of the right eye 0 The foreign body could be seen in the vitreous. X-ray localization placed it in the globe. The locator gave no response. The magnet when applied did not produce any motion of the fragment nor did the patient experience any subjective sensation. a magnetic extraction was not indicated, o o oApplause..c 163 LTo COLo GILBERT 0. STRUBLE, Chief, Eye Surgical Center, Crila General Hospital, read a paper on ’’Technical Refinements in the Removal of Magnetic Intra-ocular Foreign Bodies from the Posterior Segment of the Eye” which was followed by a motion picture0 This paper, prepared by Lt« Col0 Strubie and Major L* J„ Croll, will be published in a forthcoming issue of the American Journal of Ophthalmologyo Colo Strubie described a method of check localization of intra- ocular foreign bodies which he has used since 1942„ This method consists of pinching a lead shaving to a black silk suture and sewing this lead plate to the sclera at the point indicated by the X-ray localization.. This procedure is carried out at the time of the operative removal of the foreign body. X-ray films in the lateral and PoAo views are now taken with a portable X-ray machine in the operating roonu The authors point out that by using rapid developer solution, the films can be returned to the surgery in eight minutes to be read; by the surgeon. From a study of the relationship of the foreign body to the lead marker, any necessary correction as to proper localization can be made before the sclera- tomy is done. The authors refer to this as pin-point localization and believe it is especially indicated where the foreign body is imbedded in the retina, choroid or ciliary body to prevent lateral drag and tearing of these structures as would be the case should the surgical removal be attempted from the side instead of directly over the particle 0 Colo Etruble described some experimental work performed by Major Croll and himself in which metallic foreign bodies were introduced into the eye and their removal attempted from different distances. His presentation was illustrated by a moving picture film showing the method advocated by the authors for the removal of magnetic foreign bodies from inside the globe without penetrating the uvea with the tip of the magneto DIB CUES I0K MAJOR TRYGVE GUI®EREON (Eye Consultant , Surgeon General9 s Office)s I would just like to say that the Berman Locator has not been issued to very many hospitals in this country, as you doubtless know0 Not being issued in this country, of courses, it was not issued abroad either„ In the North African Mediterranean Theater, this was certainly true0 We wanted one very badly« Fortunately, we had Colonel Carney with us, who had a great many gadgets, and he devised one of these locators, that you might call the Carney locator„ It is easily made from mine detectors, and 1 will leave it to him to tell you how he supplied somewhere in the vicinity of 60 or 80 of these instruments to practically all hospitals thereD In some regards, I feel quite sure that his instrument was superior to this one, It had a greater affinity for non-magneti® foreign bodies and it also had a very special little needle for intro- duction into the eye, which proved to be vary useful,, I would like to hear from Colonel Carney• LT„ COLo Ho J. CARNEY (FortDevens): I am in the Dental Corps and have not read up on my eye work, but 1 enjoyed Colonel Riwchun’s talk on the Berman Locator and also Major Abbott’s paper0 I will just, in brief, give a little history of the necessity of making an'instrument that I thought a fighter could use„ After.the Tunisian Campaign, 1 set out to try to help out the General Surgeon, principally to locate large particles throughout the body,. 1 went with.what I could get from the Signal Corps, having been refused several times„ I managed to get a worn-out mine detector and converted the search coil into a small paddle about three inches in diameter with a small hole in the center, and proceeded on that assumption to at least locate.in conjunction with the X-ray, these foreign bodies that were left in from time to time,, If you are not familiar with the mine detector, it is an 18-inch disc that is traversed across the earth, possibly six or eight inches above the earth, looking for that perpetual enemy that we had over there„ I reduced this paddle or search coil down to a three-inch disc with a handle„ It was set into balance„ It had earphones that ware placed over the head, over the surgeon’s head, back up his gown and attached, and thence to the machinec It was traversed over the suspected area of the foreign body,, That was generally located by X-ray, and by means of traversing ever and back I got the highest maximum of tone and a deflection on the needle, possibly the same, I don’t kmowo This is the first time I ever saw the Berman Locator in actiono Maybe it is the same setup,, You get the largest tone in one plane„ Keeping that same plane, you go at right angles to it ~ X marks the cross„ But that does not give you the third dimension„ So I added a little bit to this by taking two straight cutting needles, skin needles, and got from the Eye Service needle holderso I used the eye needle holders as handles for two needles, with two wires back to the same machine that 1 called the locator,. The first part I called the detector, that gave me the cross. The locator gave me the third dimension, and I would introduce one needle into the wound or into the suspected area where X marks the spot, and in another position tried to strike the foreign body„ When I made contact with the foreign body , it would deflect the needle, giving a registration that you have made contact with metal and not with bone0 Removing the eye needle holders, you have two needles in position, and the surgeon goes down on, wherever his position for the anatomy may desire0 This is all done in the operating room and it is done in position on the table0 The detector has a range of about 4-1/2 inches deep, and you can tune it into whatever you care to, ©r whatever sound you care to0 There are a few other features in which I think mine is different from the Berman locator, according to the presentations we have hado It is not powered by any 110 voltso It is merely two flashlight batteries and a B battery0 They are easily replaced„ As you know the only thing the Medical Corps gets, from the Signal Corps is two flash- light batterieso We manage to have them service this instrument and produce it with the aid of German and Italian help0 ‘They made up some seventy or more instruments» I cannot recall the exact numberc I delivered them and showed each platoon in the field hospital, every general hospital and all station hospitals that were doing any surgical work how to use them.. Later on I was sent to another sector. It happened to be an eye center, I did not know much about eye work, but I just looked over the shoulder and said, "Well, they can roll an eye fairly well0 Probably I can apply this0H 1 saw the surgical procedure» I revamped the instrument so that 1 could formulate an indicator or a coil that was about as big as a fountain pen, not unlike the one I saw presented here, that has action of just a half inch depth. Assuming that I had a diameter of an inch, I worked on a half“inch basis, and with the rolling of the eye, you could get its nearest approach, whatever position it was, If it is in the posterior, 1 worked on that assumption that you can pick up. 1 had no interest in that, because 1 ms told that the magnet took the foreign bodies out that were ferrous or magnetic and took them out wello The purpose I worked with principally was for the non-magnetic - that is, copper, aluminum, lead, zinc, B~B balls, whatever you have0 It will not take glass, acrylic or woodo In addition, I revamped the locators into a miniature broncho- scope, that has its outside diameter about the size of a 20-gauge needle, That is so wide that it will return to the locator, but when you have located, on rolling the eye, into the quadrant you think that it is (and I think this location of methylene blue with the diathermy is a good marker) the introduction into that particular quadrant and the approach by physical contact of this instrument that is so powered that it will register on the dial, that you are in contact with that same instrument by the moving of the leverage of the faucet of the holders. You may operate the jaw and grasp the foreign body, and when you do have the grasp on the foreign body, it will also maintain its registrationc Thereby with only one insertion of this locator, it will remove the foreign body0 This phase of the work, the reconversion for the eye, was in the last part of the campaign over in Italy and Major Hick more or less played along with it© It wasnH dow to perfection, but since then I have foo]ed around for the various size foreign bodies and got it comparable more or less to the size that 1 have seen in the diagram as presented in-the other room on display» Thank you, (Applause) CAPTAIN ALSTON CALLAHAN (Northington General Hospital)s We ran a series of 25 cases, using a fiber modification of the contact lens for localization of foreign bodies. In a small series of 25 cases, we felt we located the foreign body more accurately with the contact lens. That is, we do a Sweet and we do the Pfeiffer method, too, on the same case, and when the foreign body was located we would check with the findings and find that the Pfeiffer lens had located it more accurately. Of course, the Pfeiffer lens cannot be used in nerve injuries where there is any ectodermosis, and it is not applicable in cases where there are several intra-ocular foreign bodies, because then you have some markings on the X-ray that you are not able to tell what you are looking at© One addition that has been made to the technique by our X-ray man has been the use of the two X-ray machines and a right angle holder for the casettes, which allows almost simultaneous exposure of the two films, the lateral and the P,Ao view. Naturally, we couldn°t get simultaneous exposure because the X-ray would follow the opposite field, but we built the right-hand angle holder so one could set within and we could shoot from above and had a portable X-ray outfit at the side, ‘-'ome of the patients are not highly intellectual, and we were afraid they would move their eyes around while the X-ray machine was shifting to the side. That method of shooting one and bringing the other casette from behind the screen and putting in place and shooting with the portable unit for lateral view, we thought gave us certain superiority over the usual procedure or method of bringing the lateral, LTo COL© So Ao FOX: We have made several observations in regard to foreign bodies, intra-ocular foreign bodies, in our place© I would like to know whether other men have had similar experiences. First, we were struck by the fact that despite a large number of intra-ocular foreign bodies, we received (and 1 suppose other centers have too) relatively, not absolutely, a small number with magnetic© I think the men overseas did an excellent job© They cer- tainly got a large majority of magnetic intra-ocular foreign bodies© but since Secondly,, we were struck by the fact that the giant magnet was of relatively little use. When we were able to get the foreign body, we got it with the hand method„ ’When we were unable to get it with the hand method, only in a few cases was the giant magnet of any value at all. The third observation was that the postoperative course of eyes which had had successful removal of the Intra-ocular foreign bodies is not too good on the whole. For instance, 1 think we probably did BO enucleations In the past year, of which approximately 20, after the successful removal of intra-ocular foreign body, as far as we could tell from the overseas history, completely clearing up of the eye, and yet some time after that there was siderosis® LTo GOLc EDWARD E„ BURCH: I might say that your experience with regard to the incidence of nonmagnetic foreign bodies has been very closely paralleled at O’Reilly., We have seen a great many nonmagnetic foreign bodies® MAJOR GUNDERSON: There are a few other things 1 would like to say, if I may, 1 was very much interested in Major Scheie’s oxygen injection and we would certainly like to see the sphereogram. It appeals to me a great deal, I cannot help but mention a new textbook on "Operative Ophthalmology" by Rudolph Teal, published in Germany during the last year of the war® It was in two volumes® It struck me as being perfectly extraordinary that a nation on the verge of collapse had oculists in the nation who could publish a book under those circumstances. In the Teal surgery communication, Berg has written a long chapter on the extraction of foreign bodies, where he describes his method and all its variations. It is excellent® One difficulty that 1 am sure you have all had in taking a P®Ao view, is to keep the eye still® He has devised a nice little mirror which sits off at 4b degrees before the gpod eye, in vtfiich the patient fixes the light and where the eye can be kept still during the period of exposure, which as you know with the ordinary field X«ray unit is a matter of seconds rather than split seconds® It becomes very important when you are photographing tiny foreign bodies® Another thing which he pointed out and which X later had the pleasure of using, was the Mellinger magnet, which some of you may have seen but 1 am sure many of you have not® It was made in Berne, Switzerland, I think, first devised by Mellinger® It consists of a huge coil of wire, oval shape, about the size of your head, into which the head can fit. The coil of wire is about as big as your thigh or somewhat smaller. The core remains outside. You vary the amount of strengths first of all, by the intensity of the current, and second, by the size of the core which you use. The smallest cores are tiny things about the'size of a pencil which you hold in your hand, and- indeed they have points on them which can be actually placed in the anterior chamber. The largest core is possibly four inches in diameter0 vVhen the magnet is in operation it cannot possibly be held in the hando Therefore, it is fixed on a stand so .that it is held in place, in spite of the tremendous current.. This is by all odds the strongest magnet I have ever seen. You might say, "What is the use of the strong magnet any way if you are going to take them all out posteriorly?” I think we should be on our guard and not be the last to give up the old, and in my opinion there still are a number of foreign bodies that had best be taken out anteriorly0 1 had such an individual that came from the 15th Air Corps, which Major Sand of the Minnesota Unit sent to me after he had siderosiso The foreign body has been in six months, lying below the disc about 2 mm*,, imbedded in the retina, I think it would have been prac- tically impossible to have gotten it out with the posterior route „ This came out very easily by the anterior region, with no tear in the retina or no difficulty whatever*, /mother type which 1 think is very well taken out through the anterior route is the free floating one in the vitreous, regardless of how long it has been in the eye„ Another type 1 think are the ones who have traumatic cataract, where the eye has resumed a quiet phase*, I think it is perfectly feasible to take out the cataract first, see the foreign body, and if it is not attached to the retina, I believe it is perfectly reasonable to take that out to the pupil and remove through a lateral corneal incision„ I like Colonel Struble°s name, "pinpoint localizationo" I have searched for such a word for a long time*, I think it hits it right on the pinpoint*, I believe it is very important*, I think the Comberg method, combined with this sewing on of a small ring or disc, is the most rapid possible, with the exception of the oxygen injection with which 1 have had no experience, and the most accurate method with which we had any contact„ The question as to whether foreign bodies are emergencies or not has been one which has been discussed for a long time among oculists*, I think the general impression was that the intra- ocular foreign bodies were emergencies,, There the tendency to begin with was to get ophthalmologists forward in evacuation hospitals. My own opinion, after seeing catastrophes that have come from this 169 surgery's forwarded to small hospitals where facilities are bad, where the rush is tremendous and X-ray facilities are not as good, and where evacuation is often done the following day with a single eye bandage, my own feeling is very strongly in accord with Dr, ?>lheeler who I believe once said that there is no such thing as ocular emergency,. Of course, that is putting it a little bit strong, but I have come more and more to the belief that intra-ocular foreign bodies had better be considered as non-urgent things in time of war, 1 believe there is more damage done by their removal by inadequately trained personnel under adverse situations than by the better facilities and better trained people you will find further back, LTo COL, E0 Lo SHIFLETTs It looks as if the radiologists in some ways might occasionally get on the spot* I have some suggestions to make and also some constructive criticism„ I personnaly think that any man who is doing surgery on the eye should be familiar with each type of foreign body localization and should be able to do it himself„ 1 rarely find ophthalmologists able to do thato Unless he is going to do that, he is not able to judge whether nor not his assistant is competent,. Let’s divide this up in a logical discussion0 Let’s state, first, the personnel, 1 am surprised at the number of boys I question, who come back from overseas with foreign bodies in their eyes, at the number who have been examined by technicians, enlisted men technicians. The radiologist does not even supervise it. You can have a well trained technician in the mechanical aspects of this game, but he is not cognizant of the pathology that might influence localization, and as far as I can determine, no men have been interested enough to go in and see that that is being done. That is not the fault of anyone in particular, except the radiologist in chargeo This is my third year in this hospital now. Never has a technician made a localization of the foreign body. We have tried to teach them how to do it so if they got on the battlefield they might be of some help to you men, but not one localization in this hospital has been made from a film made by a technician. It has either been made by myself or by my assistant. Now Let’s divide the method of examination. We have the Sweet, the Comberg, the Pfeiffer, and various other methods. After using the Sweet method for twelve years, 1 do not think there is anything as accurate, that offers the least chance of personal error on the part of the patient, I think that the man should use the method with which he is best acquainted, because with that method he will make less errors. None of these methods of triangulation of localization of foreign bodies in a small object like the globe of the eye is satisfactory. Another thing you have to remember is the fact that you are dealing with abnormal eyes, In civilian life, you are dealing with the normal eye, that has a small fragment in it, that you get one hour or two hours after injury. You do not encounter that in wartime unless you do encounter it at the front. 1 haven’t been over there; I don’t know. The chief difficulty we have with the method at the present time is the lateralization and not the P,a, film, In fact, the P.A. film hardly enters into the accurate localization of the foreign body in the globe. Of course, you depend on the P,A8 with the Pfeiffer method, localize it with the quadrant and get at the rest of it. We investigated the Combers method. If you will compare the instruction of the Gomberg and Aweat, you will find there are a great number of possible errors because of the frequent change in technical factors while you are doing examination. The only difficulty with the Sweet is when the patient is unable to look through infinity. He has not moved during examination. Nothing is moved except your tube, and it offers the least possible chance of error and error on the part of the patient0 There is another thing that I have noticed, I always go over these localizations that come back from overseas. We have had numerous ones here. There is a carelessness with which they are plotted, the dots here and dots there and broad pencil lines here and there, cephalocaudad and caudocephalad shifts, all kinds of techniqueo Of course, I have checked the cephalocaudad shift. That is what it should be, but to reverse it, I have checked those out because I didn’t want to make a nut of myself by criticizing that and 1 find it doesn’t make any difference0 If you are going to localize these bodies accurately, use the grid on localization sheet, plot your points, and forget your lines, because a broad pencil will throw you out two or three millimeters. We have sought for protection here. We do not consider any localization that is off as much as a millimeter worth a dollar. We consider it an error, The one that Colonel Struble used this afternoon was used to demonstrate to you the value of the pinpoint localization. That represents the farthest error we have made since he has been here, and we can show you those In which they are superimposed, I think it is a wonderful method, and he is to be congratulated on developing it and using it because we realize we make errors on these cases. We can’t help it, I think with the high development of technical skill in some of the laboratories of this country, it might be worthwhile for the radiologists and ophthalmologists to get together and contribute this problem to some of the main technical organizations of this country and see if they can devise a better method of localization,. I think it would be worthwhile„ We need something that will emphasize the PoAo. rather than the lateral„ The lateralization is what gives the trouble,, Now, as to the injection of Tenon’s capsule, that emphasizes the necessity of adapting methods to look at problems encountered at the time of injury0 It is a good method, provided that you can use it, but all men do not see steresocopically through the millimetere As Colonel Struble has emphasized, you have to have pinpoint localization,. If you realize how many tangents must be made to a sphere, that anybody that is not on the summit of the sphere in two planes will appear to be in the globe, with air in Tenon’s capsule, 1 think you can appreciate the tremendous job that has to be done and how much greater is the compliment that Major ocheie deserves for what he did overseaso It is merely when you get it outside, and two perpen- dicular tangents to a given point on a sphere„ Otherwise, 1 wouldn’t trust stereoscopic vision„ I wouldn’t trust myself, and I wouldn’t trust yoUo If anybody went into ray good eye, I would get a gun on him if I ever got out of the operating room. That is the way I feel about Ito All those factors have to be taken into consideration in dis- cussing localization„ You can get them accurate if you work hard enough and work long enough0 It demands the closest cooperation between the radiologist and the ophthalmologist<= One must completely forget these little professional jealousies that exist between specialties and work together,. If you try to dominate a radiologist you probably won’t get any c©operation„ If he tries to dominate you, you won’t get any cooperation,. It is necessary to forget every- thing except the welfare of the patient, to accept equal responsi bility0 If anybody says he can’t get rid of them,he shouldn’t be on the jobo (Applause) LT„ COLc RANDOLPH? At Valley Forge, during the early spring months and during the summer, foreign bodies seemed to be at the highesto We were doing, I suppose, about an average of three or four a week, that is, attempting them,. I can certainly say that the giant magnet was successful in only one attempt, and there were plenty of them that we didn’t geto In only one case was the giant magnet successful,, I understand that previous to February, at which time 1 came, only one' had been done0 We are quite sold on the pars plana approach and consider it, when it is unsuccessful, as a very benign procedure, certainly not more dangerous than a cyclodialysis, provided, of course, you don’t go through the choroid„ 172 In those cases where we see a foreign body, particularly imbedded, particularly large, located in the region of the equator or behind, we think there is danger of pulling off the retina with a para plana approach, and we have occasionally, under direct observation with the ophthalmoscope, put a diathermy puncture over the area to localize it, and have gone in over it. 1 certainly am with you, Colonel Shiflett, in what you say on localization. I think me ought to get together, I don’t think anyone believes the local ophthalmologist0 LT. COL. BURCH: Gentlemen, owing to the lateness of the hour, it has been decided this will conclude the program, I should like to say, in conclusion, that 1 think this is one of the very finest meetings that 1 have ever attended, I think that Colonel Gunderson and Colonel Randolph deserve a great deal of credit for having arranged this meeting and Colonel Emerson and Colonel Hall and Colonel Struble have made superb arrangements for our comfort. We owe them a great debt of gratitude. I certainly hope that we v/ill be able to have more of these meetings. I imagine that some of you probably will not be in the service, but if there are enough to make it worthwhile, 1 certainly hope that Colonel Randolph will try to arrange another meeting next year, sometime in the spring. LT. COL. RANDOLPH: A year from the spring? LT. COL. BURCH: No, this next spring. That will be late enough. oco The meeting adjourned at 4:30 o’clock.