Accidental Self-inflicted Burns as a Complication of Bilateral Patching To the Editor.\p=m-\Bilateralpatching is a practice in the treatment of many eye disorders. Problems arising from bilateral occlusion include dissociative reactions and accidental selfinflicted trauma. We would like to common
emphasize the dangerous combination of bilateral patching and cigarette smoking. A 72-year-old man was admitted to Barnes Hospital Retina Service, St Louis, for
procedure eye. His
a
retinal reattachment
performed on his left general medical condition to be
good. He had no coordination problems and was alert and oriented. No patching was done preoperatively. He underwent an uncomplicated retinal reattachment procedure under local anesthesia and was bilaterally patched on flat bed rest. Two eye patches (Chaston) were secured to the was
face with 2.5-cm paper tape. On the first postoperative day the patient freed the inferior half of the right patch by releasing the paper tape from his cheek. While the patient attempted to light a cigarette, the paper tape was ignited, as well as the
patch. patient sustained first- and second-degree burns of the nose, first-degree burns of the right eyelids, and singed eyebrow and lashes. No ocular damage resulted. eye
The
Paul E. Tornambe, MD Richard Escoffery, MD St Louis
Perspective
on
Perimetry
To the Editor.\p=m-\Instudying the artiby Trobe and Glaser (Archives 96:1210-1216, 1978), I was struck by two facets that deserve mention. First, the authors refer to a color saturation difference at the vertical
cle
meridian
as a hemiachromatopsia. Theoretically, the authors are actually defining a hemidyschromatopsia since there is a dysfunction of color appre-
ciation and not a total loss of color vision in one hemifield. Secondly, the authors seem to me to have overemphasized the importance of normal central acuity, which militates against the possibility of a compressive optic neuropathy. It has been shown in the monkey that the arcuate nerve fiber bundles continue segregated even into the optic chiasm.1 Kearns and Rucker in 1958 reported four cases of arcuate
defects in patients with chromophobe adenomas.2 Harrington has recorded nine case reports of middle cranial fossa lesions that resulted in arcuate scotomas.3 It must be remembered that even in the face of normal acuity, a field defect such as an arcuate scoto¬ ma may be the harbinger of serious intracranial disease, including com¬
pressive
masses.
Robert A. Laibovitz, MD Austin, Tex
1. Hoyt WF: Anatomic considerations of arcuate scotomas associated with lesions of the optic nerve and chiasm. Bull Johns Hopkins Hosp 3:57-71, 1962. 2. Kearns TP, Rucker CW: Arcuate defects in the visual fields due to chromophobe adenoma of the pituitary gland. Am J Ophthalmol 45:505-507, 1958. 3. Harrington DO: The Bjerrum scotoma. Trans Am Ophthalmol Soc 62:324-348, 1964.
In Reply.\p=m-\Dr Laibovitz has raised two questions, the first of which is easy to answer: "hemidyschromatopsia" is indeed the more accurate term since not all color appreciation is categorically
lost. The second point is of greater interest and bears some discussion. Basically, do we see optic nerve compression with normal acuity? Of the four cases reported by Kearns and Rucker,1 two of the four eyes with arcuate defects did indeed have lowered visual acuity; two eyes apparently had normal acuity. The cases reported by Harrington2.3 consisted of nine eyes with defects that were due to "lesions in the posterior nerve and chiasm"; unfortunately, the acuity was not indicated in seven eyes, and in the two eyes where acuity was noted, it was indeed diminished. One of us (J.D.T.) has previously reported a case4 of monocular temporal hemianopic arcuate scotoma with chiasmal compression, but again central visual acuity in that eye was diminished to a level of 20/50 a short time after that patient's initial complaints. Figure 3 in our report under discussion shows yet another example of an arcuate scotoma due to compression of the nerve, and again acuity was not spared. Finally, Schmidt and Biihrmann"' have recorded 11 case reports of inferior "altitudinal hemianopias" due to chiasmal compression, and visual acuity was indeed diminished in all such affected eyes. While we recognize the existence of rare cases of visual field defects due to optic nerve compression that do not involve central acuity (excluding eyes with only temporal hemianopic field
defects, coupled with contralateral visual acuity and field loss), we still maintain that the finding of normal corrected acuity in a patient with a neural field defect would militate
strongly against the presence of tumoral compression. Exceptions to this rule are extraordinary and we found no central sparing in our series, as opposed to a 24% sparing of acuity with optic neuritis. Where a diagnos¬ tic dilemma still exists, serial perimet¬ ric examinations
are
indicated,
as are
appropriate radiodiagnostic studies.
Joel S. Glaser, MD Miami Jonathan D. Trobe, MD Gainesville, Fla
1. Kearns TP, Rucker CW: Arcuate defects in the visual fields due to chromophobe adenoma of the pituitary gland. Am J Ophthalmol 45:505-507, 1958. 2. Harrington DO: The Bjerrum scotoma. Trans Am Ophthalmol Soc 62:324-348, 1964. 3. Harrington DO: Differential diagnosis of the arcuate scotoma. Invest Ophthalmol 8:96-105, 1969. 4. Trobe JD: Chromophobe adenoma presenting with a hemianopic temporal arcuate scotoma. Am J Ophthalmol 77:388-392, 1974. 5. Schmidt D, B\l=u"\hrmannK: Inferior hemianopia in parasellar and pituitary tumors, in Glaser JS (ed): Neuro-Ophthalmology: Symposium of the University of Miami. St Louis, CV MosbyCo, 1977, vol 9, pp 236-247.
Extrusion of Postenucleation Orbital
Implant To the Editor.\p=m-\Theauthors of "Postenucleation Orbital Implant Extrusion" (Archives 96:2064-2065, 1978) have observed that six consecutive patients with postenucleation orbital implant extrusion demonstrated nonkeratinized stratified squamous epithelium lining the implant pouch. They attribute this "conjunctival" lining to conjunctival ingrowth and the subsequent extrusion to that ingrowth. While there is no question that a buried section of conjunctiva
might produce
an
implantation cyst,
which in turn could lead to extrusion, it is my experience that all orbital implants are lined with a "pseudoconjunctiva" that represents, presumably, a metaplasia of the superficial cells of Tenon's capsule into this stratified squamous epithelial lining. The layers of this pseudoconjunctiva, we have observed, have always been uniform in depth and are invariably present over the full surface of the implant pouch. While one rarely has the opportunity to examine an implant that is not extruding, I am sure
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