|Year : 1956 | Volume
| Issue : 3 | Page : 59-67
A Belgian ophthalmologist's studentship in India - Part II - ophthalmic medicine
|Date of Web Publication||10-May-2008|
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Lebas P. A Belgian ophthalmologist's studentship in India - Part II - ophthalmic medicine. Indian J Ophthalmol 1956;4:59-67
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Lebas P. A Belgian ophthalmologist's studentship in India - Part II - ophthalmic medicine. Indian J Ophthalmol [serial online] 1956 [cited 2020 Aug 6];4:59-67. Available from: http://www.ijo.in/text.asp?1956/4/3/59/40749
| Eye Lids and Lacrymal Apparatus|| |
While trachomatous entropion is very common, the senile variety is rare. Blepharitis unexpectedly is not very common although when one gets it due to the Morax diplobacillus, because of Vitamin A deficiency it is much more severe and chronic. Palpebral edema and erysipelas are rare. Exceptionally rare are epitheliomas. I saw only one case, even then very doubtful even for Prof. Lindner. In Madras where there was a big service of anatomopathology for ophthalmology with systematic examination among others of chalazion, the late Dr. Muthaya told me how frequent was the Meibomian adenocarcinoma. He had seen 16 cases in 1954 and he suspected every chalazion in people over 40 to be cancerous.
I have seen some cases of ptosis and congenital colobomas which did not seem to be more frequent than here, a nice blepharophimosis, and a rare case probably of a mycotic infection of the roots of the eyelashes with calculosis.
Acute and chronic dacryocystitis with or without lacrymal fistula, often of tuberculous etiology, were very frequent; dacryocystitis was the operation of choice save in Calcutta where a dacryocystorhinostomy was routine. In Bombay Dr. Dhurandhar did a dacryocystectomy combined with a rhinostomy with pretty good results. I was informed by Dr. Cooper that strangely, in a district of Bombay state Satara district - the incidence of dacryocystitis was much higher and that of trachoma very low.
Dr. Shukla of Aligarh told me he had noticed the predilection of dacryocystitis in women for the side corresponding to the nose ring the Indian females wear. Lacrymal obstruction in newborn seemed to be rare; lacrynal mycosis are not so rare in some districts; in Madras rhinosporidiosis was reputed to be not uncommon.
| The Conjunctiva|| |
Indian conjunctiva is less thick than the European; it allows therefore more clear cut dissections but on the other hand is more haemorrhagic consequent to either the trachomatous process or to chronic congestion. Many bulbar conjunctivas indeed show, mostly in the inter palpebral area, a mraked congestion in relation probably with the climatic conditions.
Conjunctivitis are very frequent mainly from Weeks' bacilli, diplobacilli, phlyctenular and follicular conjunctivitis and vernal catarrh. A viral form of conjunctivitis, where no organisms can be cultivated from the conjunctival smear although full of pus, is also recognised particularly during the monsoon season.
Gonoccocic conjunctivitis is exceptional in adults as well as in children even in cities where gonococcic urethritis is not uncommon. I have not seen a single case of gonoccocic conjunctivitis in 13 months and was told that it was not a coincidence. I do not know at all the reason why this disease is rare in India.
Phlyctenular keratoconjunctivitis is very common; phyctenes often many and big reach sometimes quite an uncommon size. I am reminded of one case with phyctene of 5 to 6 mm. in diameter which I thought was a small conjunctival abscess. Never have I seen such a big phlyctenc. Dr. Shukla of Aligarh suspected besides tuberculosus allergy avitaminosis A: as for me I would suspect an avitaminosis B because I was struck in Calcutta by the frequent association of phlyctene-cheilitisglossitis.
Follicular conjunctivitis, mainly seen in children presents quite an unusual and puzzling clinical picture. The follicles stud the whole conjunctiva, bulbar included. This latter form is mainly seen in Bombay in young boys and associated with bilateral and preauricular adenopathies. Dr. Ghosh of Calcutta told me he had often improved or cured such follicular conjunctivitis with the treatment of intestinal parasitosis.
Conjunctival tuberculosis is fairly common, especially the pseudotumoral cock's-comb form in Bombay.
Ophthalmia nodosa was a daily occurrance in Calcutta when I was there. When the caterpillar hair gets the bad idea to enter the cornea, the ophthalmologist has to have much dexterity, patience and tenacity. In an old case in a child, 4 years old one could see with the ophthalmoscope a white mass protruding in the vitreous which could be as well a glioma or a pseudoglioma or the inflammatory reaction to a caterpillar hair.
Probably peculiar to India is the conjunctivitis with maggot caused by milk instillation, the milk being a collyrium popular in some districts. Instillation of cow-urine, very popular too, and of other bacteriodynamics of the same kind and the instillation of very irritating substances in the formix and used to provoke congestion of the eyes and therefore the demoniac aspect of some Indian dancers should certainly cause pretty nice ocular and conjunctival lesions. I had not the opportunity to see any such case.
Fingueculas are commoner and bigger than in our countries; pinguecular inflammation i.e. congestion of the pinguecula with sensation of sand in the eyes and even a vague pain, is almost of daily occurrence and it is not always easy to differentiate it from the phlyctenular conjunctivitis or episcleritis.
Pterygium is often quite common; it is sometimes very aggressive as in one case of double pterygium having covered almost the whole cornea, sometimes very fanciful as in a case of bilateral infero temporal pterygium. Classical surgical treatment is almost left aside, the recurrences being too frequent. Most of the surgeons use technique based on the double assertion that (1) the cause of the pterigium is in the episcleral or the subconjunctival tissue which is consequently largely removed, and (2) that the corneal epithelium must win the race over the conjunctival one after dissection of the pterygium, where one allows the sceral rectangle to remain quite uncovered from any conjunctiva at the level of the neck. In Bombay the use of zinc drops after an operation of pterigium are insisted upon because of isolation of Morax Axenfield bacillus in many cases of pterygia.
Tumours are rare and I can remember one of a juxtalimbic melanoma on the way to malignancy and some lymphatic and lacrymal cysts.
| Cornea|| |
Pathology of cornea is a big chapter of Indian ocular pathology many sections of which end with a question mark; besides many other sections are still waiting to be written. Our Indian colleagues know very well the corneal pathology, better than we on an average I think, because they meet it in practice daily. Therefore I shall mention more than one remark or opinion of theirs.
It is one of the most frequent ocular affections; out of a 100 ocular patients there are often half a dozen hypopion ulcers. Trachoma and dacryocystitis arc the chief causes. The average Indian is not easily perturbed as his western double by an ocular trauma. If he comes with his hypopion filling 2/3 of the anterior chamber without having awaited the end-ophthalmitis or the panophthalmitis, it would be considered lucky.
Exceptional in our countries, the advanced stage of pseudocornea is not exceptional in India. The patients delay coming soon so much that when the eyelids are drawn apart. one falls directly upon the iridocristallin diaphragm, cornea having disappeared or being reduced to a small paralimbic edge; I have seen some cases and was astonished to see how slowly the iris and lens so in contact with the air get altered.
In treatment it is the usual routine one. I have not seen used the treatment advocated by some British authors viz. applications of solid crystals of penicillin to the whole ulcer. Popular with the Indian ophthalmologists is the general treatment with milk injections, vitamins and insulin (5 units) which latter stimulates the metabolic processes particularly in the cornea.
Paracentesis is relied on for resistant ulcers. Saemisch's section seen only once by me is rarely performed, but I would not do it myself. Prof. Lindner believed that it acts more by provoking a secretion richer in antibodies, and this can be achieved by an Ellliot's trephination or repeated paracentesis.
Descemetoceles were frequent. A permanent conjunctival bridge is drawn over the ulcer and kept in position after cauterising the edges of the ulcer. An Elliot's trephining may be done to combat an expected hypertony.
I saw at least 6 cases in a year of Mooren's ulcer. One of these perforated, which is exceptional. This was due to secondary infection.
Superficial punctate keratitis is very common especially just preceding and during the monsoon. Found in young people much more in males it is characterised by unilaterality, preauricular Iymphadenopathy, punctate fluorescein-positive opacities visible only with a magnifier. It is preceded by a mild conjunctival or nasal catarrh. Treatment is of little avail and it heals spontaneously. In resistant cases, I must confess I have seen spectacular improvement with Vitamin C. 500 mg. intravenously.
One particularly resistant case of recurrent erosion deserves mentioning. It was in Bombay. and it was a young man who was treated for weeks for recurrent erosions of the cornea without much success. There was an associated spring catarrh. Even Cortisone therapy proved useless. The patient who had disappeared reappeared after a few days with intense photophobia. The corneal epithelium was completely denuded in both the eyes. The patient was hospitalised and binocular pads and bandage were applied for a few days. The patient left the hospital with the corneal epithelium and also his keratitis and vernal catarrh.
Tuberculous Keratitis. Phlyctenular keratitis is frequent but not so much the fascicular type. Interstitial keratitis is common which is sometimes found with such little corneal nodules that one can speak of a true corneal miliary tuberculosis.
Syphilitic interstitial keratitis is very rare and that is strange if we consider the high birth-rate and incidence of syphilis in India.
Small-pox Keratitis. I have seen it much too frequently not so much in the acute stage which occurs during convalescense as the catastrophic sequelae.
Herpetic Keratitis. Considering the frequency of febrile affections in the tropics the rarity as compared to Belgium of superficial forms of ulcers and dendrites appears puzzling. On the other hand I saw a case of a beautifully circular disciform keratitis and another of numular keratitis which improved with cortisone but not with antibiotics.
Lagophthalmic Keratitis. Because of bad surgery of entropion by quacks (some of them could be called palpebrectomies) in some cases one can understand this form of keratitis. On the other hand is seen a similar keratitis with a horizontal upper edge involving the inferior quarter of the cornea and the neighbouring conjunctivae and always without the least anatomic or functional lagophthalmas for the etiology of which I believe I can provide an explanation. One afternoon when walking on a busy street of Bombay. when many take a nap during the recess, they do it in the open park or street. I noticed that some were sleeping with half-open eyes and what is more amazing with the eyes not supraverted. This first suspicion was confirmed when a few weeks later I saw a typical case of lagophthalmic keratitis in a young man in perfect health who in good English confessed that his companions joked about his sleeping with open eyes. Do many Indians sleep with open eyes not supraverted, is another question. Can it be the damp heat of the tropics, I wonder.
Unusual Keratitis : I saw three varieties which I consider unusual. The first consists of a limited opacification, often paracentral involving the whole thickness of the cornea without oedema of the epithelium or swelling of the cornea. It appears spontaneously and except for defective vision there are no symptoms nor any redness. At first sight it looks like an ordinary leucoma. According to Dr. Cooper, questioning the patient is the only way to prevent falling into a diagnostic trap because the patient insists that it was never there before and he had never suffered from sore eyes. Confusion is easy because corneal sensibility is not altered and biomicroscopy does not allow a view of the punctate leococytic chararter of the corneal infiltration. It may resolve spontaneously but may remain permanent in spite of all treatment.
The second named Golden Drops Keratitis was seen in Calcutta thanks to a collyrium made by an apothecary and named "Dr. Guha's Golden Drops." These eye-drops provoke after a long use a generalised oedema of all the corneal layers but mainly marked in Bowman and Descemet membranes with gelatiniform aspect of the conjunctiva. The oedema, first reversible causes after a time a very dense and definite corneal opacification. The chemical analysis of Golden Drops disclose as the contents acriflavin, anethain, ephedrin and sulphamide.
The third one is the Keratitis which we may call "flower petal" cat print Keratitis" or "tiger print Keratitis". It is an opacification distributed in some juxtaposed foci, with clearcut edges with folds in Descemet's membrane observed following a cataract operation during which the surgeon has generously irrigated the anterior chamber. The opacities disappear moreover in 8 to 10 days. I saw a similar Keratitis after ocular contusion.
Corneal Dystrophies. Secondary ectasias are many, particularly as a consequence of fleshy trachomatous pannus I have seen some cases of marginal ectasias described by Terrien. I have also seen in babies bilateral symmetrical Keratectasias of the lower quarter or one third of cornea. I believe secondary to a lagophthalmos due to asthenia, for these babies were most often in a pitiful state of health. Should we assume a peculiar weakness of the cornea in these babies full of various deficiencies.
Secondary bandshaped keratitis is very frequent; the primary form i.e. occurring otherwise in normal eyes are not uncommon. Some have an atypical appearance; for instance girdle-shaped keratitis where the calcareous infiltration is replaced with a lipoidic infiltration or one where the calcareous distrophy designs concentric streaks, peripheral and parenchymatous, or unilateral as I saw in a young man. 25 years old, situated in the superior sector in an eye otherwise normal, except for remnants of pupillary membrane.
I had the opportunity to see some Groenouw, dystrophies of macular and nodular types and bilateral paralimbic symmetrical superior yellowish white dystrophy in a patient with a cholesterinaemia at 90 mg. Corneal argyrosis: the high incidence of conjunctivitis and trachomas have made the Indians use silver medications. In the cornea in fine optical section one notices a carpet of bluish dust in the endothelio Descemet, as described by Berliner, but in very fine optical section the brightness of endothelio-Descemet is much more marked than that of Bowman's, whereas normally it is the opposite.
Kerotoconus. It is not more frequent in India than here. I have already said how difficult it was sometimes to differentiate from secondary keratectasia. I have seen three cases operated upon according to Sato's technique or a similar technique.
Professor Lindner operated upon a liquid matress made by continuous injection of saline in the anterior chamber; after a chamber puncture with a needle, he intrduced a canula with a smooth extremity and round section of equal diameter to the needle one. Meanwhile the assistant maintained a continuous stream of saline the surgeon entered with Sato knife and made the endothelio-Descemetic incisions. It is not an easy job. During the two operations made by Professor Lindner. the cornea much thinner in keratoconus; was perforated in one case, meanwhile in the other case the lens had to endure the fate generally meant for the endothelio-Descemet.
In the third case Dr. Dhurandhar of Bombay made a keratotomy with the keratome at 12 and after iridectomy scratched the endothelio-Descemet with a simple cystitome.
Corneal Anomalies. Microcorneas seemed to me fairly frequent and often associated with other anomalies, particularly uveal and optic nerve colobomas. As a curious case I saw in a woman 45 years old, myopic 2.5 D in both eyes an embryotoxon, bilateral with iris dysplasia, hyaline formations of the endothelio-Descemet and Krukenburg spindleshaped pigmentation fullfilling the classical conditions.
Tumours. They are rare. I saw only two limbus epitheliomas.
Keratoplas ties. There is tremendous material for keratoplasty. Unfortunately grafts are lacking and it is only in Bombay I could see some kertoplasties. Obstacles are of law, social and religious nature. If the first can be easily got over, and the Indian Society of Ophthalmology occupies itself now with it the two latters are big ones.
In Bombay the technique used was Franceschetti trephines. The graft is kept in its place by means of a contact glass stitched to the corneal periphery or the limbic sclera. When I was there, there were in some cases postsurgical incidents of which the utmost was the moving away of the contact glass and the graft. Ten mm. diameter grafts even with a previous decompression did not give any good result. The graft gets opaque and a tenacious secondary glaucoma sets in. On the other hand I have seen in cases operated upon in Bombay simply marvellous results, and should the junction line not have been there, it would have been impossible even with the biomicroscope to recognise the case as having had a keratoplasty.
| The Iris|| |
Iritis and iridocyclitis are about as frequent in India as in Belgium, but the Indian Ophthalmologists can less often than we, have the help of a vague rheumatismal syndrome to label an always tiresome diagnosis of the etiology. Rheumatismal iridocyclitis is indeed extremely rare; also our Indian colleague falls back not without reason on a focal infection particularly on a tuberculous one. Tuberculosis and syphilitic iridocyclitis and uveitis seemed to me relatively less frequent in India than in Belgium. In the former Dr. Cooper was very fond of Koch purified tuberculin desensitization.
Fuchs' heterochromia is exceptional. I have not seen one case. Dr. Chaudary confirmed my impression and added that heterochromia is rare in heavily pigmented eyes or at least in pigmented people. It is possible.
| Exophtalmos|| |
They were frequent, more than in Europe, and I saw many causes : traumas and in one case an impressive insect sting, pansinusitis, orbital periostitis or cellulitis, thyrotoxic and thyrotropic forms of goiter (the latter so malignant that in one case the patient had a generalised bilateral abscess of the cornea) ethmoidal mucocele. aneurysm of the ophthalmic artery. angiomas, neurofibromas with malignant degeneration. metastasis of femoral sarcoma, and some cases in Madras of Suprarenal tumours in young children (Hutchinson's disease) and gumma.
| Neurofibromatosis|| |
The many cases I have seen, have been in Madras; in Madras hospital one case could be seen every fortnight at least and it happened that during an afternoon walk through the city I could see 3 cases. Dr. Hemerijckx, 30-40 miles from Madras. told me also the extraordinary frequency of neurofibromatosis in this area, because he had to do the differential diagnosis with leprosy. That was so true that in Calcutta I saw one case and was told that the patient's parents were also from Madras. The Madrasces having a darker skin, the "cafe au lait" spots could not he seen well; on the other hand neurofibromas are many. In the ocular area, temporopalpebral tumors and yellowish iris nodules are frequently to be seen. In no case I saw a lesion of the fundus or could suspect a glioma of the optic nerve; in one case, skull X-ray showed erosion of the petrous bone caused probably by a tumour of the eighth nerve.
| Ophthalmoscopic Lesions|| |
For them alone, a whole conference would be necessary. So I just gathered some images, poor and clumsy ones. I hope you will excuse me. I shall comment on them.
Choroiditis and chorioretinitis are frequent in India as they are here and often of uneasily determined etiology. Atrophic choroiditis and choroidosis too. Familial macular choroiditis, like that of Doynes was sometimes met with.
Arteriosclerotic, hypertensive, albumin uric, diabetic retinopathies, occlusion of central vessels have no special characteristics in India. Proliferant retinitis is very frequent, very severe and almost always observed in Eales' disease.
Septic choroiditis or retinitis are not frequently seen, because too often the patient does not come before endophthalmitis or panophthalmitis.
Pigmentary retinitis was very frequent; I have seen many cases where the Bordet-Wasserman was and kept negative even after reactivation and 3 cases they were met with the cerebral lesions of Vogt Spielmayer Stock Syndrome.
Punctata albescent retinitis or similar affections were extraordinarily frequent and it seemed to me, confined in some areas; most of them indeed I saw in one month in Bihar.
Macular lesions were also very frequent especially photolesions. There was a sun eclipse in May and thanks to the opthalmoscopic aspect of a lesion, I could guess the aspect of the eclipse which I had not seen. The imprudence often done to look at the sun eclipse with naked eye is often forgiven here but not in India by the sun where it is much more aggressive.
Gliomas seemed to me rare; I saw some in Madras but there in 2 months I saw 4 or 5. Optic atrophy is very frequent and of uneasily determinable etiology. Smallpox and cerebral malaria are readily suspected but often nothing in the history can prove it.
According to Dr. Mutthayya from Madras, a virus neuritis has been invading in these last years India, coming from Ceylon and would now spread from South to North, striking mainly young people but leaving no severe seqelloe.
Parasitic lesions of the fundus oculi, like toxoplasmosis and histoplasmosis are beginning to be recognized thanks to the availability of these tests in India. For this reason the relative frequency of these diseases along with that of brucelosis in comparison with European countries cannot be determined.
| Eales' Disease|| |
It is extremely frequent in India and almost all the cases I saw were in young men, many of them teachers or students. According to Lindner, this disease was much more frequent and severe in India than in Europe; Eales' disease in Vienna became rarer and slighter like tuberculosis, thanks to social, economic and hygienic measures taken by the Austrian Government.
Lindner thought tuberculosis paravascular infiltration causes vascular rupture and hemorrhages in the eye like in the lungs and that vitreous haemorrhages are equivalent to haemoptisis.
From the symptomatologic point of view, the disease in India is different because proliferant retinitis appears very early and is important; relatively discrete hemorrhages were met along with relatively large proliferant retinitis although history did not suggest a big vitreous hemorrhage. Hence much more often than in Belgium blindness was the final result with big proliferant retinitis and retinal detachment.
Professor Appelmans having pointed out to me, I'll mention I did not meet especially frequent keloid scars particularly after dacryocystectomy, pointing to no special reactivity of mesenchymatous tissues.
Lindner thought a vitreous detachement was always present and showed to us one in every case he was asked to; for him, haemorrhages and fibroglial proliferation are retrovitral. Laboratory examinations did not give any more interesting results than here. Often the long and expensive treatment had to be discarded because the uncertain result would not justify the sacrifice.
Lindner in some cases with detachment did total perforating sclerectomies with very partial results. In Bombay they did in one or two cases replacement of the vitreous by spinal fluid without real improvement.
In Madras where Eales' disease was especially frequent. Dr. Mutthaya tried to prove his hypothesis of filarial etiology.
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