|Year : 1980 | Volume
| Issue : 3 | Page : 121-125
Ophthalmic changes in electro-convulsive therapy
GL Dhar1, RK Chaudry2
1 Department of Ophthalmology, Govt. Medical College, Jammu, India
2 Department of Psychiatry, Govt. Medical College, Jammu, India
G L Dhar
29-D Sector C Block-C, Gandhi Nagar, Jammu (Tawi) 180004
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dhar G L, Chaudry R K. Ophthalmic changes in electro-convulsive therapy. Indian J Ophthalmol 1980;28:121-5
Electrically induced convulsions - called `Electro-Convulsive Therapy' (E.C.T.) - was introduced to replace pharmacological convulsive therapy for treatment of schizophrenia. This method has established itself as one of the most commonly used methods for the treatment of acute and catatonic type of schizophrenia, depression (both agitated and retarded), acute maniac attacks not responding to drug treatment, puerperal psychosis, besides other few psychotic conditions in which it is sometimes used.
In standard technique, the electrodes are applied to both temples and skin resistance to current is decreased by application of salt solution or electro-jelly. The amount of current applied by the originators of this method was 70-130 volts for 0.1-0.5 sec. and a bidirectional current is usually used. The electric shock induces a series of changes in musculoskeletal cardiovascular, respiratory and nervous systems.
Whereas different changes that take place in different body systems in response to an electric shock, as given in E.C.T., are recorded in literature, the ophthalmic changes taking place simultaneously have been given only a passing reference in the available literature. Only changes such as, alteration in size and reaction of pupils and changes in retinal vasculature have been mentioned. It was, therefore, sought to study the normal pattern of ophthalmic changes that accompany and follow an E.C.T. and to record eye complications, if any. No reference could be traced in the available world literature.
| Materials and methods|| |
The present study deals with 82 patients who were admitted with various psychiatric problems which needed E.C.T. as a part of their treatment. The E.C.T. used was of a standard type. Facilities for modified E.C.T. were not available, but all the patients received intravenous diazepam (10 mg) before electric shock. An electric impulse of alternating, bidirectional current of 90-120 volts was used for 0.6-1.0 precipitate convulsions in all these cases.
Every patient in this study was given a detailed ophthalmic check-up and abnormality, if any, noted down : this included only examination under oblique illumination under corneal loup magnification, ophthalmoscopic examination and recording of intra-ocular pressure with Schiotz tonometer. The visual status could not be reliably worked out as most patients did not co-operate. In those patients where fundus oculi could not be studied because of a small or highly reacting pupil, 10% phenylephrine drops were used to achieve pupillary dilatation. All the 82 patients were subjected to a detailed general check up before an E.C.T. and were found to be normal, except for their psychiatric disorders.
Ophthalmic changes that occurred in each E.C.T. were noted down and, in order to record their timings accurately, the same assistant was directed to record the duration of one particular event with the help of a stop-watch. Any eye complication that followed E.C.T. was also noted down. Total time taken in various changes or complications, if any, were also noted down in multiple observations.
Whereas some patients received only one E.C.T. during this study, others received 2-4 electric shocks. This study comprises analysis of a total of 213 E.C.Ts' on 82 patients in age group of 15-43 years, comprising 42 females and 40 males. Of these 12,21,33 and 15 received 1, 2, 3 and 4 E.C.Ts. respectively.
| Observations|| |
Changes observed in patients during E.C.T. are recorded in [Table - 1]. In 194 E.C.Ts. the changes started almost instantaneously, once the electric stimulus was transmitted. Only in 12 cases there was a latent period before the convulsions started, and in 7 cases a second electric stimulus had to be passed because the first failed to precipitate a convulsion.
1. Tonic contraction of lids: This was observed almost instantaneously with the transmission of electric stimulus in 194 E.C.Ts. The tonic contraction of orbicularis oculi resulted in severe blepharospasm which marked the beginning of an electric convulsion. This phase lasted for at least 7 sec and at the most for 12 sec. with a mean average of 8.82 recorded in [Table - 2].
In 12 cases this phase was observed only after a latent period of 1-3 sec. The phase of tonic contraction of lids were smaller in duration than the phase of tonic contraction of other body muscles, which lasted for only about 10 sec on average.
2. Clonic contraction of lids: This phase immediately follows the phase of tonic contraction of lids. During this phase rhythmic contraction and relaxation of lids was observed. These rhythmic contractions are fast to start with, but progressively slow down till they ultimately die down. The amplitude of these contractions builds up slowly and becomes stronger and stronger till ultimately they disappear altogether.
The duration of this phase was variable from 19 sec to 43 sec in this study with a mean average of about 31.5 sec. as recorded in [Table - 3].
The mean average duration of clonic phase of contraction of eye lids was almost of same duration as clonic phase of contraction in rest of the body muscles where its average duration was 30-40 sec.
3. Opening of palpebral aperture and fixed gaze of eyes: With the cessation of clonic contractile movements of lids the palpebral aperture started opening up gradually. The patients entered a stage when they stared blankly and their gaze got fixed. The gaze may get fixed straight upwards or in one particular direction. The gaze remained fixed in this manner for a variable duration of 21-70 sec. This variation was sometimes recorded in the same individual who had received more than one electric shock, under identical medication and electric stimulus, similar in duration and intensity.
4. Phase of conjugate deviation of eyes: Of the 213 E.C.Ts. studied, 196 showed gradual deviation of eyes in one or the other direction. The conjugate deviation was slow in onset and return of eyes to primary position was also gradual. The conjugate deviation of eyes in different directions is recorded in [Table - 4].
Conjugate deviations to left were predominant, being seen in 113 E.C.Ts, while conjugate deviation to the right were seen only in 65 E.C.Ts. The vertical deviations were far less in number than lateral deviations. The deviations downwards were least in number, being seen only in 2 E.C.Ts. compared to 16 E.C. Ts. where eyes moved upwards. Further, the pattern of conjugate deviations was not always identical in all patients who received multiple E.C.Ts. under identical conditions, though in majority it remained same. Thus, there was a definite variation observed in 19 repeat E.C. Ts. where previous pattern of conjugate deviations was not seen again.
In 17 E.C.Ts. the eye movements were bizarre conjugate movements resembling opsoclonus which died down after a brief existence of 7-33 sec.
5. Congestion of eyes: The redness of eyes resulting from congestion was seen in as many as 201 E.C.Ts. immediately after convulsions ceased. In all these cases there was conjunctival congestion while in 4 cases ciliary congestion was also observed.
The extent of conjunctival congestion of eyes ranged from mild to severe. Although ciliary congestion was mild in all the 3 cases, in one case it was marked. Congestion also appeared in all those cases who had received a drop of 10% phenylephrine in their eyes for mydriasis. The time for congestion to disappear varied from 4-min. 43 sec. to a maximum of 28 min.
6. Watering of eyes: Watering from eyes was observed in 114 E.C.Ts. It was profuse only in 22 cases but confined to only 1-3 drops spilling from eyes in 57 E.C.Ts., while in 35 E.C.Ts. no frank spilling of tear fluid took place but the eyes were laden with tears.
7. Pupillary changes: These were observed in 207 E.C.Ts. These comprised of dilatation, temporary loss of direct and consensual reflex and alternate periods of reaction and rigidity even when the direct light reflex had been initially established.
Mydriasis took place in all the 207 E.C.Ts. This happened in those cases also where pupils were partially dilated with 10% phenylephrine. The pupillary dilatation ranged from 4-6 mm in patients who had not received any phenylephrine, while in the patients who had received it, it was as much as 7 mm. The pupils did not show any reaction to light (direct or consensual) from 1 min -56 3min.-54 sec. after electric shock, After this period, the pupils were still dilated but reacting to light.
In 38 E.C. Ts. the pupils showed alternate period of rigidity and reaction to light even when the reaction had been established initially.
The pupils did not dilate in 6 E.C.Ts. Four of such pupils were observed in 4 different patients in whom there were dense posterior synaechiae (even 10% phenylephrine failed to dilate it) from previous attacks of anterior uveitis. In the remaining 2 cases no reason could be attributed to non dilatation of pupils except that they showed only slight reaction to light and were very slightly dilated with 10% phenylephrine even after repeated instillations for 30-45 min.
8. Calibre changes in retinal vessels : When seen after the phase of convulsions, the retinal vessels were dilated. The dilatation of the vessels was seen in 194 E.C.Ts. The veinous dilatation could be seen even 6-7 min. after electric shock. However, in 19 of these E.C.Ts., where convulsions were delayed or a second electric shock had to be given to precipitate a convulsion, the retinal vessels were seen to have undergone an initial constriction followed by a dilatation. The initial constriction of the blood vessels could not be seen in all the E.C.Ts, as the convulsions were precipitated almost simultaneously with the passage of the electric stimulus and thus, the observation was not possible with the eye-lids in a state of tonic contraction.
9. Retinal oedema: This was observed in 34 E.C.Ts. Its presence was characterized by increase in the number of retinal reflexes and increase of sheen of fundus background. In one case, who had apparently old healed choroiditis, there appeared milky hue in fundus background and the blood vessels were seen partially buried in the retina. The milky hue was still present, though considerably diminished, even at the end of 24 hours when the patient was re-examined.
10. Changes at optic disc: In 112 E.C.Ts. definite congestion of the optic disc was made out. Out of these, 21 cases also showed blurring of the whole or part of disc margins. No case showed any measurable degree of swelling of the optic nerve head. The blurring of the disc margins, if any, along with the congestion had completely disappeared when the cases were re-examined 4 hours after the electric shock.
11. Vitreous haze: A well market vitreous haze developed in 4 E.C.Ts. These included 3 cases who had a history of recent attacks of anterior uveitis and one case of old healed choroiditis. In the latter case the haze was still present when examined 24 hours after electric shock, though appreciably reduced.
12. Changes in intra-ocular pressure Intra-ocular pressure could be recorded satisfactorily with Schiotz Tonometer, before ant 5 min after electric shock, only in 69 E.C.Ts All these patients showed a rise of intraocular pressure of 4-7 mm Hg.
| Discussion|| |
In many psychiatric centres modified E.C.T. is still not possible and E.C.T. as giver in our patients is still practiced. An attempt has been made to study the eye changes that accompany and follow an E.C.T. and find out if such E.C.T. could cause any ocular complications.
Various changes that accompany ant follow an E.C.T. and hitherto not describes have been recorded, such as, two different patterns of orbicularis activity, changes it palpebral aperture, movements of globs (conjugate in majority), congestion ant watering of eyes and changes in intra-ocular pressure.
Possible psychopathological changes, such as, changes in visual acuity, form vision alterations in visual fields and colour vision changes, could not be included in this stud) because of the difficulty in obtaining the co-operation of the patients and thereby causing difficulty in the interpretation of the pre-and post-E.C.T. responses of these patients. It was also not clear as to why conjugate deviations of the eyes should occur in most but not in all as a result of electric stimulation of frontal cortex. Similarly, the variation in the direction of conjugate movements in the same individuals under identical conditions of E.C.T. cannot be explained satisfactorily except by attributing it to the plasticity and/or flexibility of the cortical responses. That some patients had congestion of conjunctiva, watering of eyes, optic disc and retinal oedema may be related to muscular activity following the E.C.T. and altered permeability of retinal vessels as a result of electric shock.
Observation of the increase in the intraocular pressure is significant and, although only mild rise occurred in these patients, it is worthwhile to study in detail the duration of rise in the intra-ocular pressure. It would also be interesting to observe as to whether there is difference in the rise of intra-ocular pressure in normal, ocular-hypertensives and glaucomatous patients, after an E.C.T. The effect of pupillary dilatation also requires a detailed study to observe its effect in patients with narrow angle.
The retinal oedema and vitreous haze occurred in patients who had recent attacks of acute anterior uveitis and apparently healed choroiditis. Although their number was very small, the observation is, however, significant and one should proceed with caution in patients with recently healed uveitis.
| Summary|| |
The ocular changes following electric convulsive therapy has been described in 82 cases.
| References|| |
Cerlett. U. and Bini, L, 1938, Arch. Gen. Neurol. Psychiat. Psicoanal. 19: 266.
Freedman, A.M., Kaplan, H I. and Saddock, B.J., 1976, Modern synopsis of comprehensive Text Book of Psychiatry-II, Second Asian Edition (1976), pp 989-993. Publishers Williams and Wilkins Co., Baltimore.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]