A system of overlying suture in partial penetrating keratoplasty

We have evolved a system of a single thread, ten-bridge equally spaced overlying suture, aided by egg membrane, artificial fibrin and immediate strong mydriatic for central partial penetrating keratoplasty no bigger than 6.5 mm. It has given us results, mechanical and visual, better than we have had with direct sturing or with the Katzin 3-leaf clover overlying suture or a combination of both. We suggest that others give it a trial. (Conclusion)

Cataract extraction in diabetes mellitus

1. When indicated, senile cataract in diabetes mellitus should be extracted 2. A little extra care is needed in the pre-operative and post-operative management 3. Attempts to bring the pre-operative blood sugar level to normal values at the cost of a feeling of weakness, does not seem to be advantageous and justified provided there is no acetone in the urine and prothrombin time is not prolonged 4. A blood sugar level of around 150 to 160 mg. seems to be an optimum level 5. The over-all visual results of cataract extraction in senile diabetics can compare favorably with non-diabetics. (Conclusion)

The use of sutures in cataract surgery

1) The use of suture to coaptate the wound in cataract surgery enables the ophthalmologist to remove cataracts from cases he would hesitate to operate on without its aid. It gives early and more freedom of movement to the patient2) It will enable him to be less timid in the various steps of the operation, to avert disaster, should prolapse of the vitreous occur, to be more sure of his toilet of the wound, and to lessen his operative and post-operative complications3) Although it lengthens and complicates the operation, requiring proper materials and much practice, suturing of the operative wound in cataract surgery will increase the "batting average" of an ophthalmologist in obtaining a higher percentage of useful and good visual results4) After having given methods of suturing used in different ophthalmologist centers in the United States a trial in the first thirty-five cases of 100 consecutive cataract extractions, I have found McLeans suture the ideal suture. (Summary and Conclusion)

Neosynephrine pack for flat and shallow anterior chamber after cataract extraction

1. Ten percent neosynephrine cotton pact for 30 to 60 minutes in the lower fornix is a simple, convenient and effective procedure in restoring the depth of flat and shallow anterior chamber after cataract extraction. It succeeds where atropine and neosynephrine drops fail2. It relieves whatever relative insufficiency exists in the openings in the iris-hyaloid diaphragm and by lessening aqueous information, it decreases the pressure posterior to the diaphragm3. Sealing whatever leaks there is in the operative wound tends to raise the pressure anterior to the iris-hyaloid diaphragm and enhances its backward replacement4. It is preferable to apply the pack on the third day after the anterior chamber has become flat or shallow5. Its complications and side reactions are rare and mild. (Conclusions)

Disturbances of the associated or conjugate movements of the eye

Disturbances of divergence and convergence should be kept in mind in cases where diplopia is a complaint and can be elicited throughout the visual field, especially when no definite squinting is presentIn any case of disturbance of the associated or conjugate ocular movements a brain tumor and encephalitis should be considered among other causes. Whenever a brain tumor is suspected, the presence of paralysis of any associated or conjugate movement is a localizing finding. (Summary and conclusion)

Some ophthalmological misconceptions in medical practice in the Philippines

We should get rid of the concept and practice of waiting for the cataract to become fully mature before extracting it, not only because of the mental torture and the social and economic sacrifices which the period of waiting entails to the patient, but also with the use of forceps, sutures, other safety devices,and intracapsular extraction, the removal of immature cataract is technically not more difficult, if not really easier; and the visual results are equal to, if not actually better than, that of the mature cataract. This statement is based on my experience with, and of the results obtained in 300 consecutive cataract extractions during a period of 22 months. Of these cases, 103 were immature, and 46 private cases with corrected postoperative vision were followed up. Out of the 30 uncomplicated cases, 87% had a vision of 20/20 to 20/30, while 95% had a vision of 20/50 or better. Old age, over 75 years, slight to moderate cough, diabetes, and hypertension are not contraindications to cataract extraction if proper precautions are takenWe should enjoy freedom from fear of trachoma in the Philippines. Studies have revealed that, while trachoma exists in this country, mostly among Chinese, Hindus, and Indo-Chinese, it is a rarity among Filipinos; and blindness from trachoma among Filipinos is practically nil. Folliculosis and follicular conjunctivitis are common among our children and these are mistaken for trachoma. These children should not be required to undergo scraping of their conjunctivae before they are allowed to attend classes because of the mistaken concept that they have trachomaAcute non-bacterial kerato-conjunctivitis of viral origin exists here in endemic form with occasional epidemic flare-upsThere should be a widespread concern for glaucoma, because this is the most frequent cause of irremediable blindness in this country. To combat glaucoma, not only should the public be made aware of its dangers but the opticians, medical practitioners and specialists should also be more informed about itSquinting should be treated and if necessary, operated on during the pre-school age, in order to prevent the development of inferiority complex in the child and crumpling of his personality, to avoid blindness from amblyopia, to secure more permanent and better cosmetic results, and to insure binocular single visionThe ophthalmologists should do more ophthalmic plastic surgery and get rid of the fear of excising lid tumors before they cause suffering and threaten lifeAn "oculist" or "ophthalmologist" should not be confused with an "optician" and "optometrist."Refraction is only a part of an ophthalmological examination for eyestrain, the causes of which are many times not an error of refraction, but improper or overuse of the eyes in an unfavorable internal and external environment. Hence, the treatment of eyestrain is not always the wearing of correct glasses or exercises for the extraocular muscular imbalance, but also the proper use of the eyes, providing sufficient lighting and elimination of glare, together with improvement of some medical internal trouble or the relief of some psychosomatic problems. (Summary)

The extraction of the immature cataract

1. The classification of the senile cataract into immature and mature stages based on either an objective or subjective criterion will be found confusing and not reliable as a guide for surgical intervention2. The basis for the time of surgical intervention should be not so much the maturity or immaturity of the cataract, but more the degree of visual impairment of the better seeing eye, in relation to the particular work or temperament of the patient3. By the use of intracapsular extraction, and the aid of sutures and other safety devices of modern cataract surgery, the removal of the immature cataract is technically not more difficult, if not actually easier, than that of mature cataract4. In a series of 100 private and charity cases of cataract extraction, 25 cases were found to be immature, based arbitrarily on a middle ground classification of a visual acuity of counting fingers at one foot as the subjective criterion dividing the immature from the mature cataract. The results from these extractions compare favorably, if not better than, the mature cataracts of the series5. The Filipino physicians and ophthalmologists should get rid of the concept and practice of waiting for the cataract to become fully mature before extracting it. Because of the mental torture and the social and economic sacrifices which the period of waiting entails to the patient, the public should be mroe fully informed that it is unnecessary under modern methods to wait for a caratact to mature before it can be operated. (Conclusion)

The glaucoma problem in the Philippines

Glaucoma is the cause of the greatest number of irremediable blindness in adults in the Philippines. I have reviewed and analyzed 80 private cases of glaucoma at the St. Lukes Hospital Eye Clinic, and 65 charity cases at the Philippine General Hospital, for the purpose of finding out the various phases of our glaucoma problem in this country. I have cited specific cases for illustration. Some suggestions are made to our eye physicians, medical practitioners, opticians, and the general public on the recognition and management of glaucomaWhile the basic problem of glaucoma is etiologic, in the Philippines it is primarily education about its dangers, earlier recognition, and more up-to-date management. There must be a campaign against this major cause of blindness in this country. The education of the educators and ophthalmologists should go hand in hand with increasing the knowledge of our medical practitioners and of the public about glaucoma. (Summary)

Microscopic conjunctival keratinization in ocular hypovitaminosis A

The pipette and the scraping methods for exfoliative cytology of the conjunctiva and cornea for keratinization were compared. Eskelung, Papanicolau, Giemsa and Mallory connective tissue stains were tried to demonstrate the keratinized cells. Using the scraping method and Mallory stain, among groups of 102 and 20normal individuals, one-half had 1 to 4 with an average of 2 keratinized cells. All 13 children from Leyte from 3 to 16 years old and two adults 23 and 41 years old, with complaints of night blindness and 20/20 visual acuity, with dryness and wrinkling of the conjunctiva with or without Bitots spots had hyperkeratinization of the corneae and all portions of the conjunctivae. These varied from 71 to 100 keratinized cells with an average of 82.2 anucleated and 12.5 nucleated. Bitots spots showed keratinization with hyperplasia of its deeper portions. Local instillation of vitamin A did not improve the night blindness nor change the gross appearance of the conjunctiva and cornea. There was however less keratinization in Bitots spots and the cells became less polygonalAmong 35 children of the slum area in Leveriza, Manila, 12 were found fairly nourished and 23 malnourished by the weight-height criterion of WHO. These two groups were examined by exfoliative cytology for conjunctival keratinization and for vitamin A content of the blood by the micro method of triflouroacetic acid. About half of them were also tested for night blindness by a color test designed at the Philippine Eye Research Institute. Only 2 of the 12 fairly nourished children had very slight keratinization above normal. Sixty-five percent of the malnourished children had slight to moderate hyperkeratinization of the conjunctiva. The vitamin A content of the serum was low in about 30 of them. Only one who was complaining of night blindness gave a negative color responseLocal and available foreign literature on the tests for ocular and systemic vitamin A deficiency and its manifestations, the metabolism of vitamin A, keratinization and vitamin A, genetics and the biological bases of medicine were reviewed to assess the meaning and implications of our observations. This is the first report on the microscopic conjunctival keratinization as a test for ocular and systemic hypovitaminosis A. Based on our findings and current medical and ophthalmological concepts, a classification of the manifestations of ocular hypovitaminosis A is made. The fundamental implications are discussed and concepts on the mechanism of conjunctival keratinization and Bitots spot formation in vitamin A deficiency are formulatedThe practical applications of microscopic conjunctival keratinization in ocular hypovitaminosis are enumerated. (Summary)

Psychosomatic aspects of ophthalmology

I have not mentioned hysterical blindness, or malingering, which has definite psychosomatic tice-ups, because they are well covered in our textbooks. I have discussed the less obvious but more frequent psychosomatic aspects of ophthalmologic practice in this country. I think that ophthalmologists should at least know how to spot a psychosomatic patient; and if he has the time, he should develop an inclination and sufficient knowledge to handle them, before referring him to a psychiatristWith all the interest we can develop in, and all the information we can gather about, psychosomatic medicine, we must follow up our patients if we are to gain in knowledge of this aspect of ophthalmology. (Conclusions)

Freezing in vascularized cornea

As far as we can ascertain in the literature, this is the first time cryogenic procedure has been applied to the difficult problem of obliterating or artificially regressing corneal blood vesselsUtilizing-50 degree celsius we froze a series of 25 cases of vascularized corneas and have carefully and systematically observed clinically the obliteration and complete regression of the blood vessels by the aid of biomicroscope, operating microscope and with the help of intravenous flourescein. Diagrams of the individual vessels were recorded and photographs of various stages of regression were takenHistopathological examinations of the frozen corneal tissues were made. Photomicrographs of the sections showed the death, disintegration, disapperance of the endotholial cells of the blood vesel with extravasation, some inflammatory reaction and complete disappearance of the vessels. The changes in the non-vascular, cellular and non-cellular structures have been shown. Several cases of frozen vascularized cornea have been subjected to keratoplasty after 4 to 5 months with more favorable results than if the corneal freezing had not been done. (Summary)

A national research program for the Philippines

For many years there has been a feeling and thinking among our medical scientist and medical research supporters that there is something fundamentally lacking in our total research activities. Several meetings and conferences have been called to crystalize and spell out our national medical research problems. All these brought out that our main problems are those of direction and more effectiveness in our research efforts. This led to the realization that what we need as a starting point is the formulation of a national medical research program for the Philippines (Author)

The concept of focal infections in ophthalmology

The state of controversy over the concept of focal infection is mentioned. Its role in ophthalmology in the light of local clinical materials and experience is discussed and illustrated by representative and instructive case reports. The clinical deduction from these cases as well as the objections to the concept of focal infection are summarized and a scheme of the workings of the concept is presented aided by diagram. Although the authors believe in the concept of focal infection in ophthalmology they take a balanced, cautious attitude toward it. They are against indiscriminate removal of any focus of infection. Individualization of cases is advocated and multiplicity of factors is emphasized. They hold the concept "not with the over enthusiasm of faith, but with the hope and modesty of knowledge."(Summary)

Enzymatic debridement of corneal ulcers with fibrinolysin and desoxyribonuclease

1. Fibrinolysin and DNAase can effectively debride the necrotic tissue in artificially produced rabbit corneal ulcers without injuring the non-necrotic, viable portion of the cornea2. By comparing the treated and untreated bacterial and chemical corneal ulcers in rabbits, there was noted generally less inflammatory reaction and a faster and better healing in those where enzymatic debridement were done3. The basis for the clinical use of enzymatic debridement of corneal ulcers by fibrinolysin and DNAase has been amply demonstrated. (Summary and conclusions)

Retinoblastoma vaccine

We have prepared a retinoblastoma autolyzed cell vaccine which seems to be the first of its kind. It can be used safely in rabbits and children with retinoblastoma. Its potency is enhanced by adjuvants. Its immunizing potency is demonstrated in rabbits. The direct FA technique pointed to the presence of specific antigen on the surface of the retinoblastoma cell. Its effectivity as an additional therapy in the management of retinoblastoma in man seems promising. The vista of the immunological approach in the treatment of retinoblastoma has cleared and widened by this vaccine. (Conclusion)

Trasplantation of tissues on the bare sclera in pterygium operations

1. In auto-conjunctival grafts on bare sclera, practically all their structures survive2. In homo-conjunctival transplants, practically all their elements do not survive and are eventually replaced3. In hetero-conjunctival monkey transplants all their elements do not survive and are replaced4. In heterotopic auto-transplants of buccal mucosa, there is partial survival and partial replacement of its elements particularly the vascular5. For practical purposes after pterygium, when the bare sclera is small there is no advantage in covering it with a graft. When large, the first choice biologically is an autograft from the same or opposite eye, although the second and more practical preference would be a buccal mucosa graft. (Conclusions)

Our ophthalmological heritage

The history, development, and progress of Philippine Ophthalmology is presented. Its merits and weaknesses are discussed and the challenge to its heritage posed

Eye referral without the patient

This report is based on 26 consecutive eye referrals without the patient to the Eye Department of the Philippine General Hospital coming from 16 provinces of the Philippines during a period of one year. They were referred by resident physicians and Chiefs of Provincial Hospitals, municipal and rural health officers and private medical practitioners. These referrals were usually coursed thru the Social Welfare Administration. 77 per cent had no history; 73 per cent had no description of the lesion while 65 per cent had no mention of the vision. With such insufficient data, the consultant ophthalmologist had much difficulty in giving the proper advice. It is therefore suggested that referring physicians should know how to take the minimum vision, light perception, light projection and color perception, and they should include a description of the diseased eye with its size and tension by palpation. A registry of eye physicians available to health workers and an increase in eye beds as well as physicians with training in eye diseases is also advocated. (Summary)

Mindoro blindness from corneal degeneration

The Mindoro corneal blindness is a difficult ophthalmological problem in the Philippines. It is degenerative in nature and familial in tendency, with heredity, nutrition and trauma as probable additional factors. There are no evidences to consider it a part of a dermatological, so-called "lapnus syndrome," and there are insufficient findings to incriminate stored rice as the sole cause of it. It is certainly not due to ariboflavinosis. A small, 6.5 mm., central penetrating corneal transplant may remain transparent for many years in the early cases. For moderately advanced cases, it seems to be the first choice, but for the advanced cases, a wide, 9 mm. or more, penetrating keratoplasty, has been followed by opacification of the graft after about a month. A preliminary wide anterior lamellar grafting needs further trial for those advanced casesThe pathologic picture of degenerative keratopathy may be distinct and pure in the beginning but as the lesion advances, those of inflammation, proliferation, death and even necrosis may appear probably because of biological chain reactionsThe pathogenesis of degenerative keratopathies is probably a disturbance or a defect in one or more parts of the metabolic mechanism which interferes with one or more events in metabolismThe etiology of degenerative keratopathies is often multiple and varies with race, heredity, geography, nutrition and other factorsDegenerative keratopathies should be studied along cellular and non-cellular aspects. (Conclusions)

Rizal operated on the cataract of his mother

Rizals operations on his mother for cataract extraction were conceived in the love of a son for his mother, preceded by an and dedicated preparation in the best Eye Clinics of Europe and the tutorship of the greatest ophthalmic surgeons of the time; intertwined with the patriotic activities of the sublime Hero for his motherland they entailed prolonged but judicials waiting. They were performed under tying circumstances, in a foreign land and in exile in his own native country. It reflected the best in ophthalmological science and practice of the era, portrayed one of the most unique cataract extractions ever performed, that of an ophthalmic surgeon on his mother. Replete with human pathos, misinterpreted by historians, biographers and Rizalists, due to the paucity of authentic documents and conflicting versions, it was finally crowned with sufficient success that fulfilled the realization of one of the fondest dreams of our national Hero. (Summary)