Doctor Rush's eye water and the opening of the American west.

It has now been almost 200 years since Meriwether Lewis and William Clark set out from St. Louis on their successful western exploration in search of a practical overland and water route to the Pacific Ocean. Prior to their departure, Lewis traveled to Philadelphia to seek advice from the famous Dr. Benjamin Rush and others. Rush provided him with an elementary medical education, a liberal supply of his famous purgative pills, a chest of medical instruments, and a recipe for a lead acetate eye wash, together with the chemicals needed for its manufacture. In their journals, Lewis and Clark make frequent allusions to various eye afflictions suffered by their own troops and by the Native Americans encountered on their journey. Although herbal remedies were in common use, Rush's eye water proved very popular among the Native Americans for relief of their pain. It was so popular, in fact, that the explorers were able to make good use of it as diplomatic currency.

Ectopic brain tissue in the orbit.

PURPOSE: The authors report findings in a 9-month-old male infant with heterotopic brain tissue in the orbit, and compare and contrast the characteristics in this patient with the few other descriptions of such lesions in the literature. METHODS: Excisional biopsy of the growth was undertaken by means of an anterior orbitotomy. RESULTS: A 9-month-old male infant had a history of congenital left 'anophthalmia' and a slowly growing mass in the left orbit. An MRI scan revealed an orbital mass with solid and cystic components. Histological study of the excised tissue was performed and revealed a choristomatous arrangement of dysplastic brain tissue with intermixed primitive retina including pigmented epithelium. There was no connection between the orbit and cranial cavity. CONCLUSIONS: The mass must be considered a rare example of heterotopic brain tissue in the orbit and is the only instance we could find in the literature in which a formed eye was absent but in which a scattered primitive ocular structure could be identified.

Idiopathic reactive hyperplasia of the retinal pigment epithelium.

OBJECTIVES: To present and discuss 2 patients with acquired peripapillary pigmented lesions. METHODS: We reviewed the patients' clinical records and histopathologic findings. RESULTS: The first patient was diagnosed with a pigmented papillary lesion that was followed up for 38 years. The second patient was a child with neurofibromatosis type 1 who developed a pigmented peripapillary lesion following excision of an optic nerve glioma. Histologic findings in both cases demonstrated hyperplasia of the retinal pigment epithelium with associated findings. CONCLUSIONS: The lesions presented an idiopathic reactive hyperplasia of the retinal pigment epithelium. The clinical and histopathologic findings resemble findings reported with the combined hamartoma. We suggest that such lesions are reactive in nature, rather than hamartomatous.

Delayed-onset fungal keratitis after endophthalmitis.

PURPOSE: This study aimed to present two patients with delayed-onset, endogenous fungal keratitis after treatment for fungal endophthalmitis after cataract surgery. METHODS: The authors retrospectively reviewed the clinical course of two patients in whom deep stromal fungal keratitis developed 2 weeks and 3 months, respectively, after apparent successful aggressive therapy for fungal endophthalmitis. Before the onset of the keratitis, both patients underwent vitrectomies with intraocular injection of 7.5 to 10.0 mcg amphotericin B, as well as treatment with systemic fluconazole and topical antifungal therapy. In case 1, a pre-existing prosthetic intraocular lens and lens capsular bag were removed at the time of vitrectomy, whereas in case 2, the intraocular lens was left in place and a posterior capsulectomy was performed. RESULTS: The keratitis worsened in both patients, despite intensive systemic and topical antifungal therapy. Both patients underwent therapeutic penetrating keratoplasties. In case 1, this resulted in successful resolution of the infection and no recurrences 3 months after the transplant. The corneal transplant was complicated by an expulsive choroidal hemorrhage in the other patient. Fusarium solani was cultured from the initial vitrectomy specimen in patient 1, and although it was not cultured from the keratitis, septate hyphal elements were present on histopathologic examination. The causative organism in case 2 was Acremonium kiliense, which was cultured from both the original vitrectomy specimen and the deep corneal stromal infiltrate. CONCLUSIONS: Fungal organisms may not be eradicated completely from eyes with endophthalmitis despite aggressive therapy and apparent initial successful treatment. These patients need to be monitored for prolonged periods, and treatment should be reinitiated at the earliest sign of recrudescence of infection.

Chronic localized conjunctival chemosis.

Conjunctival chemosis is a commonly encountered clinical finding stemming from the presence of excess fluid in the conjunctiva. It is typically self-limiting or reversible if the underlying condition is treated. The authors present a series of seven cases of chronic localized conjunctival chemosis. Each patient had a localized area of dependent conjunctival edema for >or= 6 months. Evaluation of each patient included clinical examination, laboratory studies, and neuroimaging to attempt to elucidate the pathogenesis of the chemosis. Conjunctival biopsy was performed in six of the seven patients. In all of the patients studied, clinical examination uncovered no definitive signs of local inflammation. Laboratory evaluation was normal, and neuroimaging failed to confirm obstruction of venous or lymphatic drainage. Conjunctival biopsies showed chronic tissue inflammation or lymphangiectasia. The diagnosis of chronic localized conjunctival chemosis (CLCC) can be made if localized conjunctival edema persists for 6 months. Evaluation of biopsy specimens supports the theory that CLCC may result from scarring and structural alteration of conjunctival lymphatics, which appears to irreversibly affect the distribution of fluid in the conjunctiva.

Corneal endothelial polymerization of histoacryl adhesive: a report of a new intraocular complication.

Tissue adhesive are commonly used in ophthalmology to seal small corneal perforations. We report a case of inadvertent instillation of cyanoacrylate adhesive (Histoacryl) in the anterior chamber resulting in polymerization of the glue on the corneal endothelial surface, with iridocorneal and iridolenticular adhesion.

William Fisher Norris: a Philadelphia ophthalmologist.

In 1870, William Fisher Norris returned from studies abroad to find himself at the forefront of new developments in American ophthalmology. Recognition of the specialty was just beginning and Norris was named Professor of Ophthalmology in the department just established at the University of Pennsylvania. Norris was well-qualified for the job. As a member of a prominent Philadelphia family he had the right connections. He was dedicated to the science of ophthalmology and to medical education. He was a born leader, bending his efforts toward the development of a new department, and recruiting a faculty all dedicated to the creation of a new and better specialty.

Eosinophilic granuloma of the eyelid.

A 15-year-old girl presented with a left lower eyelid tumor consistent with a nonresolving chalazion. The specimen was biopsied. Histopathologic examination revealed eosinophilic granuloma, an entity that rarely presents on the eyelid. The histopathologic features of eosinophilic granuloma--a member of the histiocytosis X group of diseases--are reviewed. Our patient responded well to incisional biopsy and has required no additional treatment.

Application of the potassium-titanyl-phosphate laser during extraocular muscle surgery: technique and histopathology.

We determined laser parameters and delivery system requirements for successful use of the potassium-titanyl-phosphate (KTP) laser for strabismus surgery and its histopathologic effect on extraocular muscle, tendon, sclera, and cornea of human and rabbit eyes. Enucleated cadaver eyes and exenterated rabbit orbital contents were used. Using a 200-microns fiberoptic tip delivery system, varying laser energies were used to perform muscle insertion site and corneal damage, tenotomies, and myotomies. Pulse durations of 0.5 second and energies above 0.8 watt were needed for tenotomy or myotomy. No damage to the surrounding tissues or sclera was observed with laser tenotomy or myotomy performed 0.5 mm from the insertion site. Energy above 0.8 watt applied directly caused full thickness disruption. In comparison to scissor myotomy, the laser provided charring of the superficial tissues. This study shows that the KTP laser can be safely and accurately used for extraocular muscle tenotomy or myotomy.

Origins and evolution of the Lancaster Course in ophthalmology.

The Lancaster Course was created in 1945 to meet a need for training in the basic sciences of ophthalmology. At that time the course was designed particularly for young physicians who were discharged from the Armed Services at the end of World War II. For nearly five decades, the course has been given each summer at Colby College in Waterville, Maine, with the participation of some of the most illustrious figures in ophthalmology. It has undergone numerous changes in faculty and student body, having become less directed toward the experienced physician and more toward the beginning resident. What has not changed in the informal environment combined with intensive study, which allows students to learn basic sciences and to interact with outstanding leaders in ophthalmology.

The unexpected guest: problem of iris reposition.

A 31-year-old male presented with a corneal laceration and iris prolapse in the left eye. The surgical repair was complicated by epithelial ingrowth on the lens capsule. The appropriate management of both the initial trauma and subsequent complication is discussed.

Bilateral ocular disease as the initial presentation of malignant lymphoma.

Malignant lymphocytic lymphoma rarely involves the eye. In two patients we found ocular signs and symptoms as the initial presentation of systemic disease. In the first patient periorbital swelling and ptosis of one year's duration ultimately proved to be the result of malignant lymphoma. After resolution of swelling and ptosis with chemotherapy, the patient returned with diffuse iris involvement and uveitis with a hypopyon. In the second patient an acute change of refractive error proved to be the result of a lymphomatous deposit in the choroid. In both instances common symptoms were the initial manifestations of a diffuse malignant disease.

Late hyphema due to vascularization of the cataract wound.

Nineteen patients with hyphema due to fibrovascular tissue in the cataract wound were seen. In 3 patients the hyphema occurred after closure of an unitentional filtering bleb. Two patients receiving anticoagulants before and after the hyphema occurred did not have recurrence of the bleeding. In one patient the hyphema was induced by scleral depression. This benign condition is frequently misdiagnosed. When erythrocytes are seen in the anterior chamber of an aphakic patient, vascularization of the cataract wound should be suspected and confirmed by gonioscopy.

Orbital neurilemoma.

The diagnosis of orbital tumors is a challenging one. Neurilemomas are among the rarer causes of lesions in this location and usually are curable by local excision. The results of tests used in diagnosing orbital tumors are inconsistent in patients with this disease entity. Four patients with orbital neurilemoma are reported. Radiographic (including arteriogram, venogram, and computerized axial tomography) and ultrasonic findings were helpful in making the diagnosis.

Some consequences of ciliary process swelling in the rabbit and in the human.

Experimental and clinical observations have been evaluated in an attempt to gain further information about the effect of ciliary process enlargement on the angle of the anterior chamber. Swelling of the ciliary processes produced by the topical instillation of prostaglandin E2 into the eyes of rabbits has been described and compared to similar changes in a patient with ciliary block glaucoma. There seems little question but that most of what is manifest in the anterior chamber is but a reflection of very significant pathologic change in the posterior chamber.