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Table 1. Demographic data, ocular characteristics, surgical interventions and outcomes of traumatized eyes with no light perception after closed globe injury.
Age (years)
Mechanism of injury
Time to PPV (days)
1
44
Tumble down
15
2
17
Metallic missile
19
3
13
Bump on the desk
10
4
42
Hit by a flying brick
12
5
44
Firecrackers blast
31
6
29
Fist
11
7
19
Traffic accident
14
8
3
Hit by a falling object
15
9
37
Explosion
10
25
Wood block
22
11
51
Hit by a blunt object
33
12
24
18
13
39
Assaulted by a wood stick Fall from a height
14
16
Fist
No
9
27 6
Main surgical interventions*
Main intraocular findings Ciliary body detachment, severe VH, avulsion of the optic nerve Traumatic cataract, VH, macular hole, trau matic optic neuropathy Hyphaema, traumatic cataract, severe VH, RD, choroidal detachment Corneal oedema, hyphaema, lens dislocation, RD, PVR-C, choroidal detachment Hyphaema, traumatic cataract, RD, PVR-C, choroidal rupture, optic atrophy Corneal oedema, haemophthalmia, lens dislocation, ciliary body detachment, severe VH, RD, suprachoroidal haemorrhage Iridodialysis, corneal abrasion, hyphaema, traumatic cataract, VH, haemorrhagic RD, macular pucker VH, RD, choroidal detachment, traumatic optic neuropathy Haemophthalmia, ciliary body detachment, RD, choroidal rupture Severe VH, retinal contusion, RD, traumatic optic neuropathy Hyphaema, lens subluxation, ciliary body detachment, RD, PVR-C Corneal lamellar laceration, hyphaema, traumatic cataract, VH Iridodialysis, lens subluxation, severe VH, RD, PVR-C, macular hole Hyphaema, severe VH, haemorrhagic RD, choroidal rupture, avulsion of the optic nerve
F⁄U (months)
Outcome (BCVA)
C3F8
6
AR (NLP)
Lx, BSS
7
AR (NLP)
Lx, SO
18
SO-S (20 ⁄ 200)
SB, Lx, MP, SO
12
AR (HM)
Lx, MP, Rx, SO
16
SO-S (NLP)
TKP, Lx, Rx, TSD, SO
11
SO-S (HM)
Lx, SO
12
SO-S (20 ⁄ 160)
SO
67
SO-S (NLP)
En
–
En (NLP)
C3F8
10
AR (HM)
Lx, MP, Rx, SO
8
PB (NLP)
Lx, C3F8
7
AR (20 ⁄ 100)
Lx, MP, SO
13
AR (CF 0.5¢)
En
–
En (NLP)
AR = anatomical restoration; BCVA = best-corrected visual acuity; BSS = balanced salt solution; CF = counting finger; En = enucleation or evisceration; F ⁄ U = period of follow-up; HM = hand movement; Lx = lensectomy; MP = membrane peeling; NLP = no light perception; PB = phthisis bulbi; PPV = pars plana vitrectomy; PVR = proliferative vitreoretinopathy; RD = retinal detachment; Rx = retinotomy or retinectomy; SB = scleral buckle; SO = silicone oil; SO-S = silicone oil–sustained eye; TKP = temporary keratoprosthesis; TSD = trans-scleral drainage; VH = vitreous haemorrhage. * All cases underwent 20G PPV except for cases 9 and 14; endolaser and perfluorocarbon were used in cases, which required a retinal operation.
presenting with NLP, and we do not recommend the routine use of the procedures, such as primary enucleation or observation.
References Bull N (2010): Legislation as a tool to prevent firework-related eye injuries. Acta Ophthalmol 89: e654–e655. Kuhn F, Morris R, Witherspoon CD, Heimann K, Jeffers JB & Treister G (1996): A standardized classification of ocular trauma. Graefes Arch Clin Exp Ophthalmol 234: 399–403. Rasmussen MLR, Prause JU, Johnson M, Kamper-Jørgensen F & Toft PB (2010): Review of 345 eye amputations carried out in the period 1996–2003, at Rigshospitalet, Denmark. Acta Ophthalmol 88: 218–221. Wang JD, Xu L, Wang YX, You QS, Zhang JS & Jonas JB (2011): Prevalence and inci-
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dence of ocular trauma in North China: the Beijing Eye Study. Acta Ophthalmol [Epub ahead of print]. Yeung L, Chen TL, Kuo YH et al. (2006): Severe vitreous hemorrhage associated with closed-globe injury. Graefes Arch Clin Exp Ophthalmol 244: 52–57.
The historical development of the concept of glaucoma Andrzej Grzybowski1,2 and Jaroslaw Sak3 1
Correspondence: Zhi-zhong Ma Peking University Eye Center Peking University Third Hospital Huayuan North Street 49 Haidian Beijing 100191 China Tel: + 8610 82089948 Fax: + 8610 82089951 Email:
[email protected]
Department of Ophthalmology, Poznan´ City Hospital, Poznan´, Poland 2 Medical Faculty, University of Warmia and Mazury, Olsztyn, Poland 3 Department of Ethics and Human Philosophy, Medical University of Lublin, Lublin, Poland doi: 10.1111/j.1755-3768.2011.02306.x
Editor, nders Heijl (2011) makes an innovative attempt to present
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the development of knowledge about glaucoma based on sociological metaanalysis. However, there exist other, in our opinion more adequate concepts, including thought-style (Fleck 1979; Harwood 1993, 1996), thoughtcollective (Fleck 1979; Aronowitz 1998) and cultural patterns (Harwood) to study the history of ophthalmology. In the analyses conducted by Fleck (1979) and Harwood (1993, 1996), the concept of thought-styles is extremely crucial. It was defined as ‘the readiness for directed perception, with corresponding mental and objective assimilation of what has been so perceived’ (Fleck 1979). The carrier of a thought-style is a thought-collective, which is the community of scientists, people working in a certain profession or united by an idea (science, religion, politics, etc.). The scientist is a part of
the thought-collective. At the same time, he may be under the influence of even several thought-styles: scientific (one or more), religious, political, etc. Every observer has been shaped by a particular culture and represents a thought-style of a definite scientific group, and his style determines the range of his observations. According to Fleck, the process of obtaining knowledge is not only an accomplishment of the most prominent scientists. In explaining the scientific discoveries, it is necessary to take into account social and cultural context in which the scientists (discoverers) function. Fleck’s concept of thought-styles can be applied to study the development of medical knowledge about glaucoma. Using the conceptual framework proposed by Fleck, it is possible to point to active and passive
elements of scientific facts relating to the diagnosis and treatment of glaucoma. According to Fleck, passive elements of scientific facts determine an objective reality to which the collective attention of researchers of a given historical epoch is drawn. Therefore, it is possible to talk about two types of passive elements. On one hand, in medicine, they are a reflection of a ‘disease reality resistance’, which is dealt with by physicians or scientists in the primary cognitive experience. On the other hand, these are the ideas or theories that seem compelling or without a doubt at a given time period, e.g. contemporary concept of neurooptic vision. Passive elements of scientific facts constitute a ‘hard ground’ on which scientists of subsequent epochs ‘walk on’. Active elements of scientific facts directly results
Table 1. Briefly interpretation of history of glaucoma using Ludwik Fleck’s theory of thought-styles. Thought-style in history of ophthalmology
Scientist
Active elements of scientific facts concerning glaucoma
Passive elements of scientific facts concerning glaucoma
Humoral (initial)
Hippocrates of Cos (460 BC – ca. 370 BC)
Bloodlettings Emetics or laxatives
Humoral and anatomical (initial)*
Richard Banister (1580–1653)
Anatomical and iatromechanical (initial) Anatomical and iatromechanicalà
William Mackenzie (1791–1868) Albrecht von Graefe (1828–1870)
Iatromechanical and ophthalmoscopic (initial)§ Iatromechanical and ophthalmoscopic– Ophthalmoscopic
Hermann von Helmholtz (1821–1894)
Four basic symptoms of glaucoma: long duration, no perception of light, increased hardness and no dilatation of the pupil on bandaging the sound eye Surgical incision and pricking of the sclera Iridectomy in the acute form of glaucoma Tonometry Ophthalmoscopic observations
Loss of sight Pain Blue-green shade of the pupil Loss of sight Pain Blue-green shade of the pupil Bloodlettings* Emetics or laxatives*
Ophthalmoscopic and micropathophysiological (initial)** Micropathophysiological and genetic
Hermann Snellen (1834–1908) Jannik Petersen Bjerrum (1851–1920) Harry Moss Traquair (1875–1954)
Measure visual acuity (optotypes)
Contemporary thought-collective of ophthalmologists
Puzzling issues: light-damage theory, local and systemic ischemic injury, oestrogen deficiency and low CSF pressure
Campimetry Perymetry
Four basic symptoms of glaucoma Surgical incision and pricking of the scleraà Four basic symptoms of glaucoma Iridectomy and surgical incision of the sclera§ Four basic symptoms of glaucoma Ophthalmoscopic observations– Tonometry– Ophthalmoscopic observations Tonometry Ophthalmoscopic observations Tonometry Campimetry** Ophthalmoscopic observations Tonometry Perymetry
* Active elements of the initial humoral style, which suggested treating patients with bloodletting were converted into passive elements. Active elements of the initial anatomical style (four basic symptoms of glaucoma) were converted into passive elements. à Active elements of the initial iatromechanical style (surgical incisions of the sclera) were converted into passive elements. § Iridectomy was converted into passive element. – Active elements of the initial iatromechanical (tonometry) and ophthalmoscopic styles were converted into passive elements. ** Perymetry was converted into passive element.
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from given thought-style and are incomprehensibly for scientists who represent another scientific thoughtstyle. What was the active component of one scientific fact e.g. increased tension of the eyeball in the anatomical style (this symptom was still a novelty in Banister’s times and at the same, a diagnostic achievement of this style) in later thought-styles: iatromechanical and ophthalmoscopic became the passive element of scientific facts, that is the ‘object’ of research of these styles. We presented this idea briefly in the Table 1. The pathogenesis of glaucoma is one of the most important and puzzling issues in the 21st century ophthalmology. Many concepts were recently presented, including lightdamage theory, local and systemic ischaemic injury, oestrogen deficiency and low CSF pressure. It shows its multifactorial profile and our present deficiency in understanding its real nature. The possible reason for this might be our scientific thought-style, which determines our present perception of the disease and possible concepts of its pathogenesis, which are verified in clinical and experimental research. The collective thought-style, in this case regarding the nature of glaucoma, might easily eliminate any new idea or non-conventional hypothesis. We believe that understanding the principles that govern the development of science allows for an understanding of our own limitations in this respect (contemporary thought-style), which frequently prevent us from looking at the matter in a non-standard way.
References Aronowitz RA (1998): Making sense of illness: science, society, and disease. Cambridge UK; New York: Cambridge University Press. Fleck L (1979): Genesis and development of a scientific fact. In: Trenn TJ & Merton RK (eds). Genesis and development of a scientific fact. Chicago, IL: University of Chicago Press: 1–148. Harwood J (1993): Styles of scientific thought: the German genetics community, 1900–1933. Chicago and London: University of Chicago Press. Harwood J (1996): Weimar culture and biological theory: a study of Richard Woltereck (1877–1944). Hist Sci 34: 347–377.
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Heijl A (2011): Perimetry, tonometry and epidemiology: the fate of glaucoma management. Acta Ophthalmol 89: 309–315.
Correspondence: Andrzej Grzybowski, MD, PhD, MBA Department of Ophthalmology Poznan City Hospital ul. Szwajcarska 3 61-285 Poznan´ Poland Tel.: 004861 8739 169 Fax: 004861 8739 169 Email:
[email protected]
‘Persistant bilateral relative central scotomas induced by taking an excessive dose of sildenafil’ Shahrnaz Izadi,1 Samantha Roshani De Silva,1 David Sculfor,2 Larry Benjamin2 and Susan M Downes1 1
Oxford Eye Hospital, Oxford John Radcliffe, Oxford, UK 2 Department of Ophthalmology, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK doi: 10.1111/j.1755-3768.2011.02362.x
Editor, 48-year-old man presented with a 4-day history of central visual blurring and chromatopsia. His symptoms began on waking, having taken 1500 mg of sildenafil over a 4-hr period (20· the recommended dose). He had purchased the drug via the Internet. A sample tablet was sent to the poisons laboratory for analysis and was found to be 100% sildenafil. He denied any other concurrent drug ingestion and had no other symptoms or history of note. Visual acuities were 6 ⁄ 4 in both eyes. Pupillary responses, anterior segments, intraocular pressures and fundal examination were all normal. Humphrey 24-2 threshold perimetry revealed central relative scotomas. The 10-2 testing protocol showed that the scotomas subtended 6 degrees,
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centred on fixation. Ocular coherence tomography (OCT) scan, fundus fluorescein angiography and autofluorescence imaging were normal. At 5-month review, Humphrey visual field testing confirmed persistent central visual field ring scotomas (Fig. 1). Electrophysiology testing including ISCEV-standard visual-evoked potentials (VEP), pattern electroretinogram (PERG) and full-field electroretinogram (ERG) was carried out. The VEP to 1 degree and 15-min check sizes showed normal amplitudes but with time-to-peak towards the upper limit of normal. The P50 amplitude of the PERGs was markedly reduced although implicit times were normal. Photopic and scotopic full-field ERGs showed normal amplitude and implicit times. Sildenafil is a phosphodiesterase (PDE) 5 inhibitor. It is used to treat male erectile dysfunction (VIAGRA). It is also an effective treatment for pulmonary arterial hypertension, Raynaud syndrome and coronary insufficiency (REVATIO). However, it is widely available over the Internet leading to recreational use without monitoring by a physician. Sildenafil is known to cause transient ocular side effects including chromatopsia blurring of central vision, photosensitivity and photopsia. Visual symptoms appear within 30 min of ingestion and subside in a dose-dependent manner. Visual symptoms are thought to affect 40–50% of individuals using a dose >100 mg (Fabbri et al. 1999). Phosphodiesterase 5 has been demonstrated to be present in bipolar cells, ganglion cells and the endothelial and smooth muscle cells of the vascular wall in retinal and choroidal vessels. PDE 6 plays an important role in the phototransduction cascade, being expressed in both rods and cones (Foresta et al. 2008). Sildenafil has a tenfold greater affinity for PDE 5, but it is postulated that the interruption of PDE 6 function may be responsible for the manifestation of visual symptoms. Small transient disturbances of the ERG have been reported. A reduction in a-wave and b-wave amplitude has been demonstrated one hour after ingestion of 100 mg sildenafil, with total normalisation of ERG findings in 5 hr (Vobig et al. 1999). Other studies have shown a significant
