NOTES, CASES, INSTRUMENTS

S P E C T A C L E S F O R

M O N O C U L A R P R O P T O S I S

JAMES Ε. LEBENSOHN, M . D .

Chicago, Illinoit

In the subject of this report, a patient with monocular proptosis and presbyopia, fitting the normal eye for distant vision and the lower proptosed eye for near vision proved immediately acceptable and was prob­ably the only means by which satisfactory far and near vision could be attained in this case.

CASE REPORT

The patient, a middle-aged white man, was first seen in 1958. Protruding from the upper part of the left forehead was a painless, elevated, hony mass measuring 5.0 by 7.0 cm that had been present for eight years. For the previous three years, the left eye was proptosed and displaced downward. The upper lid was edematous and the affected eye teared rather excessively. An X-ray film of the skull, taken in 1951, disclosed meningioma but the patient refused surgical intervention. Unaided visual acuity was: R.E., 20/25; L.E., 20/70; pinhole, R.E., 20 /15 ; L.E., 20/20. The pupils were equal and re­acted well. Corneal sensation, ocular tension, visual fields and ocular motility were normal. The left fundus showed only a mild venous engorgement. Operation for the meningioma was urged hut was delayed until the patient became alarmed by a severe left epistaxis five years later.

On January 2, 1963, he entered the Michael Reese Medical Center. The rhinologist observed an irregular, polypoid mass that reached down to the left middle meatus. Biopsy confirmed his suspicion of soft-tissue meningioma. X-ray films revealed widespread hyperostosis involving the left frontal hone, lesser wing of the sphenoid, base of the ante­rior fossa and cribriform plate, with breaks into the roof of the orhit and through the roof of the left nasal fossa. A left carotid arteriogram showed a marked displacement of the anterior cerebral artery to the right.

On January 14, 1963, the neurosurgeon, I. J . Spiegel, operated. The skull over the operative site was more than twice normal thickness and ex­tremely vascular. Recovery was uneventful but the proptosis persisted without change.

On July 9, 1963, the patient, now 58 years of age, returned to me to be fitted for glasses. A depression was evident in the upper part of the left forehead where the bony lump had previously protruded. The left eye showed 18 mm. of proptosis and eight mm. downward displacement (fig. 1 ) . Ocular mo­

tility, ocular tension, fundi and visual fields were essentially normal. Unaided vision was: R.E., 20/30, L.E., 20/100. Distance correction was: R.E., + 1.25D. sph, 20 /13 ; L.E., +2.0D. sph. Ζ +0.25D. cyl. ax. 180°, 20/20. Because of the extreme propto­sis and downward displacement of the left eye and the good correctable vision of both eyes, the right eye was fitted for distance and the left eye for near (add -I-2.5D. sph.).

To fit the specific requirements, the optician designed a special frame with the left lens eight mm. lower than the right and with a 20-mm. arm to the nose pad on the right side, a regular two-mm. arm to the nose pad on the left. Both arms were soldered in line and the bridge on the nose was likewise level so as to simulate the appearance of a normal frame. On account of the 18-mm. for­ward displacement of the right lens and the conse­quent change in vertex refraction, the right lens was reduced 0.25D. sph. to +1.0D. sph. The cosmet­ic appearance, as well as the functional result, was surprisingly good (fig. 2 ) .

COMMENT

The immediate acceptance of alternating vision by this patient is probably due to the marked dissociation of the eyes. Possibly another factor was his habituation to blurred distant vision in the left eye, as he had pre­viously used only reading glasses. My suc­cess in this case is in marked contrast with

Fig. 1 (Lebensohn). Proptosis of left eye second­ary to meningioma of nine years' duration, with good correctable vision in both eyes.

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NOTES, CASES, INSTRUMENTS

Fig. 2 (Lebensohn). The patient fitted with glasses. (Right) Lens for distant vision. (Left) Lens for near vision.

patients having paralysis of a vertically act­ing muscle as the following example illus­trates :

A woman, aged 67 years, had developed a per­manent paresis of the left superior rectus following a severe blow to the left eye. She had diplopia and kept the right eye constantly closed. As the left eye was lower than the right, glasses were prescribed in which the right eye was fitted for distance and the left eye for near. She returned in two months contending that she could not get adjusted to this arrangement and asked for a bifocal prescription.

When I saw her again, five years later, she had bilateral lenticular nuclear sclerosis with some perinuclear clouding. Her refraction then was: R.E., - 1 . 2 S D . sph. G -0 .7SD. cyl. ax. 165°, 20/30; L.E, —LSD. sph. Ζ - 1 . 7 S D . cyl. ax. 10°, 20/40. She had the same degree of paresis of the left superior rectus, measuring in the primary position 14* base-up, left eye.

Considering her age of 72 years and the antici­pated progressive increase of her lenticular nuclear sclerosis, I prescribed alternate vision glasses with an add of -f3.2SD. sph. to the prescription for the left eye in spite of my previous experience. Two months later she complained as before. I again dem­onstrated that with this arrangement she saw both for far and near, did not see double and did not need to close one eye. This time my moral suasion apparently succeeded.

COMMENT

In presbyopes with good corrected acuity

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ROTATABLE REFLECTING PLATE*

FOR B I N O C U L A R INDIRECT

O P H T H A L M O S C O P E

PAUL A. OBIS , M.D.

Saint Louis, Missouri

The purpose of this brief publication is to present a modification of the reflecting plate originally designed for the Fison bin­ocular indirect ophthalmoscope (Keeler 1 ) . Malbran- made this device attachable to

* From the Department of Ophthalmology and the Oscar Johnson Institute, Washington University School of Medicine. This investigation was sup­ported in part by a research grant, B-1789, from the National Institute of Neurological Diseases and Blindess of the National Institutes of Health, Bethesda, Maryland.

in each eye, the optical problems associated with high anisomyopia have been solved fre­quently by adapting the less myopic eye to far vision and the more myopic eye to near. Nowadays when almost everyone drives a car, the patient wants good distant vision in each eye. In such cases, contact lenses with appropriate bifocals are a more efficient solu­tion. The promotion of alternating vision for distance and near may be attempted in pres­byopes with permanent vertical diplopia but with inconsistent success; a surgical correc­tion is far more satisfactory. One feature in the case reported, of proptosis secondary to meningioma, is unusual, though probably not unique; that is, the good correctable vision in the affected eye though the proptosis was present for more than nine years. It is this that indicated alternating vision as the solu­tion to his optical problem and rendered this arrangement successful.

4010 West Madison Street (60624).

A C K N O W L E D G E M E N T

I am indebted to Mr. Emil Schuh of Boll and Lewis Optical Company for designing the special spectacle frame required and for taking the re­quested photographs; to Dr. I. J . Spiegel for access to the patient's hospital record; and to the patient for permission to publish this report.