P R O D U C I N G A N G L E B L O C K I N R A B B I T S 1091

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Rabbit no . 2

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Fig . 2 ( S a m i s ) . T h e typical response of the intraocular pressure.

at 15 minutes and at 30 minutes and that the eye receiving phospholine iodide and methyl cellulose and the eye receiving methyl cellu-lose only had equal pressures.

C O N C L U S I O N

Methyl cellulose is an excellent agent to block aqueous humor outflow. This pro-duces reliable and total angle obstruction. There was no significant difference between

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F ig . 3 ( S a m i s ) . Result when there is a small leak along the needle tract.

the eyes treated with phospholine iodide and the control eyes, which would tend to prove that phospholine iodide has no effect on aqueous production.

75 Castlewood Road (12).

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

I am indebted to Dr . W . R. F . Luke, Dr . R. K. MacDonald and Dr . Clement McCulIoch for their assistance.

E Y E P A I N A N D H O M O N Y M O U S H E M I A N O P I A *

D A V I D L . K N O X , M . D . , A N D D A V I D G. C O G A N , M . D .

Boston, Massachusetts

Pain in or about the eye may be a symp-tom of a vascular lesion in the parieto-occip-ital area of the cerebral cortex. This symp-tom does not appear to be generally recog-nized. There is no mention of it in the standard neuro-ophthalmic texts, but we did

* F r o m the H o w e Laboratory of Ophthalmology, Harvard Univers i ty Medical School, and the M a s -sachusetts E y e and E a r Infirmary. Thi s work w a s supported in part by a Special Traineeship BT-734 , National Institute of Neurological Diseases and Blindness Public Heal th Service.

find an incidental reference to it in a case report by Förster in 1890.1 Forster's pa-tient was described as having a "deep, though not severe pain in the left forehead" in association with a right homonymous hemianopia of sudden onset. The hemian-opia was presumed to have been due to a vascular lesion in the occipital area.

The present report describes five pa-tients who presented with pain in one eye and contralateral hemianopia. The lesion in

1092 D A V I D L . K N O X A N D D A V I D G. C O G A N

all was either proved or presumed to have

been caused by a vascular accident in the

parieto-occipital area.

C A S E H I S T O R I E S

CASE 1

T h i s 59-year-old whi te m a n had l ow-g rade , un -t r ea t ed hyper tens ion fo r a t least 10 yea r s . A t the age of 12 y e a r s and aga in a t 37 years , the pa t ien t had several episodes of t r ans ien t b l u r r i n g of the left visual field. O n e m o n t h p r i o r to the onset of his p e r m a n e n t hemianopia the pat ient developed ver t igo , uns teadiness of ga i t and some associa ted nausea and vomi t ing . N y s t a g m u s w a s p resen t on r i gh t la tera l gaze. T h e pa t ien t w a s though t t o h a v e a labyr in th i t i s and w a s t r ea ted w i th D r a m a m i n e ® and nicot inic acid. W i t h i n 10 days all symp toms d isappeared .

W h i l e r id ing to w o r k on the subway, the pat ient not iced tha t h e w a s seeing only t h e r i g h t half of fami l ia r s ta t ion s igns. T h e whole left visual field w a s b lanked out. A t th is t ime and for one h o u r a f t e r w a r d the pat ient w a s a w a r e of a dull ach ing pa in in the r igh t eye. H e w a s admi t t ed t o the hos -pital and found t o have a left h o m o n y m o u s hemi -anopia in which the upper q u a d r a n t w a s less densely involved. Opt icokine t ic n y s t a g m u s t e s t ing g a v e poo r responses w i th the t a r g e t s m o v i n g f r o m lef t t o r igh t . N o o the r abnormal i t i e s w e r e found a n d the pa t ien t w a s d i scharged f r o m the hospi ta l . H e h a s cont inued to w o r k .

CASE 2

T h i s 72-year-old wh i t e w o m a n w a s admi t t ed for eva lua t ion of "bl indness in the r i g h t e y e " of fou r days dura t ion . S h e had been hospi ta l ized s ix t imes previous ly fo r hyper tens ion , myoca rd i a l in-fa rc t ion and conges t ive fa i lure . T h e ocu la r h i s to ry revealed t h a t she had been a w a r e of flashes of l ight in the r i g h t v isual field in t e rmi t t en t ly fo r five yea r s . F o u r days p r i o r to en t e r i ng the hos -pital she s a w flashes of l ight in the r i gh t field on a w a k e n i n g , and then lost all vis ion in the r i g h t field. S h o r t l y a f t e r t h e onset of the b l u r r e d vis ion she became a w a r e of pa in above the left eye and a const r ic t ive feel ing a r o u n d the head. E x a m i n a -t ion a t tha t t ime disclosed a r i gh t h o m o n y m o u s hemianopia and n o r m a l fundi. A t th is t ime p l an t a r reflexes w e r e e x t e n s o r bi la tera l ly .

T w o m o n t h s l a t e r the pa t ien t developed p a r e s -thesias in the legs and t w o h o u r s l a t e r became comatose. S h e w a s admi t t ed t o the hospi ta l and found to have a r i g h t hemipares i s , r o v i n g eye movemen t s and n o r m a l pupi l lary responses to l ight . S h e w a s unable t o communica t e t h o u g h she wou ld ra i se a n a r m in response t o pa infu l s t imuli . S h e died s i x weeks a f t e r admiss ion.

A u t o p s y revealed t h a t she had an old in fa rc t ion of t h e lef t v isual c o r t e x and a f r e she r in fa rc t ion of t h e r i g h t occipi tal lobe. T h e r e w e r e sca t te red i n f a r c t s in the pons, t h a l a m u s and ce rebra l h e m i -spheres .

CASE 3

A 55-year-old whi te m a n w a s admi t t ed to the hospi ta l fo r eva lua t ion of numbness of the left side of the face and a defect of the left visual field of seven weeks dura t ion . T h e past h i s to ry was compat ib le w i th a r te r iosc le ro t ic ca rd iovascu la r disease as man i fes ted by a n g i n a pector is and in-t e rmi t t en t c laudicat ion. E leven weeks be fo re ad-miss ion the pa t ien t had t ing l ing of the left side of the face, a r m and leg las t ing 30 seconds. A f t e r th is episode the pa t i en t complained of m o r e f requent and severe ang ina pector is .

Seven weeks be fo re admiss ion the pat ient had the sensat ion of a sudden in te rna l p r e s s u r e in the head and a t the same t ime the left leg became weak. H e wa lked wi th some s w a y i n g and noticed tha t he could not see to the left side. T h e same n igh t the pat ient complained of pain in t h e r ight eye. T h i s pain pers is ted for one week. H e w a s ad -mi t ted t o an outs ide hospi ta l and la te r t r a n s f e r r e d to the M a s s a c h u s e t t s Genera l Hosp i t a l . T h e ad-miss ion physical findings w e r e a dense left lower q u a d r a n t i c hemianop ia and a n opt icokinet ic n y s t a g -m u s response which w a s poor fo r t a r g e t s mov ing f r o m the left to the r ight .

CASE 4

T h i s 66-year-old m a n presen ted w i th the chief compla in t of difficulty wi th vision in the left eye for t w o days . T h e pa t ien t ' s r i gh t eye had been in-j u r e d 60 y e a r s be fo re and had main ta ined 2 /200 vis ion since then. T h e pa t i en t h a d been h y p e r t e n -sive fo r m a n y yea r s .

H i s s y m p t o m s began wi th a v a g u e mala i se which caused h i m to lie d o w n a f t e r t h e even ing meal . H e a r o s e one h o u r l a t e r and not iced tha t his vision w a s impai red in the r i gh t v isual field. A t th i s t ime he h a d mode ra t e ly severe pain in and a r o u n d the left eye. T h e genera l mala i se pers is ted w i th some nausea and he came t o the emergency r o o m w h e r e he w a s found to h a v e e levated blood p r e s -su re and a nasa l hemianop ia in the left eye. T h e opt icokinet ic response w a s poor fo r t a r g e t s m o v i n g f rom right t o the left.

CASE 5

A 50-year -o ld w o m a n en te red the hospi ta l be -cause of headaches and a recent impa i rmen t of vision. S h e had been obese for mos t of h e r l ife a n d had m o d e r a t e hyper tens ion . F o u r weeks p r i o r to en t e r i ng the hospi ta l she developed a severe headache in bo th temples w i th occasional local iza-t ion behind the r i gh t eye. S h e w a s found t o h a v e n o r m a l visual acui ty wi th a comple te left h o m o n -y m o u s hemianopia . B e f o r e studies could be com-pleted a n d aga in s t medical advice, she lef t the hospi ta l .

T h e pa t i en t r e t u r n e d four m o n t h s la ter , d e -men ted and wi th on ly quest ionable l igh t percept ion in the r i g h t eye. P u p i l l a r y l ight ref lexes w e r e n o r m a l and she w a s t h o u g h t to be cor t ica l ly blind. S tud ies a t th is t ime w e r e nega t ive w i t h t h e excep-t ion of a ve r t eb ra l a r t e r i o g r a m w h i c h showed n a r -

E Y E P A I N A N D H O M O N Y M O U S H E M I A N O P I A 1093

rowing of the posterior cerebral arteries. E ighteen months later the patient w a s still blind and de-mented.

D I S C U S S I O N

The clinical histories of these five pa-tients and that of Förster show that ocular pain can be significantly associated with a vascular lesion of the parieto-occipital area of the brain. In one of our patients this site was proven by the finding of an old infarct of the striate occipital cortex.

The mechanism of this referred pain may be attributed to the sensory innervation of the dura mater. Recurrent branches (nervi tentorii) leave the ophthalmic division of the trigeminal nerve in the cavernous sinus and spread over the ipsilateral tentorium cerebelli, the posterior third of the falx cerebri and the outer surface of the pari-etal-occipital region of the cerebral hemi-sphere.2 Infarcted tissue in the parietal-oc-cipital area could produce painful stimuli which would be referred to the eye.

Walsh* states that ocular pain may ac-company ophthalmic migraine with hemian-

opic scotomas; the eye pain being on the side of the headache. He also describes eye pain as a manifestation of tumors in occipi-tal areas and that patients experience eye pain at the time of needle puncture when ventriculography is performed through the occipital lobe.

S U M M A R Y

Pain in the eye may be a symptom of a vascular accident in the parieto-occipital area of the brain and is associated with homonymous hemianopia. In five of our pa-tients and in one patient described in the literature, the pain was localized on the side of the lesion, was not severe and was no-ticed only after the visual field defect had become apparent. Three of these patients had an associated defect of opticokinetic nystagmus. This referred pain is presumed to be mediated through the dural branches of the ophthalmic division of the trigeminal nerve.

243 Charles Street (14).

R E F E R E N C E S

1. Förs ter : Ueber Rindenblindheit. Arch. f. Ophth., 36 :94 , 1890 . 2. Brash, J. C , and Jamieson, E . B. ( e d . ) : Cunningham's Textbook of Anatomy. London, Oxford ,

1951, p. 999. 3. Walsh , F . B . : Clinical Neuro-Ophthalmology. Baltimore, Wi l l iams & Wilk ins , 1956, ed. 2, pp. 1044;

1137.

E X P E R I M E N T A L H Y P H E M A IN R A B B I T S *

V . T H E P R O D U C T I O N O F A H E M O L Y T I C A G E N T A N D I T S E F F E C T

O N T H E R A T E O F A B S O R P T I O N

R O B E R T M . S I N S K E Y , M . D . A N D A L I C E R . K R I C H E S K Y , A . B .

Los Angeles, California

It was noted in the hyphema studies re-ported in 1957 that hemolyzed red blood cells leave the anterior chamber very rap-idly.4 This report concerns the investiga-

* From the Divis ion of Ophthalmology, Depart-ment of Surgery, Univers i ty o f California Medical Center. Thi s investigation w a s supported by grant-in-aid B-929 from the National Institute of N e u r o -logical Diseases and Blindness, Uni ted States P u b -lic Hea l th Service, Bethesda, Maryland.

tion of hemolytic agents and their effective-ness in lysing red blood cells in the anterior chamber of the rabbit eye.

M E T H O D S A N D M A T E R I A L S

C H E M I C A L A N D P H Y S I O C H E M I C A L H E M O -

L Y T I C A G E N T S

The use of chemical and physiochemical hemolytic agents to produce hemolysis of