O C U L A R FINDINGS IN K A L A - A Z A R IN C E N T R A L CHINA,
T . P. L E E , M . D .
For a wider study in the ocular findings in kala-azar the writer went to Central China to study the eye lesions in connection with other studies being made of 140 cases. Statistics of these cases are presented and detailed reports of 4 cases in which retinal hemorrhages were observed. From the Department of Ophthalmology, Peking Union Medical College, Peking, China.
Since hemorrhagic retinitis was found in two out of twenty cases of kala-azar examined in the Peking Union Medical College Hospital (see preceding article), it was thought worth while to control these findings by a study of a large number of cases of this disease. A study of such cases was therefore made in the Presbyterian Mission Kala-azar Station at Hschoufu, Kiangsu Province , where the Peking Union Medical Col lege is conduct ing a field study of kala-azar under Dr. C. W . Young. One hundred and forty cases were examined in a period of nine days.
T h e class of patients examined at Hschoufu is in many respects distinctly different from that in the kala-azar clinic in Peking. F o r this reason, it seems advisable to give a brief account of these patients.
In the first place, the kala-azar patients at Hschoufu are all outpatients. T h e y c o m e from different vi l lages in the vicinity, and many have to travel distances of from ten to twelve miles to attend the clinic. On account of the greater number of male patients, these are seen daily except Sunday, while the female cases are seen on Tuesday, Thursday and Saturday. Each morning from 9 to 11 o 'c lock fifty to seventy patients attend the clinic. Children are seen in either the men's or the women ' s clinic.
Secondly, except for a b lood globulin precipitation test, no laboratory examination, such as b lood count ing or hemoglobin estimation is attempted. This is due to the enormous number of patients w h o m the doctors of the mission hospital are called upon to see.
Thirdly, no facilities are provided in this hospital for the examination of eyes. Consequently, the ophthalmologic examination was conducted in an improvised dark room. The procedure was limited to an external examination
and ophtha lmoscopy. These examinations had to be made before, or immediately after, the patients had received their injections, because many of them were not at all eager to stay for any eye examination.
Because of these handicaps, this survey must be considered as a preliminary study. I t may serve, however , as a stimulus t o further investigations of the ocular changes in this disease b y men w h o have to deal with kala-azar in other parts of the wor ld .
1. General : 1. A g e of patients examined :
Under 10, 38 cases 10 t o 19, 56 cases 20 to 29, 34 cases 30 to 39, 11 cases 40 to 49, 0 case 50 to 60, 1 case 2. S e x : Male, 120; female, 20. 3. Duration of disease: 2 months to
4 years. 4. Number of injections: 1 to 80
(6 cases had n o n e ) . The drug used in the treatment of kala-azar at Hschoufu is potassium antimony tartrat given intravenously in ascending doses of 0.5 c c . to 5. c c . of a 2 % aqueous solution. W h e n convalescence sets in the dosage is gradually decreased.
II . Ocular F ind ings :
A . External Examination.
Region Kala-Azar Other Eye Diseas
1. Li.Ia Edema 2 2. Coajunctiva Marked pallor 10
Subconjunctival hemorrhage 2
Trachoma IS Folliculosis 2 Nevus. I Pterygium 1
3. Cornea Adherent leucoma 1
Macula 8 Pannus 1 Phthisis bulbi 1 Total
staphyloma 1 4. Pupils Nevus of iris 1
MyctriasisCChineie medicine) 1
835 . P. L E E
. Fundus Examination.
RcEion Kala-Azar Other Kye Diseases
1. Lens Incipient cataract 1
2. Medi,i (refraction) High myopia 1
3. Retina Hemorrhages 4 Veins unusually
T h e retinal hemorrhages found in four patients were multiple. The details of these cases were as f o l l o w s :
CASE 1. Male, 24 years of age, has had kala-azar for over a year, and has received five injections of potassium antimony tartrat. H e appears weak and looks pale. Globulin precipitation test is positive. The lids, corneae, and pupils are normal. A small subconjunctival hemorrhage is found in the middle of the palpebral conjunctiva of the left lower lid.
Fundus Examination: O .D . Media clear. Disc is slightly vertically oval, margin regular and well defined, color normal. Four small areas of hemorrhage, rather dark red in color , are present around the d i sc : ( a ) a small spindle shaped hemorrhage lying about one-fourth d.d. (disc diameter) away from the upper nasal disc margin; ( b ) a small, roughly rectangular area of hemorrhage lying radially from the disc margin at 4 o 'c lock; ( c ) a roundish area of hemorrhage about the size of the disc almost one dd. from the disc margin at 7 o 'c lock. ( In this hemorrhage the course of a vein is interrupted. T h e outline of the hemorrhage is not very distinct but fades into the surrounding retina.) ( d ) a pear shaped hemorrhage half as large as the disc about one-fourth d.d. from the upper temporal quadrant of the disc margin. T h e b lood vessels are normal but the veins are especially dark in color . O.S. Normal findings.
CASE 2. Male, 34 years of age, has had kala-azar for one and a half years. H e has received eleven injections. Patient looks very pale but not weak.
Globulin precipitation test positive. The lids, corneas, and pupils are normal. A small subconjunctival hemorrhage is present in the left lower lid.
Fundus Examination: O .D . Media clear. Disc is slightly vertically oval with a regular but slightly blurred margin. Disc color is normal. L y i n g in the nasal part of the disc is a small area of hemorrhage. Extending from the disc margin between 12 to 1 o 'c lock, there is another hemorrhage, about one-half the size of the disc. This is rather pale in color and sharply defined. A third hemorrhage, seemingly a very recent one by its bright red color, is seen just b e l o w the disc. It is larger than the disc and is fairly well defined. A fourth hemorrhage is found one-fourth d.d. from the upper temporal margin of the disc, which is quite pale in color and is about one-ha f the size of the disc. Al l these areas of hemorrhage are closely related to the b lood vessels, which appear normal. O . S. Media clear. T h e disc is almost round with a regular and well defined margin. Disc is normal in color . On the nasal side of the disc, about one d.d. from it, a small hemorrhage is found measuring about one third the size of the disc. B l o o d vessels are normal.
CASE 3. Male, 26 years of age, has suffered from kala-azar for one and a half years. He has received only three treatments, being a new patient at the clinic. H e also looks very pale and weak. His globulin precipitation test is positive. External examination ; lids are normal; conjunctivas are markedly injected ; corneas are clear and pupils are normal.
Fundus Examination: O .D. Media clear. Disc is almost round and of g o o d c o l o r ; its margin is regular and well defined. A triangular patch of old hemorrhage is seen on the temporal half of the disc, extending horizontally from the center of the disc, in which its apex lies, toward the temporal side with the base in the adjacent retina. Minute black spots are seen in this hemorrhage. These are undoubtedly particles of b lood pigment. B lood vessels are normal,
O . S. Fundus normal.
LEE LESIONS IN K A L A - A Z A R 837
CASE 4. Male, 24 years of age, states that he has had kala-azar for about one year, and has received eight inject ions of antimony. His general appearance closely resembles that of the three cases mentioned above. His globulin precipitation test is also positive. External examination is negative.
Fundus Examination: O .D. Media clear. The disc is almost round with a regular and well defined margin and normal color . There are three areas of hemorrhage in the retina, the general characteristics of which resemble closely those found in the other cases. B lood vessels are normal. O . S. Media clear. D i sc is slightly vertically oval, margin regular and well defined, co lor normal. Four areas of hemorrhage are found in the fundus, apparently rather recent. B lood vessels are normal.
From these data it will be seen that hemorrhages are the most important ocular manifestation of kala-azar. The patients with retinal hemorrhages had a marked anemia. T h e y appeared sall o w and weak. It is interesting to note that none of them complained of disturbance of vision. These cases had had very few treatments, as compared with the majority of cases examined. The fact that retinal hemorrhages are not usually present in cases of kala-azar which have had a p ro longed course of treatment with ant imony agrees very wel l with the observations made in Peking. It has been noticed also that when patients have had a thoro course of treatment and are convalescing, their anemia disappears, their nutrition improves, and a cure is the rule in the majority of treated cases.
The subconjunctival hemorrhage
seems to be a complicat ion resulting from the treatment of kala-azar. Its occurrence may be explained by the fact that the drug used for the treatment of this disease is a powerful expectorant, for somet imes, immediately after the injection of the drug, the patients cough severely for several minutes and expectorate copiously. In some children vomi t ing is produced soon after treatment. T h e examination is often interrupted by these paroxysms of cough ing and expectoration. Undoubted ly these attacks are the immediate occas ion of the subconjunctival hemorrhage ; instances of this are found in children suffering from w h o o p i n g cough, or in old people with bronchial affections.
1. Retinal hemorrhages were found in four out of one hundred and forty cases of kala-azar. T w o of the patients with retinal hemorrhage also had subconjunctival hemorrhage.
2. Retinal hemorrhages are the most important ocular manifestation in kala-azar. T h e y are usually multiple and closely related to the bloodvessels of the retina, around the disc.
3. Subconjunct ival hemorrhages are probably a result of the treatment of kala-azar rather than a direct manifestation of the disease itself, the expectorant property of the drug used in the treatment being responsible for their occurrence.
4. T h e four patients with retinal hemorrhage and marked anemia had had very few treatments. Patients having had a p ro longed course of treatment have only mild anemia and ocular changes are absent. Marked anemia is undoubtedly a factor in the occurrence of retinal hemorrhages.