864 NARENDRA KRISHNA AND BARBARA MITCHELL

yvinyl alcohol in saline. In contrast, in­creased vascularity and proliferation at the injection site and retention of the injected material was the rule when 0.5% methylcel­lulose in isotonic saline was injected subcon-junctivally in rabbits. This would indicate that, like aqueous preparations, various drugs in 1.4% polyvinyl alcohol vehicle may be safely used subconjunctivally when indi­cated without danger of fibrous tissue reac­tion or undue retention resulting from the vehicle.

2. The rabbit eye seems to tolerate well 1.4% polyvinyl alcohol in isotonic saline in­jected into the anterior chamber. There was no conjunctival or corneal reaction in any of the eyes treated. However, mild to moderate degrees of conjunctival injection (both superficial and deep) and corneal edema were observed in a statistically significant number of eyes treated with 0.5% methylcellulose in isotonic saline. Again, a highly significant number of eyes showed a similar reaction when methylcellulose was administered in the form of anterior chamber irrigation. The increase in the number of eyes showing

reaction, and the severity of the reactions with this mode of administration, might have been due in part to superimposed sur­gical trauma to which the eyes were subject­ed in this procedure. This may also have been a factor in the mild superficial con­junctival injection in five eyes treated with 1.4% polyvinyl alcohol in isotonic saline by this method. It may be assumed from this study that 1.4% polyvinyl alcohol in isotonic saline is innocuous to the eye when it gains access to the interior of the eye and is a safe vehicle to use for various ophthalmic prep­arations in open ocular wounds.

In conclusion, 1.4% polyvinyl alcohol in isotonic saline is nonirritating to the rabbit eye, when injected subconjunctivally or ad­ministered into the interior of the eye. This, in addition to the several other advantages noted in the previous study, 1 should make it a highly appropriate vehicle for the various ophthalmic agents which may be employed in open ocular wounds, whether postsurgical, posttraumatic or postinfective in nature.

1601 Spring Garden Street (19130).

REFERENCES

1. Krishna, N, and Brow, F.: Polyvinyl alcohol as an ophthalmic vehicle: Effect on regeneration of corneal epithelium. Am. J . Ophth, 57 :99-106, 1964.

2. Anderson, D. L , and Shea, M.: Tissue response to polyvinyl alcohol implants in rabbits. Am. J . Ophth, 51:1200-1203, 1961.

O V E R T B E H A V I O R M A N I F E S T E D I N B I L A T E R A L L Y

P A T C H E D P A T I E N T S *

A C O M P A R A T I V E S T U D Y OF OBSERVATIONS ON A N O P H T H A L M O L O G Y U N I T

GLENN O. DAYTON, JR., M . D , WILMA J . TRABER, M . S . , MARGARET A .

KAUFMANN, ED.D, A N D LAURIE M . GUNTER, PH.D.

Los Angeles, California

INTRODUCTION eral eye patches behave in a manner dif-The primary purpose of this study was to f e r e n t from patients who are not bilater-

determine whether patients who have bilat- i n g > University of California. This study was sup-ported in part by U.S.P.H.S. grant No. GN-6604C

* From the School of Medicine, Department of (Principal investigator: Dean Lulu \V. Hassen -Surgery/Ophthalmology, and the School of Nurs- plug).

BILATERALLY PATCHED PATIENTS 865

ally patched. Patients with bilateral patches on an ophthalmology unit provide an oppor­tune situation for the observation and study of behavior, as reported to or observed by the nurse, which may be attributed to the effects of reduced sensory stimulation. The effects on human behavior of "sensory dep­rivation," or reduced sensory stimulation, have been extensively investigated. How­ever, most of the research on the subject has been done under experimental conditions which are not typical of real life situations. Findings have been contradictory and leave much to be answered.

In a study of 21 patients with bilateral senile cataracts, Linn et al. 1 reported that 95% of the patients showed some alteration in behavior, and 65% had severely disturbed reactions. They concluded that these distur­bances in behavior were due to a complex interaction of a number of factors.

Ziskind et al. 2 reported observations of mental disabilities during patching on 10 surgical patients with detached retina and 88 with cataracts. Mental symptoms occurred in 100% of patients with retinal detachment and in 30% of those having cataract extrac­tion. The symptoms were described and re­lated to sensory deprivation effects. In a later study reported by the same investiga­tors 3 of 174 patients with patches over both eyes after ocular operations, 35% were ob­served to have one or more symptoms of mental aberrations. In a smaller group who had repair of retinal detachment and there­fore had to wear eye patches for a much longer time, the incidence of mental symp­toms was 100%.

Although all the investigators reviewed agreed that some form of behavioral distur­bance occurs in selected patients, only one group 3 made observations before, during, and after the period of bilateral patching which provided controls in evaluating men­tal symptoms. None of the studies reported concurrent or comparative studies of behav­ioral symptoms in eye patients who were not

subjected to "sensory deprivation." Hence, a further purpose of this study was to exam­ine the behavior of all the patients in an ophthalmology unit in order to gain addi­tional knowledge which may be used to pre­dict medical and nursing care problems.

MATERIAL A N D METHODS

The study sample consisted of structured observations of patient behavior and patient comments and reports as noted by hospital nursing service personnel regularly assigned to the unit as part of their employment. These observations were made on all eye pa­tients on the ophthalmology unit over a peri­od of approximately six weeks on a nearly 24-hour basis.

An "Eye Patient Rating Scale" was de­vised, which consisted of two major cate­gories: ( 1 ) subjective statements made by the patient to the nurse which might in­dicate symptoms of anxiety 4" 6 and (2 ) nursing observations, the criteria for which were developed from a compilation of other "sensory deprivation" s tudies . 1 3 ' 7 " 9

Each Eye Patient Rating Scale contained 29 observations, 13 relating to "patient's re­ports" and 16 relating to "nurse's observa­tions." Each member of the nursing service staff was asked to check this "Eye Patient Rating Scale" for each patient in his nurs­ing care assignment every day.

A description of the patient population in terms of age and sex is presented in Table 1. The population consisted of 41 patients who were bilaterally patched and 37 un-patched patients. The term "unpatched" was used to designate those patients in the ophthalmology unit who had been hospital­ized because of disease or injury to their eyes, but who did not have both eyes ban­daged. The term "bilaterally patched" was used to designate the patients who had ban­dages covering both eyes. Some patients fell in both the bilaterally patched and the un­patched groups at different times.

866 D A Y T O N , T R A B E R , K A U F M A N N A N D G U N T E R

T A B L E 1

B I L A T E R A L L Y P A T C H E D A N D U N P A T C H E D P A T I E N T S O B S E R V E D F O R S E L E C T E D B E H A V I O R A L SYMPTOMS B Y A G E GROUP A N D S E X

Age (yr)

Bilaterally Patched Unpatched Age (yr) Total No.

Patients Male Female Total No. Patients Male Female

Under 2 0 1 1 0 2 2 0

2 1 - 3 5 2 1 1 3 3 0

3 6 - 5 0 6 4 2 1 2 9 3

5 1 - 6 5 1 9 7 1 2 1 1 3 8

Over 6 5 1 3 7 6 9 3 6

T O T A L S 4 1 2 0 2 1 3 7 2 0 1 7

RESULTS

The total number of observations made on the bilaterally patched and on the un­patched patients is shown in Table 2. Under the section "nurse observes," 1.9% more symptoms were noted for the bilateral­ly patched group of patients than were noted for the unpatched group, and under the "patient's reports" were 1.2% more symptoms than for the unpatched group.

Gathered by age groups, data on the se­lected behavior (table 3) indicated that pro­portionately more symptoms of behavioral disturbance occurred in the bilaterally

patched group of patients in all of the age groups.

In this study, the two patients in the under-20 age group showed the most symp­toms of behavioral disturbance. The next largest percentage of disturbances occurred in patients who were bilaterally patched and over 65 years of age. The same was not true for the unpatched group. More symptoms were observed in the unpatched patients in the age group between 51 and 60 years. Data gathered from both sexes was ana­lyzed and more women than men were found to express behavioral aberrations (table 4 ) .

TABLE 2 F R E Q U E N C Y A N D P E R C E N T A G E S OF O B S E R V A T I O N S OF S E L E C T E D B E H A V I O R A L SYMPTOMS AS N O T E D SY

N U R S I N G S E R V I C E P E R S O N N E L I N B I L A T E R A L L Y P A T C H E D A N D U N P A T C H E D GROUPS OF P A T I E N T S

Patient Behavior as Noted by Nursing Personnel

Ratings for Patients Bilaterally Patched

Total Observations: 1 2 , 1 5 2

Ratings for Patients Unpatched

Total Observations: 6 , 3 2 4 Patient Behavior as Noted

by Nursing Personnel Never to Occasionally

Often to Always

Never to Occasionally

Often to Always

No. % No. % No. % No. % Patients' Reports of Symptoms 5 , 4 8 1 9 8 . 3 9 8 1 . 7 2 , 9 1 1 9 9 . 5 1 4 0 . 5

Nurses' Observations of Symp­toms 6 , 3 3 7 9 6 . 4 2 3 6 3 . 6 3 , 3 4 2 9 8 . 3 5 7 1 . 7

T O T A L S 1 1 , 8 1 8 3 3 4 6 , 2 5 3 7 1

A Chi-square test of significance for differences between the "nurses' observations" and "patient's reports" of selected behavioral symptoms in bilaterally patched and unpatched patients was significant beyond the 0 . 0 0 1 level of confidence with one degree of freedom.

BILATERALLY PATCHED PATIENTS 867

TABLE 3

F R E Q U E N C Y OF OBSERVATIONS OF SELECTED BEHAVIORAL SYMPTOMS A S REPORTED B Y NURSING S E R V I C E PERSONNEL ON B I L A T E R A L L Y PATCHED AND UNPATCHED PATIENTS B Y A G E GROUP

Age Bilaterally Patched Unpatched

(yr) Never to Occasionally Often to Always Never to Occasionally Often to Always

Under 20 263 37 255 8

21 to 35 1 ,015 15 296 2

36 to 50 2,026 46 2,671 23

51 to 65 6 ,143 160 2,044 30

Over 65 2,371 76 987 8

T O T A L S 1 1 , 8 1 8 334 6,253 71

The numbers of symptoms observed dur­ing the different times of day were analyzed (table 5 ) . The bilaterally patched patients showed more symptoms of behavioral dis­turbance in all three divisions of the day, with by far the greatest percentage of these symptoms occurring in the evening. The largest percentage of behavioral disturbances, when they occurred in the unpatched pa­tients, was also in the evening.

The differences between symptoms ob­served in bilaterally patched patients and unpatched patients who were on medications and those who were not on medications were analyzed (table 6 ) . Those patients in the bi­laterally patched group on medications mani­fested behavioral symptoms more frequently than did the patients not on medications.

The patients in the unpatched group who were not on medications exhibited signifi­cantly more behavioral symptoms, a reversal of the finding in the bilaterally patched group.

Within the patient population of this study a subgroup was created which served to clarify and support the general findings of the study. This subgroup consisted of 10 patients, three men and seven women, on whom observations were made before, dur­ing, and after patching, and the results were analyzed. More behavioral disturbances oc­curred during bilateral patching than either before or after patching (table 7 ) .

COMMENT

The findings of the study demonstrated

TABLE 4 FREQUENCY AND PERCENTAGES OF OBSERVATIONS OF SELECTED B E H A V I O R A L SYMPTOMS A S NOTED B Y NURSING S E R V I C E PERSONNEL IN B I L A T E R A L L Y PATCHED AND UNPATCHED G R O U P S OF PATIENTS, B Y S E X

Ratings of Patients Bilaterally Patched (N = 12 ,152)

Ratings of Patients Unpatched (N =6 ,324)

X ever to Occasionally Often to Always Never to Occasionally Often to Always

Sex No. % Xo. % Xo. % No. % Male 5,065 98 126 2 3,527 98 .6 49 1 .4

Female 6,753 97 208 3 2,726 99 .1 22 0 .9

T O T A L S 1 1 , 8 1 8 334 6,253 71

The Chi-square test of significance for differences in the behavior of bilaterally patched men and women was significant at the 0.05 level of confidence with one degree of freedom.

868 DAYTON, TRABER, K A U F M A N N AND GUNTER

TABLE 5

FREQUENCY OF OBSERVATIONS OF SELECTED B E ­HAVIORAL SYMPTOMS A S REPORTED B Y NURSING SERVICE PERSONNEL ON B I L A T E R A L L Y PATCHED A N D

UNPATCHED PATIENTS, B Y TIME OF D A Y

Bilaterally Patched Unpatched

Time of Day Never

to Occasion­

ally

Often to

Always

Never to

Occasion­ally

Often to

Al­ways

Day 7:00 A . M . -3:00 P .M. 4,709 110 2,700 32

Evening 3:00 P . M . -11:00 P .M. 2,323 94 1,077 23

Night 11:00 Ρ . Μ . -7:00 A . M . 4,786 130 2,476 16

T O T A L S 1 1 , 8 1 8 334 6,253 71

TABLE 6 FREQUENCY OF OBSERVATIONS OF BEHAVIORAL S Y M P ­TOMS ON PATIENTS B I L A T E R A L L Y PATCHED AND UNPATCHED, MADE B Y NURSING S E R V I C E PERSONNEL, B Y THOSE ON MEDICATIONS AND THOSE NOT ON

MEDICATIONS*

Bilaterally Patched

(Patient Ν =41)

Unpatched (Patient Ν =37)

Medications

Never to

Occasion­ally

Often to

Al­ways

Never to

Occasion­ally

Often to

Al­ways

Receiving medication (Patient N = 51) 10,552 321 5,249 20

Not receiving medication (Patient N = 27) 1,266 13 1,004 51

* Those patients classified as "on medications" received sleeping pills every night, tranquilizers every day, and/or Demerol for pain beyond one day postoperatively.

The Chi-square test of significance for differences between observations of selected behavioral symp­toms on bilaterally patched patients who were on medications, and those who were not on medications, was significant beyond the 0.001 level of confidence with one degree of freedom.

that there was a significant difference in the frequency but not in the kind of behavioral symptoms observed in the bilaterally patched group as compared with the unpatched group of patients on the ophthalmology unit. How­ever, the cause of the difference in amount of this behavior cannot be definitely attrib­uted to the bilateral patching or "sensory deprivation." The majority of these patients had surgical repair of retinal detachment, and twice as many observations of behavioral symptoms were made in this group. How­ever, the total number of patched patients was only greater by four patients than the total number of unpatched patients.

Additional findings of the study seem to indicate that patients show more behavioral disturbances during the evening hours than any other time of day. This may be due in part to observations on the patients who have returned from surgery after general anesthesia. Another possibility is that the patient may become increasingly aware of his isolation and feelings of helplessness with the onset of night and may become frightened for his safety and securi ty . 1 0 ' 1 1

A third consideration is that the patient is in a state of reduced awareness prior to sleep and becomes more anxious because of a lessened contact with reality or a blurring

TABLE 7

FREQUENCY OF OBSERVATIONS OF SELECTED B E ­HAVIORAL SYMPTOMS MADE B Y NURSING S E R V I C E PERSONNEL ON A S U B G R O U P O F T E N PATIENTS B E F O R E ,

DURING, AND A F T E R PATCHING

Status of Patching

Symptoms Occurred Never to

Occasionally

Symptoms Occurred Often to Always

Total

Before 316 3 319

During 2,835 105 2,940

After 1,766 12 1,778

T O T A L S 4 ,917 120 5,037

A Chi-square test of significance for differences between observations of selected behavioral symp­toms before, during, and after patching was signi­ficant beyond the 0.001 level of confidence with two degrees of freedom.

BILATERALLY PATCHED PATIENTS 869

of sensory input. This idea has been postu­lated in varied forms by Jackson et al., 2

Rosenzweig,8 Weisman and Hackett, 1 3

Ziskind and Augsburg, 9 Mendelson et a l . 1 4

and Freedman." This study seems to pre­sent evidence against the finding of Linn et al. 1 that the symptoms occur most often at night.

Findings from the analysis of the data gathered on the subgroup of 10 patients who were observed before, during, and after patching showed a significantly higher frequency of behavioral disturbances occur­ring during patching. This would seem to support the theory that the behavioral symp­toms are due, at least in part, to the eye patching rather than to the premorbid per­sonality, as suggested by Linn et al . 1 and other investigators. 7 ' 9 , 1 6

The significant difference found between bilaterally patched patients who were on medication and those who were not on medi­cation versus the opposite findings in the unpatched patients on medication and those not on medication, was an unexpected find­ing and cannot be explained in terms of the available data.

SUMMARY

The primary purpose of this study was to determine whether patients who have bilat­eral eye patches manifest different behav­ior, as reported to or observed by the

nurse, than patients who are not bilaterally patched.

The study sample consisted of structured observations of patient behavior made by nursing service personnel regularly assigned to the unit using an "Eye Patient Rating Scale." The observations covered a six-week period and included 41 bilaterally patched and 37 unpatched patients.

Analysis of the data of the total study offered evidence that there was a significant difference in the frequency in occurrence of behavioral symptoms reported to, and ob­served by the nurse between bilaterally patched and unpatched patients. More often than chance, the bilaterally patched patients showed more symptoms than did the un­patched patients. The data also demonstrated a significant difference in the frequency of behavioral symptoms between men and women in the bilaterally patched group, with the women showing significantly more dis­turbances of behavior than the men. Further, there was proportionately a higher frequency of symptoms of behavioral disturbances oc­curring in both bilaterally patched and un­patched patients during the evening hours than in any other portion of the 24-hour period. The bilaterally patched patients on medication showed a higher frequency of be­havioral symptoms than did those not on medication. The reverse was true for the un­patched patients.

Department of Surgery.

REFERENCES

1. Linn, L , Kahn, R, Coles, R , Cohen, J , Marshall, D , and Weinstein, Ε.: Patterns of behavior dis­turbance following cataract extraction. Am. J . Psychiat, 110 :281-289, 19S3.

2. Ziskind, E , Jones, H , Filante, W , and Goldberg, J . : Observations of mental symptoms in eye-patched patients: Hypnagogic symptoms in sensory deprivation. Am. J . Psychiat, 116:893-900, 1960.

3. Filante, W , Goldberg, J , Jones, H , and Ziskind, E.: Sensory deprivation on an eye service. Calif. Med, 93:3SS-3S6, 1960.

4. Höfling, C, and Leininger, Μ.: Basic Psychiatric Concepts in Nursing. Philadelphia, Lippincott, 1960, pp. 145-148, 241-244.

5. Kalkman, M.: Introduction to Psychiatric Nursing, New York, McGraw-Hill, 1958, pp. 134-135. 6. Peplau, H . : Interpersonal Relations in Nursing. New York, Putnam, 1962, pp. 119-157. 7. Flynn, W. R.: Visual hallucinations in sensory deprivation. Psychiat. Quart, 36 :55-65, 1962. 8. Rosenzweig, Ν.: Sensorv deprivation and schizophrenia : Some clinical and theoretical similarities. Am.

J . Psychiat, 116:326-329, 1959. 9. Ziskind, E , and Augsburg, T.: Hallucinations in sensory deprivation—method or madness? Science,

137 :992-993, 1962. 10. Effects of sensory deprivation, isolation and confinement (editorial). Canad. M. A. J , 85:39-40, 1961.

870 DAYTON, TRABER, KAUFMANN AND GUNTER

11. Solomon, Ρ , Liederman, Η, Mendelson, J , and Wexler, D.: Sensory deprivation: A review. Am. J . Psychiat, 114:357-363, 1957.

12. Jackson, C. \ V , Pollard, J . C, and Kansky, E. \V.: The application of findings from experimental sensory deprivation to cases of clinical sensory deprivation. Am. J . M. Sei, 243 :558-563, 1962.

13. Weisman, A , and Hackett, T.: Psychosis after eye surgery. New England J . Med, 258:1284-1289 (June 26) , 1958.

14. Mendelson, J , et al.: The physiological and psychological aspects of sensory deprivation: A case analysis. In Solomon, P , et al. (editors) : Sensory Deprivation. Cambridge, Harvard, 1961, pp. 91-113.

15. Freedman, S. J . : Perceptual changes in sensory deprivation: Suggestions for a conative theorv. f. Nerv. & Ment. Dis, 132:17-21, 1961.

16. Agostini, L , and Montanari, F.: A case of Lilliputian hallucinations in a patient with an ocular affection. Excerpta Med. Ophth, 15 :370, 1961.

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

SIMULATING CHOROIDAL M E L A N O M A

J . REIMER WOLTER, M . D .

Ann Arbor, Michigan

CARL A . BENZ, M . D .

Adrian, Michigan A N D

F. DALE ROTH, M . D .

Flint, Michigan

A typical early phase of disciform degen­eration of the macula (Kuhnt-Junius 1) may exhibit a dark, central, elevated retroretinal mass without degenerative changes of the retina and pigment epithelium in that area and with some central loss of visual func­tion. With present-day methods, it is vir­tually impossible to distinguish this early phase of disciform degeneration from ma­lignant melanoma of the central choroid. 2 - 1 5

Disciform degeneration of the macula is a disease of advanced age and usually in­volves both eyes. It may, however, some­times occur in younger individuals and be much more advanced in one eye. Thus, it may appear to be unilateral. Disciform de­generation of the macula may occur rather suddenly in some cases. The patients with this disease complain of central visual loss, metamorphopsia and a positive central sco-

* From the Departments of Ophthalmology and Pathology, University of Michigan Hospital, Ann Arbor. This study was supported by grant No. B-2 873 of the U. S. Department of Health, Edu­cation and Welfare.

toma. The fundus typically shows hemor­rhages under the retina, as well as central elevation in the early stages. Later, degener­ation of the pigment epithelium and the cen­tral retina, as well as ingrowth of blood ves­sels and scar tissue from the choroid, result in a disk-shaped yellowish-white mound in the macular area.

A break in Bruch's membrane of the fo­veal choroid seems to be the basic defect of disciform macular degeneration 8 - 8 and this has, therefore, been considered a localized form of the angioid streak disease (Groen-blad-Strandberg 0 ' 1 0) with breaks of Bruch's membrane all over the fundus. In disciform degeneration of the macula, exudate and/or hemorrhage first develop on the inside of Bruch's membrane, causing detachment of the pigment epithelium. Liter, fibrovascular tissue from the choroid grows through the break in Bruch's membrane and into the fluid to organize it.7 Thus, a scar forms. The pigment-cell layer commonly breaks and ex­udate and hemorrhage will extend directly under the retina. After some time, the