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Eye Surgeon's Report, February 28, 1936

PRESENT CONDITION:

Patient states that while engaged in his duty as doorman at 304 West 75th Street, N. Y., a chauffeur struck his right eye with some sharp instrument causing him to seek immediate treatment for injury sustained to this eye. He immediately reported to Dr. M. Janes, 118 W. 74th Str., who stated in a C-4 report that there was a "large deep laceration of the forehead on the right side. Ecchymosis of the upper and lower 896 eyelids on the right eye with marked edema of

both lids. Acute engorgement of the sclera and conjunctivae of the right eye due to trauma. The right eye is shut because of the edematous condition of both eyelids."

Note: In describing this injury you state that the lids were so tightly closed that you were unable to see the globe of the eye. You have made no description as to whether or not the globe was injured. It is therefore probable, from my findings, at the present time and hereinbefore stated, that the present intraocular con906 dition of the lens and iris are the direct result of this injury and that the causal relation is definitely established.

OPHTHALMOLOGICAL EXAMINATION:

Vision: O. D. light perception. O. S. 20-15.
Lids: There is a depressed freely movable well-

healed scar about 1 inch long in the right
eyebrow with some loss of hair and no-
table disfigurement. The lids otherwise
are good color, no crusts or ulcerations;
no cysts or tumors palpable. No other
scarring of eyelids.

Eye Surgeon's Report, February 28, 1936

Cilia: O. U. None misdirected; growing in the proper manner.

Tear Sac: O. U. No fluid expressed on pressure with index finger. No excessive secretion.

Conjunctiva: O. U. good color; smooth; no gran-
ulations; retrotarsal fold is negative. 0.

D. as above, but there is a small exten-
sion of bulbar conjunctiva on to the cor-
nea extending over the surface of the cor-
nea for a distance of about 3 mm., triang-
ular in shape, a traumatic ptergyium or
pseudo-ptergyium as a result of an injury.
This is firmly adherent.

Cornea: O. D. There is, at about 4 o'clock at
the site of the ptergyium before men-
tioned, an anterior synechia which pulls
the iris nasally and is firmly adherent to
the cornea. Strong mydriatics have no
effect upon this synechia. O. S. clear
throughout.

Iris: O. U. of bluish color.

O. D. shows an eccentric pupil horizontally
oval in shape, pulled toward the nasal side
in the direction of the traumatic ptergyium
as a result of the synechia. This synechia
is also posterior being attached also the
lens behind it where there is a large clump
of iris pigment. The temporal border of
the lens is freely movable. The nasal
border is firmly attached by these synechiæ.
The anterior chamber is slightly shallow
as a result of this synechia.

Pupils react well to direct and consensual
light stimulation with the exception of the

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Eye Surgeon's Report, February 28, 1936

point of synechial attachment to the right iris.

LENS: O. D. reveals a definitely traumatic cataract with a pull of the anterior lens capsule on to the iris nasally. This did seem to indicate a perforating wound of the globe through the lens which is so dense that one is not able to see any of the fundus markings at all. The anterior capsule of the lens has become so definitely striated as to show where the traumatism actually occurred.

Fundus: O. D. could not be seen through cataractous lens.

O. S. Negative throughout.

DIAGNOSIS: (1) Traumatic cataract, O. D. (2)
Traumatic (pseudo) ptergyium O. D. (3)
Anterior and posterior synechiæ, O. D. (4)
Scar and disfigurement of eyebrow, O. D.

In my opinion, this lens and iris condition is 90d definitely due to an injury and could definitely have been caused by the injury sustained on October 19th, 1935, in the manner described by the patient. In my opinion, this man should be X-rayed again despite the past findings, because in my experience after several X-rays, as many as 5 and 6 had been taken, a very minute foreign body has been found somewhere in the orbit.

The only treatment that can be advised in this condition, is removal of the lens, preferably by the Homer-Smith operation.

be,

Thanking you for your courtesy, believe me to

Very truly yours,

WALTER R. LOEWE, MD. F. A. C. S.

WRL:IM

Medical Report of Dr. Davidson, March 17,

1936.

91

35410501

Christopher Hanify

West End Av & 75 St Corp.
Royal

State of New York,
County of N. Y., SS:

Dr. Davidson, being duly sworn, deposes and says that he is an Examiner of the Medical Staff of the Bureau of Workmen's Compensation of the Labor Department of the State of New York; that he has this day examined the claimant and makes the following report and findings therefrom:

Re-examination shows the same findings previously reported.

The medical data requested by Dr. Janes is not yet available and no further progress can be made.

LS

92

DR. DAVIDSON. 93

Subscribed and sworn to before me

this 17 day of March, 1936.

Signature of Notary not legible.

94 Medical Report of Dr. Davidson, June 16,

35410501

1936.

95

Christopher Hanify

West End Avenue 75th Street Corp
Royal Indemnity

NY

State of New York,
County of N. Y., SS:

Dr. Davidson, being duly sworn, deposes and says that he is an Examiner of the Medical Staff of the Bureau of Workmen's Compensation of the Labor Department of the State of New York; that he has this day examined the claimant and makes the following report and findings therefrom:

Re-examination shows the same findings previously reported. Dr. Janes' testimony is in the folder. While Dr. Janes affirms that the right eye looked to him normal on Nov. 12 he not being an ophthamologist, considering the 96 description of the original accident and the findings on the C-5, may have overlooked the sequence of the injury which seems to have been a serious one competent to produce the condition found by me.

There is therefore a permanent schedule loss of vision of 100% of the right eye.

DW

DR. DAVIDSON.

Subscribed and sworn to before me

this 16th day of June, 1936.

Signature of Notary not legible.

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