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Massive Detachment of the Choroid*
1134
NOTES. C A S E S , I N S T R U M E N T S REFERENCES
1. Duke-Elder, S.: Textbook of Ophthalmology. London, Kimpton, 1952, p. 5561. 2. Nath, K , and Shukla, B. R.: Orbital leiomyoma. Brit. J . Ophth, 47:369, 1963. 3. Jennings, J . S . : Congenital rhabdomyoma of the orbit. Am. J . Ophth, 12:204, 1929. 4. Alt, Α.: A case of rhabdomyoma of the eyelid. Am. J . Ophth, 13:109, 1896. 5. Wible, E.: Tumor of orbit. Am. J . Ophth, 1:277, 1918. 6. Forrest, A. YV.: Intraorbital tumors. Arch. Ophth, 4 1 : 1 9 8 , 1949. 7. Calhoun, F. P , and Reese, A. B.: Rhabdomyosarcoma of the orbit. Arch. Ophth, 27:558, 1942. 8. Bocchi, Α.: Fibromioma dell'orbita. Arch. Ottal, 5 : 5 9 , 1897. 9. Posey, YV. C.: Small round cell myosarcoma of orbit with extension into eyeball. Ophth. Ree, 2 1 : 57, 1912. 10. Pascheff, C : Besondere Muskelbildungen in der Orbita. Ber. deutsch. Ophth. Gesell, 44:436, 1927. 11. Mayer, Κ.: Rhabdomyoma of the eyelid. Am. J . Ophth, 12:293, 1929. 12. Bietti, Α.: Ueber einen Fall von typischen Rhabdomyom des Musculus ractus extemus bei einem, 7 Ojahzigen Manne. Klin. Monatsbl. Augenh, 43:129, 1927. 13. Schnaudigel, O.: Ein Rhabdomyom des Orbicularis. Arch. f. Ophth, 74:272, 1910. 14. Stallard, H. B . : A plea for lateral orbitotomy with certain modification. Brit. J . Ophth, 44:718, 1960. 15. Boyd, W . : Pathology for Surgeons. Philadelphia, Saunders, 1955, ed. 7, p. 613. 16. Evans, R. W . : Histological Appearance of Tumor. London, Livingstone, 1956, p. 29. 17. Wolf, E. • A Pathology of the Eye. London, Lewis, 1951, ed. 3, p. 317.
M A S S I V E DETACHMENT OF T H E CHOROID* J . S. GUPTA, F.R.C.S. ARIN CHATTERJEE, M.B.B.S. AND
K . KUMAR, M.B.B.S. Chandigarh,
India
According to Duke-Elder, the differential diagnosis of conditions resembling choroidal detachment usually is not difficult. History of intraocular operation, a shallow or absent anterior chamber, folds in Descemet's mem brane and hypotony lead one to suspect cho roidal detachment. Further, the solid appear ance of the choroid, its smooth and regular surface, reddish-brown in color, and normal retinal blood vessels with unchanged color distinguish this condition from retinal de tachment which appears wavy and mobile and is usually associated with a tear. The diagnosis of this condition is not, however, always easy. Sometimes choroidal detachment may be associated with retinal detachment, while at other times it may be 1
• F r o m the Department of Ophthalmology, Insti tute of Postgraduate Medical Education and Re search.
so massive as to fill almost all of vitreous cavity, even obstructing the view of the optic nervehead and macula. Normally one expects, as is stressed by Stine, that a tem poral choroidal detachment cannot go be yond the visual axis and the posterior pole, and that a nasal detachment will not extend beyond the nasal margin of the disc. In the following case, a temporal choroi dal detachment was so massive that it com pletely filled the posterior segment of the globe, extending from the temporal to the nasal equator, and without apparent damage to the venae vorticosae. The case is also un usual because the choroidal detachment fol lowed iridencleisis which is known to be free from such a complication. Because of its un usual features the case remained undiagnosed until the detachment started showing spon taneous regression. 2
CASE REPORT G. S. S , a 25-year-old man, was first seen in consultation on January 14, 1964, complaining of gradual loss of vision in both eyes for the last II months. Vision in the right eye was 4/60 and in the left eye 3/60. Examination revealed glaucomatous cup ping in both eyes. Tension was 45 mm Hg, right eye; 40 mm Hg (Schiøtz) left eye. Peripheral
NOTES, C A S E S ,
Fig. 1 (Gupta, Chatterjee and Kumar). Massive detachment of choroid as seen with Hruby's lens. fields showed marked constriction, more so in the left eye. Gonioscopically both eyes showed open an gles, wide entry, prominent Schwalbe's line and a few goniosynechiae. The patient was immediately admitted to the hospital with a diagnosis of open-angle glaucoma. Tension was reduced with 2.0% pilocarpine drops and Diamox (250 mg three times daily). On January 22, a double pillar iridencleisis was done on the right eye. The postoperative period was uneventful except for a mild flare. Tension re mained round about 13 mm Η g (Schiøtz). On February 5, iridencleisis was done on the
Fig. 2 (Gupta, Chatterjee and Kumar). Choroidal detachment, showing regression.
1135
INSTRUMENTS
left eye, with incarceration of the temporal pillar. There was no complication during the operation. The postoperative period was again uneventful until February 11, when the patient complained of complete loss of vision in the left eye. On examination, vision was finger counting 0.5 m, right eye; doubtful perception in the left eye. Ophthalmoscopic examination of the left eye revealed a large reddish-brown mass with an almost flat, granular surface, extending from the temporal to the nasal equator. Markedly narrowed blood vessels were seen on the surface of the mass; some were of normal color, while others showed complete occlusion, not unlike silver wire arteries. They followed no regular pattern. The disc and the macula could not be seen (fig. 1 ) . Slitlamp examination confirmed the ophthalmoscopic findings. The diagnosis of choroidal detachment could not be made at this stage because the optic nervehead was totally obscured. The patient was given complete bedrest and an ophthalmoscopic examination was done every third day. On February 15, a dark area appeared at the extreme nasal periphery. On February 2 1 , the mass was greatly reduced and an elevated ridge was seen. It passed vertically downward, three disc diameters from the optic nervehead on the temporal side (fig. 2 ) . A t this stage there was no doubt that the case was one of choroidal detachment. The patient was discharged on March 2 with tension of 14 mm Hg, right eye; 16 mm Hg, left eye (Schiøtz). The detachment had completely receded, leaving no significant residua (fig. 3 ) . The vision also improved from light perception to 3/60.
COMMENTS Classically a choroidal detachment is described as a reddish hemispheric prominence. Generally, it affects the temporal and the nasal quadrants but, occasionally, the superior and inferior quadrants can also be involved. Infrequently, the detachment may occupy the entire circumference, giving an annular appearance; however, the view of the disc is not obscured as the choroid is attached firmly at the disc margins, with the venae vorticosae in the midperipheral region and, still further, with the scleral spur seen indirectly through the ciliary body. Because
Fig. 3 (Gupta, Chatterjee and Kumar). Diagrammatic representation of regression of detachment.
1136
NOTES, C A S E S , I N S T R U M E N T S
of these attachments and the assumption that the venae vorticosae will make way, Stine hypothesized that a temporal choroidal de tachment cannot go beyond the posterior pole. On reviewing the literature we could find only a few case reports in which the detach ments were so massive as to reach the cen tral axis. McKinney reported a case of choroidal detachment which started from the nasal side and obscured the optic disc. Forster reported a case in which the nasal and temporal quadrants came in contact with each other to obscure the macula and optic papilla. O'Brien, analyzing 50 cases of choridal detachment, mentions emphati cally that no matter how extensive the de tachment may be it does not reach the re gion of the macula or optic nervehead. Keeping these descriptions in mind, our 3
4
5
case seems rather unusual, with complete choroidal detachment and yet without any damage to the two temporal venae vort icosae, which is proved by the fast and spontaneous regression. This case complete ly refutes the hypothesis of Stine, who em phasizes that the radius of curvature of the detachment must be equal to that of the undetached portion. The follow-up of our case, as shown diagrammatically in Figure 3, in dicates that this curvature may not maintain the same relationship in every case of exten sive detachment. This can be explained by the elasticity of the choroid and the stretch ing of the ocular portions of venae vort icosae. It is possible that extensive detach ments can occur without tearing the venae vorticosae, resulting in devastating subchoroidal hemorrhage. Department
of
Ophthalmology.
REFERENCES 1. 2. 3. case. 4. 5. with
Duke-Elder, S . : Textbook of Ophthalmology. London, Kimpton, 1940, v. 3, pp. 2538-2543. Stine, G. Η.: Detachment of the choroid and retina. Am. J . Ophth, 30:897, 1947. McKinney, J . W . : Choroidal detachment following operation for retinal detachment: Report of a Am. J . Ophth., 30 :208, 1947. Forster, W . : Total choroidal detachment following cataract surgery. Arch. Ophth, 62:731, 1959. O'Brien, C. S . : Detachment of the choroid after cataract extraction: Clinical and experimental study a report of 75 cases. Arch. Ophth, 14 :527, 1935.
S I M P L E METHOD FOR VIEWING STEREOSCOPIC PHOTOGRAPHS* J . DONALD FITE, M.D. AND HAROLD N. JACKLIN, M.D. Atlanta,
Georgia
Stereoscopic ocular fundus photography has become increasingly popular. Handviewers for the stereoscopic slides and printed pictures presently in use are outdated 1, s
* From the Department of Ophthalmology, Emory University School of Medicine, and the Grady Clay Eye Clinic, Grady Memorial Hospital, and Veterans Administration Hospital.
or expensive. W e have recently found ah in expensive, simple method for viewing these photographs (fig. 1 ) . The slides can be mounted in metal weather-stripping obtain able at most hardware stores. This stripping can be easily cut to the correct length. A bright light source is needed. A simple desk lamp is effective. The viewer consists of a + 10D. pair of aphakic glasses. Most ophthal mologists will have a discarded pair of such glasses, since they are often used as tempo rary corrections for postoperative cataract patients. As pointed out by Allen, a trial frame with +10D. trial lenses can also be used to view the photographs. Interposing the 2
NOTES. C A S E S , I N S T R U M E N T S REFERENCES
1. Duke-Elder, S.: Textbook of Ophthalmology. London, Kimpton, 1952, p. 5561. 2. Nath, K , and Shukla, B. R.: Orbital leiomyoma. Brit. J . Ophth, 47:369, 1963. 3. Jennings, J . S . : Congenital rhabdomyoma of the orbit. Am. J . Ophth, 12:204, 1929. 4. Alt, Α.: A case of rhabdomyoma of the eyelid. Am. J . Ophth, 13:109, 1896. 5. Wible, E.: Tumor of orbit. Am. J . Ophth, 1:277, 1918. 6. Forrest, A. YV.: Intraorbital tumors. Arch. Ophth, 4 1 : 1 9 8 , 1949. 7. Calhoun, F. P , and Reese, A. B.: Rhabdomyosarcoma of the orbit. Arch. Ophth, 27:558, 1942. 8. Bocchi, Α.: Fibromioma dell'orbita. Arch. Ottal, 5 : 5 9 , 1897. 9. Posey, YV. C.: Small round cell myosarcoma of orbit with extension into eyeball. Ophth. Ree, 2 1 : 57, 1912. 10. Pascheff, C : Besondere Muskelbildungen in der Orbita. Ber. deutsch. Ophth. Gesell, 44:436, 1927. 11. Mayer, Κ.: Rhabdomyoma of the eyelid. Am. J . Ophth, 12:293, 1929. 12. Bietti, Α.: Ueber einen Fall von typischen Rhabdomyom des Musculus ractus extemus bei einem, 7 Ojahzigen Manne. Klin. Monatsbl. Augenh, 43:129, 1927. 13. Schnaudigel, O.: Ein Rhabdomyom des Orbicularis. Arch. f. Ophth, 74:272, 1910. 14. Stallard, H. B . : A plea for lateral orbitotomy with certain modification. Brit. J . Ophth, 44:718, 1960. 15. Boyd, W . : Pathology for Surgeons. Philadelphia, Saunders, 1955, ed. 7, p. 613. 16. Evans, R. W . : Histological Appearance of Tumor. London, Livingstone, 1956, p. 29. 17. Wolf, E. • A Pathology of the Eye. London, Lewis, 1951, ed. 3, p. 317.
M A S S I V E DETACHMENT OF T H E CHOROID* J . S. GUPTA, F.R.C.S. ARIN CHATTERJEE, M.B.B.S. AND
K . KUMAR, M.B.B.S. Chandigarh,
India
According to Duke-Elder, the differential diagnosis of conditions resembling choroidal detachment usually is not difficult. History of intraocular operation, a shallow or absent anterior chamber, folds in Descemet's mem brane and hypotony lead one to suspect cho roidal detachment. Further, the solid appear ance of the choroid, its smooth and regular surface, reddish-brown in color, and normal retinal blood vessels with unchanged color distinguish this condition from retinal de tachment which appears wavy and mobile and is usually associated with a tear. The diagnosis of this condition is not, however, always easy. Sometimes choroidal detachment may be associated with retinal detachment, while at other times it may be 1
• F r o m the Department of Ophthalmology, Insti tute of Postgraduate Medical Education and Re search.
so massive as to fill almost all of vitreous cavity, even obstructing the view of the optic nervehead and macula. Normally one expects, as is stressed by Stine, that a tem poral choroidal detachment cannot go be yond the visual axis and the posterior pole, and that a nasal detachment will not extend beyond the nasal margin of the disc. In the following case, a temporal choroi dal detachment was so massive that it com pletely filled the posterior segment of the globe, extending from the temporal to the nasal equator, and without apparent damage to the venae vorticosae. The case is also un usual because the choroidal detachment fol lowed iridencleisis which is known to be free from such a complication. Because of its un usual features the case remained undiagnosed until the detachment started showing spon taneous regression. 2
CASE REPORT G. S. S , a 25-year-old man, was first seen in consultation on January 14, 1964, complaining of gradual loss of vision in both eyes for the last II months. Vision in the right eye was 4/60 and in the left eye 3/60. Examination revealed glaucomatous cup ping in both eyes. Tension was 45 mm Hg, right eye; 40 mm Hg (Schiøtz) left eye. Peripheral
NOTES, C A S E S ,
Fig. 1 (Gupta, Chatterjee and Kumar). Massive detachment of choroid as seen with Hruby's lens. fields showed marked constriction, more so in the left eye. Gonioscopically both eyes showed open an gles, wide entry, prominent Schwalbe's line and a few goniosynechiae. The patient was immediately admitted to the hospital with a diagnosis of open-angle glaucoma. Tension was reduced with 2.0% pilocarpine drops and Diamox (250 mg three times daily). On January 22, a double pillar iridencleisis was done on the right eye. The postoperative period was uneventful except for a mild flare. Tension re mained round about 13 mm Η g (Schiøtz). On February 5, iridencleisis was done on the
Fig. 2 (Gupta, Chatterjee and Kumar). Choroidal detachment, showing regression.
1135
INSTRUMENTS
left eye, with incarceration of the temporal pillar. There was no complication during the operation. The postoperative period was again uneventful until February 11, when the patient complained of complete loss of vision in the left eye. On examination, vision was finger counting 0.5 m, right eye; doubtful perception in the left eye. Ophthalmoscopic examination of the left eye revealed a large reddish-brown mass with an almost flat, granular surface, extending from the temporal to the nasal equator. Markedly narrowed blood vessels were seen on the surface of the mass; some were of normal color, while others showed complete occlusion, not unlike silver wire arteries. They followed no regular pattern. The disc and the macula could not be seen (fig. 1 ) . Slitlamp examination confirmed the ophthalmoscopic findings. The diagnosis of choroidal detachment could not be made at this stage because the optic nervehead was totally obscured. The patient was given complete bedrest and an ophthalmoscopic examination was done every third day. On February 15, a dark area appeared at the extreme nasal periphery. On February 2 1 , the mass was greatly reduced and an elevated ridge was seen. It passed vertically downward, three disc diameters from the optic nervehead on the temporal side (fig. 2 ) . A t this stage there was no doubt that the case was one of choroidal detachment. The patient was discharged on March 2 with tension of 14 mm Hg, right eye; 16 mm Hg, left eye (Schiøtz). The detachment had completely receded, leaving no significant residua (fig. 3 ) . The vision also improved from light perception to 3/60.
COMMENTS Classically a choroidal detachment is described as a reddish hemispheric prominence. Generally, it affects the temporal and the nasal quadrants but, occasionally, the superior and inferior quadrants can also be involved. Infrequently, the detachment may occupy the entire circumference, giving an annular appearance; however, the view of the disc is not obscured as the choroid is attached firmly at the disc margins, with the venae vorticosae in the midperipheral region and, still further, with the scleral spur seen indirectly through the ciliary body. Because
Fig. 3 (Gupta, Chatterjee and Kumar). Diagrammatic representation of regression of detachment.
1136
NOTES, C A S E S , I N S T R U M E N T S
of these attachments and the assumption that the venae vorticosae will make way, Stine hypothesized that a temporal choroidal de tachment cannot go beyond the posterior pole. On reviewing the literature we could find only a few case reports in which the detach ments were so massive as to reach the cen tral axis. McKinney reported a case of choroidal detachment which started from the nasal side and obscured the optic disc. Forster reported a case in which the nasal and temporal quadrants came in contact with each other to obscure the macula and optic papilla. O'Brien, analyzing 50 cases of choridal detachment, mentions emphati cally that no matter how extensive the de tachment may be it does not reach the re gion of the macula or optic nervehead. Keeping these descriptions in mind, our 3
4
5
case seems rather unusual, with complete choroidal detachment and yet without any damage to the two temporal venae vort icosae, which is proved by the fast and spontaneous regression. This case complete ly refutes the hypothesis of Stine, who em phasizes that the radius of curvature of the detachment must be equal to that of the undetached portion. The follow-up of our case, as shown diagrammatically in Figure 3, in dicates that this curvature may not maintain the same relationship in every case of exten sive detachment. This can be explained by the elasticity of the choroid and the stretch ing of the ocular portions of venae vort icosae. It is possible that extensive detach ments can occur without tearing the venae vorticosae, resulting in devastating subchoroidal hemorrhage. Department
of
Ophthalmology.
REFERENCES 1. 2. 3. case. 4. 5. with
Duke-Elder, S . : Textbook of Ophthalmology. London, Kimpton, 1940, v. 3, pp. 2538-2543. Stine, G. Η.: Detachment of the choroid and retina. Am. J . Ophth, 30:897, 1947. McKinney, J . W . : Choroidal detachment following operation for retinal detachment: Report of a Am. J . Ophth., 30 :208, 1947. Forster, W . : Total choroidal detachment following cataract surgery. Arch. Ophth, 62:731, 1959. O'Brien, C. S . : Detachment of the choroid after cataract extraction: Clinical and experimental study a report of 75 cases. Arch. Ophth, 14 :527, 1935.
S I M P L E METHOD FOR VIEWING STEREOSCOPIC PHOTOGRAPHS* J . DONALD FITE, M.D. AND HAROLD N. JACKLIN, M.D. Atlanta,
Georgia
Stereoscopic ocular fundus photography has become increasingly popular. Handviewers for the stereoscopic slides and printed pictures presently in use are outdated 1, s
* From the Department of Ophthalmology, Emory University School of Medicine, and the Grady Clay Eye Clinic, Grady Memorial Hospital, and Veterans Administration Hospital.
or expensive. W e have recently found ah in expensive, simple method for viewing these photographs (fig. 1 ) . The slides can be mounted in metal weather-stripping obtain able at most hardware stores. This stripping can be easily cut to the correct length. A bright light source is needed. A simple desk lamp is effective. The viewer consists of a + 10D. pair of aphakic glasses. Most ophthal mologists will have a discarded pair of such glasses, since they are often used as tempo rary corrections for postoperative cataract patients. As pointed out by Allen, a trial frame with +10D. trial lenses can also be used to view the photographs. Interposing the 2