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Ossification of the Choroid
274
NOTES, CASES A N D I N S T R U M E N T S
tending thru tlie cornea, at a location near the periphery, at about 5 o'clock. This we assume is undoubtedly the point of entrance of a small foreign body, 20 years ago, that also pene trated the lens and caused the forma tion of the cataract. During cataract extraction it often occurs that only a central part of the anterior capsule is removed, allowing only an exit for the lens nucleus. The retained peripheral cortical masses may be completely co\ered by capsule, so that they can not be influenced by the solving action of the aqueous. This imprisoned cortical material, together with proliferating capsular epithelium, may produce a sausage shaped mass, or a more or less complete ring. This structure was probably first described by Soemmering, an oculist of Mainz, who wrote a comprehensive book on Ophthalmology about one hundred years ago. This ring is seldom seen, as when present, it is normally held in position behind the iris, by the zonu lar fibers of the lens. In extremely rare cases, this mass may be luxated into the anterior chamber. Search of the literature has revealed only one other similar case. At a meeting of the Berliner Ophthalmo logical GeselLschaft of Jan. 26, 1911, C. Adam reported the luxation of a Soemmering ring into the anterior chamber. This patient fourteen years previously had had a cataract opera tion. He ;vas then 48 years old. The cortex was reported as still relatively soft. A year preceding his report, a Soemmering ring luxated into the an terior chamber. Vision was reduced to fingers at two meters. After a week the ring returned to its normal posi tion, behind the iris, spontaneously. When this case was reported the Soemmering ring had again luxated into the anterior chamber. He re ported some reduction in vision and tension. Wessely and others have re ported cases of luxation into the vitreous. In addition to showing the patient, I am presenting stereoscopic photo graphs of this rare and interesting con dition taken by Dr. Robt. V o n der Heydt, and I wish also to reproduce
a diagram taken from a recent edition of Fuchs, of a Soemmering's Crystal line Swelling, in its normal position behind the iris. (Fig. 2.) The eye has since been operated and the mass removed. The ring could not be delivered en masse thru a large keratome incision without tear ing it to pieces, because it was so firmly attached in several places, prob ably by zonular fibers. The contents of the sausage like structure was a milky fluid. Presented at a meeting of the Chi cago Ophthalmological Society, Dec. 20, 1926. η Ν. State St., Chicago. O S S I F I C A T I O N OF T H E CHOROID. D R . G . N . BRAZEAU, MILWAUKEE, WIS.
Like most of the cases of this kind, this one was discovered only after an examination of the enucleated eyeball. The operation was done to relieve pain in and about the eye and in the fore head. The patient, a woman of fiftyfour years of age, had been blind since the age of fifteen from an old iridocy clitis. These calcareous changes in the eye have no symptomatology pe culiar to themselves, that would per mit of their diagnosis in any other way. I could not understand why pain should be present in the absence of all .symptoms of reaction, but because no other cause could be found it was thought best to operate, and to our great satisfaction all symptoms were relieved. Calcareous changes, like these, do not follow any special rule, therefore, they may appear either as isolated islets or they may involve the tissues of the eyeball, as we will see they did in this case. The little that was left of the vitreous was encased by the osseous mass. Macroscopically the eye was reduced in size, hard to the touch, and irregular in shape. The cornea was enlarged and transparent, up to the part usually occupied by the arcus senilis, which, by the way, was very
N O T E S , CASES A N D I N S T R U M E N T S
opaque. The region of the optic nerve was surrounded by a shoulder like thickening, cartilaginous to the touch. This part of the eyeball is where os sification usually begins, preparatory to involving the rest of the eye. The anterior chamber was very deep, with the iris funnel shaped and tightly ad herent to the opaque lens; which had been drawn backward by the retracted intraocular mass. Contrary to my ex pectations, the tension of the eye was low. Pathologists report that ossification results from colloid degeneration of
275
the intraocular tissue, which is very avid of water. A s it swells the degen erated mass takes on calcareous salts from the osmotic streams which trav erse it, and precipitates them. Later on, the mass undergoes further degen eration with calcareous incrustation, between the striae of which the scle rosed conjunctival tissue organizes it self into new medullary tissue; just as the fibrous membranes do in the regu lar process of ossification, in which veritable osteoblasts are born and with them true osseous tissues. 720 Majestic Bldg.
SOCIETY PROCEEDINGS THE
R O Y A L SOCIETY OF MEDICINE. Section of Ophthalmology. January 14, 1927.
MR.
ERNEST CLARKE, C . V . O.,
held on it, but Mr. Hine did an exen teration and followed this with eight applications of roentgen rays applied deeply. So far there had been no re currence, and the boy's health to date had remained good.
Crystals of Cholesterin in the Anterior Chamber. MR. B . CRIDLAND showed a patient MR. COLE MARSHALL removed a growth last November from this boy. whom he first saw in 1913, when an It had recurred when he next pre eye had been faulty six years and was sented himself, after Christmas, the the seat of retinitis proliferans, with situation being the upper and outer extensive retinal detachment. In 1919 angle of the orbit. It now had the ap when he again saw the patient, the eye pearance of sarcoma, and that the was blind. Then in October, while microscope confirmed. Mr. Marshall cycling, the man was struck in this asked whether exenteration of the or blind eye, and one morning two bit should not now be done; there was months later, he awoke with great pain a bruit audible over the growth, and in the eye which lasted some hours, that might add to the gravity of the and next morning it showed the cho lesterin crystals n o w seen. The pa operation. tient's blood cholesterin was 211, a Discussion. M R . J. H. FISHER high figure, but not pathologic. recommended clearing out of the orbit, Discussion. M R . H U M P H R E Y NEAME and that without much loss of time. spoke of a similar condition in an eye Othervvise the globe would probably which had been sent to him. be much displaced and sloughing of Dermoid Tumors in Both Eyes. the cornea might follow. President. Sarcoma of the Orbit.
MR. MONTAGUE H I N E spoke of a case
he had of similar nature. It proved to be an endothelioma, and after it had been removed there was a recurrence, with rapid extension, so that during a three weeks' delay in getting the patient into the hospital the growth had indented the eyeball. A very grave view was taken of the case at the consultations
D R . DAVID W I L S O N showed a case of
this kind in a girl, aged 13, who also was born with a supernumerary au ricle, and it was suggested that both abnormalities were due to the pressure of amniotic bands at or before birth. Foreign Body in Vitreous. MR.
J.
W . TUDOR T H O M A S showed
a case of foreign body in the vitreous.
NOTES, CASES A N D I N S T R U M E N T S
tending thru tlie cornea, at a location near the periphery, at about 5 o'clock. This we assume is undoubtedly the point of entrance of a small foreign body, 20 years ago, that also pene trated the lens and caused the forma tion of the cataract. During cataract extraction it often occurs that only a central part of the anterior capsule is removed, allowing only an exit for the lens nucleus. The retained peripheral cortical masses may be completely co\ered by capsule, so that they can not be influenced by the solving action of the aqueous. This imprisoned cortical material, together with proliferating capsular epithelium, may produce a sausage shaped mass, or a more or less complete ring. This structure was probably first described by Soemmering, an oculist of Mainz, who wrote a comprehensive book on Ophthalmology about one hundred years ago. This ring is seldom seen, as when present, it is normally held in position behind the iris, by the zonu lar fibers of the lens. In extremely rare cases, this mass may be luxated into the anterior chamber. Search of the literature has revealed only one other similar case. At a meeting of the Berliner Ophthalmo logical GeselLschaft of Jan. 26, 1911, C. Adam reported the luxation of a Soemmering ring into the anterior chamber. This patient fourteen years previously had had a cataract opera tion. He ;vas then 48 years old. The cortex was reported as still relatively soft. A year preceding his report, a Soemmering ring luxated into the an terior chamber. Vision was reduced to fingers at two meters. After a week the ring returned to its normal posi tion, behind the iris, spontaneously. When this case was reported the Soemmering ring had again luxated into the anterior chamber. He re ported some reduction in vision and tension. Wessely and others have re ported cases of luxation into the vitreous. In addition to showing the patient, I am presenting stereoscopic photo graphs of this rare and interesting con dition taken by Dr. Robt. V o n der Heydt, and I wish also to reproduce
a diagram taken from a recent edition of Fuchs, of a Soemmering's Crystal line Swelling, in its normal position behind the iris. (Fig. 2.) The eye has since been operated and the mass removed. The ring could not be delivered en masse thru a large keratome incision without tear ing it to pieces, because it was so firmly attached in several places, prob ably by zonular fibers. The contents of the sausage like structure was a milky fluid. Presented at a meeting of the Chi cago Ophthalmological Society, Dec. 20, 1926. η Ν. State St., Chicago. O S S I F I C A T I O N OF T H E CHOROID. D R . G . N . BRAZEAU, MILWAUKEE, WIS.
Like most of the cases of this kind, this one was discovered only after an examination of the enucleated eyeball. The operation was done to relieve pain in and about the eye and in the fore head. The patient, a woman of fiftyfour years of age, had been blind since the age of fifteen from an old iridocy clitis. These calcareous changes in the eye have no symptomatology pe culiar to themselves, that would per mit of their diagnosis in any other way. I could not understand why pain should be present in the absence of all .symptoms of reaction, but because no other cause could be found it was thought best to operate, and to our great satisfaction all symptoms were relieved. Calcareous changes, like these, do not follow any special rule, therefore, they may appear either as isolated islets or they may involve the tissues of the eyeball, as we will see they did in this case. The little that was left of the vitreous was encased by the osseous mass. Macroscopically the eye was reduced in size, hard to the touch, and irregular in shape. The cornea was enlarged and transparent, up to the part usually occupied by the arcus senilis, which, by the way, was very
N O T E S , CASES A N D I N S T R U M E N T S
opaque. The region of the optic nerve was surrounded by a shoulder like thickening, cartilaginous to the touch. This part of the eyeball is where os sification usually begins, preparatory to involving the rest of the eye. The anterior chamber was very deep, with the iris funnel shaped and tightly ad herent to the opaque lens; which had been drawn backward by the retracted intraocular mass. Contrary to my ex pectations, the tension of the eye was low. Pathologists report that ossification results from colloid degeneration of
275
the intraocular tissue, which is very avid of water. A s it swells the degen erated mass takes on calcareous salts from the osmotic streams which trav erse it, and precipitates them. Later on, the mass undergoes further degen eration with calcareous incrustation, between the striae of which the scle rosed conjunctival tissue organizes it self into new medullary tissue; just as the fibrous membranes do in the regu lar process of ossification, in which veritable osteoblasts are born and with them true osseous tissues. 720 Majestic Bldg.
SOCIETY PROCEEDINGS THE
R O Y A L SOCIETY OF MEDICINE. Section of Ophthalmology. January 14, 1927.
MR.
ERNEST CLARKE, C . V . O.,
held on it, but Mr. Hine did an exen teration and followed this with eight applications of roentgen rays applied deeply. So far there had been no re currence, and the boy's health to date had remained good.
Crystals of Cholesterin in the Anterior Chamber. MR. B . CRIDLAND showed a patient MR. COLE MARSHALL removed a growth last November from this boy. whom he first saw in 1913, when an It had recurred when he next pre eye had been faulty six years and was sented himself, after Christmas, the the seat of retinitis proliferans, with situation being the upper and outer extensive retinal detachment. In 1919 angle of the orbit. It now had the ap when he again saw the patient, the eye pearance of sarcoma, and that the was blind. Then in October, while microscope confirmed. Mr. Marshall cycling, the man was struck in this asked whether exenteration of the or blind eye, and one morning two bit should not now be done; there was months later, he awoke with great pain a bruit audible over the growth, and in the eye which lasted some hours, that might add to the gravity of the and next morning it showed the cho lesterin crystals n o w seen. The pa operation. tient's blood cholesterin was 211, a Discussion. M R . J. H. FISHER high figure, but not pathologic. recommended clearing out of the orbit, Discussion. M R . H U M P H R E Y NEAME and that without much loss of time. spoke of a similar condition in an eye Othervvise the globe would probably which had been sent to him. be much displaced and sloughing of Dermoid Tumors in Both Eyes. the cornea might follow. President. Sarcoma of the Orbit.
MR. MONTAGUE H I N E spoke of a case
he had of similar nature. It proved to be an endothelioma, and after it had been removed there was a recurrence, with rapid extension, so that during a three weeks' delay in getting the patient into the hospital the growth had indented the eyeball. A very grave view was taken of the case at the consultations
D R . DAVID W I L S O N showed a case of
this kind in a girl, aged 13, who also was born with a supernumerary au ricle, and it was suggested that both abnormalities were due to the pressure of amniotic bands at or before birth. Foreign Body in Vitreous. MR.
J.
W . TUDOR T H O M A S showed
a case of foreign body in the vitreous.