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An Unusual Clinical Phenomenon Occurring in a Case of Iritis
NOTES, CASES AND INSTRUMENTS
43
CHICAGO
seen numerous cells in slow motion. The iris was swollen and engorged. There was a fairly dense pigmented posterior adhesion at axis 250° and there was considerable iris pigment dotted on the anterior capsule. Vision was 18/200. Tension was plus 1, but was reduced rapidly to subnormal by the use of adrenalin once. At the same time, the corneal edema disappeared. The patient was admitted to the hos pital, where a thorough search for possible etiological factors resulted in the finding of six infected tooth roots. These were extracted as rapidly as possible. Three milk injections of 10 c.c. each resulted in a very rapid improvement of the iritis, so that the patient was discharged from the hospital in about one week. The usual local treatment of atropin and heat was continued. On August 27 the eye was practically pale. The fibrin on the posterior corneal surface had contracted into the form of a few ill-defined posterior precipi tates. The anterior chamber was much clearer and contained many less cells. Six gelatinous nodules had begun to develop in the iris near the pupillary margin and these increased in size very slowly. Local treatment was continued and sodium iodide was given internally. The change in condition from here on was very slow.
During the course of a case of iritis that presented no other unusual clinical features, there appeared a condition that was markedly out of the ordinary. This can best be described by a con densed review of the clinical record. A 43 year old man appeared on August 8 complaining that the left eye had been sore and red for four days. The right eye was essentially normal. There was considerable edema of the left eyelids and a rather intense ciliary injection was present. The lower and nasal quadrants of the cornea were slightly edematous and the posterior surface was heavily plastered with fibrin. No formed posterior precipitates were present. The beam of the slit lamp was moderately visible in the anterior chamber and in it could be
On October 1 the eye was pale but flushed slightly on manipulation. The posterior precipitates were practically goneand the anterior chamber was nearly clear. Two of the gelatinous nodules which had reached a diameter of about 0.7 mm. had been extruded by the iris and were adherent to the posterior surface of the cornea. They were essentially the same in shape and size as when they lay within the iris tissue. Two nodules that still lay within the iris were in the process of being extruded. It seemed as though they were being forced forward by pressure from behind, and the iris fibers that lay within their path were being pushed to one side or the other. There was no definite bed in which these nodules lay, and the more or less plastic iris tissue closed in behind them.
There was no history or evidence of a primary lesion and no eruption, but a few small areas of alopecia areata were found on the scalp. These were of recent origin. Sections of the masses showed the characteristics of granula tion tissue. A strongly positive Wassermann test was obtained and the first dose of neoarsphenamin caused a very marked improvement. The masses had almost disappeared within a few days after a second dose. In a limited survey of the literature I have not found this condition des cribed. All text books describe syphil itic ulcers but I can find no mention of exuberant granulations due to that disease. The prompt disappearance of the masses following antisyphilitic treatment, when they had resisted other forms of therapy for several weeks, makes it almost certain that we are dealing with one of the rarer manifesta tions of syphilis, probably in the second ary stage. 1300 Walker avenue. AN UNUSUAL CLINICAL PHENOM ENON OCCURRING IN A CASE OF IRITIS HARRY S. GRADLE,
M.D.
44
NOTES, CASES AND INSTRUMENTS
Fifteen days later, three nodules were adherent to the posterior surface of the cornea, and the three nodules remain ing within the iris were shrinking and disappearing. At no time were the nodules found free in the anterior cham ber, nor at any time was motion of the nodules discernible as the eye moved. Under 105 times magnification, the nodules seemed to have shrunken after having been extruded and soon pre sented a granular appearance. The consistency, which when within the iris seemed to be gelatinous, seemed to have increased so that the nodules appeared firmer. The nodules gradually decreased in size, lost their rounded contour, and eventually became flat discs with crenated edges, closely adherent to the posterior surface of the cornea. There has been no change in their appearance since that stage was reached. This was a case of iritis due un doubtedly to infected tooth roots, as all other possible etiological factors were investigated with negative results. The development of the gelatinous nodules in this type of iritis is in itself an unusual feature. The extrusion of the nodules from the surface of the iris into the anterior chamber, where they were carried to the posterior surface of the cornea, to which they became adherent, is a most unusual phenomenon. It would seem that the nodules, after their formation, acted as a foreign body within the iris, and hence were forced out into the anterior chamber between the iris fibers. Owing to their undoubted sticky nature, they became adherent to the cornea at the first point of contact. Here they seemed to lose in substance until nothing but a shell was left, which was plastered tightly against the endothelium. This, too, shrank as shown by the crenation of the edges, and in the course of time will undoubtedly disappear. (This patient was seen again on De cember 17th, and no trace of the nodules, either on the cornea or in the iris, was longer to be seen.) 58 East Washington street.
AN EPITHELIAL NEVUS HARVEY D. LAMB,
M.D.
SAINT LOUIS
S. M., a girl of fifteen years, con sulted Dr. N. R. Donnell because of a small growth on the caruncle of the right eye. This growth had been noticed for several years by the parents and was apparently becoming slowly larger. It was excised by Dr. Donnell after the injection of a few drops of two percent novocain. The excised piece of tissue was roughly spherical and about two mm. in diameter. It was fixed in ten percent formalin, imbedded in paraffin, sectioned, and stained with hematoxylin and eosin. Surface epithelium covers the entire circumference of the growth, except for the small area where the section was made. This epithelium is very thin and consists of three to five layers of flattened epithelium. In places there are downgrowths of epithelium of varying depth and breadth. Some of the deeper epithelial downgrowths show mucous degeneration. The growth is almost entirely com posed of nevus cells. Toward the peri phery of the growth, these cells are generally larger, with large round or oval lightly staining nuclei; whereas over the central part of the growth the nevus cells are for the most part small and their irregularly shaped nuclei stain very darkly. The latter are evi dently degenerated nevus cells. In the periphery, the nevus cells have mostly an alveolar arrangement. Just beneath the covering epithelium over the sum mit of the growth, there are isolated small groups of pigmented nevus cells. The epithelium here, apart from the groups of pigmented nevus cells, shows in its basal layers in places a loosening of the cells and a transformation from flat epithelial cells to nevus cells; a small number of fine grains of pigment are present in some of these new-formed nevus cells. On one side near the base of the growth, the formation of nevus cells from surface epithelium can be studied thoroughly. Here dense masses of nevus cells lie just beneath the
43
CHICAGO
seen numerous cells in slow motion. The iris was swollen and engorged. There was a fairly dense pigmented posterior adhesion at axis 250° and there was considerable iris pigment dotted on the anterior capsule. Vision was 18/200. Tension was plus 1, but was reduced rapidly to subnormal by the use of adrenalin once. At the same time, the corneal edema disappeared. The patient was admitted to the hos pital, where a thorough search for possible etiological factors resulted in the finding of six infected tooth roots. These were extracted as rapidly as possible. Three milk injections of 10 c.c. each resulted in a very rapid improvement of the iritis, so that the patient was discharged from the hospital in about one week. The usual local treatment of atropin and heat was continued. On August 27 the eye was practically pale. The fibrin on the posterior corneal surface had contracted into the form of a few ill-defined posterior precipi tates. The anterior chamber was much clearer and contained many less cells. Six gelatinous nodules had begun to develop in the iris near the pupillary margin and these increased in size very slowly. Local treatment was continued and sodium iodide was given internally. The change in condition from here on was very slow.
During the course of a case of iritis that presented no other unusual clinical features, there appeared a condition that was markedly out of the ordinary. This can best be described by a con densed review of the clinical record. A 43 year old man appeared on August 8 complaining that the left eye had been sore and red for four days. The right eye was essentially normal. There was considerable edema of the left eyelids and a rather intense ciliary injection was present. The lower and nasal quadrants of the cornea were slightly edematous and the posterior surface was heavily plastered with fibrin. No formed posterior precipitates were present. The beam of the slit lamp was moderately visible in the anterior chamber and in it could be
On October 1 the eye was pale but flushed slightly on manipulation. The posterior precipitates were practically goneand the anterior chamber was nearly clear. Two of the gelatinous nodules which had reached a diameter of about 0.7 mm. had been extruded by the iris and were adherent to the posterior surface of the cornea. They were essentially the same in shape and size as when they lay within the iris tissue. Two nodules that still lay within the iris were in the process of being extruded. It seemed as though they were being forced forward by pressure from behind, and the iris fibers that lay within their path were being pushed to one side or the other. There was no definite bed in which these nodules lay, and the more or less plastic iris tissue closed in behind them.
There was no history or evidence of a primary lesion and no eruption, but a few small areas of alopecia areata were found on the scalp. These were of recent origin. Sections of the masses showed the characteristics of granula tion tissue. A strongly positive Wassermann test was obtained and the first dose of neoarsphenamin caused a very marked improvement. The masses had almost disappeared within a few days after a second dose. In a limited survey of the literature I have not found this condition des cribed. All text books describe syphil itic ulcers but I can find no mention of exuberant granulations due to that disease. The prompt disappearance of the masses following antisyphilitic treatment, when they had resisted other forms of therapy for several weeks, makes it almost certain that we are dealing with one of the rarer manifesta tions of syphilis, probably in the second ary stage. 1300 Walker avenue. AN UNUSUAL CLINICAL PHENOM ENON OCCURRING IN A CASE OF IRITIS HARRY S. GRADLE,
M.D.
44
NOTES, CASES AND INSTRUMENTS
Fifteen days later, three nodules were adherent to the posterior surface of the cornea, and the three nodules remain ing within the iris were shrinking and disappearing. At no time were the nodules found free in the anterior cham ber, nor at any time was motion of the nodules discernible as the eye moved. Under 105 times magnification, the nodules seemed to have shrunken after having been extruded and soon pre sented a granular appearance. The consistency, which when within the iris seemed to be gelatinous, seemed to have increased so that the nodules appeared firmer. The nodules gradually decreased in size, lost their rounded contour, and eventually became flat discs with crenated edges, closely adherent to the posterior surface of the cornea. There has been no change in their appearance since that stage was reached. This was a case of iritis due un doubtedly to infected tooth roots, as all other possible etiological factors were investigated with negative results. The development of the gelatinous nodules in this type of iritis is in itself an unusual feature. The extrusion of the nodules from the surface of the iris into the anterior chamber, where they were carried to the posterior surface of the cornea, to which they became adherent, is a most unusual phenomenon. It would seem that the nodules, after their formation, acted as a foreign body within the iris, and hence were forced out into the anterior chamber between the iris fibers. Owing to their undoubted sticky nature, they became adherent to the cornea at the first point of contact. Here they seemed to lose in substance until nothing but a shell was left, which was plastered tightly against the endothelium. This, too, shrank as shown by the crenation of the edges, and in the course of time will undoubtedly disappear. (This patient was seen again on De cember 17th, and no trace of the nodules, either on the cornea or in the iris, was longer to be seen.) 58 East Washington street.
AN EPITHELIAL NEVUS HARVEY D. LAMB,
M.D.
SAINT LOUIS
S. M., a girl of fifteen years, con sulted Dr. N. R. Donnell because of a small growth on the caruncle of the right eye. This growth had been noticed for several years by the parents and was apparently becoming slowly larger. It was excised by Dr. Donnell after the injection of a few drops of two percent novocain. The excised piece of tissue was roughly spherical and about two mm. in diameter. It was fixed in ten percent formalin, imbedded in paraffin, sectioned, and stained with hematoxylin and eosin. Surface epithelium covers the entire circumference of the growth, except for the small area where the section was made. This epithelium is very thin and consists of three to five layers of flattened epithelium. In places there are downgrowths of epithelium of varying depth and breadth. Some of the deeper epithelial downgrowths show mucous degeneration. The growth is almost entirely com posed of nevus cells. Toward the peri phery of the growth, these cells are generally larger, with large round or oval lightly staining nuclei; whereas over the central part of the growth the nevus cells are for the most part small and their irregularly shaped nuclei stain very darkly. The latter are evi dently degenerated nevus cells. In the periphery, the nevus cells have mostly an alveolar arrangement. Just beneath the covering epithelium over the sum mit of the growth, there are isolated small groups of pigmented nevus cells. The epithelium here, apart from the groups of pigmented nevus cells, shows in its basal layers in places a loosening of the cells and a transformation from flat epithelial cells to nevus cells; a small number of fine grains of pigment are present in some of these new-formed nevus cells. On one side near the base of the growth, the formation of nevus cells from surface epithelium can be studied thoroughly. Here dense masses of nevus cells lie just beneath the