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Contribution to the Anatomy of Congenital Ectropium Uveæ (Flocculi Iridis)
AMERICAN JOURNAL OF OPHTHALMOLOGY Number 9
September, 1931
Volume 14
CONTRIBUTION TO THE ANATOMY OF CONGENITAL ECTROPIUM U V E i E (FLOCCULI IRIDIS) PROF. DR. ADALBERT F U C H S VIENNA, AUSTRIA TRANSLATED BY BERTHA KLIEN-MONCREIFF,
M.D.
Two cases of this interesting formation are described clinically and histologically with drawings showing it to consist of an abundant growth of large pigment epithelial cells giv ing rise to the formation of folds and figures of spiral form. From the Ophthalmic Depart ment of the Allgemeine Policlinic in Vienna (Prof. Dr. A. Fuchs). Translator is Assistant Professor of Ophthalmology, Rush Medical College, Chicago.
In the literature subsequent to 1920 one finds various descriptions of a con genital anomaly, which was first de scribed in the year 1869 by Colsmann, as papilloma iridis, and then in 1873 by E. C. Holmes of Chicago, who even at that time likened it to the pigment pro liferation which one finds especially often in horses.
partly are bent forward, resting on the anterior surface of the iris. Usually they are symmetrically situated, and are best developed in the upper half of the pupil. Their connection with the pigment epithelium is easily seen with the slitlamp. These pigmented flocculi may be come separated from the pupillary mar gin, fall into the anterior chamber and remain floating freely in the aqueous, or
Fig. 1.
Fig. 2.
Subsequently in Hirschberg's Clinic1, the designation Ektropium Uveae Congenitum was employed, which subse quently was used for a long time, until Stahli in 1920 redescribed the anomaly and again referred to its similarity to the "Traubenkorner" of horses, apply ing the term Flocculus formation. Clinically this condition is well known, and is not of such especially rare occurrence. It may be described as con sisting of dark brown wart- or tuft-like excrescences of the pigment epithelium, which partly project into the pupil, and
may disappear from time to time behind the limbus, reappearing with changing positions of the head. Occasionally they give rise to cyst formation, as E. Fuchs 2 has described. Schiiller 3 reports a case in which such a free pigment body in the anterior chamber was observed by the patient himself, and mistaken for a foreign body. In spite of the frequency of ectropium uveae congenitum, which has been am ply described clinically, histological studies in man have been few, although there are numerous descriptions of it in
865
866
PROF. DR. ADALBERT FUCHS
domestic animals. Consequently I shall give the anatomy of this condition in the human eye in two cases. Case 2459, History : A man S3 years of age came to me with the complaint of failing vision of the left eye of several months' duration. A sarcoma of the choroid was found to be the cause of the trouble. Both irides exhibited a few ex
excrescences projected partly straight forward into the anterior chamber, and were partly bent over so as to rest on the anterior surface of the iris (Fig. 2), without, however, having a direct con nection with it. In fact, in one place (Fig. 3) it was distinctly discernible that the connection of the excrescences did not reach further forward than the pupillary margin of the sphincter mus cle, and they had no connection with the anterior border layer, which begins at
Fis. 3.
Fig. 5.
crescences of the pigment epithelium at the upper pupillary margin. The histological examination revealed multiple excrescences of the pigment epithelium around the pupil, some of them very well developed. Most of them were deeply serrated in such a way that in cross sections the transition of the pos terior layer of the epithelium into the
this point. The larger excrescences were so large that they could easily be seen in the sections as black points, with the unaided eye. The diameters of the larger flocculi were 0.29 mm., 0.39 mm., re spectively, and the largest was 0.46 mm. Case 2584. The second eye was that of a negro from America, in sections of which these flocculi occurred. This eye was very markedly pigmented, but not
Fig. 4.
Fig. 6.
anterior layer was not a simple turning, but at the turning point there were in dentations from the front or back (Fig. 1-3). A few of these excrescences were con nected with the epithelium by only a thin band, which accounts for the ap pearance in the sections of apparent iso lation or cutting off from the epithelium of some of the large leaf-like parts with in the pupil. Fig. 4 shows an excrescence with marked multiple serrations. These
so deeply, however, as negro eyes from Central Africa. The anterior border lay er was densely filled with large clumps of pigment. The pigment epithelium, knotty, thickened and folded, projected 0.3 mm. into the pupil (Fig. 5), at first lining only the free margin of the pupil, and thence extending centralward away from the iris. Tangential sections through the pupil may produce forma tions which simulate the findings in this case. In such tangential sections, the
CONGENITAL ECTROPIUM UVEJE pupillary pigment seam also appears markedly enlarged, on account of the oblique direction of the section. Thick enings resembling flocculi may be pro duced also by a somewhat irregular pupillary margin of the pigment epithe lium. One glance at the contralateral side and at the width of the pupil shows this error. Fig. 6 shows a very slight ectropium uveae in a tangential section. One recognizes the direction of the sec tion by some isolated folds the cross sections of which are seen near the pu-
867
flat, spindle shaped and attenuated in the periphery, forming the dilator mus cle, become rounded and cuboidal. This layer resembles more and more the pos terior layer of cells as it turns at the pupillary margin (P) and merges into the posterior layer. A little cavum ( H ) , about the size of two epithelial cells, enclosed by the two layers of epitheli um, is visible in this part of the pupil lary margin. It is not situated directly behind the turning point, and corre sponds probably to von Szily's sinus of
V.%.
Fig. 7 (Fuchs). Section from albinotic eye (X 250).
pillary margin on both sides within the narrow pupil. The ectropium is indi cated by the pigment epithelium rest ing on the anterior surface of the iris. In order to recognize the finer histological structure of the flocculi, I studied some depigmented sections of the first case. For purposes of compari son I want to describe first the pupillary margin of an albinotic eye, since the normal conditions at the turning of the inner epithelial layer into the outer lay er are well seen in these cases. The albinotic eye (Fig. 7) does not show a trace of pigment. At A, 0.22 mm. from the anterior margin of the pupil, the cells of the anterior layer of the pig ment epithelium (V.Z), which are more
the embryonic eye. How far it extends within the pupillary margin, I cannot tell, as I do not possess the entire series. The depigmented sections (Fig. 8) of the first case of ectropium uveae congenitum show very well the various kinds of cells. No cavum is seen between the two epithelial layers; the cells which form the excrescences are all relatively large, larger than those adjoining them immediately behind. The anterior and posterior layers of the pigment epitheli um are about equally thick within the pupillary margin in a normal eye, and the cells are of about equal size (Fig. 7, to the right of A). In our case the an terior layer of cells is very low, and the cells are considerably smaller than those
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P R O F . DR. A D A L B E R T
of the posterior layer, both layers of cells becoming equal in size only just before the epithelium thickens, forming the flocculus (A, Fig. 8). This may ex plain why in many of the sections from the first case (Figs. 1-3) and also from the second case (Fig. 5) the pigment
FUCHS
margin in normal eyes, I found nearly always values between 50 and 70 mi crons, the width of the pupil being of no importance for the thickness of the epi thelium. Apparently, therefore, ectropium uveae congenitum consists of an abun
Fig. 8 ( F u c h s ) . D e p i g m c n t e d section; case 2459 ( X 250).
epithelium (both layers together) was abnormally thin at or somewhat pe ripheral to the pupillary margin. I found the thickness of the layers different in different places, for example 22 microns (Fig. 3), 24 microns, and 34 microns (Fig. 1 and Fig. 5). In measuring the thickness of the two epithelial layers to gether immediately behind the pupillary
dant growth of'large pigment epithelial cells, which give rise to the formation of folds and figures of spiral form on ac count of their abundant growth, with a thinning of the epithelium near the zone of reflection, where the epithelium turns from the posterior surface of the iris to the free margin of the iris. Allgemeine Policlinic.
References 1
H i r s c h b e r g . Klin. M. f. Augenh., v. 65, p. 349. F u c h s , E. Graefes Archiv., v. IS, p. 7. Schiillcr. Klin. M. f. Augenh., v. 74, p. 154. * C o s m e t t a t o s . Ann. d'ocul., v. 161, p. 761. 6 C o l d e n . Klin. M. f. Augenh., v. 71, p. 15. " Greeff. Graefes Archiv., v. 105, p. 134. 2 3
September, 1931
Volume 14
CONTRIBUTION TO THE ANATOMY OF CONGENITAL ECTROPIUM U V E i E (FLOCCULI IRIDIS) PROF. DR. ADALBERT F U C H S VIENNA, AUSTRIA TRANSLATED BY BERTHA KLIEN-MONCREIFF,
M.D.
Two cases of this interesting formation are described clinically and histologically with drawings showing it to consist of an abundant growth of large pigment epithelial cells giv ing rise to the formation of folds and figures of spiral form. From the Ophthalmic Depart ment of the Allgemeine Policlinic in Vienna (Prof. Dr. A. Fuchs). Translator is Assistant Professor of Ophthalmology, Rush Medical College, Chicago.
In the literature subsequent to 1920 one finds various descriptions of a con genital anomaly, which was first de scribed in the year 1869 by Colsmann, as papilloma iridis, and then in 1873 by E. C. Holmes of Chicago, who even at that time likened it to the pigment pro liferation which one finds especially often in horses.
partly are bent forward, resting on the anterior surface of the iris. Usually they are symmetrically situated, and are best developed in the upper half of the pupil. Their connection with the pigment epithelium is easily seen with the slitlamp. These pigmented flocculi may be come separated from the pupillary mar gin, fall into the anterior chamber and remain floating freely in the aqueous, or
Fig. 1.
Fig. 2.
Subsequently in Hirschberg's Clinic1, the designation Ektropium Uveae Congenitum was employed, which subse quently was used for a long time, until Stahli in 1920 redescribed the anomaly and again referred to its similarity to the "Traubenkorner" of horses, apply ing the term Flocculus formation. Clinically this condition is well known, and is not of such especially rare occurrence. It may be described as con sisting of dark brown wart- or tuft-like excrescences of the pigment epithelium, which partly project into the pupil, and
may disappear from time to time behind the limbus, reappearing with changing positions of the head. Occasionally they give rise to cyst formation, as E. Fuchs 2 has described. Schiiller 3 reports a case in which such a free pigment body in the anterior chamber was observed by the patient himself, and mistaken for a foreign body. In spite of the frequency of ectropium uveae congenitum, which has been am ply described clinically, histological studies in man have been few, although there are numerous descriptions of it in
865
866
PROF. DR. ADALBERT FUCHS
domestic animals. Consequently I shall give the anatomy of this condition in the human eye in two cases. Case 2459, History : A man S3 years of age came to me with the complaint of failing vision of the left eye of several months' duration. A sarcoma of the choroid was found to be the cause of the trouble. Both irides exhibited a few ex
excrescences projected partly straight forward into the anterior chamber, and were partly bent over so as to rest on the anterior surface of the iris (Fig. 2), without, however, having a direct con nection with it. In fact, in one place (Fig. 3) it was distinctly discernible that the connection of the excrescences did not reach further forward than the pupillary margin of the sphincter mus cle, and they had no connection with the anterior border layer, which begins at
Fis. 3.
Fig. 5.
crescences of the pigment epithelium at the upper pupillary margin. The histological examination revealed multiple excrescences of the pigment epithelium around the pupil, some of them very well developed. Most of them were deeply serrated in such a way that in cross sections the transition of the pos terior layer of the epithelium into the
this point. The larger excrescences were so large that they could easily be seen in the sections as black points, with the unaided eye. The diameters of the larger flocculi were 0.29 mm., 0.39 mm., re spectively, and the largest was 0.46 mm. Case 2584. The second eye was that of a negro from America, in sections of which these flocculi occurred. This eye was very markedly pigmented, but not
Fig. 4.
Fig. 6.
anterior layer was not a simple turning, but at the turning point there were in dentations from the front or back (Fig. 1-3). A few of these excrescences were con nected with the epithelium by only a thin band, which accounts for the ap pearance in the sections of apparent iso lation or cutting off from the epithelium of some of the large leaf-like parts with in the pupil. Fig. 4 shows an excrescence with marked multiple serrations. These
so deeply, however, as negro eyes from Central Africa. The anterior border lay er was densely filled with large clumps of pigment. The pigment epithelium, knotty, thickened and folded, projected 0.3 mm. into the pupil (Fig. 5), at first lining only the free margin of the pupil, and thence extending centralward away from the iris. Tangential sections through the pupil may produce forma tions which simulate the findings in this case. In such tangential sections, the
CONGENITAL ECTROPIUM UVEJE pupillary pigment seam also appears markedly enlarged, on account of the oblique direction of the section. Thick enings resembling flocculi may be pro duced also by a somewhat irregular pupillary margin of the pigment epithe lium. One glance at the contralateral side and at the width of the pupil shows this error. Fig. 6 shows a very slight ectropium uveae in a tangential section. One recognizes the direction of the sec tion by some isolated folds the cross sections of which are seen near the pu-
867
flat, spindle shaped and attenuated in the periphery, forming the dilator mus cle, become rounded and cuboidal. This layer resembles more and more the pos terior layer of cells as it turns at the pupillary margin (P) and merges into the posterior layer. A little cavum ( H ) , about the size of two epithelial cells, enclosed by the two layers of epitheli um, is visible in this part of the pupil lary margin. It is not situated directly behind the turning point, and corre sponds probably to von Szily's sinus of
V.%.
Fig. 7 (Fuchs). Section from albinotic eye (X 250).
pillary margin on both sides within the narrow pupil. The ectropium is indi cated by the pigment epithelium rest ing on the anterior surface of the iris. In order to recognize the finer histological structure of the flocculi, I studied some depigmented sections of the first case. For purposes of compari son I want to describe first the pupillary margin of an albinotic eye, since the normal conditions at the turning of the inner epithelial layer into the outer lay er are well seen in these cases. The albinotic eye (Fig. 7) does not show a trace of pigment. At A, 0.22 mm. from the anterior margin of the pupil, the cells of the anterior layer of the pig ment epithelium (V.Z), which are more
the embryonic eye. How far it extends within the pupillary margin, I cannot tell, as I do not possess the entire series. The depigmented sections (Fig. 8) of the first case of ectropium uveae congenitum show very well the various kinds of cells. No cavum is seen between the two epithelial layers; the cells which form the excrescences are all relatively large, larger than those adjoining them immediately behind. The anterior and posterior layers of the pigment epitheli um are about equally thick within the pupillary margin in a normal eye, and the cells are of about equal size (Fig. 7, to the right of A). In our case the an terior layer of cells is very low, and the cells are considerably smaller than those
868
P R O F . DR. A D A L B E R T
of the posterior layer, both layers of cells becoming equal in size only just before the epithelium thickens, forming the flocculus (A, Fig. 8). This may ex plain why in many of the sections from the first case (Figs. 1-3) and also from the second case (Fig. 5) the pigment
FUCHS
margin in normal eyes, I found nearly always values between 50 and 70 mi crons, the width of the pupil being of no importance for the thickness of the epi thelium. Apparently, therefore, ectropium uveae congenitum consists of an abun
Fig. 8 ( F u c h s ) . D e p i g m c n t e d section; case 2459 ( X 250).
epithelium (both layers together) was abnormally thin at or somewhat pe ripheral to the pupillary margin. I found the thickness of the layers different in different places, for example 22 microns (Fig. 3), 24 microns, and 34 microns (Fig. 1 and Fig. 5). In measuring the thickness of the two epithelial layers to gether immediately behind the pupillary
dant growth of'large pigment epithelial cells, which give rise to the formation of folds and figures of spiral form on ac count of their abundant growth, with a thinning of the epithelium near the zone of reflection, where the epithelium turns from the posterior surface of the iris to the free margin of the iris. Allgemeine Policlinic.
References 1
H i r s c h b e r g . Klin. M. f. Augenh., v. 65, p. 349. F u c h s , E. Graefes Archiv., v. IS, p. 7. Schiillcr. Klin. M. f. Augenh., v. 74, p. 154. * C o s m e t t a t o s . Ann. d'ocul., v. 161, p. 761. 6 C o l d e n . Klin. M. f. Augenh., v. 71, p. 15. " Greeff. Graefes Archiv., v. 105, p. 134. 2 3