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Intraocular Foreign Body, Siderosis Bulbi and Phacoanaphylactic Endophthalmitis*
MACULAR DEGENERATION AND
CHLOROQUINE
385
15. P a g e , F . : Treatment of lupus erythematosus w i t h mepacrine. Lancet, 2 : 7 5 5 ( O c t . 2 7 ) 1951. 16. P a u , H , and Baumer, Α . : Corneal chloroquine deposits. Klin. Monatsbl. f. A u g e n h , 1 3 5 : 3 6 2 , 1959. ( A b s t r a c t e d A m . J. O p h t h , 4 9 : 3 9 7 , 1960.) 17. Reese, F . M . : E d e m a of the corneal epithelium caused by Atabrine. Bull. J o h n s H o p k i n s H o s p , 6:325 ( J u n e ) 1946. 18. Pillsbury, D . M , and Jacobson, C : Treatment of chronic discoid lupus erythematosus with chloroquine. J . A . M . A , 154:1330, 1954. 19. Sternberg, T . H , and Laden, E . : Discoid lupus erythematosus: Bilateral macular degeneration due to chloroquine. Α Μ Α A r c h . D e r m , 7 9 : 1 1 6 , 1959. 20. Traquair, Η . M . : A n Introduction to Clinical Perimetry. St. Louis, Mosby, 1944, ed: 4, pp. 156. 21. Zeller, R. W , and Deering, D . : Corneal complications of chloroquine ( A r a l e n ) phosphate therapy. J . A . M . A , 1 6 8 : 2 2 6 3 , 1958.
INTRAOCULAR
FOREIGN
BODY,
PHACOANAPHYLACTIC MAXIMILIAN
O.
SIDEROSIS
BULBI
A N D
ENDOPHTHALMITIS* GOLDSMITH,
M.D.
Far Rockaway, New York Unquestionably, numerous foreign bodies have remained within the globe indefinitely without untoward effects. However, it is a wiser policy to consider intraocular foreign bodies as imminent sources of danger to vision and usefulness of an eye. War injuries and industrial accidents contribute the majority of these intraocular accidents. The composition, nature and magnetic properties of a foreign body are important. Some foreign bodies are chemically inert and elicit no specific irritation, while others set up a severe and purulent reaction. E x amples of chemically inert and precious metals are gold, silver, platinum and tantalum. Ferrous metallic fragments, frequent in incidence, set up a different reaction and are easier to remove because of magnetic properties. Duke-Elder states that a metallic fragment may migrate after it has been in the eye for some time. H e cites a case wherein a shot pellet migrated from the interior of the eye to the angle of the chamber after 15 months. This is regrettable, especially with sharp particles, such as glass which, in one case, came in contact with the lens, forming a cataract after having caused no reaction in the eye for 10 years. 1
* F r o m the Manhattan E y e , Ear, and Hospital.
Throat
Crawford tells of a fire cracker fragment which migrated from the posterior segment to the anterior chamber of the eye 13 weeks after injury. The following case is one of an intraocular foreign body which migrated from the posterior segment to the anterior chamber after a period of nine years. 2
REPORT
OF
CASE
T h e patient, a 32-year-old P u e r t o Rican veteran of the K o r e a n W a r , w a s first seen o n A u g u s t 9, 1960, with history of irritation of the right eye during the course of his work. Physical examination revealed no evidence of industrial injury. Slitlamp examination revealed considerable epithelial bedewing, much pigment dusting of the deeper corneal layers and a small, s o m e w h a t irregular aphakic pupil. Intraocular pressure w a s 57 m m . H g , R . E . ; 20 m m . H g , L . E . V i s u a l acuity w a s light perception, O . D . ; 2 0 / 2 0 - 2 , O.S. Hospitalization w a s recommended but deferred until A u g u s t 17, 1960, w h e n the patient w a s admitted t o the Manhattan E y e , Ear, and T h r o a t Hospital with a diagnosis o f iritis and secondary glaucoma, w i t h a dislocated lens to be ruled out. Only upon this admission w a s his w a r history elicited. H e w a s wounded by shrapnel f r a g m e n t s in December, 1951. H i s face, head, neck and right eye w e r e involved. Treatment w a s g i v e n at a holding hospital and he w a s then sent to one o f the larger general hospitals in Japan w h e r e he w a s treated medically for o n e month. Evacuation to the U n i t e d States and a large army installation followed. T h e patient stated that he underwent eye surgery early in 1952 at the hospital but w a s v a g u e about details. H o w e v e r , inquiry f r o m the proper veterans'
386
M A X I M I L I A N Ο.
F i g . 1 ( G o l d s m i t h ) . Location of foreign body in right orbit o n A u g u s t 18, 1960. facility failed to elicit any history of surgery. Furthermore, there is a variance o f opinion a s to the date o f injury, the V e t e r a n s Administration listing it as April, 1951. It w a s also stated that a retained foreign body w a s found in the right eye but the location w a s not given nor w a s it revealed whether a n y attempts w e r e made to remove it. O t h e r findings w e r e traumatic choroiditis w i t h total blindness in the right eye, present upon the patient's separation from service. O n his first admission, the vision w a s questionable light perception, O . D . ; 2 0 / 2 0 - 3 , O . S . E x a m i nation of the right e y e showed four-plus congestion of the bulbar conjunctiva. T h e cornea w a s quite cloudy on gross examination. Slitlamp examination revealed the same heavy pigment dusting of the
F i g . 2 ( G o l d s m i t h ) . X - r a y film taken on A u g u s t 30, 1960, s h o w i n g forward migration o f intraocular foreign body.
GOLDSMITH
deeper corneal layers noted earlier. T h e iris of the right e y e seemed t o be somewhat darker than that of the left. T h e lens w a s not seen. Iridodonesis w a s noted. T h e right pupil w a s small, irregular and sluggish in reaction. T h e anterior chamber had three-plus flare w i t h heavy albuminous content. T h e anterior vitreous and fundus could not be visualized. Intraocular pressure w a s : O . D . , 60 m m . H g ; O.S., 22 mm. H g . T h e l e f t eye w a s essentially negative. Laboratory findings w e r e : S e r o l o g y : K o l m e r 4 + , Mazzini 3 + ; R B C , 5,600,000; hemoglobin, 15.85 g m ; W B C 9,200 w i t h polys 75 percent, lymphs 25 percent. T h e urine analysis w a s not remarkable. X - r a y films o f the right orbit revealed an opaque f o r e i g n body approximately 2.5 m m . in size situated five m m . above the horizontal plane of the cornea, five m m . temporal to the vertical plane o f the cornea and 14 m m . back of the center of the cornea. T h e chest plates w e r e negative. D u r i n g his hospital stay, the patient received D i a m o x intravenously and per os, intensive philocarpine therapy, D e m e r o l ( 5 0 m g . every four h o u r s ) f o r pain, Meticorten ( 1 0 mg. every s i x h o u r s ) at the onset and A C T H in five-percent g l u cose. N e o c o r t e f w a s g i v e n e v e r y three hours topically. I n addition, the patient w a s given one million units o f penicillin daily f o r 10 days. H e w a s d i s charged o n A u g u s t 26, 1960, somewhat relieved o f pain but with tension still over 35 mm. H g , despite medication.
Fig. 2A
( G o l d s m i t h ) . F o r e i g n body on anterior chamber.
floor
of
SIDEROSIS
BULBI A N D
T h e patient w a s readmitted o n A u g u s t 30, 1960, w i t h an exacerbation o f pain and e x a g g e r a t i o n o f his previous complaints. Conjunctival injection w a s three plus. T h e r e w a s a t w o - p l u s aqueous ray. O c casional cells w e r e noted. R e s t i n g in the anterior chamber at the 6-o'clock position w a s a f o r e i g n body. T e n s i o n w a s : R . E . , 7.0 m m . H g ; L . E . , 10.7 mm. H g . X - r a y films on the second admission s h o w e d a metallic foreign body 3.0 by 2.0 b y 3.0 in the right e y e : o n modified S w e e t localization, o n e m m . above horizontal the midplane, t w o m m . temporal to the vertical plane and t w o m m . i n back o f the center of the cornea. T h e f o r e i g n body had m o v e d f a r anteriorly—from posterior t o anterior chamber. I n a s m u c h a s there w a s still questionable light perception and a natural reluctance o n the part o f the patient t o lose his eye, it w a s decided to remove the f o r e i g n body. T h e r e w e r e n o illusions, h o w e v e r , as t o the ultimate f a t e o f the eye. U n d e r local anesthesia, a limbus-based flap w a s prepared and a B a r d - P a r k e r incision m a d e a t the 12-o'clock position. A small hand m a g n e t immediately s w e p t the f o r e i g n body out o f the anterior chamber. A postplaced corneoscleral suture w a s placed and the flap closed. T h e patient had an u n eventful postoperative course but, o n discharge, n o light perception w a s noted in the right e y e and the e y e w a s still irritable. A l m o s t intractable, continuous pain, O . D . , led to a third admission o n F e b r u a r y 6, 1961. T h e pain had caused loss o f sleep, increased f r e t f u l n e s s and irritability. T h e patient n o w requested removal o f the eye. E x a m i n a t i o n revealed n o light percep-
F i g . 3 ( G o l d s m i t h ) . Ganglion cells o f the macula are well preserved. Several microcysts occupy the foveal area ( χ 4 5 0 ) .
ENDOPHTHALMITIS
387
F i g . 4 ( G o l d s m i t h ) . L e n s material containing macrophages, g i a n t and polymorphonuclear cells. (X4S0). tion and an ocular tension, O . D . , o f 10 m m . H g . T h e cornea w a s heavily infiltrated w i t h siderotic deposits. T h e anterior chamber w a s deep w i t h a two-plus flare. O n February 7, 1961, the right e y e w a s e n u cleated under general anesthesia. T h e postoperative course w a s not remarkable. T h e socket healed well and the patient w a s f r e e o f pain. F o l l o w i n g are the findings reported by the A r m e d F o r c e s Institute o f P a t h o l o g y : Gross. X - r a y films s h o w n o radiopaque foreign bodies in the globe. T h e specimen consists o f a s o f t right e y e m e a s u r i n g 27 b y 25 by 26 m m . w i t h t w o mm. o f optic nerve attached. T h e cornea is completely opaque. T h e r e is n o transillumination of the globe. T h e e y e is opened in the horizontal plane. T h e e y e i s stained inside and out w i t h a y e l l o w dye. T h e anterior chamber is filled w i t h a w h i t e flocculent material. T h e vitreous cavity c o n tains w h i t e flocculent material similar t o that in the anterior chamber. T h e retina is thickened and contains several fibrous plaques scattered in t h e equatorial region. O n l y the lens nucleus remains. Microscopic. Peripherally the corneal epithelium is undermined by a fibrous stroma. T h e peripheral stroma is vascularized. Descement's membrane is i n t a c t T h e anterior chamber is s h a l l o w but h a s open angles. I t is filled w i t h fine granular e o s i n o philic material. T h e iris stroma and trabecular m e s h w o r k are heavily infiltrated w i t h macrophages laden w i t h positive iron-staining material. I n addition, the dilator muscle, pigmented and nonpigmented ciliary epithelium, the retinal pigment epithelium and the retina, particularly the nerve fiber layer, contain h e a v y deposits of iron-positive material. T h e muscles of the ciliary body are atrophic
M A X I M I L I A N Ο.
388
GOLDSMITH
the velocity of a particle penetrating the globe is sufficiently great, it may pass through all the ocular layers coming to rest in the outer layers or in the orbital tissues. Donohue describes a metallic fragment from a hammer striking a steel bracket and moving at such a great speed that it penetrated all the ocular layers including the retina, choroid and posterior sclera, coming to rest on the external surface of the sclera. Often, however, the greater part of the velocity is spent in piercing the outer coats of the eye and the particle comes to a halt within the globe, either in the vitreous or on the retina. Multiple foreign bodies are often retained within the eye and have been known to enter both eyes. Gager and Grayson* reported an unusual case of bilateral intraocular foreign bodies in a 34-year-old white man. Investigation revealed an intraocular foreign body in the posterior lens cortex of the right eye 3
F i g . 5 ( G o l d s m i t h ) . T h e retina, retinal pigment epithelium and especially the nerve fiber layer contain heavy deposits of iron-staining material. (X930). but it is otherwise not remarkable. T h e lens capsule is wrinkled with several tears. Anteriorly, there is a thick cuticle containing positive iron-staining material. T h e lens material is fragmented at the edges and infiltrated by a layer of polymorphonuclear leukocytes. T h i s in turn is surrounded by macrophages, epithelioid cells and giant cells. Peripherally there is e x t e n s i v e scarring of the inner retinal layers. T h e ganglion cells of the macula are well preserved. Several microcysts occupy the foveal area. T h e optic disc is not remarkable. T h e r e is no optic atrophy. Diagnoses. Siderosis bulbi, phacoanaphylactic endophthalmitis, secondary glaucoma. DISCUSSION
Clinical findings are often influenced by the speed at which the foreign body enters or penetrates the globe. Quite naturally, the size plays an important role, inasmuch as the greater damage is caused by the larger foreign body. Enucleation is more likely to follow in this case. War injuries from shrapnel, shell fragments, mines and so forth cause grave damage to the globe. If
F i g . 6 ( G o l d s m i t h ) . T h e angle is open. T h e trabecular meshwork contains macrophages ladened with siderotic material. ( X 9 3 0 . )
SIDEROSIS BULBI A N D
ENDOPHTHALMITIS
389
and a metallic intraocular particle in contact with the retina of the left eye, both of which were successfully removed with insignificant visual loss. Cross states that occasionally foreign bodies are allowed to remain in the posterior segment of the eye because ( 1 ) numerous cases with retention of vision and absence of inflammation have been reported; ( 2 ) attempted removal of a foreign fragment from an already damaged globe speeds up destructive changes therein. Iron in the vitreous has been known to extrude itself from the globe but the majority of ophthalmologists appear to favor removal of an intraocular foreign body. 5
Haik" summarizes his military ophthalmic experience in World War II by stressing that ( 1 ) each case of intraocular foreign body is an individual problem, ( 2 ) seriousness of wound depends on location, ( 3 ) speed of removal is less important than pinpointing the foreign body, ( 4 ) removal procedure is related to the location and type of foreign body, ( 5 ) emergency enucleation is seldom justified unless there is irrevocable damage. The most significant characteristic of a foreign body is its magnetic quality which determines the ease or difficulty of removal. In wars prior to World War II, missile fragments contained more iron and were more easily magnetized. In the last conflict, the iron and magnetic content was appreciably less. Tolerance by the ocular tissues of a foreign body varies considerably. The ciliary body reacts most markedly, giving rise to a plastic iridocyclitis. On the other hand, the lens reacts but little unless there is capsular rupture, allowing the aqueous access to the lens contents. Highly noxious and toxic elements may elicit no reaction in the lens for many years. Reaction to inert substances appears greatest in the posterior segment of the globe where degenerative changes with liquefaction and shrinkage of the vitreous usu-
F i g . 7 ( G o l d s m i t h ) . T h e anterior chamber a n g l e is open but it is filled w i t h fine granular eosinophilic material. T h e iris stroma is heavily infiltrated w i t h macrophages ladened with positive iron-staining material. T h e pigmented and nonpigmented ciliary epithelium contain deposits of siderotic material. ( χ 4 5 0 . )
ally occur. Exudative and proliferative reactions occur in the retina which may become detached, with neural atrophy and overgrowth of the neuroglial elements. Albers reported a case of a blackberry thorn in the anterior chamber of the eye for a period of 12 years. Following an initial period of anterior segment inflammation, there was no further reaction in the eye, although vision was lost. Lead may migrate from one portion of the eye to the other and may cause sympathetic ophthalmia. Mercury elicits a marked purulent inflammation in the eye, terminating in phthisis bulbi. Copper causes a suppurative reaction in 7
390
M A X I M I L I A N Ο.
its pure state. In copper alloys, the reaction is much less virulent. Pure copper causes acute iridocyclitis, with hypopyon in the anterior chamber. In the posterior segment it leads to vitreous contraction and detachment, retinal degeneration and phthisis bulbi. The metal may be widely distributed throughout the tissues of the eye, giving the classical picture of chalcosis. Mishler and Harley have recorded a case in which copper was present in the eye for 30 years without evidence of chalcosis. In fact, during the last eight months of observation, the ophthalmoscopic appearance simulated an expanding intraocular tumor. The chemically active elements are predominantly represented by iron and steel, most numerous in industrial accidents and war injuries. The delayed chemical reaction set up in the ocular tissues by iron is termed siderosis and is a chronic degenerative process ending in blindness. Siderosis has appeared and cleared spontaneously. Holland cited a case of siderosis bulbi of 32 years' duration in which siderotic changes in the iris cleared and the intraocular foreign body was absorbed. Chorioretinal scarring, retinal atrophy and dislocation of a cataractous lens occurred, with a final central visual acuity of 2 0 / 2 0 with aphakic correction. A number of cases have been recorded of ferrous foreign bodies in the posterior segment of the globe with no undue effects other than visual. Pollock reported four cases of steel fragments in eyes for periods of 26 days, nine months, five months, and eight months, respectively, without the patients being aware of their presence until defective vision forced them to seek ophthalmic consultation. Encapsulated metallic fragments which have long remained dormant may spontaneously shift location and set up an inflammation so fulminating as to require enucleation. Exacerbation of inflammatory episodes may occur after a long quiescent period, resulting in hypopyon, plastic endophthalmitis and 8
9
10
GOLDSMITH
phthisis bulbi. Rarely, sympathetic ophthalmia occurs. In siderosis, the pathologic changes depend on the size, chemical composition and location of the particle. The worst locations are in the posterior segment and ciliary body. The clinical picture is characterized by the rusty color of the lens and iris and by degenerative retinal changes. Duke-Elder mentions Bunge's differentiation into ( 1 ) direct siderosis wherein iron is deposited directly around the foreign body and ( 2 ) indirect siderosis where there is dissemination throughout the eye, ending in blindness from degeneration, or glaucoma or retinal detachment. In the first type, the rust ring reaction in the cornea, subconjunctiva and sclera are well-known examples. Encapsulation may occur in the iris. In the lens there may be siderosis in situ if total cataract does not develop. In the retina, encapsulation with adjacent siderosis and pigmentary degeneration takes place. In the indirect type (as in the case presented here) there is generalized rusty staining of the cornea, especially in the corneal corpuscles. (In this case, the siderotic material appeared on slitlamp study to have permeated all the corneal layers.) The iris may have a rusty color, varying from red, green, brown to yellow. The pupil may be dilated and may not react to light. If the siderosis is in the anterior chamber, only a local reaction may be detected. Large rusty brown patches appear on the lens prior to cataract maturity. A siderotic cataract can remain indefinitely but often there is such marked shrinkage that iridodonesis develops, or zonular degeneration leads to spontaneous subluxation or complete dislocation into the vitreous. (In the case presented here, this may have been the course of events.) The vitreous also undergoes structural disruption and shows grossly pigmented opacities. Retinal complications are most severe—pigmentary degeneration,
SIDEROSIS BULBI A N D
macular optic changes, obliterative sclerotic changes in the arteries, retinal detachment and rusty color of the optic disc. Secondary glaucoma is usual with untreated siderosis, the tension rising progressively over a period of 18 months to 19 years. (In my case, the period was nine years.) The glaucoma is of the chronic simple type which does not respond well to fistulization procedures and usually the eye has to be removed because of pain. ( I n my case, removal of the spontaneously displaced foreign body was followed by hypotony but no relief of pain, with the final result enucleation.) The heaviest siderotic deposits are on the anterior surface and sphincter and dilator muscles of the iris, the trabeculae of the angle of the anterior chamber, the subcapsular lens epithelium, epithelium of the ciliary body and throughout the peripheral retina. The lens changes have been discussed. In the retina, iron collects on the limiting membranes and pigment cells. The ganglion cells swell, atrophy and disappear. Ultimately the entire retina is filled with iron and degenerates, with glia replacing the neural tissues. Cibis, Yamashita and Rodriguez discussed the clinical aspect and pathologic findings of ocular siderosis and hemosiderosis. They state that in electron micrographs the two conditions are morphologically indistinguishable. They presented evidence that the pathogenesis of both conditions is founded on ( 1 ) iron linkage to mucopolysaccharides of the vitreous, the perivascular tissue of the retinal blood vessels and the outflow channels of Schlemm's canal ; ( 2 ) cytoplasmic variations in endothelial cells of the ocular vessels; ( 3 ) irreversible cytoplasmic changes in the endothelial and epithelial cells inside the eye. Cibis, Brown and H o n g demonstrated siderotic deposits in the ciliary body, choriocapillaris. retina and retinal pigment epithelium of a patient who had received many transfusions for aplastic anemia. They pro11
12
ENDOPHTHALMITIS
391
duced degenerative eye changes in dogs similar to siderosis bulbi and retinitis pigmentosa in man by a series of replated intravenous injections of either saccharated iron oxide or multiple blood transfusions. It is believed that the siderotic process depends on the electrolytic dissociation caused by the constant current present in the eye. Itoi proved this experimentally by placing a nail in a rabbit's eye and found that it rusted. However, if it were connected with a zinc plate buried subcutaneously, there was a reversal in ionic flow with no rust. Thus a galvanic cell is set up wherein the nail is a cathode and positive iron ions are attracted. In the eye, there is a diffusion of iron posteroanteriorly. Phacoanaphylactic endophthalmitis generally follows second or subsequent lens discissions or an extracapsular cataract extraction in which the lens cortex may not have been completely removed. It is usually restricted to the anterior segment of the globe, although the posterior segment may be involved. 13
An inflammatory reaction results from disintegration of fragments of lens substance in the anterior chamber, where morgagnian droplets, lens fibers and lens nucleus are surrounded by disintegrating polymorphonuclears. A localized fibrinous exudate and cellular infiltration with mononuclears, eosinophils and occasional giant cells can be seen. Granulation tissue comprised of epithelioid cells, plasma cells and lymphocytes may surround the lens material. Irvine and Irvine" point out that lens capsule rupture is not necessary to produce this condition. Increased permeability of the capsule may also be the cause. Phacoanaphylactic endophthalmitis can be a bilateral disease when the contralateral unoperated eye becomes involved after extracapsular cataract extraction. This was reported by Courtney and De Veer as quoted in Theodore and Schlossmann Injury to the lens capsule in the case presented here may have freed lens protein 5
392
M A X I M I L I A N Ο.
which, during absorption, produced general and local hypersensitivity; further absorption produced an anaphylactic reaction. Whether the lens capsule was ruptured at the time of the war injury or during the passage of the intraocular foreign body from the posterior segment into the anterior chamber cannot be ascertained. Another possible cause of phacoanaphylactic reaction is a hypermature traumatic cataract from which there is egression of lens proteins to precipitate anaphylactic uveitis and ultimate glaucoma. Yet Irvine and Irvine state that it is not quite clear how free lens material in the anterior chamber or, as in this case, the vitreous chamber, can cause uveitis and glaucoma. Often lens material fails to exert any nocuous influence. Lenses have been posteriorly dislocated for many years without an inflammatory or glaucomatous response. The dislocated cataractous lens may have caused cyclitis by its constant irritation of the ciliary body, with subsequent excess secretion of intraocular fluid and glaucoma. Glaucoma may also have resulted from inflammatory cell obstruction of the trabecular spaces and from anterior peripheral synechia formation. The latter was not evident in the pathologic studies. There is a considerable resemblance between the anaphylactic type of reaction and the phacotoxic reaction. The latter is caused by hypermature lens material spilling out into the ocular spaces, causing uveitis and glaucoma. The leak may occur through a
GOLDSMITH
partially torn capsule. Histologically, lymphocytic and plasma cell infiltration of the iris occurs. The ciliary body becomes inflamed with plasma cells and mononuclears. The distinguishing feature from the phacoanaphylactic type is the absence of polymorphonuclear and giant cells. SUMMARY
The case presented is unusual in that there was spontaneous migration of an intraocular foreign body from the posterior segment to the anterior chamber of the eye after nine years, accompanied by siderosis bulbi and unsuspected phacoanaphylactic endophthalmitis. Secondary glaucoma persisted until the foreign body was removed, after which hypotony was noted until the time of enucleation. The reaction of ocular tissues to both chemically active and inert substances was given. Pathologic findings and ultimate outcome of siderosis were discussed and the mechanism by which the siderotic process is believed to take place was described. The role of phacoanaphylactic endophthalmitis in the production of secondary glaucoma and its similarity to phacotoxic uveitis were considered. 1320 Cornaga Avenue. ACKNOWLEDGMENTS I wish to thank D r s . Echols, Wintrich and Burns of the house staff, and D o n W o n g of the P h o t o g r a p h y Department, Manhattan E y e , E a r and T h r o a t Hospital, as well as the A r m e d Forces Institute of P a t h o l o g y .
REFERENCES
1. D u k e - E l d e r , S.: T e x t b o o k of Ophthalmology. St. L o u i s M o s b y , 1954, pp. 6142-60, 6173, 6182-6186, 6189-6192, 6201-6209. 2. Crawford, B . : Peripatetic intraocular foreign body. Α Μ Α Arch. Ophth., 6 4 : 3 9 2 - 3 9 5 ( S e p t . ) 1960. 3. D o n o h u e , H . : Unusual case of an intraocular f o r e i g n body. A m . J. O p h t h , 4 2 : 6 4 2 - 6 4 5 ( O c t . ) 1956. 4. Gager, J , and Grayson, M . : Bilateral foreign bodies. A m . J. O p h t h , 4 2 : 6 4 6 - 6 4 7 , 1956. 5. Cross, G. : Injuries of the eye. In Berens, C. : T h e E y e and its Diseases. Philadelphia, Saunders, 1950, pp. 784, 786. 6. H a i k , G : Intraocular foreign bodies. J . A . M . A , 135:894-900 ( D e c . 6 ) 1947. 7. Albers, E . : Blackberry thorn in the anterior chamber of the e y e f o r 12 years. A r c h . O p h t h , 2 5 : 6 6 2 ( A p r . ) 1941. 8. Mishler, J , and H a r l e y , R.: Copper within the eye 3 0 years simulating tumor. A m . J. O p h t h , 3 5 : 687-690 ( M a y ) 1952.
SIDEROSIS BULBI A N D
393
ENDOPHTHALMITIS
9. Holland, M . : Siderosis bulbi and spontaneous clearing. Ara. J. O p h t h , 4 5 : 2 5 9 - 2 6 4 ( F e b . ) 1958. 10. Pollock, W . : E y e injuries': W h e r e presence of a piece of steel within the globe w a s u n k n o w n t o patient. G l a s g o w M. J , 1 2 6 : 1 2 2 - 1 2 4 ( J u l y ) 1936. 11. Cibis, P , Yamashita, T , and Rodriguez, R.: Clinical aspects of ocular siderosis and hemosiderosis. Α Μ Α A r c h . Ophth. 6 2 : 1 8 0 - 1 8 7 ( A u g . ) 1959. 12. Cibis, P , B r o w n , E , and H o n g , S . : Ocular effects of systemic siderosis, A m . J. O p h t h , 4 4 : 1 5 8 171, 1957. 13. Itoi: A c t a Soc. Ophth. Japan, 4 1 : 6 6 9 1937. 14. Irvine, S , and Irvine, Α . : Lens-induced uveitis and glaucoma. I n H a i k , G , and M c F e t r i d g e , E . : S y m p o s i u m on D i s e a s e s and S u r g e r y of the Lens. St. L o u i s , M o s b y , 1957, pp. 186-194. 15. Theodore, F , and Schlossman, Α . : Ocular A l l e r g y . Baltimore, W i l l i a m s & W i l k i n s , 1958, pp. 350352, 357.
LIGHT
COAGULATION
IN
PIGMENT
SCLERAL WALTER
J.
GEERAETS,
M.D.,
DUPONT
WILLIAM GUERRY,
Richmond,
Shortening procedures of the globe in certain cases of retinal detachment have been widely used since they were introduced. A number of modifications of the original method have been described and innovations have been introduced. The combined use of buckling procedures and light .coagulation was advocated by Linnen in 1959. Boeke applied the Custodis operation combined with light coagulation and Girard described a method of employing an encircling silicone rubber rod combined with light coagulation. 3
ATROPHY
FOLLOWING
BUCKLING*
1
2
In some instances light coagulation becomes necessary some weeks or months following surgery, when the retina and choroid underlying the buckle may have become atrophic to such an extent that the tissue becomes completely depigmented and consequently fails to absorb sufficient light to result in adequate light coagulation. In the normally pigmented eye, the first site of heat generation is the pigment epithelium and from here thermal energy is conducted posteriorly to the choroid and anteriorly to the receptor cell layer of the retina. Fast dissipation of thermal energy
* F r o m the Department of O p h t h a l m o l o g y and Research-Ophthalmology, the Medical College of Virginia. T h i s study w a s supported in part by the K n i g h t s - T e m p l a r E y e Foundation.
III,
G.
EVERETT,
M.D.,
AND
M.D.
Virginia
by blood flow prevents histologic changes in the choroid with very mild exposures, but the temperature might still rise sufficiently in the retinal pigment cells and rod and cone layers to cause protein denaturation. In this study pigmented plastic strips were embedded in the suprachoroidal space of albino rabbit eyes and light coagulation was then carried out over the area where the foreign material had been placed. This experiment was based on the assumption that the heat generated within the pigmented plastic material under light exposure would have sufficient effect on the underlying tissues by conduction to produce the desired inflammatory response. From a practical clinical standpoint it goes without saying that such pigmented plastics could be of value only in cases of scleral resection where the plastic material lies in the suprachoroidal space, or perhaps in some cases of lamellar scleral resection where the remaining sclera is left extremely thin. In such instances heat, generated in the pigmented plastic Under light exposure, is conducted from the suprachoroidal zone through the entire thickness of the richly vascularized choroid before retinal coagulation can take place; consequently greater intensity than that necessary for eyes with normal pigment epithelium is required.
CHLOROQUINE
385
15. P a g e , F . : Treatment of lupus erythematosus w i t h mepacrine. Lancet, 2 : 7 5 5 ( O c t . 2 7 ) 1951. 16. P a u , H , and Baumer, Α . : Corneal chloroquine deposits. Klin. Monatsbl. f. A u g e n h , 1 3 5 : 3 6 2 , 1959. ( A b s t r a c t e d A m . J. O p h t h , 4 9 : 3 9 7 , 1960.) 17. Reese, F . M . : E d e m a of the corneal epithelium caused by Atabrine. Bull. J o h n s H o p k i n s H o s p , 6:325 ( J u n e ) 1946. 18. Pillsbury, D . M , and Jacobson, C : Treatment of chronic discoid lupus erythematosus with chloroquine. J . A . M . A , 154:1330, 1954. 19. Sternberg, T . H , and Laden, E . : Discoid lupus erythematosus: Bilateral macular degeneration due to chloroquine. Α Μ Α A r c h . D e r m , 7 9 : 1 1 6 , 1959. 20. Traquair, Η . M . : A n Introduction to Clinical Perimetry. St. Louis, Mosby, 1944, ed: 4, pp. 156. 21. Zeller, R. W , and Deering, D . : Corneal complications of chloroquine ( A r a l e n ) phosphate therapy. J . A . M . A , 1 6 8 : 2 2 6 3 , 1958.
INTRAOCULAR
FOREIGN
BODY,
PHACOANAPHYLACTIC MAXIMILIAN
O.
SIDEROSIS
BULBI
A N D
ENDOPHTHALMITIS* GOLDSMITH,
M.D.
Far Rockaway, New York Unquestionably, numerous foreign bodies have remained within the globe indefinitely without untoward effects. However, it is a wiser policy to consider intraocular foreign bodies as imminent sources of danger to vision and usefulness of an eye. War injuries and industrial accidents contribute the majority of these intraocular accidents. The composition, nature and magnetic properties of a foreign body are important. Some foreign bodies are chemically inert and elicit no specific irritation, while others set up a severe and purulent reaction. E x amples of chemically inert and precious metals are gold, silver, platinum and tantalum. Ferrous metallic fragments, frequent in incidence, set up a different reaction and are easier to remove because of magnetic properties. Duke-Elder states that a metallic fragment may migrate after it has been in the eye for some time. H e cites a case wherein a shot pellet migrated from the interior of the eye to the angle of the chamber after 15 months. This is regrettable, especially with sharp particles, such as glass which, in one case, came in contact with the lens, forming a cataract after having caused no reaction in the eye for 10 years. 1
* F r o m the Manhattan E y e , Ear, and Hospital.
Throat
Crawford tells of a fire cracker fragment which migrated from the posterior segment to the anterior chamber of the eye 13 weeks after injury. The following case is one of an intraocular foreign body which migrated from the posterior segment to the anterior chamber after a period of nine years. 2
REPORT
OF
CASE
T h e patient, a 32-year-old P u e r t o Rican veteran of the K o r e a n W a r , w a s first seen o n A u g u s t 9, 1960, with history of irritation of the right eye during the course of his work. Physical examination revealed no evidence of industrial injury. Slitlamp examination revealed considerable epithelial bedewing, much pigment dusting of the deeper corneal layers and a small, s o m e w h a t irregular aphakic pupil. Intraocular pressure w a s 57 m m . H g , R . E . ; 20 m m . H g , L . E . V i s u a l acuity w a s light perception, O . D . ; 2 0 / 2 0 - 2 , O.S. Hospitalization w a s recommended but deferred until A u g u s t 17, 1960, w h e n the patient w a s admitted t o the Manhattan E y e , Ear, and T h r o a t Hospital with a diagnosis o f iritis and secondary glaucoma, w i t h a dislocated lens to be ruled out. Only upon this admission w a s his w a r history elicited. H e w a s wounded by shrapnel f r a g m e n t s in December, 1951. H i s face, head, neck and right eye w e r e involved. Treatment w a s g i v e n at a holding hospital and he w a s then sent to one o f the larger general hospitals in Japan w h e r e he w a s treated medically for o n e month. Evacuation to the U n i t e d States and a large army installation followed. T h e patient stated that he underwent eye surgery early in 1952 at the hospital but w a s v a g u e about details. H o w e v e r , inquiry f r o m the proper veterans'
386
M A X I M I L I A N Ο.
F i g . 1 ( G o l d s m i t h ) . Location of foreign body in right orbit o n A u g u s t 18, 1960. facility failed to elicit any history of surgery. Furthermore, there is a variance o f opinion a s to the date o f injury, the V e t e r a n s Administration listing it as April, 1951. It w a s also stated that a retained foreign body w a s found in the right eye but the location w a s not given nor w a s it revealed whether a n y attempts w e r e made to remove it. O t h e r findings w e r e traumatic choroiditis w i t h total blindness in the right eye, present upon the patient's separation from service. O n his first admission, the vision w a s questionable light perception, O . D . ; 2 0 / 2 0 - 3 , O . S . E x a m i nation of the right e y e showed four-plus congestion of the bulbar conjunctiva. T h e cornea w a s quite cloudy on gross examination. Slitlamp examination revealed the same heavy pigment dusting of the
F i g . 2 ( G o l d s m i t h ) . X - r a y film taken on A u g u s t 30, 1960, s h o w i n g forward migration o f intraocular foreign body.
GOLDSMITH
deeper corneal layers noted earlier. T h e iris of the right e y e seemed t o be somewhat darker than that of the left. T h e lens w a s not seen. Iridodonesis w a s noted. T h e right pupil w a s small, irregular and sluggish in reaction. T h e anterior chamber had three-plus flare w i t h heavy albuminous content. T h e anterior vitreous and fundus could not be visualized. Intraocular pressure w a s : O . D . , 60 m m . H g ; O.S., 22 mm. H g . T h e l e f t eye w a s essentially negative. Laboratory findings w e r e : S e r o l o g y : K o l m e r 4 + , Mazzini 3 + ; R B C , 5,600,000; hemoglobin, 15.85 g m ; W B C 9,200 w i t h polys 75 percent, lymphs 25 percent. T h e urine analysis w a s not remarkable. X - r a y films o f the right orbit revealed an opaque f o r e i g n body approximately 2.5 m m . in size situated five m m . above the horizontal plane of the cornea, five m m . temporal to the vertical plane o f the cornea and 14 m m . back of the center of the cornea. T h e chest plates w e r e negative. D u r i n g his hospital stay, the patient received D i a m o x intravenously and per os, intensive philocarpine therapy, D e m e r o l ( 5 0 m g . every four h o u r s ) f o r pain, Meticorten ( 1 0 mg. every s i x h o u r s ) at the onset and A C T H in five-percent g l u cose. N e o c o r t e f w a s g i v e n e v e r y three hours topically. I n addition, the patient w a s given one million units o f penicillin daily f o r 10 days. H e w a s d i s charged o n A u g u s t 26, 1960, somewhat relieved o f pain but with tension still over 35 mm. H g , despite medication.
Fig. 2A
( G o l d s m i t h ) . F o r e i g n body on anterior chamber.
floor
of
SIDEROSIS
BULBI A N D
T h e patient w a s readmitted o n A u g u s t 30, 1960, w i t h an exacerbation o f pain and e x a g g e r a t i o n o f his previous complaints. Conjunctival injection w a s three plus. T h e r e w a s a t w o - p l u s aqueous ray. O c casional cells w e r e noted. R e s t i n g in the anterior chamber at the 6-o'clock position w a s a f o r e i g n body. T e n s i o n w a s : R . E . , 7.0 m m . H g ; L . E . , 10.7 mm. H g . X - r a y films on the second admission s h o w e d a metallic foreign body 3.0 by 2.0 b y 3.0 in the right e y e : o n modified S w e e t localization, o n e m m . above horizontal the midplane, t w o m m . temporal to the vertical plane and t w o m m . i n back o f the center of the cornea. T h e f o r e i g n body had m o v e d f a r anteriorly—from posterior t o anterior chamber. I n a s m u c h a s there w a s still questionable light perception and a natural reluctance o n the part o f the patient t o lose his eye, it w a s decided to remove the f o r e i g n body. T h e r e w e r e n o illusions, h o w e v e r , as t o the ultimate f a t e o f the eye. U n d e r local anesthesia, a limbus-based flap w a s prepared and a B a r d - P a r k e r incision m a d e a t the 12-o'clock position. A small hand m a g n e t immediately s w e p t the f o r e i g n body out o f the anterior chamber. A postplaced corneoscleral suture w a s placed and the flap closed. T h e patient had an u n eventful postoperative course but, o n discharge, n o light perception w a s noted in the right e y e and the e y e w a s still irritable. A l m o s t intractable, continuous pain, O . D . , led to a third admission o n F e b r u a r y 6, 1961. T h e pain had caused loss o f sleep, increased f r e t f u l n e s s and irritability. T h e patient n o w requested removal o f the eye. E x a m i n a t i o n revealed n o light percep-
F i g . 3 ( G o l d s m i t h ) . Ganglion cells o f the macula are well preserved. Several microcysts occupy the foveal area ( χ 4 5 0 ) .
ENDOPHTHALMITIS
387
F i g . 4 ( G o l d s m i t h ) . L e n s material containing macrophages, g i a n t and polymorphonuclear cells. (X4S0). tion and an ocular tension, O . D . , o f 10 m m . H g . T h e cornea w a s heavily infiltrated w i t h siderotic deposits. T h e anterior chamber w a s deep w i t h a two-plus flare. O n February 7, 1961, the right e y e w a s e n u cleated under general anesthesia. T h e postoperative course w a s not remarkable. T h e socket healed well and the patient w a s f r e e o f pain. F o l l o w i n g are the findings reported by the A r m e d F o r c e s Institute o f P a t h o l o g y : Gross. X - r a y films s h o w n o radiopaque foreign bodies in the globe. T h e specimen consists o f a s o f t right e y e m e a s u r i n g 27 b y 25 by 26 m m . w i t h t w o mm. o f optic nerve attached. T h e cornea is completely opaque. T h e r e is n o transillumination of the globe. T h e e y e is opened in the horizontal plane. T h e e y e i s stained inside and out w i t h a y e l l o w dye. T h e anterior chamber is filled w i t h a w h i t e flocculent material. T h e vitreous cavity c o n tains w h i t e flocculent material similar t o that in the anterior chamber. T h e retina is thickened and contains several fibrous plaques scattered in t h e equatorial region. O n l y the lens nucleus remains. Microscopic. Peripherally the corneal epithelium is undermined by a fibrous stroma. T h e peripheral stroma is vascularized. Descement's membrane is i n t a c t T h e anterior chamber is s h a l l o w but h a s open angles. I t is filled w i t h fine granular e o s i n o philic material. T h e iris stroma and trabecular m e s h w o r k are heavily infiltrated w i t h macrophages laden w i t h positive iron-staining material. I n addition, the dilator muscle, pigmented and nonpigmented ciliary epithelium, the retinal pigment epithelium and the retina, particularly the nerve fiber layer, contain h e a v y deposits of iron-positive material. T h e muscles of the ciliary body are atrophic
M A X I M I L I A N Ο.
388
GOLDSMITH
the velocity of a particle penetrating the globe is sufficiently great, it may pass through all the ocular layers coming to rest in the outer layers or in the orbital tissues. Donohue describes a metallic fragment from a hammer striking a steel bracket and moving at such a great speed that it penetrated all the ocular layers including the retina, choroid and posterior sclera, coming to rest on the external surface of the sclera. Often, however, the greater part of the velocity is spent in piercing the outer coats of the eye and the particle comes to a halt within the globe, either in the vitreous or on the retina. Multiple foreign bodies are often retained within the eye and have been known to enter both eyes. Gager and Grayson* reported an unusual case of bilateral intraocular foreign bodies in a 34-year-old white man. Investigation revealed an intraocular foreign body in the posterior lens cortex of the right eye 3
F i g . 5 ( G o l d s m i t h ) . T h e retina, retinal pigment epithelium and especially the nerve fiber layer contain heavy deposits of iron-staining material. (X930). but it is otherwise not remarkable. T h e lens capsule is wrinkled with several tears. Anteriorly, there is a thick cuticle containing positive iron-staining material. T h e lens material is fragmented at the edges and infiltrated by a layer of polymorphonuclear leukocytes. T h i s in turn is surrounded by macrophages, epithelioid cells and giant cells. Peripherally there is e x t e n s i v e scarring of the inner retinal layers. T h e ganglion cells of the macula are well preserved. Several microcysts occupy the foveal area. T h e optic disc is not remarkable. T h e r e is no optic atrophy. Diagnoses. Siderosis bulbi, phacoanaphylactic endophthalmitis, secondary glaucoma. DISCUSSION
Clinical findings are often influenced by the speed at which the foreign body enters or penetrates the globe. Quite naturally, the size plays an important role, inasmuch as the greater damage is caused by the larger foreign body. Enucleation is more likely to follow in this case. War injuries from shrapnel, shell fragments, mines and so forth cause grave damage to the globe. If
F i g . 6 ( G o l d s m i t h ) . T h e angle is open. T h e trabecular meshwork contains macrophages ladened with siderotic material. ( X 9 3 0 . )
SIDEROSIS BULBI A N D
ENDOPHTHALMITIS
389
and a metallic intraocular particle in contact with the retina of the left eye, both of which were successfully removed with insignificant visual loss. Cross states that occasionally foreign bodies are allowed to remain in the posterior segment of the eye because ( 1 ) numerous cases with retention of vision and absence of inflammation have been reported; ( 2 ) attempted removal of a foreign fragment from an already damaged globe speeds up destructive changes therein. Iron in the vitreous has been known to extrude itself from the globe but the majority of ophthalmologists appear to favor removal of an intraocular foreign body. 5
Haik" summarizes his military ophthalmic experience in World War II by stressing that ( 1 ) each case of intraocular foreign body is an individual problem, ( 2 ) seriousness of wound depends on location, ( 3 ) speed of removal is less important than pinpointing the foreign body, ( 4 ) removal procedure is related to the location and type of foreign body, ( 5 ) emergency enucleation is seldom justified unless there is irrevocable damage. The most significant characteristic of a foreign body is its magnetic quality which determines the ease or difficulty of removal. In wars prior to World War II, missile fragments contained more iron and were more easily magnetized. In the last conflict, the iron and magnetic content was appreciably less. Tolerance by the ocular tissues of a foreign body varies considerably. The ciliary body reacts most markedly, giving rise to a plastic iridocyclitis. On the other hand, the lens reacts but little unless there is capsular rupture, allowing the aqueous access to the lens contents. Highly noxious and toxic elements may elicit no reaction in the lens for many years. Reaction to inert substances appears greatest in the posterior segment of the globe where degenerative changes with liquefaction and shrinkage of the vitreous usu-
F i g . 7 ( G o l d s m i t h ) . T h e anterior chamber a n g l e is open but it is filled w i t h fine granular eosinophilic material. T h e iris stroma is heavily infiltrated w i t h macrophages ladened with positive iron-staining material. T h e pigmented and nonpigmented ciliary epithelium contain deposits of siderotic material. ( χ 4 5 0 . )
ally occur. Exudative and proliferative reactions occur in the retina which may become detached, with neural atrophy and overgrowth of the neuroglial elements. Albers reported a case of a blackberry thorn in the anterior chamber of the eye for a period of 12 years. Following an initial period of anterior segment inflammation, there was no further reaction in the eye, although vision was lost. Lead may migrate from one portion of the eye to the other and may cause sympathetic ophthalmia. Mercury elicits a marked purulent inflammation in the eye, terminating in phthisis bulbi. Copper causes a suppurative reaction in 7
390
M A X I M I L I A N Ο.
its pure state. In copper alloys, the reaction is much less virulent. Pure copper causes acute iridocyclitis, with hypopyon in the anterior chamber. In the posterior segment it leads to vitreous contraction and detachment, retinal degeneration and phthisis bulbi. The metal may be widely distributed throughout the tissues of the eye, giving the classical picture of chalcosis. Mishler and Harley have recorded a case in which copper was present in the eye for 30 years without evidence of chalcosis. In fact, during the last eight months of observation, the ophthalmoscopic appearance simulated an expanding intraocular tumor. The chemically active elements are predominantly represented by iron and steel, most numerous in industrial accidents and war injuries. The delayed chemical reaction set up in the ocular tissues by iron is termed siderosis and is a chronic degenerative process ending in blindness. Siderosis has appeared and cleared spontaneously. Holland cited a case of siderosis bulbi of 32 years' duration in which siderotic changes in the iris cleared and the intraocular foreign body was absorbed. Chorioretinal scarring, retinal atrophy and dislocation of a cataractous lens occurred, with a final central visual acuity of 2 0 / 2 0 with aphakic correction. A number of cases have been recorded of ferrous foreign bodies in the posterior segment of the globe with no undue effects other than visual. Pollock reported four cases of steel fragments in eyes for periods of 26 days, nine months, five months, and eight months, respectively, without the patients being aware of their presence until defective vision forced them to seek ophthalmic consultation. Encapsulated metallic fragments which have long remained dormant may spontaneously shift location and set up an inflammation so fulminating as to require enucleation. Exacerbation of inflammatory episodes may occur after a long quiescent period, resulting in hypopyon, plastic endophthalmitis and 8
9
10
GOLDSMITH
phthisis bulbi. Rarely, sympathetic ophthalmia occurs. In siderosis, the pathologic changes depend on the size, chemical composition and location of the particle. The worst locations are in the posterior segment and ciliary body. The clinical picture is characterized by the rusty color of the lens and iris and by degenerative retinal changes. Duke-Elder mentions Bunge's differentiation into ( 1 ) direct siderosis wherein iron is deposited directly around the foreign body and ( 2 ) indirect siderosis where there is dissemination throughout the eye, ending in blindness from degeneration, or glaucoma or retinal detachment. In the first type, the rust ring reaction in the cornea, subconjunctiva and sclera are well-known examples. Encapsulation may occur in the iris. In the lens there may be siderosis in situ if total cataract does not develop. In the retina, encapsulation with adjacent siderosis and pigmentary degeneration takes place. In the indirect type (as in the case presented here) there is generalized rusty staining of the cornea, especially in the corneal corpuscles. (In this case, the siderotic material appeared on slitlamp study to have permeated all the corneal layers.) The iris may have a rusty color, varying from red, green, brown to yellow. The pupil may be dilated and may not react to light. If the siderosis is in the anterior chamber, only a local reaction may be detected. Large rusty brown patches appear on the lens prior to cataract maturity. A siderotic cataract can remain indefinitely but often there is such marked shrinkage that iridodonesis develops, or zonular degeneration leads to spontaneous subluxation or complete dislocation into the vitreous. (In the case presented here, this may have been the course of events.) The vitreous also undergoes structural disruption and shows grossly pigmented opacities. Retinal complications are most severe—pigmentary degeneration,
SIDEROSIS BULBI A N D
macular optic changes, obliterative sclerotic changes in the arteries, retinal detachment and rusty color of the optic disc. Secondary glaucoma is usual with untreated siderosis, the tension rising progressively over a period of 18 months to 19 years. (In my case, the period was nine years.) The glaucoma is of the chronic simple type which does not respond well to fistulization procedures and usually the eye has to be removed because of pain. ( I n my case, removal of the spontaneously displaced foreign body was followed by hypotony but no relief of pain, with the final result enucleation.) The heaviest siderotic deposits are on the anterior surface and sphincter and dilator muscles of the iris, the trabeculae of the angle of the anterior chamber, the subcapsular lens epithelium, epithelium of the ciliary body and throughout the peripheral retina. The lens changes have been discussed. In the retina, iron collects on the limiting membranes and pigment cells. The ganglion cells swell, atrophy and disappear. Ultimately the entire retina is filled with iron and degenerates, with glia replacing the neural tissues. Cibis, Yamashita and Rodriguez discussed the clinical aspect and pathologic findings of ocular siderosis and hemosiderosis. They state that in electron micrographs the two conditions are morphologically indistinguishable. They presented evidence that the pathogenesis of both conditions is founded on ( 1 ) iron linkage to mucopolysaccharides of the vitreous, the perivascular tissue of the retinal blood vessels and the outflow channels of Schlemm's canal ; ( 2 ) cytoplasmic variations in endothelial cells of the ocular vessels; ( 3 ) irreversible cytoplasmic changes in the endothelial and epithelial cells inside the eye. Cibis, Brown and H o n g demonstrated siderotic deposits in the ciliary body, choriocapillaris. retina and retinal pigment epithelium of a patient who had received many transfusions for aplastic anemia. They pro11
12
ENDOPHTHALMITIS
391
duced degenerative eye changes in dogs similar to siderosis bulbi and retinitis pigmentosa in man by a series of replated intravenous injections of either saccharated iron oxide or multiple blood transfusions. It is believed that the siderotic process depends on the electrolytic dissociation caused by the constant current present in the eye. Itoi proved this experimentally by placing a nail in a rabbit's eye and found that it rusted. However, if it were connected with a zinc plate buried subcutaneously, there was a reversal in ionic flow with no rust. Thus a galvanic cell is set up wherein the nail is a cathode and positive iron ions are attracted. In the eye, there is a diffusion of iron posteroanteriorly. Phacoanaphylactic endophthalmitis generally follows second or subsequent lens discissions or an extracapsular cataract extraction in which the lens cortex may not have been completely removed. It is usually restricted to the anterior segment of the globe, although the posterior segment may be involved. 13
An inflammatory reaction results from disintegration of fragments of lens substance in the anterior chamber, where morgagnian droplets, lens fibers and lens nucleus are surrounded by disintegrating polymorphonuclears. A localized fibrinous exudate and cellular infiltration with mononuclears, eosinophils and occasional giant cells can be seen. Granulation tissue comprised of epithelioid cells, plasma cells and lymphocytes may surround the lens material. Irvine and Irvine" point out that lens capsule rupture is not necessary to produce this condition. Increased permeability of the capsule may also be the cause. Phacoanaphylactic endophthalmitis can be a bilateral disease when the contralateral unoperated eye becomes involved after extracapsular cataract extraction. This was reported by Courtney and De Veer as quoted in Theodore and Schlossmann Injury to the lens capsule in the case presented here may have freed lens protein 5
392
M A X I M I L I A N Ο.
which, during absorption, produced general and local hypersensitivity; further absorption produced an anaphylactic reaction. Whether the lens capsule was ruptured at the time of the war injury or during the passage of the intraocular foreign body from the posterior segment into the anterior chamber cannot be ascertained. Another possible cause of phacoanaphylactic reaction is a hypermature traumatic cataract from which there is egression of lens proteins to precipitate anaphylactic uveitis and ultimate glaucoma. Yet Irvine and Irvine state that it is not quite clear how free lens material in the anterior chamber or, as in this case, the vitreous chamber, can cause uveitis and glaucoma. Often lens material fails to exert any nocuous influence. Lenses have been posteriorly dislocated for many years without an inflammatory or glaucomatous response. The dislocated cataractous lens may have caused cyclitis by its constant irritation of the ciliary body, with subsequent excess secretion of intraocular fluid and glaucoma. Glaucoma may also have resulted from inflammatory cell obstruction of the trabecular spaces and from anterior peripheral synechia formation. The latter was not evident in the pathologic studies. There is a considerable resemblance between the anaphylactic type of reaction and the phacotoxic reaction. The latter is caused by hypermature lens material spilling out into the ocular spaces, causing uveitis and glaucoma. The leak may occur through a
GOLDSMITH
partially torn capsule. Histologically, lymphocytic and plasma cell infiltration of the iris occurs. The ciliary body becomes inflamed with plasma cells and mononuclears. The distinguishing feature from the phacoanaphylactic type is the absence of polymorphonuclear and giant cells. SUMMARY
The case presented is unusual in that there was spontaneous migration of an intraocular foreign body from the posterior segment to the anterior chamber of the eye after nine years, accompanied by siderosis bulbi and unsuspected phacoanaphylactic endophthalmitis. Secondary glaucoma persisted until the foreign body was removed, after which hypotony was noted until the time of enucleation. The reaction of ocular tissues to both chemically active and inert substances was given. Pathologic findings and ultimate outcome of siderosis were discussed and the mechanism by which the siderotic process is believed to take place was described. The role of phacoanaphylactic endophthalmitis in the production of secondary glaucoma and its similarity to phacotoxic uveitis were considered. 1320 Cornaga Avenue. ACKNOWLEDGMENTS I wish to thank D r s . Echols, Wintrich and Burns of the house staff, and D o n W o n g of the P h o t o g r a p h y Department, Manhattan E y e , E a r and T h r o a t Hospital, as well as the A r m e d Forces Institute of P a t h o l o g y .
REFERENCES
1. D u k e - E l d e r , S.: T e x t b o o k of Ophthalmology. St. L o u i s M o s b y , 1954, pp. 6142-60, 6173, 6182-6186, 6189-6192, 6201-6209. 2. Crawford, B . : Peripatetic intraocular foreign body. Α Μ Α Arch. Ophth., 6 4 : 3 9 2 - 3 9 5 ( S e p t . ) 1960. 3. D o n o h u e , H . : Unusual case of an intraocular f o r e i g n body. A m . J. O p h t h , 4 2 : 6 4 2 - 6 4 5 ( O c t . ) 1956. 4. Gager, J , and Grayson, M . : Bilateral foreign bodies. A m . J. O p h t h , 4 2 : 6 4 6 - 6 4 7 , 1956. 5. Cross, G. : Injuries of the eye. In Berens, C. : T h e E y e and its Diseases. Philadelphia, Saunders, 1950, pp. 784, 786. 6. H a i k , G : Intraocular foreign bodies. J . A . M . A , 135:894-900 ( D e c . 6 ) 1947. 7. Albers, E . : Blackberry thorn in the anterior chamber of the e y e f o r 12 years. A r c h . O p h t h , 2 5 : 6 6 2 ( A p r . ) 1941. 8. Mishler, J , and H a r l e y , R.: Copper within the eye 3 0 years simulating tumor. A m . J. O p h t h , 3 5 : 687-690 ( M a y ) 1952.
SIDEROSIS BULBI A N D
393
ENDOPHTHALMITIS
9. Holland, M . : Siderosis bulbi and spontaneous clearing. Ara. J. O p h t h , 4 5 : 2 5 9 - 2 6 4 ( F e b . ) 1958. 10. Pollock, W . : E y e injuries': W h e r e presence of a piece of steel within the globe w a s u n k n o w n t o patient. G l a s g o w M. J , 1 2 6 : 1 2 2 - 1 2 4 ( J u l y ) 1936. 11. Cibis, P , Yamashita, T , and Rodriguez, R.: Clinical aspects of ocular siderosis and hemosiderosis. Α Μ Α A r c h . Ophth. 6 2 : 1 8 0 - 1 8 7 ( A u g . ) 1959. 12. Cibis, P , B r o w n , E , and H o n g , S . : Ocular effects of systemic siderosis, A m . J. O p h t h , 4 4 : 1 5 8 171, 1957. 13. Itoi: A c t a Soc. Ophth. Japan, 4 1 : 6 6 9 1937. 14. Irvine, S , and Irvine, Α . : Lens-induced uveitis and glaucoma. I n H a i k , G , and M c F e t r i d g e , E . : S y m p o s i u m on D i s e a s e s and S u r g e r y of the Lens. St. L o u i s , M o s b y , 1957, pp. 186-194. 15. Theodore, F , and Schlossman, Α . : Ocular A l l e r g y . Baltimore, W i l l i a m s & W i l k i n s , 1958, pp. 350352, 357.
LIGHT
COAGULATION
IN
PIGMENT
SCLERAL WALTER
J.
GEERAETS,
M.D.,
DUPONT
WILLIAM GUERRY,
Richmond,
Shortening procedures of the globe in certain cases of retinal detachment have been widely used since they were introduced. A number of modifications of the original method have been described and innovations have been introduced. The combined use of buckling procedures and light .coagulation was advocated by Linnen in 1959. Boeke applied the Custodis operation combined with light coagulation and Girard described a method of employing an encircling silicone rubber rod combined with light coagulation. 3
ATROPHY
FOLLOWING
BUCKLING*
1
2
In some instances light coagulation becomes necessary some weeks or months following surgery, when the retina and choroid underlying the buckle may have become atrophic to such an extent that the tissue becomes completely depigmented and consequently fails to absorb sufficient light to result in adequate light coagulation. In the normally pigmented eye, the first site of heat generation is the pigment epithelium and from here thermal energy is conducted posteriorly to the choroid and anteriorly to the receptor cell layer of the retina. Fast dissipation of thermal energy
* F r o m the Department of O p h t h a l m o l o g y and Research-Ophthalmology, the Medical College of Virginia. T h i s study w a s supported in part by the K n i g h t s - T e m p l a r E y e Foundation.
III,
G.
EVERETT,
M.D.,
AND
M.D.
Virginia
by blood flow prevents histologic changes in the choroid with very mild exposures, but the temperature might still rise sufficiently in the retinal pigment cells and rod and cone layers to cause protein denaturation. In this study pigmented plastic strips were embedded in the suprachoroidal space of albino rabbit eyes and light coagulation was then carried out over the area where the foreign material had been placed. This experiment was based on the assumption that the heat generated within the pigmented plastic material under light exposure would have sufficient effect on the underlying tissues by conduction to produce the desired inflammatory response. From a practical clinical standpoint it goes without saying that such pigmented plastics could be of value only in cases of scleral resection where the plastic material lies in the suprachoroidal space, or perhaps in some cases of lamellar scleral resection where the remaining sclera is left extremely thin. In such instances heat, generated in the pigmented plastic Under light exposure, is conducted from the suprachoroidal zone through the entire thickness of the richly vascularized choroid before retinal coagulation can take place; consequently greater intensity than that necessary for eyes with normal pigment epithelium is required.