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Posttraumatic Ocular Tuberculosis
POSTTRAUMATIC OCULAR TUBERCULOSIS NELSON
MILES
BLACK,
M.D.,
F.A.C.S.,
A N D
HERBERT
HAESSLER,
M.D.
M I L W A U K E E
Eye lesions following trauma are described in two cases. The one is certainly, the other probably tuberculous. The literature is reviewed for similar lesions. Read before the American Academy of Ophthalmology and Otolaryngology, October 21-25, 1929.
Posttraumatic ocular tuberculosis is an infrequently observed occurrence. Our own experience is limited to two cases, one of which is not unequivocal, and a search through the literature resulted in a rather meager yield. Case 1 Mrs. D. H., age seventy years, was first seen in October, 1926. Aside from incipient cataract with well marked radial opacities in the lenticular cortex, both eyes were free from abnormality. She was given dionin and potassium iodide solution, and by November, 1927, the lenticular opacities had advanced to a degree to make operation seem advisable. A combined iridectomy and extraction was done under local anesthesia on November 15, 1927. The eye healed satisfactorily. On discharge from the hospital November 28, 1 9 ^ , it was grossly normal with only slight hyperemia and a white mass presumably of lens cortex in the pupillary area. A sUt-lamp examination on this day revealed a shallow anterior chamber, with a large white mass, possibly exudate, interposed between the center of the cornea and the vitreous which presented in the pupillary area. The vitreous bulged so that it was nearly in contact with the cornea, and it was heavily sprinkled with large and small pigmented deposits. The iris was adherent to the vitreous and had several widely dilated bloodvessels visible in its tissue. With correcting lens the eye had a visual acuity of 6/10. In January, 1928, the eye was still hyperemic, the media somewhat hazy, and the visual acuity 6/12. In February the eye was more red and a rather thick )lastic exudate filled the entire colo)oma of the iris. Deep corneal vascularization was observed and the dilatation of the iris vessels was striking. She
was seen occasionally during the year (she came from another city). In October, 1928, we noted that the iris presented a picture typical of tuberculosis. The cornea was opaque and vascularized in the upper quadrant and there were very numerous unpigmented postcorneal deposits varying from the finest granules to large lardlike masses. The anterior chamber was shallow. The iris was firmly bound to a pseudomembrane of plastic exudate which filled the pupillary area and by its contraction displaced the iris upward. Only two small openings into the posterior chamber could be found. Distributed through the iris stroma were nine pearly grey, translucent, protruding masses, chiefly peripherally placed, though one or two were in the pupillary zone of the iris. Many of them were surrounded by dilated bloodvessels. Kriickmann's plate in the Graefe-Saemisch Handbuch illustrates this clinical picture precisely. An internist who examined her generally at this time made a diagnosis of active pulmonary tuberculosis based chiefly on the presence of fine rales over the upper right lobe and a loss of one-fifth of her body weight. There was little rise in temperature. The Wassermann reaction was negative. In August, 1929, the eye was free from hyperemia, the posterior surface of the cornea had become practically free from deposits, and the lesions interpreted as tubercles had begun to undergo retrogression. Most of these were replaced by atrophic spots in the iris stroma. To be sure, the iris picture here is not pathognomonic of tuberculosis. There is probably no form of tissue reaction in the iris which can definitely be traced to only one particular etrølogical agent. However, in the presence of an active tuberculous process in the lung, a nega-
139
140
BLACK A N D
live Wassermann reaction, and an iris presenting a clinical appearance which has until recently been generally considered as pathognomonic of tuberculosis, it seems probable that the iritis in this case was tuberculous. Case 2 A child seen at the Milwaukee Children's Hospital exhibited bilateral iritis following trauma to one eye. The child, ten years old, was struck in the eye with a piece of ice, without rupture or penetration of the eyeball. Two months later his vision was greatly decreased, and he entered the hospital with a bilateral uveitis and partial cataract. The iris in each eye was swollen and there were many synechiæ, and a thick membrane of plastic exudate in the pupillary area, as well as numerous thick unpigmented postcorneal deposits. Tuberculosis was suspected, but the internist could find no evidence of a tuberculous focus elsewhere in the body. There was no rise of temperature, no reaction to an injection of one milligram of old tuberculin. A satisfactory x-ray plate showed no evidence of intrathoracic tuberculosis. Liver and spleen were not palpable and the Wassermann was negative. Despite the vigorous local treatment with nonspecific protein therapy, administered during a long stay in the hospital, the eyes grew steadily worse. One year after the injury, translucent, sharply defined greyish swellings were seen in the iris. The appearance of the iris was in every way as characteristic of tuberculosis as in the first case described. Of course the negative Wassermann reaction does not entirely rule out syphilis, but it surely is more significant than the negative findings in a search for tuberculosis. It is also impossible to say whether the iritis is secondary to a form of infection neither tuberculous nor syphilitic. The possibility of sympathetic ophthalmia must be considered, but in the absence of evidence of perforation of either eyeball this thought has scant support. In his collective review in the Grae>fe-
HAESSLER
Saemisch Handbuch Wagenmann mentions four cases similar to our second one, but none like the first. Dr. Jonas Friedenwald was kind enough to send us the following note on a case observed by him: "The patient was a young man who had recurrent hemorrhages in the vitreous over a period of a year or more. Cataract e\entual!y developed and was extracted (not by me). Following the extraction a severe uveitis developed and the eyeball had to be enucleated. The histological examination showed a conglomerate tubercle in the flat part of the ciliary body which had discharged into the vitreous. There were miliary tubercles on the surface of the iris, on the under surface of the cornea, in the iris stroma, about the canal of Schlemm, in the sclera at the limbus, and in the episcleral tissue. There were also miliary tubercles in the choroid far anteriorly and about the retinal veins. The retina was completely detached ; lens absent; beginning phthisis bulbi. The case presents a beautiful confirmation of Dr. Verhoeff's theory that tuberculous kerato-iritis is the result of a discharge of tubercle bacilli fnto the vitreous from a localized caseous lesion in the ciliary body or farther back in the eyeball." F. W. Block reports his observations on a patient whose eye had been injured by a red hot splinter of iron. One month later he entered the clinic with a severe iritis, with hypopyon and numerous synechiæ. The cornea was hazy and had a linear scar. The eye healed under local treatment but a linear iris defect was discovered under the corneal scar. No evidence of intraocular foreign body or syphilis was found. The iritis recurred and a diagnosis of tuberculosis was made on the basis of the reaction to tuberculin. Block found no similar cases in the literature. He mentioned Müller's case of intraocular tuberculosis following a perforating injury as doubtless ectogenic. 120 East Wisconsin avenue
Reference Block, F. W., Klin. M. f. Augenh., 1921, v. 67, p. 581.
MILES
BLACK,
M.D.,
F.A.C.S.,
A N D
HERBERT
HAESSLER,
M.D.
M I L W A U K E E
Eye lesions following trauma are described in two cases. The one is certainly, the other probably tuberculous. The literature is reviewed for similar lesions. Read before the American Academy of Ophthalmology and Otolaryngology, October 21-25, 1929.
Posttraumatic ocular tuberculosis is an infrequently observed occurrence. Our own experience is limited to two cases, one of which is not unequivocal, and a search through the literature resulted in a rather meager yield. Case 1 Mrs. D. H., age seventy years, was first seen in October, 1926. Aside from incipient cataract with well marked radial opacities in the lenticular cortex, both eyes were free from abnormality. She was given dionin and potassium iodide solution, and by November, 1927, the lenticular opacities had advanced to a degree to make operation seem advisable. A combined iridectomy and extraction was done under local anesthesia on November 15, 1927. The eye healed satisfactorily. On discharge from the hospital November 28, 1 9 ^ , it was grossly normal with only slight hyperemia and a white mass presumably of lens cortex in the pupillary area. A sUt-lamp examination on this day revealed a shallow anterior chamber, with a large white mass, possibly exudate, interposed between the center of the cornea and the vitreous which presented in the pupillary area. The vitreous bulged so that it was nearly in contact with the cornea, and it was heavily sprinkled with large and small pigmented deposits. The iris was adherent to the vitreous and had several widely dilated bloodvessels visible in its tissue. With correcting lens the eye had a visual acuity of 6/10. In January, 1928, the eye was still hyperemic, the media somewhat hazy, and the visual acuity 6/12. In February the eye was more red and a rather thick )lastic exudate filled the entire colo)oma of the iris. Deep corneal vascularization was observed and the dilatation of the iris vessels was striking. She
was seen occasionally during the year (she came from another city). In October, 1928, we noted that the iris presented a picture typical of tuberculosis. The cornea was opaque and vascularized in the upper quadrant and there were very numerous unpigmented postcorneal deposits varying from the finest granules to large lardlike masses. The anterior chamber was shallow. The iris was firmly bound to a pseudomembrane of plastic exudate which filled the pupillary area and by its contraction displaced the iris upward. Only two small openings into the posterior chamber could be found. Distributed through the iris stroma were nine pearly grey, translucent, protruding masses, chiefly peripherally placed, though one or two were in the pupillary zone of the iris. Many of them were surrounded by dilated bloodvessels. Kriickmann's plate in the Graefe-Saemisch Handbuch illustrates this clinical picture precisely. An internist who examined her generally at this time made a diagnosis of active pulmonary tuberculosis based chiefly on the presence of fine rales over the upper right lobe and a loss of one-fifth of her body weight. There was little rise in temperature. The Wassermann reaction was negative. In August, 1929, the eye was free from hyperemia, the posterior surface of the cornea had become practically free from deposits, and the lesions interpreted as tubercles had begun to undergo retrogression. Most of these were replaced by atrophic spots in the iris stroma. To be sure, the iris picture here is not pathognomonic of tuberculosis. There is probably no form of tissue reaction in the iris which can definitely be traced to only one particular etrølogical agent. However, in the presence of an active tuberculous process in the lung, a nega-
139
140
BLACK A N D
live Wassermann reaction, and an iris presenting a clinical appearance which has until recently been generally considered as pathognomonic of tuberculosis, it seems probable that the iritis in this case was tuberculous. Case 2 A child seen at the Milwaukee Children's Hospital exhibited bilateral iritis following trauma to one eye. The child, ten years old, was struck in the eye with a piece of ice, without rupture or penetration of the eyeball. Two months later his vision was greatly decreased, and he entered the hospital with a bilateral uveitis and partial cataract. The iris in each eye was swollen and there were many synechiæ, and a thick membrane of plastic exudate in the pupillary area, as well as numerous thick unpigmented postcorneal deposits. Tuberculosis was suspected, but the internist could find no evidence of a tuberculous focus elsewhere in the body. There was no rise of temperature, no reaction to an injection of one milligram of old tuberculin. A satisfactory x-ray plate showed no evidence of intrathoracic tuberculosis. Liver and spleen were not palpable and the Wassermann was negative. Despite the vigorous local treatment with nonspecific protein therapy, administered during a long stay in the hospital, the eyes grew steadily worse. One year after the injury, translucent, sharply defined greyish swellings were seen in the iris. The appearance of the iris was in every way as characteristic of tuberculosis as in the first case described. Of course the negative Wassermann reaction does not entirely rule out syphilis, but it surely is more significant than the negative findings in a search for tuberculosis. It is also impossible to say whether the iritis is secondary to a form of infection neither tuberculous nor syphilitic. The possibility of sympathetic ophthalmia must be considered, but in the absence of evidence of perforation of either eyeball this thought has scant support. In his collective review in the Grae>fe-
HAESSLER
Saemisch Handbuch Wagenmann mentions four cases similar to our second one, but none like the first. Dr. Jonas Friedenwald was kind enough to send us the following note on a case observed by him: "The patient was a young man who had recurrent hemorrhages in the vitreous over a period of a year or more. Cataract e\entual!y developed and was extracted (not by me). Following the extraction a severe uveitis developed and the eyeball had to be enucleated. The histological examination showed a conglomerate tubercle in the flat part of the ciliary body which had discharged into the vitreous. There were miliary tubercles on the surface of the iris, on the under surface of the cornea, in the iris stroma, about the canal of Schlemm, in the sclera at the limbus, and in the episcleral tissue. There were also miliary tubercles in the choroid far anteriorly and about the retinal veins. The retina was completely detached ; lens absent; beginning phthisis bulbi. The case presents a beautiful confirmation of Dr. Verhoeff's theory that tuberculous kerato-iritis is the result of a discharge of tubercle bacilli fnto the vitreous from a localized caseous lesion in the ciliary body or farther back in the eyeball." F. W. Block reports his observations on a patient whose eye had been injured by a red hot splinter of iron. One month later he entered the clinic with a severe iritis, with hypopyon and numerous synechiæ. The cornea was hazy and had a linear scar. The eye healed under local treatment but a linear iris defect was discovered under the corneal scar. No evidence of intraocular foreign body or syphilis was found. The iritis recurred and a diagnosis of tuberculosis was made on the basis of the reaction to tuberculin. Block found no similar cases in the literature. He mentioned Müller's case of intraocular tuberculosis following a perforating injury as doubtless ectogenic. 120 East Wisconsin avenue
Reference Block, F. W., Klin. M. f. Augenh., 1921, v. 67, p. 581.