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Socalled Cystic Degeneration in the Peripheral Retina
AMERICAN JOURNAL OF OPHTHALMOLOGY Vol. 10
MARCH. 1927
No. 3
SOCALLED CYSTIC DEGENERATION IN T H E PERIPHERAL RETINA. SADAMI O C H I , M . D . SAPPORO, JAPAN. This condition is found most frequently in the eyes of elderly people; but sometimes is observed in the eyes of children. The author examined histologically the eyes of fifteen diildren, aged from birth to four years and seven months. N o evidence of original degenera tion was found in neighboring cells. It is pointed out that the peripheral retina, closely con nected to the vitreous body and influenced by contraction of the ciliary muscle, is liable to lymph congestion which might lead to degenerative changes.
A t what age does the socalled cystic example of cystic degeneration among degeneration take place in the periph twenty eyeballs taken from children up eral part of thp retina? It is often to eight years old, yet he is convinced found in small spots, scattered about that he found six examples of this de generation among fifty eyeballs of the ora serrata in the peripheral part of the retina, altho it is invisible to the adults, age twenty to forty years, and ordinary ophthalmoscopic examina twenty-six examples out of fortytion. These spots present various eight eyes taken from aged people, forms, round, oval and other shapes. fifty to eighty years. This shows that These are the morphologic changes the majority of aged people suflFer from which are to be found, even in eyes this degeneration. which have never contracted disease. In giving an explanation as to the A s a rule, the retina gradually loses cause of this degeneration Greeff* con its transparent nature, in due time cluded that it is due to the fact that after death, or when the eyeball is the blood circulation of aged people is enucleated. These degenerated small prevented from going fully to the pe spots will be seen as dark in color up ripheral part of the retina, by reason of on the surface of the opaque retina. a general weakening of the heart func Thus this degeneration has been taken tion. Hovrever, he accidentally found into consideration by research workers this degeneration in the eye of a child six years old. The child was troubled in earlier days. IwanofP describes this degeneration with epibulbar cancer of the eyeball, as as xeroderma pigmentosum. as edema of the retina. However, Net- well tleship* has insisted that undoubtedly Therefore he suggested the possibility it should be called "cystic disease of of the occurrence of this degeneration the retina" rather than edema. The even in the case of children, providing word "cystic," herewith used in my there was any disturbance in the cir Salzmann" title, is based on his view. In the culation of the eyeball. most of German medical books the also recognized the same fact, namely nomenclature cystoid degeneration or that this degeneration occurs in aged "Cystoide Entartung" is commonly people; but he inferred that the beginfiting of this cystic degeneration might used. be seen at a very early age, likely be With regard to the above mentioned tween sixteen and twenty years of age. degeneration Bleschig,* one of the I admit that the cystic degeneration oldest recorders, regarded it as a nor mal condition of the retina, but in the peripheral part of the retina may Iwanoff considered it as a morbid con grow more marked with age, and have tried to determine at what age this de dition. According to the research of Iwan generation takes place. T o this end I off, it was impossible to find a single obtained the following result after 161
162
SADAMI OCHI
making many examinations from spe cimens which happened to be at hand. I made an incision in the upper or lower wall, as required, of eyeballs taken from the follo\ving' subjects: three new born babies, one t\venty-two days old, one fifty-five days old, one three months, six days old, one six months and half old, one seven months and half old, one eight months old, one nine months old, one a year and three months old, one a year, four months old, one a year, eight months old, one a year, ten months old, one two years, five months old, one two years, seven months old, one three years, eight months old (female), one four years, six months old (female), and one four
Fig. 1.—Cystic degeneration in peripheral retin.T of .π girl of 3 years and 8 months.
years, seven months old (female). A thorogoing inspection ^as made of the whole of the ])criphcral part of the retina by magnifying glass or mi croscope. After examining these eyes, as to whether there was any cystic degen eration, I examined the celloidin sec tions of the peripheral part of the ret ina prepared for histologic purposes. As a result of this examination, I per ceived an initial form of cystic degen eration in the peripheral part of the retina of eyes taken from among the last three children. Among these, a girl of three years, eight months (Fig. 1), had died after forty hours, from autointoxication; a boy of four years, six months (Fig. 2) died after the lapse of two months from tuberculous men ingitis, together with serous pleurisy of the left side; and the last, a girl of four years, seven months (Fig. 3 ) , was carried off by dysentery, twenty-two days after she was attacked. In all these cases there was nothing which indicated any form of eye disease. From what has been said above, it will be seen that the socalled cystic degeneration in the peripheral part of
the retina, which has been considered as only common among aged people, is also found in children of four years old or thereabouts who never suflfered with special eye disease; one of them died within forty hours after having been attacked. Thereff)re it is impos sible to reconcile the theory of impair ment of the circulation of the eyeball as above mentioned. Needless to say that we can often observe the cystic degeneration in the l)eripheral part of the retina among people of ten, twenty and thirty years of age, where there is no heart disease noted in postmortem examination, and where no special eye disease is concerned. In such cases the theory of the cardiac weakness, proposed by Oeeff, can hardly be substantiated. As to the formation of cystic degen eration in the retina, a theory of shrink age of cells is advocated by Kuhnt," Landberg,' and Oguchi.* This is due to the growth of a cavity in the retina by the shrinkage of cells. And the same theory has been appUed to ac count for the formation of cystic de generation in the peripheral part of the retina. If the shrinkage of cells is the main reason, we ought to be able to recog nize, in the course of our examination of the specimen taken from the periph eral part of the retina, the various processes which lead to the shrinkage of cells there. Nevertheless as yet I have no sufficient evidence in regard to this point. SoiTietiiiies we observe a few metamorphic Cells, emigrating on the part affected by cystic degenera tion in the peripheral part' of the ret ina, without having any special inflam mation. Even in this case I cannot ad mit that the cystic degeneration was caused by such metamorphic cells, but rather regard it as the result of subse quent phenomena in the formation of cystic degeneration, or some other cause. While seeking an explanation for the formation of the cystic degeneration in the peripheral part of the retina, a strik ing fact carried me back to my experi ment. When I made the experiment in the staining of the neuroglia fibers in the retina, I obtained a compara tively good result by tneans of Mallory's method at the beginning. Never-
163
CYSTIC D E G E N E R A T I O N OF R E T I N A
theless in the peripheral part of the retina, in comparison with other parts, Müller's fibers were not well colored with stain, more than 0.5 to 1.5 mm. or 2.0 mm. in extent from the ora ser rata. I tried this in various ways, and supposed that it was due to the fact that the corpus vitreum adheres fairly well to a certain surface of the retina near to the ora serrata. For this rea son it is rather hard to get solutions into the tissue of the retina in the aforesaid part, with the fixing medium or mordant. Consequently it results in the tissue of the peripheral part of the retina being colored unevenly. On the whole, the peripheral part of the retina should be reckoned as a
developes a place on which a cystic form appears! I suppose, it is by reason of the corpus vitreum being ad herent to the environs of the ora ser rata, that there should exist any alter ation of lymph between them. Thus it should be possible to force the lymph to stagnate in the peripheral part of the retina. Then the cystic de generations might gradually increase in size and number with age. This is my explanation for the growth of cystic degeneration in the peripheral part of the retina. The re sult of detailed histologic examination of the regions afliected by cystic degen eration, by using various methods of staining, gives no reason to admit, that
Fig. 2.—Cystic degeneration in retina of boy of 4 years and 6 months.
Fig. 3.—Cystic degeneration in retina of girl of 4 years and 7 months.
place where many changes take place unexpectedly. My report on the linear atrophy in the peripheral part of the retina® is indicative of this fact. This portion of the retina seems to be easily influenced by the adjoining parts, or from other causes. The peripheral part of the retina, on the one hand, is closely connected with the corpus vit reum, as mentioned above, and on the other hand it is located in a place where it might be influenced by the contraction of the ciliary muscles or the strain of the zonula of Zinn. Thus, naturally, the histologic changes might easily take place there. And if the lymph is congested in the peripheral part of the retina, it will become also stagnant in the tissue of the retina where the lymph is relatively at ease between tissue elements. Then there
the wall forms a space which consists of the connective tissue, as reported by Greeff. It is, however, to be consid ered as a mechanically enlarged space, between the tissue elements of the ret ina, where there is no special wall. It is of course expected that secondary changes might result from this en largement. The form of old cystic degeneration is considerably complicated in shape, yet I found initial forms, simple in their construction, as stated above, in the eyes of children about the age of four years. The reason I adopted the above mentioned explanation as to the formation of the cystic degeneration in the peripheral part of the retina, is en tirely due to my histologic study made on such simple cases. Imperial University.
BIBLIOGRAPHY.
1. Iwanoff. Arch. f. Ophth., vol. X V ; Ht. 2. 2. Nettleship. Roy. London Ophth! Rep., vol. V I I , part. 3 3. Bleschig. Inaug. Diss. Dorpat, 18S5. 4. Greeff. Arch. f. Augenh., vol. X L , p. 99. 5. Salzmann. Die Anat. u. Hist. d. menschi, Augapfels. 6. Knhnt. Vers. O. G. Heidelberg, 1881. 7. Landberg. .^rch f Ophth., vol. X X I I I , Ht. 1. Grundriss d. path. Hist d 8. Oguchi. Arch. f. Ophth., vol. L X X X , Ht. 3. 9. Ochi. Nippon Gank. Zasshi, vol. X X I , p. 6.
Au^e.
MARCH. 1927
No. 3
SOCALLED CYSTIC DEGENERATION IN T H E PERIPHERAL RETINA. SADAMI O C H I , M . D . SAPPORO, JAPAN. This condition is found most frequently in the eyes of elderly people; but sometimes is observed in the eyes of children. The author examined histologically the eyes of fifteen diildren, aged from birth to four years and seven months. N o evidence of original degenera tion was found in neighboring cells. It is pointed out that the peripheral retina, closely con nected to the vitreous body and influenced by contraction of the ciliary muscle, is liable to lymph congestion which might lead to degenerative changes.
A t what age does the socalled cystic example of cystic degeneration among degeneration take place in the periph twenty eyeballs taken from children up eral part of thp retina? It is often to eight years old, yet he is convinced found in small spots, scattered about that he found six examples of this de generation among fifty eyeballs of the ora serrata in the peripheral part of the retina, altho it is invisible to the adults, age twenty to forty years, and ordinary ophthalmoscopic examina twenty-six examples out of fortytion. These spots present various eight eyes taken from aged people, forms, round, oval and other shapes. fifty to eighty years. This shows that These are the morphologic changes the majority of aged people suflFer from which are to be found, even in eyes this degeneration. which have never contracted disease. In giving an explanation as to the A s a rule, the retina gradually loses cause of this degeneration Greeff* con its transparent nature, in due time cluded that it is due to the fact that after death, or when the eyeball is the blood circulation of aged people is enucleated. These degenerated small prevented from going fully to the pe spots will be seen as dark in color up ripheral part of the retina, by reason of on the surface of the opaque retina. a general weakening of the heart func Thus this degeneration has been taken tion. Hovrever, he accidentally found into consideration by research workers this degeneration in the eye of a child six years old. The child was troubled in earlier days. IwanofP describes this degeneration with epibulbar cancer of the eyeball, as as xeroderma pigmentosum. as edema of the retina. However, Net- well tleship* has insisted that undoubtedly Therefore he suggested the possibility it should be called "cystic disease of of the occurrence of this degeneration the retina" rather than edema. The even in the case of children, providing word "cystic," herewith used in my there was any disturbance in the cir Salzmann" title, is based on his view. In the culation of the eyeball. most of German medical books the also recognized the same fact, namely nomenclature cystoid degeneration or that this degeneration occurs in aged "Cystoide Entartung" is commonly people; but he inferred that the beginfiting of this cystic degeneration might used. be seen at a very early age, likely be With regard to the above mentioned tween sixteen and twenty years of age. degeneration Bleschig,* one of the I admit that the cystic degeneration oldest recorders, regarded it as a nor mal condition of the retina, but in the peripheral part of the retina may Iwanoff considered it as a morbid con grow more marked with age, and have tried to determine at what age this de dition. According to the research of Iwan generation takes place. T o this end I off, it was impossible to find a single obtained the following result after 161
162
SADAMI OCHI
making many examinations from spe cimens which happened to be at hand. I made an incision in the upper or lower wall, as required, of eyeballs taken from the follo\ving' subjects: three new born babies, one t\venty-two days old, one fifty-five days old, one three months, six days old, one six months and half old, one seven months and half old, one eight months old, one nine months old, one a year and three months old, one a year, four months old, one a year, eight months old, one a year, ten months old, one two years, five months old, one two years, seven months old, one three years, eight months old (female), one four years, six months old (female), and one four
Fig. 1.—Cystic degeneration in peripheral retin.T of .π girl of 3 years and 8 months.
years, seven months old (female). A thorogoing inspection ^as made of the whole of the ])criphcral part of the retina by magnifying glass or mi croscope. After examining these eyes, as to whether there was any cystic degen eration, I examined the celloidin sec tions of the peripheral part of the ret ina prepared for histologic purposes. As a result of this examination, I per ceived an initial form of cystic degen eration in the peripheral part of the retina of eyes taken from among the last three children. Among these, a girl of three years, eight months (Fig. 1), had died after forty hours, from autointoxication; a boy of four years, six months (Fig. 2) died after the lapse of two months from tuberculous men ingitis, together with serous pleurisy of the left side; and the last, a girl of four years, seven months (Fig. 3 ) , was carried off by dysentery, twenty-two days after she was attacked. In all these cases there was nothing which indicated any form of eye disease. From what has been said above, it will be seen that the socalled cystic degeneration in the peripheral part of
the retina, which has been considered as only common among aged people, is also found in children of four years old or thereabouts who never suflfered with special eye disease; one of them died within forty hours after having been attacked. Thereff)re it is impos sible to reconcile the theory of impair ment of the circulation of the eyeball as above mentioned. Needless to say that we can often observe the cystic degeneration in the l)eripheral part of the retina among people of ten, twenty and thirty years of age, where there is no heart disease noted in postmortem examination, and where no special eye disease is concerned. In such cases the theory of the cardiac weakness, proposed by Oeeff, can hardly be substantiated. As to the formation of cystic degen eration in the retina, a theory of shrink age of cells is advocated by Kuhnt," Landberg,' and Oguchi.* This is due to the growth of a cavity in the retina by the shrinkage of cells. And the same theory has been appUed to ac count for the formation of cystic de generation in the peripheral part of the retina. If the shrinkage of cells is the main reason, we ought to be able to recog nize, in the course of our examination of the specimen taken from the periph eral part of the retina, the various processes which lead to the shrinkage of cells there. Nevertheless as yet I have no sufficient evidence in regard to this point. SoiTietiiiies we observe a few metamorphic Cells, emigrating on the part affected by cystic degenera tion in the peripheral part' of the ret ina, without having any special inflam mation. Even in this case I cannot ad mit that the cystic degeneration was caused by such metamorphic cells, but rather regard it as the result of subse quent phenomena in the formation of cystic degeneration, or some other cause. While seeking an explanation for the formation of the cystic degeneration in the peripheral part of the retina, a strik ing fact carried me back to my experi ment. When I made the experiment in the staining of the neuroglia fibers in the retina, I obtained a compara tively good result by tneans of Mallory's method at the beginning. Never-
163
CYSTIC D E G E N E R A T I O N OF R E T I N A
theless in the peripheral part of the retina, in comparison with other parts, Müller's fibers were not well colored with stain, more than 0.5 to 1.5 mm. or 2.0 mm. in extent from the ora ser rata. I tried this in various ways, and supposed that it was due to the fact that the corpus vitreum adheres fairly well to a certain surface of the retina near to the ora serrata. For this rea son it is rather hard to get solutions into the tissue of the retina in the aforesaid part, with the fixing medium or mordant. Consequently it results in the tissue of the peripheral part of the retina being colored unevenly. On the whole, the peripheral part of the retina should be reckoned as a
developes a place on which a cystic form appears! I suppose, it is by reason of the corpus vitreum being ad herent to the environs of the ora ser rata, that there should exist any alter ation of lymph between them. Thus it should be possible to force the lymph to stagnate in the peripheral part of the retina. Then the cystic de generations might gradually increase in size and number with age. This is my explanation for the growth of cystic degeneration in the peripheral part of the retina. The re sult of detailed histologic examination of the regions afliected by cystic degen eration, by using various methods of staining, gives no reason to admit, that
Fig. 2.—Cystic degeneration in retina of boy of 4 years and 6 months.
Fig. 3.—Cystic degeneration in retina of girl of 4 years and 7 months.
place where many changes take place unexpectedly. My report on the linear atrophy in the peripheral part of the retina® is indicative of this fact. This portion of the retina seems to be easily influenced by the adjoining parts, or from other causes. The peripheral part of the retina, on the one hand, is closely connected with the corpus vit reum, as mentioned above, and on the other hand it is located in a place where it might be influenced by the contraction of the ciliary muscles or the strain of the zonula of Zinn. Thus, naturally, the histologic changes might easily take place there. And if the lymph is congested in the peripheral part of the retina, it will become also stagnant in the tissue of the retina where the lymph is relatively at ease between tissue elements. Then there
the wall forms a space which consists of the connective tissue, as reported by Greeff. It is, however, to be consid ered as a mechanically enlarged space, between the tissue elements of the ret ina, where there is no special wall. It is of course expected that secondary changes might result from this en largement. The form of old cystic degeneration is considerably complicated in shape, yet I found initial forms, simple in their construction, as stated above, in the eyes of children about the age of four years. The reason I adopted the above mentioned explanation as to the formation of the cystic degeneration in the peripheral part of the retina, is en tirely due to my histologic study made on such simple cases. Imperial University.
BIBLIOGRAPHY.
1. Iwanoff. Arch. f. Ophth., vol. X V ; Ht. 2. 2. Nettleship. Roy. London Ophth! Rep., vol. V I I , part. 3 3. Bleschig. Inaug. Diss. Dorpat, 18S5. 4. Greeff. Arch. f. Augenh., vol. X L , p. 99. 5. Salzmann. Die Anat. u. Hist. d. menschi, Augapfels. 6. Knhnt. Vers. O. G. Heidelberg, 1881. 7. Landberg. .^rch f Ophth., vol. X X I I I , Ht. 1. Grundriss d. path. Hist d 8. Oguchi. Arch. f. Ophth., vol. L X X X , Ht. 3. 9. Ochi. Nippon Gank. Zasshi, vol. X X I , p. 6.
Au^e.