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Traumatic Detachment Of Retina And Of Pars Ciliaris Retinae
515
NOTES, CASES, INSTRUMENTS TRAUMATIC DETACHMENT O F R E T I N A AND O F PARS CILIARIS R E T I N A E J O H N C. LONG, M.D., AND RALPH W. DANIELSON, M.D.
Denver, Colorado
Detachment of the pars ciliaris retinae has not been frequently recorded. Duke-Elder 1 states that the cells of this layer are attached to the pigment epithelium by the same cement substance which binds the pigment cells to gether, so that the layer does not detach as does the homologous structure in the retina. Reese,2 however, has described, as of fre quent occurrence, small cysts arising from the anterior portion of the corona ciliaris and particularly at the base of the iris. The walls of these cysts are composed in part of the nonpigmented layer and in part of the pigmented epithelium and actually represent a localized separation of the two layers. Klien3 has described both the clinical and pathologic appearance of detachment of the pars ciliaris retinae. The two cases observed clinically were both eyes containing malignant melanomas of the choroid and secondary retinal detach ments. The detached pars ciliaris retinae in both cases took the form of an avascular transparent membrane of extreme delicacy bulging toward the lens. Histologic confir mation of the diagnosis was obtained after enucleation. Detachment of the unpigmented ciliary epithelium was found in eight of 14 enu cleated eyes containing malignant tumors of the posterior segment. The condition was also observed in six enucleated eyes with re tinal detachment. In five of these the detach ment was a disinsertion and had followed violent trauma. In the sixth, the detachment had followed the perforation of a corneal ulcer. Klien states that the primary factor in the pathogenesis of detachment of the pars ciliaris retinae is an increased pressure in the subretinal space of either hemorrhagic
or transudative origin. The condition has not been observed in retinal detachment in which there is merely a reduction of the intraocular pressure. Klien points out that the presence of detachment of the pars ciliaris retinae is of considerable diagnostic significance in cases of suspected intraocular tumor. CASE REPORT
We have had the opportunity to observe a case of detachment of the pars ciliaris ret inae associated with retinal detachment. K. H., a truck driver, aged 32 years, was struck violently in the left eye with pliers in November, 1948. The blow broke his glasses and produced a scleral rupture temporally. The scleral wound was repaired by Dr. William H. Droegemueller of Greeley, Colorado, to whom we are indebted for his observations and for the opportunity of seeing the case. Dr. Droegemueller reported that there seemed to be a partial dislocation of the lens immediately after the injury. The anterior chamber was approxi mately three times the normal depth. After the scleral rupture was closed, the lens assumed the normal position. There was hypotony for a time but, by the end of a month, the eye had largely recovered. Vision improved to 20/20, although the refrac tion had changed from —1.25D. sph. to -(-0.75D. sph. C +2.0D. cyl. ax. 115°. In January, 1951, Dr. Droegemueller found a retinal detachment and re ferred the patient to us. At our examination of January 26, 1951, we found the vision of the left eye to be 20/25 with a —1.25D. sph. The anterior chamber was of normal depth. The tension was 12 mm. Hg (Schijftz). On dilatation of the pupil, a delicate grayish membrane could be seen projecting forward from the region of the ora serrata. This membrane ex-
Fig. 1 (Long and Danielson). Detachment of the pars ciliaris retinae.
NOTES, CASES, INSTRUMENTS
S16
tended from the 4:30- to the 11-o'clock position and presented a finely crenated but otherwise uni formly concave border. The membrane was trans lucent and showed faint striae which were almost horizontal. The fundus presented a most striking appear ance. There were numerous yellowish-white lines extending both above and below the disc nasally, some of them reaching well into the periphery inferiorly. These lines presented the usual appear ance of choroidal ruptures but were present un altered in areas in which the retina was detached. The detachment of the retina was rather low and was confined to the inferior periphery. Prolonged search, carried out with extreme mydriasis and with pressure over the ora, failed to reveal any tear or disinsertion. It was our impression that the retinal detachment was continuous with the detach ment of the pars ciliaris retinae. On February 7, 1951, a diathermy operation for retinal detachment was done. A double row of partially penetrating diathermy applications, using the Pischel electrode and 55 ma. of current, was carried out at 13 and 14 mm. posterior to the limbus from the 4- to 12-o'clock positions. Drainage was obtained by several punctures of the penetrating electrode anterior to the line of barrage. On two occasions, as the subretinal fluid escaped, the translucent membrane almost dis appeared, only to resume again its original position. Healing occurred without incident and resulted in complete reattachment of the retina. The de tachment of the ciliary epithelium remained un changed. Unfortunately, four months after the operation, following the extraction of a tooth, the retina
again became detached. When reexamined in March, 1952, the retina was largely detached and vision was reduced to the perception of large objects. The detached pars ciliaris retinae was clearly evident but appeared somewhat more frayed than when originally seen. ' CONCLUSIONS
We believe this to be a case of anterioi dialysis or disinsertion of the pars ciliaris retinae with separation from the pigmented epithelium. As the process extended more posteriorly, the peripheral retina also became involved in the separation. This seems to be an instance in which the retinal separation was not due to a retinal tear or disinsertion but rather to a disinsertion at the anterior margin of the ciliary epithelium, fluid enter ing the subretinal space around the edge of the torn epithelium. This case differs from those described by Klien in that the anterior margin of the pars ciliaris retinae was torn free at the iris root. In her cases the epithelium remained ad herent anteriorly and the pressure of the sub retinal fluid extending forward detached the pars ciliaris retinae and caused it to balloon forward. 324 Metropolitan Building (2).
REFERENCES
1. Duke-Elder, W. S.: Textbook of Ophthalmology. St. Louis, Mosby, 1933, v. 1, p. 64. 2. Reese, A. B.: Spontaneous cysts of the ciliary body simulating neoplasms. Tr. Am. Ophth. Soc, 47 :138-146, 1949. 3. Klien, B. A.: Detachment of the pars ciliaris retinae. Arch. Ophth., 26:347-357, 1941.
METHOD TO SET P R O S T H E S E S IN DEFORMED ORBITS* J. J. SZMYT,
M.D.
Polska, Poland
After concussions, contusions, burns, or other injuries which destroy or deform the soft tissues of the orbit, it is frequently im possible to insert the eye prosthesis after enucleation, sometimes even when the atrophic eyeball is still present. Such impedi ments to prosthesis fitting as adhesions of * From the Central Ophthalmological Dispensary.
greater or less degree, symblepharons, and deformities of the lids, often accompany these injuries, and provide further com plications. Plastic operations, using skin or mucous membrane from the mouth according to the methods of Czapody, Haitz, May, or Morton, may be necessary, and such opera tions may be performed successfully even after some time has elapsed. However, since the chief aim of a prosthesis is a cosmetic one and the lack of an eye usually depresses the patient, I sought for a new and simple
NOTES, CASES, INSTRUMENTS TRAUMATIC DETACHMENT O F R E T I N A AND O F PARS CILIARIS R E T I N A E J O H N C. LONG, M.D., AND RALPH W. DANIELSON, M.D.
Denver, Colorado
Detachment of the pars ciliaris retinae has not been frequently recorded. Duke-Elder 1 states that the cells of this layer are attached to the pigment epithelium by the same cement substance which binds the pigment cells to gether, so that the layer does not detach as does the homologous structure in the retina. Reese,2 however, has described, as of fre quent occurrence, small cysts arising from the anterior portion of the corona ciliaris and particularly at the base of the iris. The walls of these cysts are composed in part of the nonpigmented layer and in part of the pigmented epithelium and actually represent a localized separation of the two layers. Klien3 has described both the clinical and pathologic appearance of detachment of the pars ciliaris retinae. The two cases observed clinically were both eyes containing malignant melanomas of the choroid and secondary retinal detach ments. The detached pars ciliaris retinae in both cases took the form of an avascular transparent membrane of extreme delicacy bulging toward the lens. Histologic confir mation of the diagnosis was obtained after enucleation. Detachment of the unpigmented ciliary epithelium was found in eight of 14 enu cleated eyes containing malignant tumors of the posterior segment. The condition was also observed in six enucleated eyes with re tinal detachment. In five of these the detach ment was a disinsertion and had followed violent trauma. In the sixth, the detachment had followed the perforation of a corneal ulcer. Klien states that the primary factor in the pathogenesis of detachment of the pars ciliaris retinae is an increased pressure in the subretinal space of either hemorrhagic
or transudative origin. The condition has not been observed in retinal detachment in which there is merely a reduction of the intraocular pressure. Klien points out that the presence of detachment of the pars ciliaris retinae is of considerable diagnostic significance in cases of suspected intraocular tumor. CASE REPORT
We have had the opportunity to observe a case of detachment of the pars ciliaris ret inae associated with retinal detachment. K. H., a truck driver, aged 32 years, was struck violently in the left eye with pliers in November, 1948. The blow broke his glasses and produced a scleral rupture temporally. The scleral wound was repaired by Dr. William H. Droegemueller of Greeley, Colorado, to whom we are indebted for his observations and for the opportunity of seeing the case. Dr. Droegemueller reported that there seemed to be a partial dislocation of the lens immediately after the injury. The anterior chamber was approxi mately three times the normal depth. After the scleral rupture was closed, the lens assumed the normal position. There was hypotony for a time but, by the end of a month, the eye had largely recovered. Vision improved to 20/20, although the refrac tion had changed from —1.25D. sph. to -(-0.75D. sph. C +2.0D. cyl. ax. 115°. In January, 1951, Dr. Droegemueller found a retinal detachment and re ferred the patient to us. At our examination of January 26, 1951, we found the vision of the left eye to be 20/25 with a —1.25D. sph. The anterior chamber was of normal depth. The tension was 12 mm. Hg (Schijftz). On dilatation of the pupil, a delicate grayish membrane could be seen projecting forward from the region of the ora serrata. This membrane ex-
Fig. 1 (Long and Danielson). Detachment of the pars ciliaris retinae.
NOTES, CASES, INSTRUMENTS
S16
tended from the 4:30- to the 11-o'clock position and presented a finely crenated but otherwise uni formly concave border. The membrane was trans lucent and showed faint striae which were almost horizontal. The fundus presented a most striking appear ance. There were numerous yellowish-white lines extending both above and below the disc nasally, some of them reaching well into the periphery inferiorly. These lines presented the usual appear ance of choroidal ruptures but were present un altered in areas in which the retina was detached. The detachment of the retina was rather low and was confined to the inferior periphery. Prolonged search, carried out with extreme mydriasis and with pressure over the ora, failed to reveal any tear or disinsertion. It was our impression that the retinal detachment was continuous with the detach ment of the pars ciliaris retinae. On February 7, 1951, a diathermy operation for retinal detachment was done. A double row of partially penetrating diathermy applications, using the Pischel electrode and 55 ma. of current, was carried out at 13 and 14 mm. posterior to the limbus from the 4- to 12-o'clock positions. Drainage was obtained by several punctures of the penetrating electrode anterior to the line of barrage. On two occasions, as the subretinal fluid escaped, the translucent membrane almost dis appeared, only to resume again its original position. Healing occurred without incident and resulted in complete reattachment of the retina. The de tachment of the ciliary epithelium remained un changed. Unfortunately, four months after the operation, following the extraction of a tooth, the retina
again became detached. When reexamined in March, 1952, the retina was largely detached and vision was reduced to the perception of large objects. The detached pars ciliaris retinae was clearly evident but appeared somewhat more frayed than when originally seen. ' CONCLUSIONS
We believe this to be a case of anterioi dialysis or disinsertion of the pars ciliaris retinae with separation from the pigmented epithelium. As the process extended more posteriorly, the peripheral retina also became involved in the separation. This seems to be an instance in which the retinal separation was not due to a retinal tear or disinsertion but rather to a disinsertion at the anterior margin of the ciliary epithelium, fluid enter ing the subretinal space around the edge of the torn epithelium. This case differs from those described by Klien in that the anterior margin of the pars ciliaris retinae was torn free at the iris root. In her cases the epithelium remained ad herent anteriorly and the pressure of the sub retinal fluid extending forward detached the pars ciliaris retinae and caused it to balloon forward. 324 Metropolitan Building (2).
REFERENCES
1. Duke-Elder, W. S.: Textbook of Ophthalmology. St. Louis, Mosby, 1933, v. 1, p. 64. 2. Reese, A. B.: Spontaneous cysts of the ciliary body simulating neoplasms. Tr. Am. Ophth. Soc, 47 :138-146, 1949. 3. Klien, B. A.: Detachment of the pars ciliaris retinae. Arch. Ophth., 26:347-357, 1941.
METHOD TO SET P R O S T H E S E S IN DEFORMED ORBITS* J. J. SZMYT,
M.D.
Polska, Poland
After concussions, contusions, burns, or other injuries which destroy or deform the soft tissues of the orbit, it is frequently im possible to insert the eye prosthesis after enucleation, sometimes even when the atrophic eyeball is still present. Such impedi ments to prosthesis fitting as adhesions of * From the Central Ophthalmological Dispensary.
greater or less degree, symblepharons, and deformities of the lids, often accompany these injuries, and provide further com plications. Plastic operations, using skin or mucous membrane from the mouth according to the methods of Czapody, Haitz, May, or Morton, may be necessary, and such opera tions may be performed successfully even after some time has elapsed. However, since the chief aim of a prosthesis is a cosmetic one and the lack of an eye usually depresses the patient, I sought for a new and simple