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Unusual Epithelial Downgrowth*
UNUSUAL EPITHELIAL DOWNGROWTH* C O M P L I C A T I N G R E T I N A L D E T A C H M E N T SURGERY A N D OCULAR EVISCERATION J.
REIMER WOLTER,
M.D.
Ann Arbor Michigan Nonkeratinizing stratified squamous epithelium was observed to grow, in one case, on the inner surface of the retina after retinal detachment surgery and, in another case, in the scierai shell after ocular evisceration. C A S E REPORTS CASE 1
This 72-year-old man was first seen in this Eye Clinic in September, 1953, with a history of having been injured by a piece of steel in his left eye in 1952. The foreign body had been removed and the resulting cataract of the left eye also had already been successfully treated elsewhere by intracapsular extraction of the lens. The examination of the left eye in September, 1953, revealed a corneal scar, an anterior synechia, aphakia and rupture of the anterior hyaloid membrane. An operation of a senile cataract of the right eye in March, 1955, and an operation for retinal detachment in the right eye in July, I960, were done in this clinic. The detachment surgery failed and the right eye had to be removed because of blindness, pain and redness in August, 1960. The patient came back to this clinic in October, 1960, with retinal detachment in his left eye. The small left pupil with the anterior synechia did not allow for proper fundus examination. Thus, a complete iridectomy was first done in the left eye to obtain a better view. The patient was then sent elsewhere for the detachment surgery. A left scierai imbrication with an encircling silicon rod measuring 1.25 mm in diameter was done elsewhere. After this the vision of the left eye improved and the retina was seen in place on a high circular buckle. The eye soon became very uncomfortable and red, however, and the patient could only be discharged when systemic steroid treatment caused temporary clearing of the eye. After discharge, the eye soon became red and painful again despite all conservative therapeutic attempts. In January, 1961, the left eye exhibited active uveitis, 12.5 mm Hg (Schi0tz) intraocular pressure, vision of 20/200 and a conjunctival granuloma over the site where the encircling tube was buried in the sciera. The ophthalmoscopic examination revealed very hazy media. The retina was seen to be in place, however, and the high circular
Fig. 1 (Wolter). Case 1, Eye cut in half, with high equatorial buckle and silicon rod (arrow). Dense vitreous veils are seen on top of the buckle (v). (Photograph, χ4.) buckle persisted. The conjunctival granuloma was excised and cauterized several times, systemic antibiotics combined with local steroids were given and
Fig. 2 (Wolter). Case 1. Histologie section of the * From the Departments of Ophthalmology and eye with the silicon rod (r), vitreous veils (v) and Pathology of the University of Michigan Medical epithelium around the rod and on the buckle (arCenter. This study was supported by Research to row). (Paraffin section, hematoxylin-eosin, photomicrograph, χ4.) Prevent Blindness, Inc., New York. 679
680
J. REIMER WOLTER systemic steroids were tried. The eye, however, showed a slowly progressive loss of vision and increasing uveitis with much pain despite all treatment. On May 23, 1964, the eye was enucleated because of unbearable pain and blindness. HlSTOPATHOLOGY
I„* '
Λ■ Fig. 3 (Wolter). Case 1. Higher power view of the epithelized rod (r) and the layer of epithelium on the retina (arrow). (Paraffin section, hematoxylin-eosin, photomicrograph, XlO.)
Pathologic study showed this eye to be grossly deformed by the encircling silicone rod (fig. 1). The retina was in place and there were rather dense veil-like vitreous opacities in the area where the rod was buried in the sciera while the remaining vitreous was liquefied. Histologically, the eye exhibited an anterior synechia, the results of an iridectomy, aphakia and an atrophie peripheral retina (fig. 2). The encircling rod was seen on the outside of the thinned-out sciera on one side (r in fig. 2) and buried under the sciera on the other side (arrow in figs. 2 and 3). The retina was attached everywhere. Extensive chronic inflammatory reaction was found around the buried portion of the silicon rod and in the vitreous on top (v in fig. 2). Epithelium of the stratified squamous
Fig. 4 (Wolter). Case 1. High-power view of the eye showing (a) a strand of epithelium (arrow) reaching from the conjunctival surface down (b) to line the scierai space around the rod ( r ) . (Paraffin section, hematoxylin-eosin. photomicrographs, XlO.)
UNUSUAL EPITHELIAL DOWNGROWTH
681
mr^HfÀ
Fig. S (Wolter). Case 1. Epithelium on the inner surface of two areas (a and b) of the retina on the scierai buckle. In (b) epithelial cells are seen to drop off into the vitreous (arrow). (Paraffin sections, hematoxylin-eosin, photomicrographs, X300.)
nonkeratinizing type extended from the conjunctiva to the buried part of the silicon rod (figs. 3 and 4a) and surrounded the rod (figs. 3 and 4-b). The same type of epithelium also covered the inner retinal surface on the buckle (figs. 3, 5-a and 5-b). No connection between the epithelium surrounding the rod and the epithelium extending on the inner surface of the retina within the eye was found in serial sections. Epithelial cells could be seen in the process of desquamation and were floating free in the vitreous surrounded by many lymphocytes and histiocytes (fig. 5-b). There was diffuse infiltration of the whole uvea with lymphocytes and some plasma cells. Foreign-body giant cells were seen
next to the silicon rod and around silk sutures in this area. The posterior retina exhibited advanced atrophy of its inner layers and the optic nervehead was atrophie and slightly swollen. COMMENT
This seems to be the first observation of epithelial downgrowth onto the retina following retinal detachment surgery. Study of the sections as well as the clinical observation of the eye seemed to indicate that the proliferation of the epithelium on the retina was not well tolerated and caused extensive inflammatory reaction all through the eye. My examination does not allow a conclusion as to how the epithelium came into the eye.
682
J. REIMER WOLTER
It can be stated, however, that it must have come from the area of the scleral imbrication—and not from the anterior eye. The fact that the epithelium readily extended onto the intermediate retina is not surprising since the retinal surface has good nutritional conditions and since epithelium characteristically lines tissue surfaces of any kind.
HlSTOPATHOLOGY
This 12-year-old girl had an evisceration of her left globe four years ago after severe penetrating trauma. A polyethylene ball implant was placed in the scleral shell at that time. The patient did well until several months ago when it became obvious that the remaining scleral shell with the implant had become progressively larger and the prosthesis that was fitted over this had become too small. Later three cysts containing clear fluid developed on top of the eviscerated eye. An enucleation was done on September 22, 1964.
Grossly the scleral shell measured 22 by 18 by 20 mm. The inner surface of the shell was seen to be covered with a very smooth and shining layer (fig. 6-a). Histologically, all of the scleral shell (fig. 6-b) was found covered with stratified squamous epithelium of the nonkeratinizing type on its inside (fig. 7-a and b ) . A very thick basement membrane had formed everywhere between epithelium and sciera (arrows in fig. 7-a and b). The optic nervehead was found at the back of the scleral shell and could be isolated. It still showed its typical architecture (fig. 8) and exhibited narrow central vessels which contained blood (fig. 9-b). The epithelium that covered the inside of the scleral shell had extended onto
Fig. 6 (Wolter). Case 2. Gross view of the scleral shell (b) at low pow
:11 (a) and of a histologie section of the epithelized (Photographs, X3.)
CASE 2
UNUSUAL EPITHELIAL DOWNGROWTH
683
the disc (fig. 9-a) and there also formed a thick basement membrane. COMMENT
Epithelial downgrowth into a scierai shell after evisceration seems to be a rare occurrence. My earlier observation of such epithelial growth in a scierai shell, simulating a slow-growing orbital neoplasm 20 years after evisceration, is believed to be the second report of such an occurrence.1 The first case of an epithelial cyst after evisceration was reported by Potechina in the Russian literature in 1929 and is listed by DukeElder.2 The present case would, thus, be the Fig. 8 (Wolter). Case 2. The optic nervehead removed from the scierai shell. (Frozen section, Hortega, photomicrograph, XlO.) third report of this unusual complication of ocular evisceration. DISCUSSION
It is characteristic of surface epithelium to spread in a thin and regular layer and to cover tissue surfaces if there is sufficient
Fig. 7 (Wolter). Case 2. Areas of epithelium (a and b) with thick basement membrane (arrow) lining the scierai shell. (Paraffin sections, hematoxylin-eosin, photomicrographs, reduced from χΙΟΟ.)
m-> Fig. 9 (Wolter). Case 2. High-power view, showing (a) the epithelium covering the optic nervehead and exhibiting a thick basement membrane and (b) the small central vessels (arrow) and the pial structures of the atrophie nervehead. (Frozen section, Hortega, photomicrographs, reduced from XlOO.)
J. REIMER WOLTER
684
nutrition. In eye surgery and after trauma this tendency to spread and to line surfaces may lead to severe complications. Epithelial downgrowth into the anterior chamber after surgery or perforting ocular trauma is a relatively common occurrence. In such cases, the epithelium is sometimes seen to grow around the pupillary border and to extend into the vitreous space or onto the peripheral retina. In the unique first case of this report epithelium proliferated on the intermediate retina in the area of an encircling silicon rod. Epithelium was also found to surround the buried portion of the rod. It is important to note that this eye with the epithelium on the retina and around a part of the encircling rod had been continuously and excessively red and painful after the retinal detachment operation, that its severe chronic irritation resisted all treatment and that the eye finally became blind. It may be learned from this case that epithelium may gain access to the
inner eye at or after retinal detachment surgery and that epithelium does not seem to be tolerated well in the eye. The second case of epithelization of a scierai shell with ball implant after ocular evisceration for trauma indicates that epithelium can survive on the bare sciera and cause trouble many years later. It is important to emphasize that both known cases of epithelization of such a scierai shell occurred in childhood when all tissues are looser and more vascularized. One should be careful, therefore, not to enclose epithelium under cornea or sciera in ocular eviscerations, especially in children. SUMMARY
The first case of epithelization of the retina after retinal detachment surgery and the third case of epithelization of a scierai shell after ocular evisceration are reported. Eye Clinic University Hospital (48104)
REFERENCES
1. Wolter, J. : Epithelial downgrowth following evisceration, simulating orbital neoplasm. Am. J. Ophth., 55:1160, 1963. 2. Duke-Elder, S. : Textbook of Ophthalmology. St. Louis, Mosby, 1938, v. 2, p. 2067.
T H E U S E O F ALLOPLASTICS* I N 45 CASES OF ORBITAL FLOOR RECONSTRUCTION CARROLL
W.
BROWNING,
M.D., AND ROBERT V. Dallas, Texas
Four and one-half years ago the Divisions of Ophthalmology and Oral Surgery of this university initiated a clinical investigation of the reliability and safety of the use of alloplastic materials for orbital floor * From the Divisions of Ophthalmology and Oral Surgery, Department of Surgery, University of Texas Southwestern Medical School. Commercial sources of implant materials. (1) Polyethylene, 3-mm sheeting, Clay-Adams Co., 141 East 25th Street, New York 10; (2) silicone (Vivosil), 3-mm sheeting, Becton-Dickinson Co.,
WALKER,
D.D.S.
reconstruction. To date 45 cases of comminuted orbital floor fractures have been reconstructed using the synthetics of polyethylene, silicone D.C., Supramyd, and Cranioplast (table 1). In the following report are presented the highlights of our experiences. The patients Rutherford, New Jersey; (3) Supramyd, 2-mm sheeting, Dr. S. Jackson, 4839 Del Ray Avenue, Bethesda, Maryland; (4) Cranioplast, "Cranioplast kit," Codman & Shurtliff, 194 Brookline Avenue, Boston 15, Massachusetts.
REIMER WOLTER,
M.D.
Ann Arbor Michigan Nonkeratinizing stratified squamous epithelium was observed to grow, in one case, on the inner surface of the retina after retinal detachment surgery and, in another case, in the scierai shell after ocular evisceration. C A S E REPORTS CASE 1
This 72-year-old man was first seen in this Eye Clinic in September, 1953, with a history of having been injured by a piece of steel in his left eye in 1952. The foreign body had been removed and the resulting cataract of the left eye also had already been successfully treated elsewhere by intracapsular extraction of the lens. The examination of the left eye in September, 1953, revealed a corneal scar, an anterior synechia, aphakia and rupture of the anterior hyaloid membrane. An operation of a senile cataract of the right eye in March, 1955, and an operation for retinal detachment in the right eye in July, I960, were done in this clinic. The detachment surgery failed and the right eye had to be removed because of blindness, pain and redness in August, 1960. The patient came back to this clinic in October, 1960, with retinal detachment in his left eye. The small left pupil with the anterior synechia did not allow for proper fundus examination. Thus, a complete iridectomy was first done in the left eye to obtain a better view. The patient was then sent elsewhere for the detachment surgery. A left scierai imbrication with an encircling silicon rod measuring 1.25 mm in diameter was done elsewhere. After this the vision of the left eye improved and the retina was seen in place on a high circular buckle. The eye soon became very uncomfortable and red, however, and the patient could only be discharged when systemic steroid treatment caused temporary clearing of the eye. After discharge, the eye soon became red and painful again despite all conservative therapeutic attempts. In January, 1961, the left eye exhibited active uveitis, 12.5 mm Hg (Schi0tz) intraocular pressure, vision of 20/200 and a conjunctival granuloma over the site where the encircling tube was buried in the sciera. The ophthalmoscopic examination revealed very hazy media. The retina was seen to be in place, however, and the high circular
Fig. 1 (Wolter). Case 1, Eye cut in half, with high equatorial buckle and silicon rod (arrow). Dense vitreous veils are seen on top of the buckle (v). (Photograph, χ4.) buckle persisted. The conjunctival granuloma was excised and cauterized several times, systemic antibiotics combined with local steroids were given and
Fig. 2 (Wolter). Case 1. Histologie section of the * From the Departments of Ophthalmology and eye with the silicon rod (r), vitreous veils (v) and Pathology of the University of Michigan Medical epithelium around the rod and on the buckle (arCenter. This study was supported by Research to row). (Paraffin section, hematoxylin-eosin, photomicrograph, χ4.) Prevent Blindness, Inc., New York. 679
680
J. REIMER WOLTER systemic steroids were tried. The eye, however, showed a slowly progressive loss of vision and increasing uveitis with much pain despite all treatment. On May 23, 1964, the eye was enucleated because of unbearable pain and blindness. HlSTOPATHOLOGY
I„* '
Λ■ Fig. 3 (Wolter). Case 1. Higher power view of the epithelized rod (r) and the layer of epithelium on the retina (arrow). (Paraffin section, hematoxylin-eosin, photomicrograph, XlO.)
Pathologic study showed this eye to be grossly deformed by the encircling silicone rod (fig. 1). The retina was in place and there were rather dense veil-like vitreous opacities in the area where the rod was buried in the sciera while the remaining vitreous was liquefied. Histologically, the eye exhibited an anterior synechia, the results of an iridectomy, aphakia and an atrophie peripheral retina (fig. 2). The encircling rod was seen on the outside of the thinned-out sciera on one side (r in fig. 2) and buried under the sciera on the other side (arrow in figs. 2 and 3). The retina was attached everywhere. Extensive chronic inflammatory reaction was found around the buried portion of the silicon rod and in the vitreous on top (v in fig. 2). Epithelium of the stratified squamous
Fig. 4 (Wolter). Case 1. High-power view of the eye showing (a) a strand of epithelium (arrow) reaching from the conjunctival surface down (b) to line the scierai space around the rod ( r ) . (Paraffin section, hematoxylin-eosin. photomicrographs, XlO.)
UNUSUAL EPITHELIAL DOWNGROWTH
681
mr^HfÀ
Fig. S (Wolter). Case 1. Epithelium on the inner surface of two areas (a and b) of the retina on the scierai buckle. In (b) epithelial cells are seen to drop off into the vitreous (arrow). (Paraffin sections, hematoxylin-eosin, photomicrographs, X300.)
nonkeratinizing type extended from the conjunctiva to the buried part of the silicon rod (figs. 3 and 4a) and surrounded the rod (figs. 3 and 4-b). The same type of epithelium also covered the inner retinal surface on the buckle (figs. 3, 5-a and 5-b). No connection between the epithelium surrounding the rod and the epithelium extending on the inner surface of the retina within the eye was found in serial sections. Epithelial cells could be seen in the process of desquamation and were floating free in the vitreous surrounded by many lymphocytes and histiocytes (fig. 5-b). There was diffuse infiltration of the whole uvea with lymphocytes and some plasma cells. Foreign-body giant cells were seen
next to the silicon rod and around silk sutures in this area. The posterior retina exhibited advanced atrophy of its inner layers and the optic nervehead was atrophie and slightly swollen. COMMENT
This seems to be the first observation of epithelial downgrowth onto the retina following retinal detachment surgery. Study of the sections as well as the clinical observation of the eye seemed to indicate that the proliferation of the epithelium on the retina was not well tolerated and caused extensive inflammatory reaction all through the eye. My examination does not allow a conclusion as to how the epithelium came into the eye.
682
J. REIMER WOLTER
It can be stated, however, that it must have come from the area of the scleral imbrication—and not from the anterior eye. The fact that the epithelium readily extended onto the intermediate retina is not surprising since the retinal surface has good nutritional conditions and since epithelium characteristically lines tissue surfaces of any kind.
HlSTOPATHOLOGY
This 12-year-old girl had an evisceration of her left globe four years ago after severe penetrating trauma. A polyethylene ball implant was placed in the scleral shell at that time. The patient did well until several months ago when it became obvious that the remaining scleral shell with the implant had become progressively larger and the prosthesis that was fitted over this had become too small. Later three cysts containing clear fluid developed on top of the eviscerated eye. An enucleation was done on September 22, 1964.
Grossly the scleral shell measured 22 by 18 by 20 mm. The inner surface of the shell was seen to be covered with a very smooth and shining layer (fig. 6-a). Histologically, all of the scleral shell (fig. 6-b) was found covered with stratified squamous epithelium of the nonkeratinizing type on its inside (fig. 7-a and b ) . A very thick basement membrane had formed everywhere between epithelium and sciera (arrows in fig. 7-a and b). The optic nervehead was found at the back of the scleral shell and could be isolated. It still showed its typical architecture (fig. 8) and exhibited narrow central vessels which contained blood (fig. 9-b). The epithelium that covered the inside of the scleral shell had extended onto
Fig. 6 (Wolter). Case 2. Gross view of the scleral shell (b) at low pow
:11 (a) and of a histologie section of the epithelized (Photographs, X3.)
CASE 2
UNUSUAL EPITHELIAL DOWNGROWTH
683
the disc (fig. 9-a) and there also formed a thick basement membrane. COMMENT
Epithelial downgrowth into a scierai shell after evisceration seems to be a rare occurrence. My earlier observation of such epithelial growth in a scierai shell, simulating a slow-growing orbital neoplasm 20 years after evisceration, is believed to be the second report of such an occurrence.1 The first case of an epithelial cyst after evisceration was reported by Potechina in the Russian literature in 1929 and is listed by DukeElder.2 The present case would, thus, be the Fig. 8 (Wolter). Case 2. The optic nervehead removed from the scierai shell. (Frozen section, Hortega, photomicrograph, XlO.) third report of this unusual complication of ocular evisceration. DISCUSSION
It is characteristic of surface epithelium to spread in a thin and regular layer and to cover tissue surfaces if there is sufficient
Fig. 7 (Wolter). Case 2. Areas of epithelium (a and b) with thick basement membrane (arrow) lining the scierai shell. (Paraffin sections, hematoxylin-eosin, photomicrographs, reduced from χΙΟΟ.)
m-> Fig. 9 (Wolter). Case 2. High-power view, showing (a) the epithelium covering the optic nervehead and exhibiting a thick basement membrane and (b) the small central vessels (arrow) and the pial structures of the atrophie nervehead. (Frozen section, Hortega, photomicrographs, reduced from XlOO.)
J. REIMER WOLTER
684
nutrition. In eye surgery and after trauma this tendency to spread and to line surfaces may lead to severe complications. Epithelial downgrowth into the anterior chamber after surgery or perforting ocular trauma is a relatively common occurrence. In such cases, the epithelium is sometimes seen to grow around the pupillary border and to extend into the vitreous space or onto the peripheral retina. In the unique first case of this report epithelium proliferated on the intermediate retina in the area of an encircling silicon rod. Epithelium was also found to surround the buried portion of the rod. It is important to note that this eye with the epithelium on the retina and around a part of the encircling rod had been continuously and excessively red and painful after the retinal detachment operation, that its severe chronic irritation resisted all treatment and that the eye finally became blind. It may be learned from this case that epithelium may gain access to the
inner eye at or after retinal detachment surgery and that epithelium does not seem to be tolerated well in the eye. The second case of epithelization of a scierai shell with ball implant after ocular evisceration for trauma indicates that epithelium can survive on the bare sciera and cause trouble many years later. It is important to emphasize that both known cases of epithelization of such a scierai shell occurred in childhood when all tissues are looser and more vascularized. One should be careful, therefore, not to enclose epithelium under cornea or sciera in ocular eviscerations, especially in children. SUMMARY
The first case of epithelization of the retina after retinal detachment surgery and the third case of epithelization of a scierai shell after ocular evisceration are reported. Eye Clinic University Hospital (48104)
REFERENCES
1. Wolter, J. : Epithelial downgrowth following evisceration, simulating orbital neoplasm. Am. J. Ophth., 55:1160, 1963. 2. Duke-Elder, S. : Textbook of Ophthalmology. St. Louis, Mosby, 1938, v. 2, p. 2067.
T H E U S E O F ALLOPLASTICS* I N 45 CASES OF ORBITAL FLOOR RECONSTRUCTION CARROLL
W.
BROWNING,
M.D., AND ROBERT V. Dallas, Texas
Four and one-half years ago the Divisions of Ophthalmology and Oral Surgery of this university initiated a clinical investigation of the reliability and safety of the use of alloplastic materials for orbital floor * From the Divisions of Ophthalmology and Oral Surgery, Department of Surgery, University of Texas Southwestern Medical School. Commercial sources of implant materials. (1) Polyethylene, 3-mm sheeting, Clay-Adams Co., 141 East 25th Street, New York 10; (2) silicone (Vivosil), 3-mm sheeting, Becton-Dickinson Co.,
WALKER,
D.D.S.
reconstruction. To date 45 cases of comminuted orbital floor fractures have been reconstructed using the synthetics of polyethylene, silicone D.C., Supramyd, and Cranioplast (table 1). In the following report are presented the highlights of our experiences. The patients Rutherford, New Jersey; (3) Supramyd, 2-mm sheeting, Dr. S. Jackson, 4839 Del Ray Avenue, Bethesda, Maryland; (4) Cranioplast, "Cranioplast kit," Codman & Shurtliff, 194 Brookline Avenue, Boston 15, Massachusetts.