VOL. 64, NO. 3 RETINAL EDEMA 449

finding; the patient is being followed close-

SUMMARY

Two cases of unilateral retinal edema sec­ondary to oral contraceptives are presented. When The Pill was discontinued, the retinal edema disappeared. When therapy was re­sumed, the same retinal lesion recurred. Both cases had complete resolution of reti­

nal edema, with no sequelae, when the oral contraceptives were again withheld.

Suite 2419, Prudential Plaza (60601)

REFERENCES

1. Walsh, F. B., Clark, D. B., Thompson, R. S. and Nicholson, D. H. : Oral contraceptives and neuro-ophthalmologic interest. Arch. Ophth. 74:628, 1965.

2. Flynn, M. A. and Esterly, D. B. : Ocular manifestations after Enovid. Am. J. Ophth. 61:907, 1966.

DETACHMENT O F T H E CORNEAL ENDOTHELIUM

I N P U R U L E N T KERATITIS AND ULCÉRATION

J. REIMER WOLTER, M.D. Ann Arbor, Michigan

Recent observations of retrocorneal mem­branes occurring as a complication of pene­trating keratoplasty1 have created new inter­est in the basic nature of the different patho­logic processes which may lead to anterior chamber membranes under various patho­logic conditions. Membranes of prolifer­ating mesodermal stroma and of detachment,1

splitting2 or new formation1-3 of Descemet's glass layer are examples.

Spontaneous membranelike desquamation of the corneal endothelium with a focal pro­liferation of free-floating endothelial cells was observed histologically in a human eye with subacute purulent keratitis and corneal ulcération in the present case.

CASE HISTORY

This 48-year-old woman had an injury to her right lid and supraorbital region at the age of 17 years. Following this, she developed chronic fron­tal and ethmoidal sinusitis as well as a chronic orbital abscess with continuous drainage from above the right eye. This was resistant to treat­ment and caused persistant proptosis. Finally, a severe exposure keratitis developed and led to

From the Departments of Ophthalmology and Pathology, University of Michigan Medical Cen­ter. This study was supported in part by Re­search to Prevent Blindness, Inc., New York.

deep acute and purulent corneal ulcération. The blind right eye was enucleated on January 17, 1967.

PATHOLOGIC FINDINGS

The right globe was normal in size and grossly exhibited corneal scarring and ulcér­ation. There also were much scierai scar­ring, pus in the anterior chamber and a cat­aract. Microscopic study showed almost total destruction of the corneal epithelium. Bowman's membrane was also missing on the central and inferior corneal surface. This area exhibited extensive corneal ulcér­ation involving the superficial stroma. Mas­sive accumulations of polymorphonuclear leukocytes were seen at the base of this ulcer. The deeper stroma had survived but it was swollen and showed infiltration with poly­morphonuclear leukocytes between its lamel­lae. Descemet's membrane was continuous.

Detachment of the endothelium in a somehwat irregular layer was observed in the zone of the corneal ulcer (fig. 1). All endothelial cells were missing from Desce­met's membrane in this zone and they were found floating free in the anterior chamber surrounded by pus (figs. 2 and 3) . Serial sections showed that these cells were still

450 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER, 1967

Fig. 1 (Wolter). Low-power view of cornea with central ulcer (u) and the detached endothelium in back of it (arrows). (Paraffin section, hematoxylin-eosin. photomicrograph, X ISO.)

1·ιΐί 2 (Wnllir) Tin· uict>iil.ir miiiilu ane of dcudiul cornea! ciidullichum (.arrows) fkuling freely in the anterior chamber surrounded by pus. Descemet's membrane without endothelial cells is seen in the top part of the picture. (Paraffin sec­tion, hematoxylin-eosin, photomicrograph, X2S0.)

part of a continuous membrane which exhi­bited many folds and defects. Higher power showed these cells to be swollen but they were not necrotic or dying (figs. 3 and 4) . At the margin of the ulcer the zone of the detachment of the endothelial cells from their normal site on Descemet's membrane could be seen (fig. 4) . Peripheral to this margin, the endothelial cells were somewhat swollen but appeared otherwise normal and were in firm contact with Descemet's mem­brane.

An island of proliferating endothelial cells was found in the anterior chamber about opposite to the center of the ulcer (fig. 5). Serial sections were used to confirm that this really represented an is­land of cells and not just a sheet of cells

Fig. 3 (Wolter). High-power view of the mem­brane of desquamated corneal endothelium floating in the anterior chamber (arrow). (Paraffin sec­tion, hematoxylin-eosin, photomicrograph, X800.)

VOL. 64, NO. 3 DETACHMENT OF CORNEAL ENDOTHELIUM 451

Fig. 4 (Wolter). Margin of endothelial detachment with endothelial cells on Descemet's membrane on the upper left. Desquamated endothelium is seen on the lower right. (Paraffin section, hematoxylin-eosin, photomicrograph, X800.)

seen in flat section. Higher power showed these cells to be alive but no mitoses were found (fig. 6) .

Pus filled most of the anterior chamber and the chamber angle. Pus also surrounded the desquamated endothelial cells. Iris and ciliary body showed few mononuclear inflammatory cells. There were posterior synechiae. The lens showed very early sub-capsular cataractous changes. The posterior portion of this eye was normal except for some early papilledema. Tenon's space on the outside of the sciera showed extensive scarring as well as diffuse lymphocytic infiltration. The histopathologic diagnosis was: Acute purulent keratitis and corneal ulcération in an eye with long-standing ex­posure keratitis and also exhibiting partial membranous desquamation of the corneal

endothelium, hypopyon, secondary iritis, early cataract and papilledema.

COMMENTS

Electron-microscopic studies have shown that each cell of the corneal endothelium is anchored to its neighbor by extensive inter-digitations of the cell surfaces.4 This per­mits the normal endothelium to be stripped off in sheets. Samuels and Fuchs6 stated that "detachment of the endothelium is a rare cause of defects in the endothelium mosaic. This is brought about by edema of the parenchyma, lifting the endothelium into flat vesicles." Except for this description, no histologie demonstrations of detachment of the human corneal endothelium were found in the literature.

Desquamation of single endothelial cells,

452 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER, 1967

on the other hand, has been demonstrated by various authors.610 Such desquamation has been explained with toxic or traumatic corneal involvement. It has been said that desquamated endothelial cells may gain lim­ited amoebic and phagocytic abilities.11

Chi, Teng and Katzin9 stated that the en-dothelium in back of corneal ulcers which they studied histologically appeared well preserved. The extensive membranelike des­quamation of the endothelium in the present case may be explained by the extended course of the keratitis and ulcération. This desquamation—especially in its association with proliferation of the free-floating cells in one area—represents a remarkable and unique observation that gives new insight into the reactive possibilities of the corneal

Fig. 5 (Wolter). The island of proliferating en­dothelial cells (arrow) in the anterior chamber surrounded by pus in back of the corneal ulcer. Cells on Descemet's membrane are inflammatory cells, not endothelium. (Paraffin section, hematoxy-lin-eosin, photomicrograph, X250.)

Fig. 6 (Wolter). The proliferating corneal en­dothelium in the anterior chamber seen at high power. No mitoses are seen. (Paraffin section, hematoxylin-eosin, photomicrograph, χ800.)

endothelium. The findings in this case make it appear possible that endothelial cells can detach, stay alive and form permanent mem­branes in the anterior chamber, such as the retrocorneal membranes seen clinically after keratoplasty. The localized proliferation of free-floating cells in the anterior chamber re­sembles the growth of cells in tissue culture and is evidence of the great viability of hu­man corneal endothelium.

SUMMARY

Detachment and local proliferation of corneal endothelium were observed in a human eye with a subacute purulent kerati­tis and corneal ulcer.

University Hospital (48104)

REFERENCES 1. Leigh, A. G. : Complications of corneal

grafting. In Trevor-Roper, P. D.: Diseases of

VOL. 64, NO. 3 DETACHMENT OF CORNEAL ENDOTHELIUM 453

the Cornea, Internat. Ophth. Clin. Boston, Little, Brown, 2:757, 1962.

2. Wolter, J. R. and Willey, E. N. : Lamellar split ting of Descemet's membrane. Am. J. Ophth. 61:331,1966.

3. Wolter, J. R. and Fechner, P. U. : Glass mem­branes on the anterior iris surface. Am. J. Ophth. 53 :235, 1962.

4. Hogan, M. J. and Zimmerman, L. E. : Ophthalmic Pathology: An Atlas and Textbook. Philadelphia, Saunders, 1962, p. 282.

5. Samuels, B. and Fuchs, A. : Clinical Pathol­ogy of the Eye. New York, Hoeber, 1952, p. 69.

6. Mayou, M. S. : The pathology of keratitis punctata. Tr. Ophth. Sox. U. K. 44:81, 1924.

7. Nagano, O. : Untersuchungen zur Pathologie

There is no doubt that in the majority of senile cataract operations, the intracapsular method gives better results with fewer com­plications than the extracapsular method. The only advantage of the extracapsular op­eration is that the capsulozonular barrier is not disturbed. There is no consensus when this method is indicated, or how to carry it out.

This publication will discuss briefly these two aspects—indications and techniques—of the extracapsular methods. The role of the vitreous is well documented in the etiology of retinal detachment; its most drastic con­sequence occurs when vitreous is lost during cataract operation. Following uncomplicated intracapsular removal of the senile cataract the hyaloid membrane is not infrequently defective or missing. This was the case in 13.5% in my series.1 It allows the vitre­ous to fill a variable portion of the anterior chamber, and even to touch the cornea. This condition can be called intraocular vitreous prolapse to differentiate it from vitreous hernia, the vitreous bulge with intact hy­aloid face. In vitreous prolapse, if other predisposing conditions of the retina or choroid are present, a mild jarring or pull­ing action of the vitreous may be sufficient to cause retinal detachment.

des Hornhautendothels. Arch. f. Augenh. 76:26, 1914.

8. Cogan, D. G. : Applied anatomy and physiol­ogy of the cornea. Tr. Am. Acad. Ophth. 55 :329, 1951.

9. Chi, H. H., Teng, C. C. and Katzin, H. M. : Histopathology of corneal endothelium : A study of 176 pathologic discs removed at keratoplasty. Amer. J. Ophth. 53 :215, 1962.

10. Busacca, A. : Biomikroskopie und Histo-pathologie des Auges, Vol. I. Zürich, Schweizer Druck- und Verlagshaus, 1945, p. 377.

11. Duke-Elder, S.: System of Ophthalmology, Vol. VIII Diseases of the Outer Eye, Part II St. Louis, Mosby, 1965, pp. 715, 723.

In the last 15 years, 22 uncomplicated cat­aract operations were done on the second eye of patients whose first eye had suffered retinal detachment; 15 detachments were primary and seven had followed cataract op­eration. Of the 22, one patient did not re­turn for a follow-up and a second had a de­tached retina at the time of the operation of his second eye. In 14, the cataract was re­moved intracapsularly, that is, with loss of capsulozonular barrier. Of these, four de­veloped retinal detachment. Six cataracts were removed by the planned extracapsular method, and none was followed by retinal detachment.

On fairly rare occasions, corneal edema and/or keratopathy may develop when formed vitreous, due to loss of the capsulo­zonular barrier, touches or adheres to the cornea.

Based on these considerations, the follow­ing indications for planned extracapsular cataract operation are suggested :

1. Spontaneous or postoperative retinal detachment in the opposite eye.

2. In persons less than 20 years of age. 3. Loss of vitreous with marked vitreous

blur following cataract extraction of the op­posite eye.

4. Loss of the other eye due to unknown

THE PLANNED EXTRACAPSULAR CATARACT OPERATION ANDREW F. DE ROETTH, M.D.

Spokane, Washington