Focal Posttraumatic Choroidal Granulomatous Inflammation
MATTHEW W. WILSON, MD., HANS E. GROSSNIKLAUS, MD., AND J. GODFREY HEATHCOTE, MB.
PURPOSE: This study was performed to describe the clinicopathologic features of a group of patients with posttraumatic unilateral focal choroidal granulomatous inflammation. METHODS: Enucleated eyes with focal choroidal granulomatous inflammation without clinical signs of contralateral ocular inflammation were identified. Clinical and pathologic features were recorded. RESULTS: Six enucleated eyes that had been injured by projectiles had focal uveal granulomatous inflammation of the posterior choroid. Four eyes had uvea attached to or incarcerated into the wound. Two eyes had foreign material associated with the granulomatous inflammation, and two eyes had a disrupted lens with lens-induced inflammation. Two eyes exhibited the focal granulomatous inflammation at the site of a choroidal rupture None of the six enucleated eyes contained Dalen-Fuchs' nodules. CONCLUSIONS: Focal choroidal granulomatous inflammation may occur as a result of penetrating ocular trauma. The origin of this condition is unknown, although it likely represents a reaction to a foreign body.
Accepted for publication Oct. 9, 1995. From the Departments of Ophthalmology (Drs. Wilson and Gross-
niklaus) and Pathology (Dr. Grossniklaus), Emory University School of Medicine, Atlanta, Georgia; and Departments of Pathology and Ophthalmology (Dr. Heathcote), St. Joseph's Health Centre and the University of Western Ontario, London, Ontario, Canada. This study was supported in part by an unrestricted departmental grant from Research to Prevent Blindness, Inc., New York, New York; and departmental core grant EY06030 from the National Institutes of Health, Bethesda, Maryland.
Reprint requests to Hans E. Grossniklaus, M.D., L. F. Montgomery Ophthalmic Pathology Laboratory, Room 1603, Emory Eye Center, 1327 Clifton Rd. N.E., Atlanta, GA 30322; fax: (404) 778-4143; E-mail: firstname.lastname@example.org
WE IDENTIFIED SIX CASES OF CLINICALLY UN-suspected posttraumatic choroidal granulomatous inflammation. All cases occurred after severe ocular injuries, with each eye undergoing primary repair. All eyes were enucleated within two weeks of initial injury because of poor visual prognosis and the risk of sympathetic ophthalmia. All fellow eyes lacked clinical signs of inflammation. The granulomatous inflammation in the traumatized eyes was focal and minimal. We studied the clinicopathologic findings of these six eyes and determined the possible origin of this posttraumatic focal choroidal granulomatous inflammation.
MATERIAL AND METHODS
BETWEEN 1941 AND 1994, 963 POSTTRAUMATIC ENUCLE-
ated eyes were accessioned in the L. F. Montgomery Ophthalmic Pathology Laboratory, Emory University, Atlanta, Georgia. Six enucleated eyes with the pathologic finding of focal choroidal granulomatous inflammation were retrieved from the group of 963 eyes. Clinical histories and ophthalmic examinations of the six patients with posttraumatic focal choroidal granulomatous inflammation were studied. We stained ten 5^m-thick step sections through the center of the enucleated eyes with hematoxylin and eosin and examined them.
ALL CASES OF GRANULOMATOUS INFLAMMATION Occurred after 1990. All patients were male, and ages ranged from 8 to 34 years (Table 1). All of the
VOL.121, No. 4 AMERICAN JOURNAL OF OPHTHALMOLOGY 1996;121:397-404 397
CLINICAL FEATURES OF SIX PATIENTS WITH POSTTRAUMATIC FOCAL CHOROIDAL
PATIENT NO., AGE (YRS),
2,14, M 3, 16, M 4, 8, M 5, 11, M 6, 37, M
LE, LE. L.E. LE. LE.
BB Pellet Pellet Rock Gunshot
TIME OF INJURY TO
10 13 10 10 7
15 3 2 3 1
traumatized eyes were left eyes. All injuries were by projectiles, and all eyes were enucleated within two weeks of injury. There was uvea associated with the wound in four eyes, and four eyes were perforated (Table 2). The lens was disrupted in four eyes, with inflammation associated with lens material in two eyes. There was pigment phagocytosis by histiocytes in four eyes and foreign material in two eyes. No eyes contained Dalen-Fuchs' nodules, bacteria, or fungi. None of the patients had any evidence of sarcoidosis or other granulomatous disease. No patients had received immunosuppressive medications.
CASE i: A 34-year-old man sustained multiple gunshots to the head, neck, and chest. The left eye
was perforated by buckshot. Visual acuity was R.E.: 20/20 and L.E.: no light perception. A limbal entrance wound was noted. Computed tomography showed that the buckshot exited posteriorly, nasal to the optic nerve. The anterior wound was repaired and, postoperatively, visual acuity was no light perception in the left eye. The blind left eye was enucleated nine days after the initial injury. The right eye retained visual acuity of 20/20, with no inflammation two weeks postoperatively. The patient failed to return for follow-up examination.
Microscopic examination of the enucleated eye disclosed a full-thickness limbal wound with incorporation of pigmented uveal tissue. The iris was intact and the ciliary body was partially avulsed. The lens was disrupted with an associated granulomatous inflammatory response, including pigment-laden foreign body giant cells (Fig. 1). The vitreous was hemorrhagic and contained lens remnants. The retina was dialyzed. The choroid was ruptured near the optic nerve and exhibited focal granulomatous inflammation with associated eosinophilic debris (Fig. 2). No Dalen-Fuchs' nodules were present. The underlying sclera was torn. The optic nerve head was edematous and contained a mild inflammatory infiltrate. Results of special staining for bacteria and fungi were negative.
CASE 2: A 14-year-old boy sustained a penetrating BB injury to his left eye. The BB entered the eye through the inferocentral cornea. The BB was removed and the wound was repaired. Three days after the injury he underwent a vitrectomy and placement of a scierai buckle with injection of intravitreal antibiotics for possible endophthalmitis. Postoperative
PATHOLOGIC FEATURES OF SIX PATIENTS WITH POSTTRAUMATIC FOCAL CHOROIDAL GRANULOMATOUS INFLAMMATION
1 2 3 4 5 6
UVEA TO WOUND
Yes No Yes Yes Yes No
PERFORATION OF GLOBE
Yes No Yes Yes Yes No
Yes Yes Yes No N Yes
Yes Yes Yes No Yes No
No No No Yes Yes No
Yes Yes-No Yes No
398 AMERICAN JOURNAL OF OPHTHALMOLOGY APRIL 1996
Fig. 1 (Wilson, Grossniklaus, and Heathcote). Case 1. A granulomatous reaction including a giant cell with intra-cytoplasmic pigment granules (arrow) is seen in association with detached lens capsule and Descemet's mem' brane (hematoxylin and eosin, X63).
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Fig. 2 (Wilson, Grossniklaus, and Heathcote). Case 1. Focal granulomas (asterisks) are present at the site of a choroidal rupture near the optic nerve head. The torn edge of Bruch's membrane (arrowhead) and sclera (S) are identified (hematoxylin and eosin, X25).
examination showed visual acuity of R.E.: 20/20 and L.E.: no light perception. His left eye was enucleated ten days after the initial injury. His right eye remained normal, with no signs of uveitis 15 months after the trauma.
Microscopic examination of the enucleation specimen showed a full-thickness corneal wound with vascularization of the stroma, suture material, and an associated foreign body giant cell reaction. The iris was adherent to the posterior corneal surface, thus occluding the trabecular meshwork. The iris and
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i "SSV: "*t>
Fig. 3 (Wilson, Grossniklaus, and Heathcote). Case 2. Detached lens capsule (L) with associated fibrocellular inflammatory tissue is present near the pars plicata of the ciliary body (CB) (hematoxylin and eosin, X25).
Fig. 4 (Wilson, Grossniklaus, and Heathcote). Case 2. A solitary granuloma (asterisk) is present in the hemor-rhagic choroid near the optic nerve head (hematoxylin and eosin, X10).
ciliary body were avulsed. Remnants of the lens capsule and cortex were present, with an associated fibrocellular inflammatory response (Fig. 3). The vitreous was hemorrhagic. The retina was detached by hemorrhage. The choroid was congested, ruptured, and detached. Inflammatory cells, some of which formed focal granulomas, were present in the choroid near the optic nerve head (Fig. 4) Pigment-laden macrophages were scattered throughout the choroid. There were no Dalen-Fuchs' nodules present. Focal granulomatous inflammation was present in several
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Fig. 5 (Wilson, Grossnikiaus, and Heathcote). Case 2. Granulomatous inflammation (asterisk) is associated with a nerve within an emissary canal in the posterior sclera (hematoxylin and eosin, X40).
emissary canals with associated uveal tissue (Fig. 5). The negative image of a scierai buckle was present. The optic nerve was pulled into the globe by the detached choroid. Results of special staining for bacteria and fungi were negative.
CASE 3: A 16-year-old boy sustained a perforating injury to his left eye from a pellet gun. Examination showed visual acuity of R.E.: 20/40 and L.E.: possible light perception. His ocular history was remarkable for amblyopia in his right eye. An entry site with uveal prolapse was identified at the inferior corneoscleral limbus of the left eye. An exit wound was located in the posterior superonasal quadrant. A lensectomy and vitrectomy were performed and, postoperatively, the patient had no light perception and severe pain. The right eye remained uninflamed. The left eye was enucleated 13 days after the initial injury. Follow-up examination three months postoperatively disclosed no inflammation in the right eye.
Microscopic examination of the left eye disclosed a limbal wound with uveal incarceration. The ciliary body was dialyzed and hemorrhagic. Lens remnants were present. The vitreous was hemorrhagic. The retina was detached and hemorrhagic. The choroid contained scattered inflammatory cells. Focal granu-lomas with epithelioid histiocytes and giant cells were present subjacent to the macula at the site of a choroidal rupture (Fig. 6). Some of the histiocytes demonstrated pigment phagocytosis. No Dalen-
Fuchs' nodules were present. The sclera was thickened, and the optic nerve was drawn into the eye. Results of special staining for bacteria and fungi were negative.
CASE 4: An 8-year-old boy sustained a pellet gun injury to the left eye. Examination showed visual acuity of R.E.: 20/20 and LE.: no light perception. The left eye was perforated, and the scierai entrance wound was closed primarily. There was no improvement in visual acuity postoperatively, and the left eye was enucleated ten days after the injury. Two months after surgery the right eye was normal and had no clinical signs of inflammation.
Microscopic examination of the left eye showed an intact cornea covering an anterior chamber filled with hemorrhage and fibrinous material. The iris was intact. The ciliary body was detached and mildly inflamed. The lens was artifactitiously disrupted but was otherwise normal. The vitreous contained hemorrhage. The retina was dialyzed, and subretinal hemorrhage was present. The choroid was detached by a suprachoroidal hemorrhage, and the posterior choroid contained a focus of granulomatous inflammation (Fig. 7) with associated macrophages displaying pigment phagocytosis. Several giant cells surrounded a foreign body in the choroid near the granulomatous inflammation. The sclera was perforated, hemorrhagic, and inflamed. The optic nerve was drawn into the globe. Results of special staining for bacteria and fungi were negative.
Fig. 6 (Wilson, Grossniklaus, and Heathcote). Case 3. Focal granulomatous inflammation (asterisk), including giant cells (arrows), is present at the site of a posterior choroidal rupture (hematoxylin and eosin, X25).
400 AMERICAN JOURNAL OF OPHTHALMOLOGY APRIL 1996
Fig. 7 (Wilson, Grossnikiaus, and Heathcote). Case 4. A solitary focus of granulomatous inflammation (asterisk) is present posteriorly within the hemorrhagic choroid. The retina (R) and sclera (S) are identified (hematoxylin and eosin, x25).
CASE 5: An 11-year-old boy sustained blunt trauma to his left eye with a rock. Examination disclosed a normal right eye with visual acuity of 20/20. His left eye had visual acuity of no light perception, and there was a corneal laceration present from the 9 to 11 o'clock meridians. The iris was avulsed, and the choroid was prolapsed into the wound. The eye was primarily repaired, and no visual improvement was noted ten days postoperatively, at which time it was enucleated. Three months later, the right eye had no clinical signs of inflammation.
Microscopic examination of the left eye showed a limbal laceration with associated monofilament suture and uveal incarceration. The anterior chamber
Fig. 8 (Wilson, Grossniklaus, and Heathcote). Case 5. Focal granulomatous inflammation (asterisk) is present within the hemorrhagic choroid near the optic nerve head (hematoxylin and eosin, X25).
was filled with blood. The iris and lens were avulsed. The ciliary body was dialyzed and hemorrhagic. The retina was dialyzed. The choroid was posteriorly ruptured adjacent to the optic nerve head. There was a focal area of granulomatous inflammation (Fig. 8) with associated foreign body giant cells in the choroid. Foreign material was present in this area (Fig. 9). The sclera next to the optic nerve was torn, and the optic nerve was normal. There were no Dalen-Fuchs' nodules present. Results of special staining for bacteria and fungi were negative.
CASE 6: A 37-year-old man sustained a buckshot wound to his left eye. Examination showed visual
Fig. 9 (Wilson, Grossniklaus, and Heathcote). Case 5. Left, A foreign body giant cell (arrow) is present in the choroid in the area of the granulomatous inflammation. Right, Foreign material (arrow) polarizes within the foreign body giant cell. A smaller fragment of foreign material is also present in the field (hematoxylin and eosin, X63).
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Fig. 10 (Wilson, Grossnikiaus, and Heathcote). Case 6. A small solitary choroidal granuloma (asterisk) is present in the posterior choroid. Bruch's membrane (arrowhead) is intact (hematoxylin and eosin, X63).
acuity of R.E.: 20/20 and L.E.: no light perception. A horizontal corneal laceration was present between the 3 and 9 o'clock meridians in the left eye, with associated uveal prolapse. The laceration was primarily repaired, and, postoperatively, there was no improvement in visual acuity. The eye was enucleated seven days after the initial injury. There was no evidence...