|Year : 1962 | Volume
| Issue : 2 | Page : 39-44
After-cataract, soemmering's ring and its dislocation
|Date of Web Publication||29-Mar-2008|
G S Guha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Guha G S. After-cataract, soemmering's ring and its dislocation. Indian J Ophthalmol 1962;10:39-44
After-cataract may appear as thin or thick strands, sheaths, veils, membranes and folds or as globules or pearls. Usually, it remains always visible in the pupillary area but in some cases, it may not be ordinarily seen except by slit-lamp, while in some rare cases, it may be seen only after the pupil is dilated or when a coloboma of the iris is present or when it is dislocated. Again, it may appear or disappear when occurring as pearls. Usually, it interferes with vision partially or completely but in some cases, may not cause visual disturbance at all at least for some time. It may remain stationary, slowly get absorbed, or increase in size, in density and in weight or may even dislocate or undergo Morgagnian, hyaline and other degenerative changes. Its colour, which is usually whitish, may sometimes be darkly pigmented due to proliferation of iris pigment cells or brownish red when stained with blood. It may exhibit polychromatic iridescence in specular reflection when occurring as veils or when containing cholestrin crystals. It may or may not produce secondary complications.
Formation of different types of after cataract:
It is well known that after cataract is usually formed by capsular and lenticular remains following an extra-capsular extraction of the lens or after its spontaneous absorption following a perforating injury to which needling or discission may be added or following its hypermaturity. With the capsular and lenticular remains, may also be found products of regeneration of the capsular epithelial cells and products of degeneration of the lens substance.
The density of the after-cataract will depend upon the amount of lens substance left behind and organised material from exudates in iritis, cyclitis, hyphema and infection. Similarly, pigmentation of the after-cataract will depend on the disturbance of the iris pigment and how much of detached portions of the posterior pigmented layers of the iris manage to get fixed to the after-cataract.
In the usual form of after-cataract the anterior and posterior capsules lie almost in contact being separated only by the two layers of irregular epithelial cells but the separation may also be due to the newly formed capsular epithelium or bladder cells or by lens fibres left behind or by proliferation of iris pigment cells between them.
Quite a variety of after-cataracts can take place and there would be no limit to their descriptions. Out of this gamut of description details we are concerned with one which is called "Soemmering's Ring."
An Interesting Form Producing Dislocation:
Some soft clear cortex of the lens in addition to the capsular remains sometimes may be left behind between the capsule layers which cannot get absorbed by the lytic action of the aqueous. Here, the cubical cells lining the anterior capsule may continue to form new lens fibres which are abortive and opaque under abnormal conditions. Sometimes, these form a dense ring between the anterior and posterior capsules and lie hidden behind the iris-known as the Soemmering's Ring. D. W. Soemmering of Mainz, (1928) who by dissecting through the equator of eyes of a number of dead persons who were operated for cataract in their life-time, found in eight cases, more or less crystal clear nearly invisible ring like substances lying behind the iris. By immersing them in spirit, these almost invisible rings became opaque. He also observed evidences of regeneration of lens fibres in some places.
The formation of the ring was shown in animal experiments by Cochteau and Lefroy d'Etiolle (1827). Later animal experiments of Gonin (1896) and Wessely (1910) proved that these ring formations take place more easily in young animals than in old ones. It is likely that the sub-capsular epithelial cells in them have a greater capacity for growth than in old animals. Poos (1931) also pointed out that the regenerative activity of the remains of the lens substance is greater in younger subjects after extracapsular extraction, discission or injury. According to Wesseley (1910) when the central part of the anterior capsule is opened up, it loses its stretching capacity and collapses forming a flat ring. Filaments of the lens substance which frequently remain at the equator of the capsular sack, in addition to the remnants of the lens nucleus and lens epithelium, remain unaffected by the lytic action of the aqueous which cannot touch them. The cells of the proliferating epithelium secrete a hyaline substance forming hyaline layers which remain separated by layers of cells. Such regenerations and new formations are no doubt important factors in the formation of a swollen ring or cushion as mere encysted lens substance and epithelial cells could not have produced rings of such dimensions as reported by observers.
Soemmering's Ring is usually derived after extra-capsular extraction of the lens or after its penetrating injury or after its discission for congenital cataract. When the operative treatment for high myopia or Fukala's operation was in vogue, such ring formations were not uncommon. This operation had in its first step, discission of the lens; the swollen lens matter formed as the result of discission, was washed out but in most cases, parts of the anterior and posterior capsules with remains of the lens fibres and subcapsular epithelium were left behind and these being encysted between the adherent margins of the capsule formed a swollen ring.
The ring is usually invisible lying behind the iris in the equator of the retro-lental space and being held in position by the zonules. It can be therefore seen only after dilating the pupil or through an iris coloboma or after dislocation. In the case reported by Pavia and Dusseldorf, where traumatic aniridia existed, ring was visible in situ.
As the central portion of the ring remains clear, unlike the usual form of after-cataract, there is no visual disturbance as a rule when it remains in its original position.
The ring may be complete or incomplete when it is composed of several irregular masses. Soemmering's Ring may have to be distinguished sometimes from 'Lifebuoy cataract' which is a congenital form of disc shaped cataract in which the missing nucleus is of the same size as the central part of the Soemmering's Ring.
| Case Report|| |
I had the opportunity of observing a very interesting case of Soemmering's Ring in which the ring formation was distinct and the ring got dislocated in the anterior chamber. From the literature, I find that such a case is rare.
The patient, a male, aged 51 years had defective vision since his childhood which increased with age. At the age of 22 yrs. he was operated for juvenile cataract in the left eye and at the age of 33 yrs. in the right eye. The operations in both eyes had to be repeated, so that in all he was operated nine times. He could then see moderately well with the help of glasses. Two days before being seen by me, he suddenly developed blurring of vision and a feeling of heaviness in that eye while working with his head slightly bent down. With the mirror, he could see a whitish object at the upper part of that eye lying partly hidden by the pupillary margin.
On examination of the left eye, a big whitish yellow ring shaped object having a diameter of 7.5 mm was found to be lying in the a.c. which was deep. The ring looked like a thick after-cataract with an oval shaped perpendicular opening. With the slit-lamp, calcification of the ring in different places could be detected. The ring therefore had a consistency such that it could get dislocated without much difficulty. By the movements of the eye, the dislocated ring which lay at the lower part of the anterior chamber, seemed to oscillate. Through the coloboma in the upper part of the ring, vitreous could be observed which did not show any opacities but on movements of the eye showed considerable fluctuations. The fundus could not be seen but the red reflex was present. The tension of the eyeball was raised.
It was therefore a case of secondary glaucoma due to dislocation of a Soemmering's Ring in the anterior chamber of an aphakic eye after operation for juvenile cataract which was also myopic.
Looking in the right eye after instillation of atropine, a greyish coloured ring could be seen lying behind the iris. A Soemmering's Ring was therefore also present in that eye which remained in situ.
The dislocated ring in the left eye was extracted with an incision at the upper corneal margin with a conjunctival flap and sutures. The result was good and the tension became normal. Vision with correction by + 6.0 Dsph was 6/18.
The Soemmering's Ring was examined histologically; it was immersed in paraffin and a section was made with a microtome which showed calcified areas in places. The histological examination showed presence of a regular thickening of the lens capsule which surrounded the opaque mass. In some places, near the capsule, epithelial cells could be recognised. The main mass of the ring consisted of crumbled products of degeneration which were partly calcified. In other places, proportionately fair amounts of degenerated lens fibres were seen. The ring in this case was therefore a calcified after-cataract containing a few living cell elements.
| Discussion|| |
Stoke (1957) published a review and three illustrative cases from the General Infirmary, Leeds of which A. Arriga's case is probably one. In two cases, ring was seen through iris coloboma and by mydriasis; in the third case it was seen after dislocation in the anterior chamber.
He describes three forms of the ring :
(1) Primary encysted with secondary regenerating lens fibres producing a small swollen necessary.
(2) Irregularly shaped lentoid masses stringing together in a ring or torus form by tenuous processes.
(3) Incomplete ring and represented by a crescentic sausaji.
A Soemmering's Ring was found in an eye containing the Ridley lenticulus.
Histological examination of one of the cases by Dr. N. Ashton showed extension of epithelium on the inner surface of the posterior capsule reduplication of the single layer of epithelial cells, some of them vacuolated bladder cells. In the cortex could be seen swollen lens fibres and granular bodies.
Ring formations in after-cataract is not very rare but its dislocation is most infrequent. Dislocation can take place under special circumstances. I have critically studied the thirteen cases of dislocated Soemmering's Ring so far published and have tabulated them.
Role of Age:
Considering the age factor at which the cataract operation or injury of the lens had occurred, it shows that in the 13 cases, it took place at the following ages;-2 in childhood, 5 between 10 and 20, 3 between 20 and 30, 1 at 36, 1 at 48, 1 at 62.
The injury of the lens in young age is probably therefore of importance. Firstly, the lens at this age has living cell elements which can grow into lens fibres; secondly, they can resist the destructive effect of the injured lens substance. Due to these factors, ring formation and its unusual growth are facilitated in young eyes. The increase in size of the ring plays no doubt an important role in its dislocation; the bigger the size of the ring, the easier it is for its dislocation.
From the 13 cases, it is seen that at least in 7 cases, the lenses during operation or injury were clear and so consisted of rich cell elements, capable of regenerating into lens fibres.
Role of Injury
One important factor for the formation of the ring is no doubt the nature of the operation. In the table, we find in three cases, rings formed after Fukala's operation got dislocated. In these cases, Fukala's operations were done at the ages of 10, 22 and 28 years. As already mentioned, in this operation after discission of the lens, the swollen lens matter is washed out. It is also usual that the anterior capsule is partly opened which gradually closes down at the margins helping in the formation of the ring. In a similar case of Wessely, the lens was injured by a knitting needle and in Schneider's case, a small foreign body had injured the lens. Out of 13 cases, having the history of operation or injury, the anterior capsule was opened up and a large part of it was left behind. Similarly in the case of Jess, his patient with polar cataract was operated at the age of 17 years a discission was followed by curette evacuation. From the remaining cases, it can be seen that extra-capsular extraction was done at relatively young ages in two cases and also in relatively higher ages in two cases (48 and 62 years), while in one case the nature of the injury of the lens was not known.
Summarising from the above findings, we see that it is not only the young age of the patient at which the injury of the lens is of importance but also the nature of the operation or injury which can cause only a moderate opening of the anterior capsule that a Soemmering's Ring may be formed.
Role of Myopia:
It is also noteworthy that proportionately frequent dislocations occur in myopic eyes. Cases 1, 3, 5, 6, 7, 9, 10, 11 and 12, in which dislocation of the ring took place, had high myopia except 5, who had low degree of myopia. It is also possible that in the case of Jess in which the aphakic corrections were done with = 9 Dsph and + 10 Dsph, a certain grade of myopia existed. Of the total 13 cases, at least 9 were myopic. The degeneration of the zonular fibres, the increase fluidity of the vitreous and the undeveloped ciliary muscles which help in the deepening of the anterior chamber, contribute to the dislocation of the ring in myopic eyes. With the presence of the degeneration of the zonular fibres in a myopic eye, a slight trauma may cause dislocation of the ring. The increase of the depth of the anterior chamber and the increase in the fluidity of the vitreous in a highly myopic eye, may cause the ring to move to and fro, thus making it prone to dislocation. In 4 cases, in which the ring got dislocated in the vitreous, we find that all had liquified vitreous.
Influence of senility in Causing Dislocation:
For the dislocation of the ring, senile degenerative changes in the eye are also of importance. Looking at the table, the ages at which dislocation of the ring took place, we find that these were at 72, 61, 50, 57, 76, 45, 40, 43, 60, 43, 49, 51 and 55 years. While the ring formation after lenticular injury or operation mostly takes place in the young, dislocation of the ring seems to take place in the old or at least in the middle aged persons. We see therefore that senile changes in the eye are no doubt contributory factors in the dislocation of the ring.
It is likely that the changes in the ring itself also play an important role in its dislocation. The increase in consistency e.g., calcification, may help in its dislocation. Definite calcification was noticed in Jess's case, in Arruga's case as well as in my case. In the remaining cases, we find the ring described as white, rugged, uterus shaped or crystal like. In all these cases, the rings did not contain clear lens fibres but had advancely degenerated lens fibres. These degenerative changes of the ring with increase of its consistency and increase of specific gravity must have played an important role in their dislocation.
If we consider all the causes which may favour dislocation, we find that trauma, direct shaking of the eyes as in cases 5, 6 and 9 and indirect shaking of the eyes as in case 7, may induce dislocation. In case 7, the patient fell down on the street. In the fall the head was injured but the eye was not hurt. How insignificantly small the external factor may be, can be shown particularly in my own case. Here the dislocation of the ring in the anterior chamber occurred during work in a bent posture of the body. In a similar case, it was not known if the dislocation had occurred after any injury. Here, as Wessely had reported in his case, there was possibility that the dislocation had already occurred at the time of the first injury or operation. To me however, it seems more probable that in such cases the so called spontaneous luxation had occurred without any external factor worth mentioning. This is also supported by the fact that while dislocation of the ring in all cases under review had taken place at a comparatively old age, the injury or operation had taken place in youth or in childhood. If the lens was displaced after the first injury or operation, then the dislocation of the ring could also be found in young persons.
According to Poos, the following factors favour dislocation of the ring :
1) The early age of the patient when the lenticular injury occurs favouring the formation of a relatively strong ring.
2) Progressive myopia gradually producing degeneration of the vitreous and of the zonules in later life.
These factors are confirmed from my findings in the 13 cases. These can however be supplemented by the fact that a small opening in the anterior capsule helps in the formation of a heavy ring. Besides, it has been shown that besides myopic changes and senile changes in the non-myopic eye, the increase of the density of the ring with its degenerative changes with age is also an important factor for dislocation. Trauma, the third factor mentioned by Poos is no doubt unquestionable for production of dislocation but even then dislocation can occur without even any perceptible shaking of the eyeball (so called spontaneous dislocation).
Complications after dislocation may occur according to the situation of the ring in which it then lies inside the eye. The most dangerous situation is in the anterior chamber. Cases No. 2, 3, 4, 5, 11, 12, 13 and also 9 had dislocation in the anterior chamber while cases No. 1, 6 and 7 had dislocation in the vitreous. In cases No. 8 and 10, the ring rested partly in the anterior chamber and partly in the posterior chamber. In six cases of dislocation in the anterior chamber, there were evidences of rise of intro-ocular tension in four cases while in one case the effect was not known in one case (Case No. 13) there was hypotony. In case No. 10, there was no rise of tension but signs of great irritation were present.
Dislocation in the vitreous has not much significance. In cases No. 1, 6 and 7 where dislocation of the ring occurred in the vitreous, there was no other complication except some disturbance of vision. Similar is the result of dislocation which occurs partly in the anterior chamber and partly in the posterior one.
| Summary|| |
After-cataract in general, formations of its different varieties and one of its interesting forms, the Soemmering's Ring are discussed. One case of dislocation of a Soemmering's Ring in the anterior chamber and the findings on its histological and slit-lamp examination are described. From the findings of this special case and from other cases published in the literature which had dislocations of the ring, we find that the cases which were susceptible to dislocation, had the following characteristics :
1) The formation of the ring and its enlargement after lenticular injury or operation takes place in young eyes.
2) The operation or injury causes a narrow opening in the anterior capsule.
3) Degenerative changes in the zonules and vitreous of a myopic eye get worse with senility.
4) Degenerative changes take place in the ring itself e.g. its clacification.
5) Trauma significant or even insignificant causing very little movement of the eye is the ultimate cause of dislocation.
| References|| |
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