|Year : 1970 | Volume
| Issue : 1 | Page : 33-36
A case of gumma of the ciliary body
Government Ophthalmic Hospital, Madras, India
C S Kalidasan
Government Ophthalmic Hospital, Madras
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kalidasan C S. A case of gumma of the ciliary body. Indian J Ophthalmol 1970;18:33-6
Chotta sahib, male, aged 55 years, attended the out-patient on 21st January 1961, with the complaint of irritation, redness and itching of the right eye and was treated as allergic conjunctivitis for two weeks. On 15th February 1961, a nodule was seen in the lower temporal region of the right eye. The iris was normal. Slit lamp examination showed a few white keratic precipitates. Investigations revealed a strongly positive Mantoux and V. D. R. L. positive 4 dilutions. Urine was normal. So from 16th February 1961, lie was given locally atropine ointment and cortisone along with Streptomycin intramuscular and I.N.H. tablets and Prednisolone orally. Two days later, an abscess in the sclera with a yellowish centre was seen. He was sent to the male V.D. department in the Government General Hospital, Madras on 3rd March 1961 for further investigations and treatment. He was discharged on 2nd April 1961 from there.
Previous history : 30 years previously, he had white discharge per urethra after an extra-marital exposure and again 10 years later, he had a sore on the penis for which he did not have proper treatment. He had cough without haemoptysis and loss of weight with irregular fever a year ago.
Family history : Married 20 years ago, there was no history of abortions in the mother. One healthy male child was alive.
General examination : The patient was emaciated and anaemic. There was no oedema of the feet. A few lymph nodes, were palpable on the right side of the neck under the sternomastoid, which were discrete and painless. There were no lesions of the skin or mucous membrane. Bilateral inguinal hernia, multiple scars on the plans penis and left sided epididymo-orchitis were present.
Cardio vascular system : No abnormality was detected. B. P. 140/90 mm Hg.
Respiratory and nervous systems:Were normal.
Local examination : A yellowish swelling ½ cm. x ½ cm., oval in shape with a yellowish white sloughing centre in the lower and outer part of the bulbar conjunctiva about ½ cm. away from the limbus with a few dilated vessels over the swelling was seen. Conjunctiva was freely movable over it. It was tender in the upper part. A number of whitish, mutton-fat K. P.'s were seen all over the endothelium, but more over the center and lower half. The anterior chamber was shallow, iris - colour and surface were normal. Posterior surface of the iris was plastered to the lens by abundant posterior synechiae. PupiIlary area was filled with whitish exudates and the pupil was inactive to light. Complicated cataract was present, the tension was low. Visionno light perception.
Left eye - Normal.
- R.B.C. Count - 3.8 million/c. mm.
- W.B.C. Count - 12,600/c. min.
- Differential count - P61, L36, E2, M I.
- E.S.R. 21 mm/hr.
- Sputum - negative for acid-fast bacilli Concentration method - negative.
- X-ray chest - Bilateral infiltration.
- Mantoux test - +++
- Blood V.D.R.L. slide test reaction - 16 Dils.
- Reiter protein compliment fixation test reaction - 16 Dils.
- C.S.F. Cells 9/c. mm. Ptoteins - 107 mgm %
- Urine - no albumin or sugar. A few pus cells.
- Biopsy of the lymph node showed only chronic inflammation. No evidence of tuberculosis.
Treatment : He was started on 10 gins. of Streptomycin and I.N.H. 300 mgms. daily (treated clinically as tuberculosis of the ciliary body), but there was no improvement in the local condition and the swelling was increasing in size. In V. D. Department, he was given another course of Streptomycin and I.N.H. along with P.A.M. 2 cc. intramusculary and Prednisolone and on 17th day of treatment, he developed vertigo and as the condition of the eye was stationary and 2 days later an abscess developed in the sclera with a sloughing centre and there was no P. L. in the eye, an enucleation was done on 27th May 1961. During operation the swelling was found to be vascular and extending behind for a futher 1 cm. The conjunctiva was also removed along with the eye ball. The wound healed well and be was given another course of Streptomycin/and 1. N. H. and he was discharged. From, 1961 - 1967 he did not have any illness and in the end of 1967, he died of cardiac failure.
Histology : of the cut section of the eye ball showed a mass near the ciliary body, purulent vitreous and diffuse thickening of the choroid and no tubercles and giant cells. It was reported as tuberculoma of the ciliary body. (Plates 1 and 2)
In the year 1968, when the author thought of reporting this case to Madras State Ophthalmic Conference at Calicut and to get a complete report of the slide, it was shown to Dr. V. C. Balasubramaniam, Pathologist Government Hospital for Women and Children, Madras. He was of the opinion that it is in favour of a GUMMA OF THE CILIARY REGION because of the following: numerous collections of lymphocytes, plasma cells and round cells around the blood vessels, endothelial proliferation of blood vessels and a few scattered giant cells. There is also diffuse thickening of choroid. (Plate 3)
Discussion : In this patient, the diagnosis was very difficult from the beginning between syphilis and tuberculosis, because the patient had signs of both. He had healed scars on the penis, V.D.R.L. was positive along with healed lesions of Koch in the lungs, and Mantoux was strong by positive. The doubt was not cleared even after histopathological study. This amply proves that syphilis can mimic any condition especially tuberculosis.
The onset of symptoms were in the manner of allergy and not of inflammation and the eye was lost in spite of early treatment in a few weeks.
According to Duke Elder, GUMMA is usually associated with syphilis of severe character, occuring early in infection (42% in first six months), but may be delayed for 10 years. The majority start in the ciliary body and appear in the angle of the anterior chamber rarely in the iris or choroid. Ciliary region may become diffusely infiltrated with granulation tissue and exudates or occupied by a localised granulomatous mass. This undergoes necrosis involving a structural disintegration of iris, cornea angle of anterior chamber and eventually fills entire globe and breaks through the sclera in the ciliary region and appears as a violet coloured staphyloma and a sloughing ulcer. This is accompanied by most violent irridocyclitis with abundant exudates and severe pain. With active antisyphilitic treatment, the condition tends to resolve in early stages.
This case differs from the classic description in the following:
- It was not associated with severe type of syphilis.
- It did not resolve even with early treatment.
- There was no other sign of tertiary syphilis.
| Summary|| |
A rare case of gumma of the ciliary body is reported. The clinical as well as histological diagnosis from tuberculoma was doubtful.
| References|| |
BERENS : Diseases of the eye, p. 52022, Saunders (1950)
BERLINER : Biomicroscopy of the eye, p. 877-88, Hoeber (1948)
DUKE ELDER W. S. - System of Ophthalmology, p. 313 - 15, Henry Kimpton (1966)
SORSBY A - Modern Ophthalmogy, p. 218-25, Butterworth (1967)
WOODS A. C. - The problem of ocular tuberculosis, American Journal of Ophthalmology 21 : 366-83, 1938
WOODS A.C. - Tuberculosis of the eye, International Clin. I (series 43), 79-111, 1933.
WOODS A.C. - Syphilis of the eye, American Journal of syph : gonor. and ven. dis, 27; 133-186, 1943.
I am greatly indebted to the following:
Dr. V. C. Balasubramaniarn, Pathologist, Government Hospital for women and Children, Madras for his report on the histopathological slide and for the microphotographs, Dr. P. N. Rangaiah, Director, Institute of Venereology, Government General Hospital, Madras for his generous help and valuable opinion and to Dr. C. N. Sowmini for her guidance.
[Figure - 1], [Figure - 2], [Figure - 3]