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Malignant Melanoma of the Limbus*
NOTES, CASES,
690
INSTRUMENTS
incidence in this case; a previous child, w h o
features o f osteopetrosis, the finding o f Palm
was born with similar facial features
er and Thomas regarding absence o f angu
and
bulging eyeballs, did not survive f o r long.
lation o f the angle o f lower j a w was not con
Unfortunately,
firmed.
of
no skiagrams
are
that sibling to confirm the
available diagnosis,
SUMMARY
though it might be mentioned that familial cases tend to present with identical special features
(Fairbanks).
It is felt that severe exophthalmos in an infant
A case o f osteopetrosis with severe bilat eral exophthalmos in an infant is reported.
suggests the possibility of osteope
trosis. Since this is not generally known, the diagnosis in the present
T h e diagnosis was mainly made on radio logic examination. S.M.S.
case was delayed
until a fracture o f the forearm revealed the
Medical
College.
ACKNOWLEDGMENT We
are grateful to J. P. Udawat, D.M.R.D.
presence o f osteopetrosis. W h i l e the radio
(Lond.), radiologist, who
logic features in this case show the classical
help in reading the skiagrams.
has
given us valuable
REFERENCES 1. Back, E. H., and Cole, W . R . : Osteopetrosis with scurvy and rickets. Brit. J. Radiol., 31:709, 1958. 2. Bhattacharya, A. K., Khurana, K. M., and Mukerjee, S. P.: Osteopetrosis. J. India M. A,, 40:123 (Feb. 1) 1963. 3. Walsh, F. B.: Clinical Neuro-Ophthalmology. Baltimore, Williams & Wilkins Company, 1957, ed. 2 4. Fairbanks, T . : An Atlas of General Affections of the Skeleton. Edinburgh & London, E. & S. Liv ingstone, 1951. 5. Karshner, R. G,: Am, J. Roentgenol., 16 :40S, 1926. 6. Nussey, A. M . : Arch. Dis. Child., 13 :61, 1938. 7. Palmer, P. E. S., and Thomas, J. E. P.: Brit. J. Radiol., 31:705, 1958. 8. Shanks, S. C , and Kerley, P.: A Textbook of X-ray Diagnosis. London, Saunders, 1950. 9. Sear, H. R.: Brit. J . Surg., 14:657, 1927.
MALIGNANT OF THE
MELANOMA
attained unusual dimensions. Previous diag noses were of epibulbar tumors
LIMBUS*
REPORT OF A CASE OF M A L I G N A N T CHANGES
recurring
after excision.
AFTER SURGERY A N D DIATHERMY OF MELANOSIS OF T H E LIMBUS MAURICIO BRIK,
M.D.
AND CARLOS C . FERREIRA CANTADOR,
M.D.
Paraná, Brazil
Malignant melanomas are well known to arise from nevi or diffuse melanosis at the limbus*'^ and surgical or physical trauma is believed to induce such metaplasias.* Precise diagnosis is often erroneously based only o n clinical findings.' T h e present case showed a circumscribed melanoma o f the limbus which • F r o m the Department of the University of Paraná.
Ophthalmology of
Fig. 1 (Brik and Cantador). Clinical view of the tumor. Intense pigmentation is seen all around the limbus.
NOTES, CASES, I N S T R U M E N T S
691
CASE REPORT C. Κ., a 50-year-oId Caucasian woman, was first seen at the Department of Ophthalmology July 8, 1963, exhibiting a large mass attached to the right eye and telling a history o f recurrent tumors at the same site. The patient related that she was first examined by another surgeon in 1959 and an epibulbar tumor was diagnosed. In 1961, the epibulbar growth was removed. Some time (which the patient was unable to specify) later the tumor recurred at the same site, show ing a more pronounced rate of growth. A second operation, performed in 1962, con sisted of removal of the limbal mass and dia thermic cauterization of the sclerocorneal bed. Again it recurred in a much shorter time, attaining a bigger size than ever. The patient related that vision was still good at that time. In August, 1962, a third operation was done. The recurrence was quick and the tumor has in creased in size, protruding out of the lid fissure and considerably impairing the vision of the right eye. Closure of the lids was impossible. A t the time of examination vision was: R.E., 0.2; L.E., 0.8. Eye ductions were limited on the right side downward and outward. A big bluish mass (1.5 by 1.5 cm.) inserted on the lower limbus, prolapsed outward from the lid fissure, partially covering the
Fig. 2 (Brik and Cantador). Low-power view of the limbal area. The tumorous mass is circum scribed to the limbus. The anterior chamber, ciliary body and iris are seen to be normal (hema toxylin-eosin, X 3 6 ) .
Fig. 3 (Brik and Cantador). High-power view of the ciliary body and anterior chamber angle, showing absence of any infiltration (hematoxylineosin, XlOO).
Fig. 4 (Brik and Cantador). Tumor section under high power, showing the classical arrange ment of a spindle-cell melanoma (hematoxylineosin, xSOO).
NOTES, CASES, I N S T R U M E N T S
692
pupillary area. Its surface showed necrotic points. Intense pigmentation of the whole limbus extended up to the lower fornix. Slight Chemosis and con gestion of the conjunctiva were present. The right pupil reacted normally to light and digital tension was thought to be normal. A provisional diagnosis of epibulbar pigmented tumor was made and the patient was admitted for further study. General health and laboratory tests revealed no abnormal findings, only an aortic ectasia being discovered. On July 13, the tumor was removed under general anesthesia. The dissection of the mass was not difficult but the fragile limbal insertion ruptured under slight traction and was followed by copious bleeding. A conjunctival flap was slid over the naked area and the postoperative course was eventless. On July 19, the pathologic examination was received. A spindle-cell malignant melanoma was diagnosed. On July 20, the right eye was enu cleated, special care being taken to remove as
much conjunctiva and episclera as possible. No sutures were laid and the cavity was filled with a furacin-soaked dressing. Five days later, the patient was transferred to the radiotherapy de partment. On July 26, the pathologic examination of the eye revealed a spindle-cell malignant melanoma circumscribed to the limbus without extension to the inside of the eye, but compromising the whole circumference of the limbus. A total of 3.5 r of X-rays were given, divided into 14 sessions. SUMMARY A
spindle-cell
malignant
melanoma
de
veloped in the limbus following three surgi cal procedures and cauterization of what ap pears to have been a diffuse melanosis of the limbus. Rua
da Gloria,
258.
REFERENCES 1. Friedenwald, J. S.: Ophthalmic Pathology: An Atlas and Textbook. Philadelphia, Saunders, 1952. 2. Hogan, Μ. J., and Zimmerman, L. E . : Ophthalmic Pathology. Philadelphia, Saunders, 1962, ed. 2. 3. Tuovinen, E . : Pedunculated malignant melanoma of the conjunctiva with bloody tears. Acta. Ophth., 40:149-152, 1962. 4. Bonnet, P.: Ophthalmologie Clinique. Paris, Doin, 1952.
EARLY
immune reaction, the odds of the second graft
REPEATED
suffering
KERATOPLASTY*
That
N O R M A N SANDERS, M . D . Fort Benning, Georgia
the
this is
same fate are a
not
increased.
donor-specific
antigen-anti
b o d y response rather than an
organ-specific
antigen-antibody response^ explains this.
T o o often the problem arises o f h o w long to wait before repeating a corneal transplant when the first graft has been unsuccessful. T h e stock answer seems to be n o less than
C A S E REPORT J. M., a 25-year-old Caucasian, was admitted to Martin Army Hospital with a unilateral keratoco-
six months. T h i s view is definitely not unanimous and many
noted
Fine,^
feel
corneal that
surgeons,
keratoplasty
including
can
be
re
peated as soon as the eye is quiet and
the
original procedure is an unquestionable fail ure. T h e purpose o f this paper is to empha size one small, but important point: that an early regraft can be done. Awareness of this possibility many If
can
months the
first
often
rehabilitate a
sooner graft
than
has
patient
anticipated.
suffered
* From the Martin Army Hospital.
from
an Fig. 1 (Sanders). Central corneal scar with keratoconus.
690
INSTRUMENTS
incidence in this case; a previous child, w h o
features o f osteopetrosis, the finding o f Palm
was born with similar facial features
er and Thomas regarding absence o f angu
and
bulging eyeballs, did not survive f o r long.
lation o f the angle o f lower j a w was not con
Unfortunately,
firmed.
of
no skiagrams
are
that sibling to confirm the
available diagnosis,
SUMMARY
though it might be mentioned that familial cases tend to present with identical special features
(Fairbanks).
It is felt that severe exophthalmos in an infant
A case o f osteopetrosis with severe bilat eral exophthalmos in an infant is reported.
suggests the possibility of osteope
trosis. Since this is not generally known, the diagnosis in the present
T h e diagnosis was mainly made on radio logic examination. S.M.S.
case was delayed
until a fracture o f the forearm revealed the
Medical
College.
ACKNOWLEDGMENT We
are grateful to J. P. Udawat, D.M.R.D.
presence o f osteopetrosis. W h i l e the radio
(Lond.), radiologist, who
logic features in this case show the classical
help in reading the skiagrams.
has
given us valuable
REFERENCES 1. Back, E. H., and Cole, W . R . : Osteopetrosis with scurvy and rickets. Brit. J. Radiol., 31:709, 1958. 2. Bhattacharya, A. K., Khurana, K. M., and Mukerjee, S. P.: Osteopetrosis. J. India M. A,, 40:123 (Feb. 1) 1963. 3. Walsh, F. B.: Clinical Neuro-Ophthalmology. Baltimore, Williams & Wilkins Company, 1957, ed. 2 4. Fairbanks, T . : An Atlas of General Affections of the Skeleton. Edinburgh & London, E. & S. Liv ingstone, 1951. 5. Karshner, R. G,: Am, J. Roentgenol., 16 :40S, 1926. 6. Nussey, A. M . : Arch. Dis. Child., 13 :61, 1938. 7. Palmer, P. E. S., and Thomas, J. E. P.: Brit. J. Radiol., 31:705, 1958. 8. Shanks, S. C , and Kerley, P.: A Textbook of X-ray Diagnosis. London, Saunders, 1950. 9. Sear, H. R.: Brit. J . Surg., 14:657, 1927.
MALIGNANT OF THE
MELANOMA
attained unusual dimensions. Previous diag noses were of epibulbar tumors
LIMBUS*
REPORT OF A CASE OF M A L I G N A N T CHANGES
recurring
after excision.
AFTER SURGERY A N D DIATHERMY OF MELANOSIS OF T H E LIMBUS MAURICIO BRIK,
M.D.
AND CARLOS C . FERREIRA CANTADOR,
M.D.
Paraná, Brazil
Malignant melanomas are well known to arise from nevi or diffuse melanosis at the limbus*'^ and surgical or physical trauma is believed to induce such metaplasias.* Precise diagnosis is often erroneously based only o n clinical findings.' T h e present case showed a circumscribed melanoma o f the limbus which • F r o m the Department of the University of Paraná.
Ophthalmology of
Fig. 1 (Brik and Cantador). Clinical view of the tumor. Intense pigmentation is seen all around the limbus.
NOTES, CASES, I N S T R U M E N T S
691
CASE REPORT C. Κ., a 50-year-oId Caucasian woman, was first seen at the Department of Ophthalmology July 8, 1963, exhibiting a large mass attached to the right eye and telling a history o f recurrent tumors at the same site. The patient related that she was first examined by another surgeon in 1959 and an epibulbar tumor was diagnosed. In 1961, the epibulbar growth was removed. Some time (which the patient was unable to specify) later the tumor recurred at the same site, show ing a more pronounced rate of growth. A second operation, performed in 1962, con sisted of removal of the limbal mass and dia thermic cauterization of the sclerocorneal bed. Again it recurred in a much shorter time, attaining a bigger size than ever. The patient related that vision was still good at that time. In August, 1962, a third operation was done. The recurrence was quick and the tumor has in creased in size, protruding out of the lid fissure and considerably impairing the vision of the right eye. Closure of the lids was impossible. A t the time of examination vision was: R.E., 0.2; L.E., 0.8. Eye ductions were limited on the right side downward and outward. A big bluish mass (1.5 by 1.5 cm.) inserted on the lower limbus, prolapsed outward from the lid fissure, partially covering the
Fig. 2 (Brik and Cantador). Low-power view of the limbal area. The tumorous mass is circum scribed to the limbus. The anterior chamber, ciliary body and iris are seen to be normal (hema toxylin-eosin, X 3 6 ) .
Fig. 3 (Brik and Cantador). High-power view of the ciliary body and anterior chamber angle, showing absence of any infiltration (hematoxylineosin, XlOO).
Fig. 4 (Brik and Cantador). Tumor section under high power, showing the classical arrange ment of a spindle-cell melanoma (hematoxylineosin, xSOO).
NOTES, CASES, I N S T R U M E N T S
692
pupillary area. Its surface showed necrotic points. Intense pigmentation of the whole limbus extended up to the lower fornix. Slight Chemosis and con gestion of the conjunctiva were present. The right pupil reacted normally to light and digital tension was thought to be normal. A provisional diagnosis of epibulbar pigmented tumor was made and the patient was admitted for further study. General health and laboratory tests revealed no abnormal findings, only an aortic ectasia being discovered. On July 13, the tumor was removed under general anesthesia. The dissection of the mass was not difficult but the fragile limbal insertion ruptured under slight traction and was followed by copious bleeding. A conjunctival flap was slid over the naked area and the postoperative course was eventless. On July 19, the pathologic examination was received. A spindle-cell malignant melanoma was diagnosed. On July 20, the right eye was enu cleated, special care being taken to remove as
much conjunctiva and episclera as possible. No sutures were laid and the cavity was filled with a furacin-soaked dressing. Five days later, the patient was transferred to the radiotherapy de partment. On July 26, the pathologic examination of the eye revealed a spindle-cell malignant melanoma circumscribed to the limbus without extension to the inside of the eye, but compromising the whole circumference of the limbus. A total of 3.5 r of X-rays were given, divided into 14 sessions. SUMMARY A
spindle-cell
malignant
melanoma
de
veloped in the limbus following three surgi cal procedures and cauterization of what ap pears to have been a diffuse melanosis of the limbus. Rua
da Gloria,
258.
REFERENCES 1. Friedenwald, J. S.: Ophthalmic Pathology: An Atlas and Textbook. Philadelphia, Saunders, 1952. 2. Hogan, Μ. J., and Zimmerman, L. E . : Ophthalmic Pathology. Philadelphia, Saunders, 1962, ed. 2. 3. Tuovinen, E . : Pedunculated malignant melanoma of the conjunctiva with bloody tears. Acta. Ophth., 40:149-152, 1962. 4. Bonnet, P.: Ophthalmologie Clinique. Paris, Doin, 1952.
EARLY
immune reaction, the odds of the second graft
REPEATED
suffering
KERATOPLASTY*
That
N O R M A N SANDERS, M . D . Fort Benning, Georgia
the
this is
same fate are a
not
increased.
donor-specific
antigen-anti
b o d y response rather than an
organ-specific
antigen-antibody response^ explains this.
T o o often the problem arises o f h o w long to wait before repeating a corneal transplant when the first graft has been unsuccessful. T h e stock answer seems to be n o less than
C A S E REPORT J. M., a 25-year-old Caucasian, was admitted to Martin Army Hospital with a unilateral keratoco-
six months. T h i s view is definitely not unanimous and many
noted
Fine,^
feel
corneal that
surgeons,
keratoplasty
including
can
be
re
peated as soon as the eye is quiet and
the
original procedure is an unquestionable fail ure. T h e purpose o f this paper is to empha size one small, but important point: that an early regraft can be done. Awareness of this possibility many If
can
months the
first
often
rehabilitate a
sooner graft
than
has
patient
anticipated.
suffered
* From the Martin Army Hospital.
from
an Fig. 1 (Sanders). Central corneal scar with keratoconus.