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A Melanotic Sarcoma, Arising from an Area of Chorioretinitis
NOTES, CASES AND INSTRUMENTS
337
of the chuck and the thumb screw is then tightened. The tightening move ment tends to draw the chuck wedgingly into the handle, causing the jaws to fit tightly on the blade when they come in contact with the inner portion of the handle. The head of the screw, being of larger diameter than the handle, abuts against it and the knife is now ready to use. It will be apparent from the above that new blades may easily and instant ly be inserted to replace the old ones at a moment's notice; and this some times becomes necessary in surgical work. It has been necessary heretofore to have the complete surgical knife sent out for sharpening after it has become dull. This is obviated with the new knife in which the old blade is readily removed and a new inexpensive one is inserted. When the knife is to be used for a cataract operation where the whole length of the cutting edge is required, the blade is inserted into the handle only a few millimeters, but for opera tions on the eyelids, where more re sistance is found, it is better to intro duce half of the blade into the handle, thereby increasing the rigidity of the instrument. The handle is made in two different shapes, square and round as shown in the figure. Its size is about the same as other handles used in eye work. I wish to express my appreciation to Dr. Bustamante, who first suggested to me the use of razor blade material for surgical purposes and to G. Little and V. Mueller for their cooperation in mak ing the knives. The instrument is made by V. Muel ler and Company, 1835 W . Van Buren Street, Chicago, Illinois. Presbyterian Hospital.
She complained of more or less per manent congestion and discomfort with occasional severe exacerbations one of which brought her to me. There were numerous faint corneal maculae which reduced the vision somewhat. Local treatment was used until June 30, on which date the following correction was given : O.S. —2.00 D.sph. = 0 —7.00 cyl. ax. 45°, vision = 20/40. One year later the refraction was —8.00 cyl. ax. 40° with the same sphere as before. There was great annoyance from this high cylinder and the conges tion persisted. Corneal cautery was sug gested after a full explanation, con sented to, and performed on June 5, 1923. It was done as a 2 mm. band at right angles to the myopic axis and ex tending from the pupillary margin well into the pericorneal tissues. This was in the lower inner quadrant of the cornea. The progress has been as follows: July 31, 1923 :—1.00 D.sph. O -^1.00 cyl. ax. 180°, V = 2 0 / 4 0 + . July 25,1928 : —1.00 D.sph. = 0 —3.50 cyl. ax. 180°; V = 2 0 / 4 0 + . March, 1931 : —5.00 D.sph. O — 1 . 0 0 cyl. ax. 180°; V = 2 0 / 4 0 + . August, 1932: —5.00 D.sph.; V = 20/40+. There has been entire absence of dis comfort and congestive attacks since the operation and the vision has re mained 20/40. I t would be interesting to know why the astigmatism has changed almost as much in the last four years as it did im mediately after the operation. I t will be noted that it was apparently increasing before operation. The result shows that in selected cases of regular astigmatism corneal cautery offers a chance for relief from the annoyances of strong cylinders. 450 Sutter street.
CORNEAL CAUTERY FOR HIGH MYOPIC ASTIGMATISM
A MELANOTIC SARCOMA, ARIS ING FROM A N AREA OF CHORIORETINITIS
RODERIC O'CONNOR, M.D. SAN FRANCISCO
Miss S. consulted me first on April IS, 1922. There was a history of measles in early childhood after which the eyes were "very bad till the tenth year".
LEWIS P. GLOVER, ALTOONA
M.D.
It is very seldom that an intraocular new growth can be followed from its beginning to its examination under the microscope. The following case report
338
NOTES, CASES AND INSTRUMENTS
would certainly make one believe that chorioretinitis can be an exciting cause of tumor, as in this case a melanotic sarcoma of the choroid followed a chorioretinitis. W . M., male, aged 68 years, came to me on September 8, 1930, complaining of hazy vision in the right eye, which had been present four months. H e had not had any pain or inflammation of the eye. Vision O.D. = 6/15+ and J.5. Tension was normal. External exami nation was negative; iris reacted promptly to light and accommodation ; media clear. The nerve was round, with
On October 30, 1930, the patient de veloped an iritis in the left eye, which promptly cleared on removal of the tonsils. By December 2, 1930, the left
Fig. 2 (Glover). The tumor in the lower half is deeply pigmented while that above is relatively free from pigment. In the latter area the morphology of the cell is well brought out. Photomicrograph X100.
eye had cleared and the hemorrhage in the right eye had been completely ab sorbed, leaving large areas of chorio retinitis on the nasal side. Vision with
Fig. 1 (Glover). The tumor occupies the right half of the globe, and is attached to the choroid. Note that the optic nerve is uninvolved. Considerable hemorrhage is scat tered throughout the tumor. The retina is completely detached. Photomicrograph X6.
a central physiologic cup. The vessels were slightly sclerotic. Over the nasal periphery of the fundus extending from "3 to 5 o'clock" were the remains of a large subretinal hemorrhage, with smaller absorbed areas of hemorrhage lying nearer the disc below on the nasal side. The macular area and temporal side were negative. Vision with the left eye was 6/6 and J.l. This eye was es sentially negative. The physical examination showed a normal blood picture and blood pres sure. Eight infected teeth were drawn. The tonsils were diseased.
Fig. 3 (Glover). Note the varying amounts of pigment in the tumor cells. Photomicro graph X3S0.
+ .75 D.sph. O + .25 cyl. axis 165° = 6 / 9 + and J.2. The field had improved. The patient was followed up every month until July 22,1931, during which time there was no recurrence, the vi-
NOTES, CASES AND INSTRUMENTS
339
sion remaining as before. On October 8 partment of Pathology, Jefferson Medi he appeared, complaining of loss of vi cal College, then gave me a report, that sion in the right eye, which was found to the tumor was malignant melanotic be reduced to 6/12. He now had what sarcoma probably arising from the appeared to be a large serous retinal choroid, with no evidence of infiltration detachment of the whole area of chorio- of the optic nerve. The sarcoma was retinitis. This remained stationary until over the corresponding area of choroidFebruary 3, 1932, when he found he itis. could not see with the eye and now The patient was at once given heavy had a total detachment of the retina. doses of radium and x-ray, following As transillumination seemed all right which the socket healed nicely. It is too nothing further was done. On June 1, early to tell if any metastasis is present 1932, he suddenly developed an acute but so far the left eye has preserved a glaucoma and two days later the globe normal field and vision. was enucleated and a gold-ball implant I am indebted to Dr. David Morgan done. and Dr. Stewart of Jefferson Medical The gold ball was hastily removed on College for the excellent photomicro June 10, when Dr. Boesinger of the graphs of the eye. Conclusion. A melanotic sarcoma can Altoona Hospital made a diagnosis of melanotic sarcoma. The globe exter arise from an area of chorioretinitis nally did not show any signs of malig within the short period of eight months. nancy. Dr. H. L. Stewart of the de 1200 Fourteenth avenue.
337
of the chuck and the thumb screw is then tightened. The tightening move ment tends to draw the chuck wedgingly into the handle, causing the jaws to fit tightly on the blade when they come in contact with the inner portion of the handle. The head of the screw, being of larger diameter than the handle, abuts against it and the knife is now ready to use. It will be apparent from the above that new blades may easily and instant ly be inserted to replace the old ones at a moment's notice; and this some times becomes necessary in surgical work. It has been necessary heretofore to have the complete surgical knife sent out for sharpening after it has become dull. This is obviated with the new knife in which the old blade is readily removed and a new inexpensive one is inserted. When the knife is to be used for a cataract operation where the whole length of the cutting edge is required, the blade is inserted into the handle only a few millimeters, but for opera tions on the eyelids, where more re sistance is found, it is better to intro duce half of the blade into the handle, thereby increasing the rigidity of the instrument. The handle is made in two different shapes, square and round as shown in the figure. Its size is about the same as other handles used in eye work. I wish to express my appreciation to Dr. Bustamante, who first suggested to me the use of razor blade material for surgical purposes and to G. Little and V. Mueller for their cooperation in mak ing the knives. The instrument is made by V. Muel ler and Company, 1835 W . Van Buren Street, Chicago, Illinois. Presbyterian Hospital.
She complained of more or less per manent congestion and discomfort with occasional severe exacerbations one of which brought her to me. There were numerous faint corneal maculae which reduced the vision somewhat. Local treatment was used until June 30, on which date the following correction was given : O.S. —2.00 D.sph. = 0 —7.00 cyl. ax. 45°, vision = 20/40. One year later the refraction was —8.00 cyl. ax. 40° with the same sphere as before. There was great annoyance from this high cylinder and the conges tion persisted. Corneal cautery was sug gested after a full explanation, con sented to, and performed on June 5, 1923. It was done as a 2 mm. band at right angles to the myopic axis and ex tending from the pupillary margin well into the pericorneal tissues. This was in the lower inner quadrant of the cornea. The progress has been as follows: July 31, 1923 :—1.00 D.sph. O -^1.00 cyl. ax. 180°, V = 2 0 / 4 0 + . July 25,1928 : —1.00 D.sph. = 0 —3.50 cyl. ax. 180°; V = 2 0 / 4 0 + . March, 1931 : —5.00 D.sph. O — 1 . 0 0 cyl. ax. 180°; V = 2 0 / 4 0 + . August, 1932: —5.00 D.sph.; V = 20/40+. There has been entire absence of dis comfort and congestive attacks since the operation and the vision has re mained 20/40. I t would be interesting to know why the astigmatism has changed almost as much in the last four years as it did im mediately after the operation. I t will be noted that it was apparently increasing before operation. The result shows that in selected cases of regular astigmatism corneal cautery offers a chance for relief from the annoyances of strong cylinders. 450 Sutter street.
CORNEAL CAUTERY FOR HIGH MYOPIC ASTIGMATISM
A MELANOTIC SARCOMA, ARIS ING FROM A N AREA OF CHORIORETINITIS
RODERIC O'CONNOR, M.D. SAN FRANCISCO
Miss S. consulted me first on April IS, 1922. There was a history of measles in early childhood after which the eyes were "very bad till the tenth year".
LEWIS P. GLOVER, ALTOONA
M.D.
It is very seldom that an intraocular new growth can be followed from its beginning to its examination under the microscope. The following case report
338
NOTES, CASES AND INSTRUMENTS
would certainly make one believe that chorioretinitis can be an exciting cause of tumor, as in this case a melanotic sarcoma of the choroid followed a chorioretinitis. W . M., male, aged 68 years, came to me on September 8, 1930, complaining of hazy vision in the right eye, which had been present four months. H e had not had any pain or inflammation of the eye. Vision O.D. = 6/15+ and J.5. Tension was normal. External exami nation was negative; iris reacted promptly to light and accommodation ; media clear. The nerve was round, with
On October 30, 1930, the patient de veloped an iritis in the left eye, which promptly cleared on removal of the tonsils. By December 2, 1930, the left
Fig. 2 (Glover). The tumor in the lower half is deeply pigmented while that above is relatively free from pigment. In the latter area the morphology of the cell is well brought out. Photomicrograph X100.
eye had cleared and the hemorrhage in the right eye had been completely ab sorbed, leaving large areas of chorio retinitis on the nasal side. Vision with
Fig. 1 (Glover). The tumor occupies the right half of the globe, and is attached to the choroid. Note that the optic nerve is uninvolved. Considerable hemorrhage is scat tered throughout the tumor. The retina is completely detached. Photomicrograph X6.
a central physiologic cup. The vessels were slightly sclerotic. Over the nasal periphery of the fundus extending from "3 to 5 o'clock" were the remains of a large subretinal hemorrhage, with smaller absorbed areas of hemorrhage lying nearer the disc below on the nasal side. The macular area and temporal side were negative. Vision with the left eye was 6/6 and J.l. This eye was es sentially negative. The physical examination showed a normal blood picture and blood pres sure. Eight infected teeth were drawn. The tonsils were diseased.
Fig. 3 (Glover). Note the varying amounts of pigment in the tumor cells. Photomicro graph X3S0.
+ .75 D.sph. O + .25 cyl. axis 165° = 6 / 9 + and J.2. The field had improved. The patient was followed up every month until July 22,1931, during which time there was no recurrence, the vi-
NOTES, CASES AND INSTRUMENTS
339
sion remaining as before. On October 8 partment of Pathology, Jefferson Medi he appeared, complaining of loss of vi cal College, then gave me a report, that sion in the right eye, which was found to the tumor was malignant melanotic be reduced to 6/12. He now had what sarcoma probably arising from the appeared to be a large serous retinal choroid, with no evidence of infiltration detachment of the whole area of chorio- of the optic nerve. The sarcoma was retinitis. This remained stationary until over the corresponding area of choroidFebruary 3, 1932, when he found he itis. could not see with the eye and now The patient was at once given heavy had a total detachment of the retina. doses of radium and x-ray, following As transillumination seemed all right which the socket healed nicely. It is too nothing further was done. On June 1, early to tell if any metastasis is present 1932, he suddenly developed an acute but so far the left eye has preserved a glaucoma and two days later the globe normal field and vision. was enucleated and a gold-ball implant I am indebted to Dr. David Morgan done. and Dr. Stewart of Jefferson Medical The gold ball was hastily removed on College for the excellent photomicro June 10, when Dr. Boesinger of the graphs of the eye. Conclusion. A melanotic sarcoma can Altoona Hospital made a diagnosis of melanotic sarcoma. The globe exter arise from an area of chorioretinitis nally did not show any signs of malig within the short period of eight months. nancy. Dr. H. L. Stewart of the de 1200 Fourteenth avenue.