- Email: [email protected]
Gamma Radiation*
NOTES, CASES, INSTRUMENTS
811
choroidal hemorrhage during expulsion of the lens and vitreous, as an operative compli cation in a patient previously infused with urea. In conclusion, we believe that slower in fusion not only obtains a substantial lower ing of the intraocular pressure but also pre vents undesirable physiologic side-reactions. Further, we also believe that rapid hypotony predisposes to intraocular bleeding.
in six cases of absolute glaucoma are pre sented. 2. Two cases of severe intraocular hemor rhage which ultimately required enucleation are reviewed. 3. The advantage of slower infusion is dis cussed and recommended to prevent serious hemorrhagic complications. 12703 West Seven Mile Road (35).
SUMMARY
We wish to thank Dr. Windsor S. Davies and the members of the Pathology Department of the Kresge Eye Institute for their invaluable assistance in the preparation of this report.
.
1. The use of intravenous urea and its ef fectiveness in lowering intraocular pressure
ACKNOWLEDGMENT
REFERENCES
1. Crews, S. J., and Davidson, S. I.: Intravenous urea therapy in glaucoma. Brit. J. Ophth., 45:769, 1961. 2. Tarter, R. C, and Linn, J. G., Jr.: Intravenous urea in glaucoma. Am. J. Ophth., 52:323-331 (Sept.) 1961. 3. Ackerman, A. L.: The action of urea in acute glaucoma. Am. J. Ophth., 52:875-880 (Dec.) 1961. 4. Galin, M. A., Aizawa, F., and McLean, J. M.: Intravenous urea in the treatment of acute angleclosure glaucoma. Am. J. Ophth., 50:379, 1960. 5. Hill, K., Whitney, J. B., and Trotter, R. R. : Intravenous hypertonic urea in the management of acute angle-closure glaucoma. AMA Arch. Ophth., 65:479, 1961. 6. Davis, M. D., Duehr, P. A., and Javid, M.: The clinical use of urea for reduction of intraocular pressure. AMA Arch. Ophth., 65:526, 1961. 7. Javid, M.: Urea: New use of an old agent: Reduction of intracranial and intraocular pressure. S. Clin. North America, 38:907-928 (Aug.) 1958. 8. Friedman, B., Herve, B., and Turtz, A.: Urea in cataract extraction. AMA Arch. Ophth., 67:421423 (Apr.) 1962. 9. Stubbs, J., and Pennybacker, J. : Reduction of intracranial pressure with hypertonic urea. The Lancet, 1:1094 (May) 1960. 10. Galin, M. A., Aizawa, F., and McLean, J. M.: A comparison of intraocular pressure following urea and sucrose administration. AMA Arch. Ophth., 63:281-282, 1960. 11. : Urea as an osmotic hypotensive agent in glaucoma. AMA Arch. Ophth., 62:347-352, 1959. 12. Fink, A. I., Binkherst, R. D., and Funahashi, T.: Intravenous urea and angle-closure glaucoma. Am. J. Ophth., 52:872 (Dec.) 1961. 13. Davies, W. S.: Personal communication.
GAMMA RADIATION* I N T H E T R E A T M E N T OF SQUAMOUS-CELL CARCINOMA O F T H E L I M B U S J U L I A N R. GOLDBERG, M.D.
Baltimore, Maryland S T A N L E Y C. B E C K E R ,
M.D.
AND H A R R Y D. R O S E N B A U M ,
M.D.
Saint Louis, Missouri * From the Section of Ophthalmology, Depart ment of Surgery, Cochran Veterans Hospital, Saint Louis.
Squamous-cell carcinoma at the limbus, the so-called limbal epithelioma, is the most common malignant tumor of the conjunctiva. It is believed to occur in pre-existing papillomatous growths or in altered epithelium. In a precancerous form, it is better known as Bowen's disease or intraepithelial epithelio ma. The treatment of both the premalignant and malignant phase of this process is excisional biopsy which, in most cases, results in complete cure. It is only in those cases in which the lesion is too large and penetrates too deeply into the corneal substance that
812
NOTES, CASES, INSTRUMENTS
problems in therapy arise. In many instances, where total excision has been impossible, enucleation has been performed. It is in those cases that some other therapy is necessary for preservation of the eye and useful vision. Since the lesion is neoplastic, a form of radiotherapy which might destroy the tumor, but not damage the eye, would be desirable. Three avenues of approach are open : ( 1 ) beta radiation, ( 2 ) X-radiation and ( 3 ) gam ma rays using surface applicators. T h e first two methods have had adequate trial but the latter means of therapy has been neglected. Beta-ray therapy has been employed for benign lesions of the conjunctiva and the cor nea which are superficial and are of a nonneoplastic nature. This is made possible by a limited penetrability of such applicators. W i t h strontium-90 applicators, the amount of irradiation is reduced after traversing two mm. of tissue to 18 percent of that at the surface. T h e lens in such cases will receive less than 10 percent of the irradiation de livered to the cornea and the average dosage received by the lens would be about three per cent of that administered to the corneal sur face. 1 It is its low penetrability which makes beta rays so useful in nonneoplastic disease ; however, this also prevents its effective use in malignant lesions of the limbus, total tu mor destruction not always being possible. Low voltage X-ray therapy has been em ployed by Lederman in treatments of such lesions. 2 With the eye cocainized, no pre cautions are taken against lens damage. The surface is treated with a daily dose of 400 r, with the total dose being 6,000 r in three weeks. Alter and Leinfelder 3 investigated the formation of cataract in rabbits after X-ray therapy. They were able to prevent cataract formation with dosages of 1,500 r by pro tecting the lens with a lead shield of twomm. thickness. They were also able to show that the equatorial portion of the lens a p peared to be most and the pupillary zone least sensitive to injury by roentgen rays. N o cata ract formed when the ciliary body received a cataractogenic dosage. Treatment with X-ray
therapy, as described by Lederman, carries with it a definite risk of lens change which is said to occur with exposure of the lens to greater than 500 roentgens. Lederman's in dications for this therapy include: ( 1 ) al ternative to surgery when such treatment results in loss of the eye, ( 2 ) for the elderly patient, ( 3 ) for any patient already showing lens change and ( 4 ) for the inoperable case. Gamma rays have not had extensive use for malignant lesions of the cornea. During the breakdown of radon, gamma rays are emitted with beta particles as the radon gas undergoes its disintegrative process. Gamma rays have marked penetrability and require 25 cm. of lead to be totally filtered.4 Reports of the use of radium applicators in various disease entities of the orbit have been few. F r y 5 reports a case of malignant orbital tumor so treated, with resultant secondary glaucoma, cataract and retinal degeneration. However, no attempt at shielding was made. Vail 6 reports a case of epithelial downgrowth treated successfully with radium plaques directly over the eyelid. Vacuolization of the cornea was prominent. However, the eye cleared and the disease process was halted. Radon seeds have been sewn to the sclera for retinoblastoma and to the conjunc tiva for melanomas of that tissue. Most cases treated with radium were done so only be cause it was felt that no other adequate ther apy was possible. W e were faced with such a problem—an extensive squamous-cell car cinoma of the limbus in the only eye of a 65year-old patient. C A S E REPORT
C. J. F. (SL-19788) was a 65-year-old white man first seen on April 1, 1959, at Marion Vet erans Administration Hospital with burning pain in the right eye for six weeks. The patient had noted visual loss for a six-month period, most marked in the six weeks prior to admission. He recalled that in 1955, while having a routine eye examination, he had been told there was a growth in his right eye. The left eye had been blind for eight years from a perforated ulcer. Physical examination revealed that the vision of the right eye was 20/70 with correction. The le sion was described as a fleshy, vascular, limbal
N O T E S , CASES, I N S T R U M E N T S mass which extended down onto the cornea from the 12-o'clock position and counterclockwise about the limbus to the 10-o'clock position. Temporally, there also appeared to be a vascular, superficial lesion of the cornea as well as considerable dis charge in the conjunctival sac, with moderate in jection of the remainder of the bulbar conjunc tiva. The anterior chamber was normal and the pupil was miotic. A red reflex was obtained but no fundus details were seen. On April 7, 1959, excisional biopsy of the con junctival lesion was attempted and microscopic study revealed a poorly differentiated squamouscell carcinoma. Because the surgeon felt that the lesion was not completely excised, the patient was referred to Cochran Veterans Hospital in Saint Louis for further therapy. The patient was admitted on April 28, 1959, at which time examination revealed that vision of the right eye was 20/50 with a pinhole. External ex amination revealed a lesion, clockwise from the 12- to 4-o'clock position, vascular and fleshy and extending onto the cornea for two mm. Another lesion was present from the 6- to 8-o'clock posi tions, with a symblepharon extending out at the 9-o'clock position from the bulbar conjunctiva to the upper lid. On May 29, 1959, another unsuccessful attempt at excision was made which was thwarted as the tumor infiltrated the deepest layers of the cornea. The biopsy from the 6- to 8-o'clock positions re vealed normal epithelium while the specimen from the 12- to 4-o'clock revealed a squamous-cell car cinoma (fig. 1). The conjunctival wound healed well but, at the site of the carcinoma, there was still a vascular, fleshy growth extending in all di rections around the original biopsy sites. It was agreed that radiation was the only means of therapy which afforded any chance of main taining the eye and useful vision. It was decided that radium with gamma irradiation be attempted with shielding of the lens. An impression of the cul-de-sac and a form of the orbit were made with an agar substance. From these forms, an acrylic mold, custom fitted for the patient's orbit and cul-de-sac, was made.
Fig. 1 (Goldberg, et al.). Biopsy specimen of the limbal lesion, revealing a poorly differentiated squamous-cell carcinoma which had penetrated into the deep layers of the corneal stroma.
813
Fig. 2 (Goldberg, et al.). A lead-lined hollow cylinder mounted on an acrylic conformer. The conformer was to be placed in the eye as a con tact lens and the patient was to fixate through the hollow cylinder on a light on the ceiling overhead. The lead-lined cylinder was to act as a shield for the lens of the eye. A lead-lined tube was mounted onto the acrylic conformer in such a way that it corresponded to the location of the lens of the eye with a hollow cavity so that the patient in a supine position could fixate on the light on the ceiling (fig. 2 ) . Since the diameter of the lens at its equator is said to be nine mm., the protective cylinder had a diameter of 10 mm. including the thickness of the lead, which was four mm. Through holes drilled in the acrylic, four radium needles were inserted so as to surround the lead cylinder. The four radium capsules, 10 mg. each, 0.5-mm. platinum filter, each two cm. of active length, were placed in a form of a square, the center of the square being approximately 1.5 cm. from the center of the cornea. Since the radium capsules overlapped each other, the two lateral capsules were approxi mately 1.5 cm. from the cornea and the two hori zontal capsules were approximately 1.3 cm. from the cornea. Using standard radium tables, it was calculated that the patient received 140 gamma r to the tumor site at each session. On July 6, 1959, the patient withstood his first treatment with great difficulty. Examination re vealed a corneal ulcer which was attributed to the drying of the cornea, as the conformer prevented blinking during the hour-long treatment. Because of the trauma to the cornea, it was decided to re move the conformer from the acrylic mold so no foreign body would be in contact with the cornea.
NOTES, CASES, INSTRUMENTS
814
The second treatment on July 21st was given as before except that the lead cylinder was de tached from the conformer and inserted into the open area of the mold to protect the lens (figs. 3 and 4). The patient now could fixate on a light through the two-mm. opening in the cylinder with out exposure of the cornea. A total of ' 35 radium treatments was. given with 40 mg. of radium. The patient received a total of 5,040 r to the bulbar conjunctiva and limbus. There, was severe to mod erate punctate staining of the cornea but this was controlled with local steroid therapy. Vacuolization of the corneal epithelium and conjunctival injec tion were prominent. - Reaction of the lids to irradi ation was considerable but with local steroid oint ment it was well controlled and became practi cally unnoticeable wil,hin a two-month period. On September 24th, the patient presented with a typical dendritic figure, possibly the result of steroid therapy. The figure cleared in 48 hours. The limbal lesion diminished in size and lost its Fig. 4 (Goldberg, et al.). The skin surface of vascular appearance. No advance in leris changes was observed by slitlamp examination. On Decem the plastic mold, showing the form which cor ber 8th, the vision was correctible to 20/70 and responded to the orbital contour. The mold could the limbal lesion had atrophied and showed marked be steadied because of its close fit to adjacent structures. loss· of vascularization. On June 10, 1960, vision of the right eye was correctible to 20/50 with lenses. Slitlamp examina (Schijftz). A nodule was present approximately tion revealed a superficial corneal vascularization six mm. from the limbus at the site of the symabout the limbus but no active lesions were seen. blepharon, 9-o'clock position, previously described. The tension of the right eye was 18 mm. Hg On September 9th, the vision of the right eye was correctible to 20/40. CONCLUSION ■.,;> ....«Ijpjjtj-,
Gamma radiation for malignant lesions of the limbus has never been employed with en thusiasm in the past. Fear of cataract forma tion, secondary glaucoma and other compli cations has discouraged its use. However, with refinement in technique and close obser vation by ophthalmologists and radiologists, effective therapy of such lesions may result in preservation of useful vision. A case of limbal epithelioma treated with 5,040 gamma r and followed for two years without pro gression of lens change or recurrence of tu mor is presented.
Fig. 3 (Goldberg, et al.). External view of the plastic mold, with the lead cylinder in its sub stance. The spaces in which the radium needles were placed can be seen. The patient fixated on a ceiling light overhead but had no conformer against the cornea.
6609 Reist erst own Road (15). ACKNOWLEDGMENT
We wish to express our appreciation to Drs. S. Kamberg and F. McNamara of the Depart ment of Radiology for their assistance.
REFERENCES
1. Thomas, C. : Cornea. Springfield, 111., Thomas, 1955. 2. Lederman, M.: Radiotherapy and diseases of the cornea. J. Faculty Radiologists, 4:97-114 (Oct.) 1952.
NOTES, CASES, INSTRUMENTS
815
3. Alter, A., and Leinfelder, P.: Roentgen-ray cataract. AMA Arch. Ophth., 49:257, 1953. 4. MacDonald, P.: Clinical radium and roentgen therapy of the eye. Am. J. Ophth., 31:1008, 1948. 5. Fry, W. E.: Secondary glaucoma, cataract and retinal degeneration following radiation. Tr. Am. Acad. Ophth., 56:888-900 (Nov.-Dec.) 1952. 6. Vail, D.: Epithelial downgrowth in the anterior chamber following cataract extraction: Arrested by radium treatment. Arch. Ophth., 15:270-282 (Feb.) 1936.
BILATERAL RECURRENT EPISCLERITIS ASSOCIATED WITH POSTERIOR CORNEAL CHANGES, VESTIBULO-AUDITORY SYMP TOMS AND RHEUMATOID ARTHRITIS
FIONA M. BENNETT, F.R.C.S. ( E D I N . ) Aberdeen, Scotland C A S E REPORT
Past history. Miss C. S., at present aged 53 years, a school teacher, gave an history of pain in her left shoulder which started in 1942 and which was followed by some swelling of her fingers. In 1946, her left knee became swollen and the con dition was diagnosed as a tuberculous knee joint, the patient being seen at several hospitals. At no time was there any bactériologie confirmation of the diagnosis but clinical and radiologie evidence were suggestive. After 10 months' splintage, it was decided to proceed with arthrodesis of the left knee joint. This operation was accordingly carried out at Stracathro Hospital in 1946. At that time it was noted in the operation notes that the joint was "probably tubercular" (but) "the infection was mild and confined entirely to the synovial mem brane." Repeated cultures of the fluid aspirated from the knee joint and from a subsequently dis charging sinus were negative for tubercle bacilli. Present history. In 1952, the patient reported to the Ear, Nose and Throat Department of Aberdeen Royal Infirmary, complaining of sudden dizziness of one week's duration, accompanied by vomiting attacks which had subsided during the previous week but which still occurred on standing. There was no tinnitus. There was an eight-year history of deafness in the left ear, the onset of the deaf ness having been immediately preceded by an at tack of vertigo. Examination revealed a positive Rinné test on the left side, with reduced absolute bone conduction on that side. An audiometer test showed a typical perceptive deafness of about 40 decibels with high tone loss. There was, in addition, some eustachian obstruction. Caloric tests carried out two days later showed a definite left canal paresis. Her skull was X-rayed to exclude the possibility of any acoustic neuroma but the X-ray film was entirely negative. An histamine test was carried out to see if the patient was likely to respond to a course of hista
mine injections, but sensitivity to histamine was very slight. Consequently, treatment with luminal, reduction of fluids, and a salt-free diet was sug gested. A diagnosis of Ménière's disease was tentatively made. In October, 1953, the patient thought that she was becoming deaf in the right ear after an ex acerbation of vertigo and vomiting 17 days previ ously. On examination, a marked deterioration of the hearing of the right ear was found, together with gross deterioration of the left side. The patient was admitted to hospital in De cember, 1953. She was practically stone deaf in both ears and no caloric reactions were now present on either side. X-ray films of skull and chest were negative. Cerebrospinal fluid findings were normal, as was her blood count, Wassermann reaction was nega tive. A medical opinion was sought at that time on account of the rapidity of the development of the bilateral deafness. The patient was seen by the professor of medi cine, who found both optic discs to be blurred, some weakness of the right hand and a doubtful left extensor plantar reflex. At his suggestion the patient was later seen by a neurosurgeon, who con firmed the previous findings but could not visu alize any definite cerebral lesion which would pick out the vestibular nerve on either side. On the whole, he thought the diagnosis of Ménière's dis ease was correct. He also offered to follow-up the patient in the out-patient department. About a week later, that is, nine weeks after the vertigo and deafness occurred, the patient de veloped a patch of left episcleritis, which was treated with local cortisone and atropine. Visual acuity then was 6/6, R.E., 6/9, L.E. Both optic discs were said to be florid but no actual papilledema was made out. Peripheral and central fields showed no abnormality and the sensation of the V cranial nerve was normal, although some nystag mus was noted at that time. It was again considered that the diagnosis must remain bilateral Ménière's disease of advanced type, though this diagnosis might be altered later. In February, 1954, it was thought that another opinion should be sought, and the patient was sent to London to see both ear and eye specialists. All the previous findings were confirmed but the eye prognosis was that the episcleritis might lead to blindness in the left eye. Throughout 1954, the patient had repeated at tacks of episcleritis which were treated with local
811
choroidal hemorrhage during expulsion of the lens and vitreous, as an operative compli cation in a patient previously infused with urea. In conclusion, we believe that slower in fusion not only obtains a substantial lower ing of the intraocular pressure but also pre vents undesirable physiologic side-reactions. Further, we also believe that rapid hypotony predisposes to intraocular bleeding.
in six cases of absolute glaucoma are pre sented. 2. Two cases of severe intraocular hemor rhage which ultimately required enucleation are reviewed. 3. The advantage of slower infusion is dis cussed and recommended to prevent serious hemorrhagic complications. 12703 West Seven Mile Road (35).
SUMMARY
We wish to thank Dr. Windsor S. Davies and the members of the Pathology Department of the Kresge Eye Institute for their invaluable assistance in the preparation of this report.
.
1. The use of intravenous urea and its ef fectiveness in lowering intraocular pressure
ACKNOWLEDGMENT
REFERENCES
1. Crews, S. J., and Davidson, S. I.: Intravenous urea therapy in glaucoma. Brit. J. Ophth., 45:769, 1961. 2. Tarter, R. C, and Linn, J. G., Jr.: Intravenous urea in glaucoma. Am. J. Ophth., 52:323-331 (Sept.) 1961. 3. Ackerman, A. L.: The action of urea in acute glaucoma. Am. J. Ophth., 52:875-880 (Dec.) 1961. 4. Galin, M. A., Aizawa, F., and McLean, J. M.: Intravenous urea in the treatment of acute angleclosure glaucoma. Am. J. Ophth., 50:379, 1960. 5. Hill, K., Whitney, J. B., and Trotter, R. R. : Intravenous hypertonic urea in the management of acute angle-closure glaucoma. AMA Arch. Ophth., 65:479, 1961. 6. Davis, M. D., Duehr, P. A., and Javid, M.: The clinical use of urea for reduction of intraocular pressure. AMA Arch. Ophth., 65:526, 1961. 7. Javid, M.: Urea: New use of an old agent: Reduction of intracranial and intraocular pressure. S. Clin. North America, 38:907-928 (Aug.) 1958. 8. Friedman, B., Herve, B., and Turtz, A.: Urea in cataract extraction. AMA Arch. Ophth., 67:421423 (Apr.) 1962. 9. Stubbs, J., and Pennybacker, J. : Reduction of intracranial pressure with hypertonic urea. The Lancet, 1:1094 (May) 1960. 10. Galin, M. A., Aizawa, F., and McLean, J. M.: A comparison of intraocular pressure following urea and sucrose administration. AMA Arch. Ophth., 63:281-282, 1960. 11. : Urea as an osmotic hypotensive agent in glaucoma. AMA Arch. Ophth., 62:347-352, 1959. 12. Fink, A. I., Binkherst, R. D., and Funahashi, T.: Intravenous urea and angle-closure glaucoma. Am. J. Ophth., 52:872 (Dec.) 1961. 13. Davies, W. S.: Personal communication.
GAMMA RADIATION* I N T H E T R E A T M E N T OF SQUAMOUS-CELL CARCINOMA O F T H E L I M B U S J U L I A N R. GOLDBERG, M.D.
Baltimore, Maryland S T A N L E Y C. B E C K E R ,
M.D.
AND H A R R Y D. R O S E N B A U M ,
M.D.
Saint Louis, Missouri * From the Section of Ophthalmology, Depart ment of Surgery, Cochran Veterans Hospital, Saint Louis.
Squamous-cell carcinoma at the limbus, the so-called limbal epithelioma, is the most common malignant tumor of the conjunctiva. It is believed to occur in pre-existing papillomatous growths or in altered epithelium. In a precancerous form, it is better known as Bowen's disease or intraepithelial epithelio ma. The treatment of both the premalignant and malignant phase of this process is excisional biopsy which, in most cases, results in complete cure. It is only in those cases in which the lesion is too large and penetrates too deeply into the corneal substance that
812
NOTES, CASES, INSTRUMENTS
problems in therapy arise. In many instances, where total excision has been impossible, enucleation has been performed. It is in those cases that some other therapy is necessary for preservation of the eye and useful vision. Since the lesion is neoplastic, a form of radiotherapy which might destroy the tumor, but not damage the eye, would be desirable. Three avenues of approach are open : ( 1 ) beta radiation, ( 2 ) X-radiation and ( 3 ) gam ma rays using surface applicators. T h e first two methods have had adequate trial but the latter means of therapy has been neglected. Beta-ray therapy has been employed for benign lesions of the conjunctiva and the cor nea which are superficial and are of a nonneoplastic nature. This is made possible by a limited penetrability of such applicators. W i t h strontium-90 applicators, the amount of irradiation is reduced after traversing two mm. of tissue to 18 percent of that at the surface. T h e lens in such cases will receive less than 10 percent of the irradiation de livered to the cornea and the average dosage received by the lens would be about three per cent of that administered to the corneal sur face. 1 It is its low penetrability which makes beta rays so useful in nonneoplastic disease ; however, this also prevents its effective use in malignant lesions of the limbus, total tu mor destruction not always being possible. Low voltage X-ray therapy has been em ployed by Lederman in treatments of such lesions. 2 With the eye cocainized, no pre cautions are taken against lens damage. The surface is treated with a daily dose of 400 r, with the total dose being 6,000 r in three weeks. Alter and Leinfelder 3 investigated the formation of cataract in rabbits after X-ray therapy. They were able to prevent cataract formation with dosages of 1,500 r by pro tecting the lens with a lead shield of twomm. thickness. They were also able to show that the equatorial portion of the lens a p peared to be most and the pupillary zone least sensitive to injury by roentgen rays. N o cata ract formed when the ciliary body received a cataractogenic dosage. Treatment with X-ray
therapy, as described by Lederman, carries with it a definite risk of lens change which is said to occur with exposure of the lens to greater than 500 roentgens. Lederman's in dications for this therapy include: ( 1 ) al ternative to surgery when such treatment results in loss of the eye, ( 2 ) for the elderly patient, ( 3 ) for any patient already showing lens change and ( 4 ) for the inoperable case. Gamma rays have not had extensive use for malignant lesions of the cornea. During the breakdown of radon, gamma rays are emitted with beta particles as the radon gas undergoes its disintegrative process. Gamma rays have marked penetrability and require 25 cm. of lead to be totally filtered.4 Reports of the use of radium applicators in various disease entities of the orbit have been few. F r y 5 reports a case of malignant orbital tumor so treated, with resultant secondary glaucoma, cataract and retinal degeneration. However, no attempt at shielding was made. Vail 6 reports a case of epithelial downgrowth treated successfully with radium plaques directly over the eyelid. Vacuolization of the cornea was prominent. However, the eye cleared and the disease process was halted. Radon seeds have been sewn to the sclera for retinoblastoma and to the conjunc tiva for melanomas of that tissue. Most cases treated with radium were done so only be cause it was felt that no other adequate ther apy was possible. W e were faced with such a problem—an extensive squamous-cell car cinoma of the limbus in the only eye of a 65year-old patient. C A S E REPORT
C. J. F. (SL-19788) was a 65-year-old white man first seen on April 1, 1959, at Marion Vet erans Administration Hospital with burning pain in the right eye for six weeks. The patient had noted visual loss for a six-month period, most marked in the six weeks prior to admission. He recalled that in 1955, while having a routine eye examination, he had been told there was a growth in his right eye. The left eye had been blind for eight years from a perforated ulcer. Physical examination revealed that the vision of the right eye was 20/70 with correction. The le sion was described as a fleshy, vascular, limbal
N O T E S , CASES, I N S T R U M E N T S mass which extended down onto the cornea from the 12-o'clock position and counterclockwise about the limbus to the 10-o'clock position. Temporally, there also appeared to be a vascular, superficial lesion of the cornea as well as considerable dis charge in the conjunctival sac, with moderate in jection of the remainder of the bulbar conjunc tiva. The anterior chamber was normal and the pupil was miotic. A red reflex was obtained but no fundus details were seen. On April 7, 1959, excisional biopsy of the con junctival lesion was attempted and microscopic study revealed a poorly differentiated squamouscell carcinoma. Because the surgeon felt that the lesion was not completely excised, the patient was referred to Cochran Veterans Hospital in Saint Louis for further therapy. The patient was admitted on April 28, 1959, at which time examination revealed that vision of the right eye was 20/50 with a pinhole. External ex amination revealed a lesion, clockwise from the 12- to 4-o'clock position, vascular and fleshy and extending onto the cornea for two mm. Another lesion was present from the 6- to 8-o'clock posi tions, with a symblepharon extending out at the 9-o'clock position from the bulbar conjunctiva to the upper lid. On May 29, 1959, another unsuccessful attempt at excision was made which was thwarted as the tumor infiltrated the deepest layers of the cornea. The biopsy from the 6- to 8-o'clock positions re vealed normal epithelium while the specimen from the 12- to 4-o'clock revealed a squamous-cell car cinoma (fig. 1). The conjunctival wound healed well but, at the site of the carcinoma, there was still a vascular, fleshy growth extending in all di rections around the original biopsy sites. It was agreed that radiation was the only means of therapy which afforded any chance of main taining the eye and useful vision. It was decided that radium with gamma irradiation be attempted with shielding of the lens. An impression of the cul-de-sac and a form of the orbit were made with an agar substance. From these forms, an acrylic mold, custom fitted for the patient's orbit and cul-de-sac, was made.
Fig. 1 (Goldberg, et al.). Biopsy specimen of the limbal lesion, revealing a poorly differentiated squamous-cell carcinoma which had penetrated into the deep layers of the corneal stroma.
813
Fig. 2 (Goldberg, et al.). A lead-lined hollow cylinder mounted on an acrylic conformer. The conformer was to be placed in the eye as a con tact lens and the patient was to fixate through the hollow cylinder on a light on the ceiling overhead. The lead-lined cylinder was to act as a shield for the lens of the eye. A lead-lined tube was mounted onto the acrylic conformer in such a way that it corresponded to the location of the lens of the eye with a hollow cavity so that the patient in a supine position could fixate on the light on the ceiling (fig. 2 ) . Since the diameter of the lens at its equator is said to be nine mm., the protective cylinder had a diameter of 10 mm. including the thickness of the lead, which was four mm. Through holes drilled in the acrylic, four radium needles were inserted so as to surround the lead cylinder. The four radium capsules, 10 mg. each, 0.5-mm. platinum filter, each two cm. of active length, were placed in a form of a square, the center of the square being approximately 1.5 cm. from the center of the cornea. Since the radium capsules overlapped each other, the two lateral capsules were approxi mately 1.5 cm. from the cornea and the two hori zontal capsules were approximately 1.3 cm. from the cornea. Using standard radium tables, it was calculated that the patient received 140 gamma r to the tumor site at each session. On July 6, 1959, the patient withstood his first treatment with great difficulty. Examination re vealed a corneal ulcer which was attributed to the drying of the cornea, as the conformer prevented blinking during the hour-long treatment. Because of the trauma to the cornea, it was decided to re move the conformer from the acrylic mold so no foreign body would be in contact with the cornea.
NOTES, CASES, INSTRUMENTS
814
The second treatment on July 21st was given as before except that the lead cylinder was de tached from the conformer and inserted into the open area of the mold to protect the lens (figs. 3 and 4). The patient now could fixate on a light through the two-mm. opening in the cylinder with out exposure of the cornea. A total of ' 35 radium treatments was. given with 40 mg. of radium. The patient received a total of 5,040 r to the bulbar conjunctiva and limbus. There, was severe to mod erate punctate staining of the cornea but this was controlled with local steroid therapy. Vacuolization of the corneal epithelium and conjunctival injec tion were prominent. - Reaction of the lids to irradi ation was considerable but with local steroid oint ment it was well controlled and became practi cally unnoticeable wil,hin a two-month period. On September 24th, the patient presented with a typical dendritic figure, possibly the result of steroid therapy. The figure cleared in 48 hours. The limbal lesion diminished in size and lost its Fig. 4 (Goldberg, et al.). The skin surface of vascular appearance. No advance in leris changes was observed by slitlamp examination. On Decem the plastic mold, showing the form which cor ber 8th, the vision was correctible to 20/70 and responded to the orbital contour. The mold could the limbal lesion had atrophied and showed marked be steadied because of its close fit to adjacent structures. loss· of vascularization. On June 10, 1960, vision of the right eye was correctible to 20/50 with lenses. Slitlamp examina (Schijftz). A nodule was present approximately tion revealed a superficial corneal vascularization six mm. from the limbus at the site of the symabout the limbus but no active lesions were seen. blepharon, 9-o'clock position, previously described. The tension of the right eye was 18 mm. Hg On September 9th, the vision of the right eye was correctible to 20/40. CONCLUSION ■.,;> ....«Ijpjjtj-,
Gamma radiation for malignant lesions of the limbus has never been employed with en thusiasm in the past. Fear of cataract forma tion, secondary glaucoma and other compli cations has discouraged its use. However, with refinement in technique and close obser vation by ophthalmologists and radiologists, effective therapy of such lesions may result in preservation of useful vision. A case of limbal epithelioma treated with 5,040 gamma r and followed for two years without pro gression of lens change or recurrence of tu mor is presented.
Fig. 3 (Goldberg, et al.). External view of the plastic mold, with the lead cylinder in its sub stance. The spaces in which the radium needles were placed can be seen. The patient fixated on a ceiling light overhead but had no conformer against the cornea.
6609 Reist erst own Road (15). ACKNOWLEDGMENT
We wish to express our appreciation to Drs. S. Kamberg and F. McNamara of the Depart ment of Radiology for their assistance.
REFERENCES
1. Thomas, C. : Cornea. Springfield, 111., Thomas, 1955. 2. Lederman, M.: Radiotherapy and diseases of the cornea. J. Faculty Radiologists, 4:97-114 (Oct.) 1952.
NOTES, CASES, INSTRUMENTS
815
3. Alter, A., and Leinfelder, P.: Roentgen-ray cataract. AMA Arch. Ophth., 49:257, 1953. 4. MacDonald, P.: Clinical radium and roentgen therapy of the eye. Am. J. Ophth., 31:1008, 1948. 5. Fry, W. E.: Secondary glaucoma, cataract and retinal degeneration following radiation. Tr. Am. Acad. Ophth., 56:888-900 (Nov.-Dec.) 1952. 6. Vail, D.: Epithelial downgrowth in the anterior chamber following cataract extraction: Arrested by radium treatment. Arch. Ophth., 15:270-282 (Feb.) 1936.
BILATERAL RECURRENT EPISCLERITIS ASSOCIATED WITH POSTERIOR CORNEAL CHANGES, VESTIBULO-AUDITORY SYMP TOMS AND RHEUMATOID ARTHRITIS
FIONA M. BENNETT, F.R.C.S. ( E D I N . ) Aberdeen, Scotland C A S E REPORT
Past history. Miss C. S., at present aged 53 years, a school teacher, gave an history of pain in her left shoulder which started in 1942 and which was followed by some swelling of her fingers. In 1946, her left knee became swollen and the con dition was diagnosed as a tuberculous knee joint, the patient being seen at several hospitals. At no time was there any bactériologie confirmation of the diagnosis but clinical and radiologie evidence were suggestive. After 10 months' splintage, it was decided to proceed with arthrodesis of the left knee joint. This operation was accordingly carried out at Stracathro Hospital in 1946. At that time it was noted in the operation notes that the joint was "probably tubercular" (but) "the infection was mild and confined entirely to the synovial mem brane." Repeated cultures of the fluid aspirated from the knee joint and from a subsequently dis charging sinus were negative for tubercle bacilli. Present history. In 1952, the patient reported to the Ear, Nose and Throat Department of Aberdeen Royal Infirmary, complaining of sudden dizziness of one week's duration, accompanied by vomiting attacks which had subsided during the previous week but which still occurred on standing. There was no tinnitus. There was an eight-year history of deafness in the left ear, the onset of the deaf ness having been immediately preceded by an at tack of vertigo. Examination revealed a positive Rinné test on the left side, with reduced absolute bone conduction on that side. An audiometer test showed a typical perceptive deafness of about 40 decibels with high tone loss. There was, in addition, some eustachian obstruction. Caloric tests carried out two days later showed a definite left canal paresis. Her skull was X-rayed to exclude the possibility of any acoustic neuroma but the X-ray film was entirely negative. An histamine test was carried out to see if the patient was likely to respond to a course of hista
mine injections, but sensitivity to histamine was very slight. Consequently, treatment with luminal, reduction of fluids, and a salt-free diet was sug gested. A diagnosis of Ménière's disease was tentatively made. In October, 1953, the patient thought that she was becoming deaf in the right ear after an ex acerbation of vertigo and vomiting 17 days previ ously. On examination, a marked deterioration of the hearing of the right ear was found, together with gross deterioration of the left side. The patient was admitted to hospital in De cember, 1953. She was practically stone deaf in both ears and no caloric reactions were now present on either side. X-ray films of skull and chest were negative. Cerebrospinal fluid findings were normal, as was her blood count, Wassermann reaction was nega tive. A medical opinion was sought at that time on account of the rapidity of the development of the bilateral deafness. The patient was seen by the professor of medi cine, who found both optic discs to be blurred, some weakness of the right hand and a doubtful left extensor plantar reflex. At his suggestion the patient was later seen by a neurosurgeon, who con firmed the previous findings but could not visu alize any definite cerebral lesion which would pick out the vestibular nerve on either side. On the whole, he thought the diagnosis of Ménière's dis ease was correct. He also offered to follow-up the patient in the out-patient department. About a week later, that is, nine weeks after the vertigo and deafness occurred, the patient de veloped a patch of left episcleritis, which was treated with local cortisone and atropine. Visual acuity then was 6/6, R.E., 6/9, L.E. Both optic discs were said to be florid but no actual papilledema was made out. Peripheral and central fields showed no abnormality and the sensation of the V cranial nerve was normal, although some nystag mus was noted at that time. It was again considered that the diagnosis must remain bilateral Ménière's disease of advanced type, though this diagnosis might be altered later. In February, 1954, it was thought that another opinion should be sought, and the patient was sent to London to see both ear and eye specialists. All the previous findings were confirmed but the eye prognosis was that the episcleritis might lead to blindness in the left eye. Throughout 1954, the patient had repeated at tacks of episcleritis which were treated with local