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Intraocular Sarcomata
INTRAOCULAR SARCOMATA
1247
12 Black, 13 Fisher, 14 Smith, 16
Melville. The Guist speculum. Amer. Jour. Ophth., 1930, December, v. 13, p. 1066. W. A. Senile cataract. Chicago Eye, Ear, Nose and Throat Col., 1925. H. Fisher's Senile Cataract. Chicago Eye, Ear, Nose and Throat Col., 1925. Barraquer, I. Fisher's Senile Cataract. Chicago Eye, Ear, Nose and Throat Col., 1925.
INTRAOCULAR SARCOMATA Report of cases L. L. M C C O Y , M.D. SEATTLE, W A S H I N G T O N
Seven cases of intraocular sarcoma of the left eye have been seen by the author. Five of these are reported in this paper. Two have been described previously in this Journal. All eyes save one were enucleated. All the patients are living after periods ranging from eight months to three years. Read before the King County Medical Society, Seattle, Wash ington, April 27, 1931. I n this series of seven cases, six of t h e t u m o r s w e r e of choroidal origin while one w a s in t h e iris. F o u r o c c u r r e d in m e n and t h r e e in w o m e n . Six of the p a t i e n t s w e r e above 43 y e a r s of age, the oldest b e i n g 71 y e a r s , while one p a t i e n t w a s 23 y e a r s of a g e . E n u c l e a t i o n w a s done in six c a s e s ; one p a t i e n t refused o p e r a t i o n a n d h a s been u n d e r c u l t i s t s ' t r e a t m e n t since. T h e left eye w a s in volved in all of the cases. All cases are u n d e r r a t h e r close o b s e r v a t i o n , t h e longest period b e i n g t h r e e y e a r s , t h e m o s t recent a b o u t e i g h t m o n t h s . Case 1 w a s r e p o r t e d in the M a y , 1929, issue of the A m e r i c a n J o u r n a l of Ophthalmology. Case 2 w a s r e p o r t e d in t h e A u g u s t , 1929, issue of this J o u r n a l . Case 3. M r s . L. B., aged 43 y e a r s , w h i t e , h o u s e k e e p e r at the S w e d i s h H o s p i t a l w a s seen D e c e m b e r 2, 1929. H e r c o m p l a i n t w a s d r o w s i n e s s , mild t e m p o r a l h e a d a c h e s and a s t h e n o p i a . P a s t h i s t o r y w a s i r r e l e v a n t except t h a t four y e a r s ago she w a s s t r u c k a severe b l o w d i a g o n a l l y across her left eye. T h e eye w a s e c c h y m o t i c for sev eral d a y s . T h r e e m o n t h s a g o she b e g a n to notice t h a t she had t r o u b l e in see i n g objects on h e r left side. F a m i l y his t o r y irrelevant. Examination: Vision R.E. was 20/25, L . E . 2 0 / 5 0 w i t h o u t correction. W i t h t h e correction she w a s w e a r i n g , it w a s R . E . 2 0 / 1 5 — , L . E . 2 0 / 1 5 — . T h e r i g h t eye w a s n o r m a l in all re
spects except for t h e refractive error. T h e left eye w a s n o r m a l e x t e r n a l l y ex cept for m o d e r a t e l y dilated blood ves sels on t h e nasal side. O p h t h a l m o s c o p i c e x a m i n a t i o n revealed clear media, a large, m o d e r a t e l y i r r e g u l a r , quite flat, g r a y , m o t t l e d , r e t i n a l d e t a c h m e n t in the u p p e r nasal q u a d r a n t , e x t e n d i n g from t h e e q u a t o r to t h e disc m a r g i n . A l o n g t h e a n t e r i o r e d g e of t h e d e t a c h m e n t a n d s p a r s e l y s c a t t e r e d over its a n t e r i o r surface w a s a c o n s i d e r a b l e n u m b e r of v a r i o u s l y sized a n d s h a p e d p i g m e n t c l u m p s . T r a n s i l l u m i n a t i o n revealed a solid m a s s u n d e r t h e d e t a c h m e n t . T e n sion w a s n o r m a l . Blood W a s s e r m a n n a n d t e s t s for t u b e r c u l o s i s w e r e nega tive. Blood p r e s s u r e w a s 122/86. S o m e pyorrhoea was present. Tonsils were large and septic. A general physical ex amination was otherwise negative. J a n u a r y 15, 1930, a h y p o d e r m i c needle w a s inserted t h r o u g h the sclera be n e a t h the d e t a c h m e n t b u t no fluid could be w i t h d r a w n . T e n t a t i v e diagnosis w a s m e l a n o t i c s a r c o m a of the choroid of t h e left eye. T r e a t m e n t : i m m e d i a t e enucleation w a s advised and w a s done on F e b r u a r y 3, 1930, u n d e r g e n e r a l anesthesia. T h e specimen w a s sent t o the A r m y Medical M u s e u m at W a s h i n g t o n , D.C., a n d t h e final r e p o r t c a m e back as fol lows : "Microscopic—flat, spindle cell, m e l a n o t i c s a r c o m a e x t e n d s from t h e n e r v e to t h e e q u a t o r . I t a p p e a r s to h a v e p a r t i a l l y o b l i t e r a t e d t h e sclera a l o n g
1248
L. L. McCOY CASE 1.
CASE 3.
CASE 2.
GASE 5
CASE 6
Drawings taken from the mounted sections showing the location, size and shape of the tumors as indicated by the shaded portion. fibers of the ciliary nerve. There is a broad shallow cyst of the retina over two-thirds of the tumor. The iris is atrophic and in contact with the pos terior surface of the cornea and there is a posterior synechia just lateral to the pupil on one side." There have been no evidences of a recurrence or metastases thus far. Case 4. C. C , aged 71 years, white man evidently quite healthy and active for his age, was seen April 4, 1930. His chief complaint was failing vision in the left eye for the previous two or three months. Personal history was otherwise ir relevant. His mother succumbed to can cer of breast. Examination: Vision R.E. was 20/70; L.E. ringers counted at two feet. His right eye was normal organically for his age. The left eye was normal as far as the lids, lacrymal apparatus, muscles, and cornea were concerned. There was considerable conjunctival congestion with quite marked brownish discoloration of the sclera below and temporally which patient said had been
there for years. The iris seemed normal and the anterior chambers of each eye were equal in depth. The left pupil was round, regular, equal to the right in size but sluggish in reaction. Tension of both eyes was equal and normal by palpation. Ophthalmoscopically, the aqueous and vitreous were clear. Pro jecting into the vitreous from the tem poral side and apparently from about the equatorial region was a large, gray ish brown, detachment of the retina, quite smooth but seemingly somewhat more pedunculated than a simple de tachment of the retina. It projected in to the vitreous nearly to the temporal edge of the disc. Transillummation was positive for a solid mass under the de tachment. Diagnosis and recommendation: Tumor of the choroid, probably melanotic sarcoma. Immediate enucleation was advised. Operation was refused. He immedi ately went to his home and placed him self in the hands of a Christian Science practitioner. Case 5. Mrs. A. M., aged 46 years,
INTRAOCULAR SARCOMATA
white, housewife, was seen April 29, 1930. Chief complaint was ill-fitting glasses and severe general headaches. The patient said it seemed as though she were trying to see with her left lid half closed. Past and family histories were irrelevant. Examination: Vision R.E. was 20/30, L.E. 20/200+ ; 20/15 and 20/200+ with glasses. Slight conver gence insufficiency was noted. Exter nally, the eyes appeared the same and healthy in appearance except that the left pupil reacted more sluggishly than the right. Ophthalmoscopically, the right eye was normal. Under mydriasis, the left anterior segment was normal and the media were clear. Projecting into the vitreous chamber, apparently from the equatorial region on the nasal side, was a large retinal detachment which obstructed the view of the optic disc. It was quite smooth, dark colored and presented no visible tear. Transillumination revealed a solid mass un der the detached retina. Tension was normal. Diagnosis: Melanotic sarcoma of the choroid. Treatment: Immediate enucleation was advised. On May 5, simple enucleation with Guist bone sphere transplant was performed under gen eral anaesthesia. The eye was sent to the Army Medical Museum, Washing ton, D.C., for diagnosis. Final report was as follows: "There is a melanotic spindle-cell sarcoma arising beside the disc and extending forward beyond the equator into the globe approximately 14 mm. There are a few areas where round cells are present but no definite penetration of the sclera is found. The retina is detached over the tumor. The iris is edematous. The tumor appears rather rapidly growing." Case 6. Mrs. O. B., a rather active white housewife, 64 years of age. Up to May 14, 1930, the patient had no dis coverable ocular disturbance except quite marked myopia. Vision : R.E. was 20/25—1 with correction, L.E. 20/25—1 with correction. On May 14, 1930, she came in complaining of sud den loss of vision in her left eye within the previous twenty-four hours. She
1249
apparently had a fairly large exudate or hemorrhage in the vitreous chamber. It was impossible to determine the con dition of the fundus by the ophthalmo scope at the time. Potassium iodide and rest were prescribed and she was re ferred to her family physician for a general physical examination. The re port of her physical examination was negative in all respects. On May 26, her condition apparently was improved. On June 28 a careful examination showed that the eye was normal except for mild conjunctival congestion and marked dilatation of blood vessels on the nasal side of the cornea. The cornea and anterior chamber were normal. In the angle of the anterior chamber be tween "6:30 and 8:30 o'clock" there was a brown discoloration 1 to 2 mm. wide. The pupil dilated slightly irregu larly with mydriatics. The lens was clear. Vitreous was quite hazy with floating opacities. Arising apparently from the ciliary body in the lower nasal quadrant and projecting into the vitre ous to such an extent that the nasal edge of the disc was just visible was a dark mass posterior to which was a detachment of the retina, grayish-white in color, quite smooth in contour. Transilhimination was positive for a solid mass under the detached retina. Tension of the eye was 19 by tonom eter. Diagnosis: intraocular tumor of the ciliary body, probably melanotic sarcoma. Immediate enucleation was advised. On July 2, 1930, the eye was sent to the Army Medical Museum at Washington for diagnosis. Following is a copy of the report: "The eye was distorted when re ceived. Melanotic mixed cell sarcoma of choroid in area of ora serrata, slightly pigmented. Deeply pigmented exten sion into the ciliary body. No tumor cells seen outside of globe." Case 7. K. P., a slender, not very healthy appearing young white man of 23 years of age, came to the Infirmary August 7, 1930, complaining of head aches with nausea. He had never worn glasses. His personal history was otherwise negative. His family history was irrelevant.
1250
L. L. McCOY
Examination: Vision was R.E. 20/15— and L.E. 20/15—. Considerable conjunctival congestion was noted with mild marginal blepharitis. The right eye was otherwise normal externally. Irides were grayish or bluish hazel in color. In the left eye there were a few small dilated blood vessels near the limbus at "3:30 o'clock" on the left side. The cornea was clear, the anterior chamber normal in depth except tem porally where it was slightly shallower at about "3:30 o'clock" where there was a small slightly grayish-brown bulging of the iris. This was hardly sufficient to be considered abnormal. However, during the process of dilata tion with homatropin for refraction, the left pupil widened normally and equally in all directions except on the temporal side where the dilatation took place very slowly between "2:00 and 5 :00 o'clock". During refraction noth ing untoward was observed about the right pupil and media but when the light was thrown into the left eye a small, rather thin object appeared pro jecting into the pupillary area from the temporal side at about "3 :30 o'clock". At first, it was thought to be a small macula of the cornea but careful ex amination of the cornea disproved this, the cornea being perfectly clear. The ophthalmoscope revealed a small cyst temporal to which was a brown growth directly posterior to the bulge in the iris, apparently one-half the size of a small pea, and extending above to "1:00 o'clock" and below to "5:00 o'clock"; from this there seemed to be a thickening of the ciliary body. The fundus and media were otherwise nor mal. The patient was kept under ob servation for two months during which time the bulge in the iris increased per ceptibly and the growth became more obvious. The patient's general physical examination was negative. Diaphanoscopy was negative. On October 3 it
was decided to perform a wide iridectomy to include the growth if possible and to examine the frozen section, then proceed accordingly. On October 4 the iridectomy was performed, a piece of iris about 3 mm. by 3 mm. being re moved Mnder local anesthesia and sent to the laboratory. The following report came back: "A frozen section was made and microscopic examination showed an excessive quantity of mela nin scattered throughout the section. There was a thickened area in which the matrix was made of young forms of connective tissue cells. Diagnosis: Melanosarcoma." The patient was giv en a general anesthetic and the eye was enucleated and a Guist's bone sphere inserted. During the operation the globe collapsed. The eye was sent to the Army Medical Museum at Washington, D.C., and the following report was received: "Gross—Opera tive iridectomy, collapsed eye. No tu mor seen. Histological—recent unhealed iridectomy, traumatic cataract, no tumor cells seen, but the eye has a very large amount of pigment, more than occurs in some eyes of the negro race." The patient has been seen numerous times since his operation and to date he is in fine condition. As stated above there seemed to be a thickening or flat growth in the ciliary body from "2 :00 o'clock to 5 :00 o'clock". This was the.reason for enucleation. The patient had expressed his desire to have the eye removed if there was any question at all as to the pos sibility of removing the entire growth by iridectomy or of recurrence. Since receiving the final report from Washington it is apparent that the growth and cyst had slightly dislocated the lens posteriorly bringing the ciliary body more clearly into view and mak ing it appear thickened. 817 Summit avenue.
1247
12 Black, 13 Fisher, 14 Smith, 16
Melville. The Guist speculum. Amer. Jour. Ophth., 1930, December, v. 13, p. 1066. W. A. Senile cataract. Chicago Eye, Ear, Nose and Throat Col., 1925. H. Fisher's Senile Cataract. Chicago Eye, Ear, Nose and Throat Col., 1925. Barraquer, I. Fisher's Senile Cataract. Chicago Eye, Ear, Nose and Throat Col., 1925.
INTRAOCULAR SARCOMATA Report of cases L. L. M C C O Y , M.D. SEATTLE, W A S H I N G T O N
Seven cases of intraocular sarcoma of the left eye have been seen by the author. Five of these are reported in this paper. Two have been described previously in this Journal. All eyes save one were enucleated. All the patients are living after periods ranging from eight months to three years. Read before the King County Medical Society, Seattle, Wash ington, April 27, 1931. I n this series of seven cases, six of t h e t u m o r s w e r e of choroidal origin while one w a s in t h e iris. F o u r o c c u r r e d in m e n and t h r e e in w o m e n . Six of the p a t i e n t s w e r e above 43 y e a r s of age, the oldest b e i n g 71 y e a r s , while one p a t i e n t w a s 23 y e a r s of a g e . E n u c l e a t i o n w a s done in six c a s e s ; one p a t i e n t refused o p e r a t i o n a n d h a s been u n d e r c u l t i s t s ' t r e a t m e n t since. T h e left eye w a s in volved in all of the cases. All cases are u n d e r r a t h e r close o b s e r v a t i o n , t h e longest period b e i n g t h r e e y e a r s , t h e m o s t recent a b o u t e i g h t m o n t h s . Case 1 w a s r e p o r t e d in the M a y , 1929, issue of the A m e r i c a n J o u r n a l of Ophthalmology. Case 2 w a s r e p o r t e d in t h e A u g u s t , 1929, issue of this J o u r n a l . Case 3. M r s . L. B., aged 43 y e a r s , w h i t e , h o u s e k e e p e r at the S w e d i s h H o s p i t a l w a s seen D e c e m b e r 2, 1929. H e r c o m p l a i n t w a s d r o w s i n e s s , mild t e m p o r a l h e a d a c h e s and a s t h e n o p i a . P a s t h i s t o r y w a s i r r e l e v a n t except t h a t four y e a r s ago she w a s s t r u c k a severe b l o w d i a g o n a l l y across her left eye. T h e eye w a s e c c h y m o t i c for sev eral d a y s . T h r e e m o n t h s a g o she b e g a n to notice t h a t she had t r o u b l e in see i n g objects on h e r left side. F a m i l y his t o r y irrelevant. Examination: Vision R.E. was 20/25, L . E . 2 0 / 5 0 w i t h o u t correction. W i t h t h e correction she w a s w e a r i n g , it w a s R . E . 2 0 / 1 5 — , L . E . 2 0 / 1 5 — . T h e r i g h t eye w a s n o r m a l in all re
spects except for t h e refractive error. T h e left eye w a s n o r m a l e x t e r n a l l y ex cept for m o d e r a t e l y dilated blood ves sels on t h e nasal side. O p h t h a l m o s c o p i c e x a m i n a t i o n revealed clear media, a large, m o d e r a t e l y i r r e g u l a r , quite flat, g r a y , m o t t l e d , r e t i n a l d e t a c h m e n t in the u p p e r nasal q u a d r a n t , e x t e n d i n g from t h e e q u a t o r to t h e disc m a r g i n . A l o n g t h e a n t e r i o r e d g e of t h e d e t a c h m e n t a n d s p a r s e l y s c a t t e r e d over its a n t e r i o r surface w a s a c o n s i d e r a b l e n u m b e r of v a r i o u s l y sized a n d s h a p e d p i g m e n t c l u m p s . T r a n s i l l u m i n a t i o n revealed a solid m a s s u n d e r t h e d e t a c h m e n t . T e n sion w a s n o r m a l . Blood W a s s e r m a n n a n d t e s t s for t u b e r c u l o s i s w e r e nega tive. Blood p r e s s u r e w a s 122/86. S o m e pyorrhoea was present. Tonsils were large and septic. A general physical ex amination was otherwise negative. J a n u a r y 15, 1930, a h y p o d e r m i c needle w a s inserted t h r o u g h the sclera be n e a t h the d e t a c h m e n t b u t no fluid could be w i t h d r a w n . T e n t a t i v e diagnosis w a s m e l a n o t i c s a r c o m a of the choroid of t h e left eye. T r e a t m e n t : i m m e d i a t e enucleation w a s advised and w a s done on F e b r u a r y 3, 1930, u n d e r g e n e r a l anesthesia. T h e specimen w a s sent t o the A r m y Medical M u s e u m at W a s h i n g t o n , D.C., a n d t h e final r e p o r t c a m e back as fol lows : "Microscopic—flat, spindle cell, m e l a n o t i c s a r c o m a e x t e n d s from t h e n e r v e to t h e e q u a t o r . I t a p p e a r s to h a v e p a r t i a l l y o b l i t e r a t e d t h e sclera a l o n g
1248
L. L. McCOY CASE 1.
CASE 3.
CASE 2.
GASE 5
CASE 6
Drawings taken from the mounted sections showing the location, size and shape of the tumors as indicated by the shaded portion. fibers of the ciliary nerve. There is a broad shallow cyst of the retina over two-thirds of the tumor. The iris is atrophic and in contact with the pos terior surface of the cornea and there is a posterior synechia just lateral to the pupil on one side." There have been no evidences of a recurrence or metastases thus far. Case 4. C. C , aged 71 years, white man evidently quite healthy and active for his age, was seen April 4, 1930. His chief complaint was failing vision in the left eye for the previous two or three months. Personal history was otherwise ir relevant. His mother succumbed to can cer of breast. Examination: Vision R.E. was 20/70; L.E. ringers counted at two feet. His right eye was normal organically for his age. The left eye was normal as far as the lids, lacrymal apparatus, muscles, and cornea were concerned. There was considerable conjunctival congestion with quite marked brownish discoloration of the sclera below and temporally which patient said had been
there for years. The iris seemed normal and the anterior chambers of each eye were equal in depth. The left pupil was round, regular, equal to the right in size but sluggish in reaction. Tension of both eyes was equal and normal by palpation. Ophthalmoscopically, the aqueous and vitreous were clear. Pro jecting into the vitreous from the tem poral side and apparently from about the equatorial region was a large, gray ish brown, detachment of the retina, quite smooth but seemingly somewhat more pedunculated than a simple de tachment of the retina. It projected in to the vitreous nearly to the temporal edge of the disc. Transillummation was positive for a solid mass under the de tachment. Diagnosis and recommendation: Tumor of the choroid, probably melanotic sarcoma. Immediate enucleation was advised. Operation was refused. He immedi ately went to his home and placed him self in the hands of a Christian Science practitioner. Case 5. Mrs. A. M., aged 46 years,
INTRAOCULAR SARCOMATA
white, housewife, was seen April 29, 1930. Chief complaint was ill-fitting glasses and severe general headaches. The patient said it seemed as though she were trying to see with her left lid half closed. Past and family histories were irrelevant. Examination: Vision R.E. was 20/30, L.E. 20/200+ ; 20/15 and 20/200+ with glasses. Slight conver gence insufficiency was noted. Exter nally, the eyes appeared the same and healthy in appearance except that the left pupil reacted more sluggishly than the right. Ophthalmoscopically, the right eye was normal. Under mydriasis, the left anterior segment was normal and the media were clear. Projecting into the vitreous chamber, apparently from the equatorial region on the nasal side, was a large retinal detachment which obstructed the view of the optic disc. It was quite smooth, dark colored and presented no visible tear. Transillumination revealed a solid mass un der the detached retina. Tension was normal. Diagnosis: Melanotic sarcoma of the choroid. Treatment: Immediate enucleation was advised. On May 5, simple enucleation with Guist bone sphere transplant was performed under gen eral anaesthesia. The eye was sent to the Army Medical Museum, Washing ton, D.C., for diagnosis. Final report was as follows: "There is a melanotic spindle-cell sarcoma arising beside the disc and extending forward beyond the equator into the globe approximately 14 mm. There are a few areas where round cells are present but no definite penetration of the sclera is found. The retina is detached over the tumor. The iris is edematous. The tumor appears rather rapidly growing." Case 6. Mrs. O. B., a rather active white housewife, 64 years of age. Up to May 14, 1930, the patient had no dis coverable ocular disturbance except quite marked myopia. Vision : R.E. was 20/25—1 with correction, L.E. 20/25—1 with correction. On May 14, 1930, she came in complaining of sud den loss of vision in her left eye within the previous twenty-four hours. She
1249
apparently had a fairly large exudate or hemorrhage in the vitreous chamber. It was impossible to determine the con dition of the fundus by the ophthalmo scope at the time. Potassium iodide and rest were prescribed and she was re ferred to her family physician for a general physical examination. The re port of her physical examination was negative in all respects. On May 26, her condition apparently was improved. On June 28 a careful examination showed that the eye was normal except for mild conjunctival congestion and marked dilatation of blood vessels on the nasal side of the cornea. The cornea and anterior chamber were normal. In the angle of the anterior chamber be tween "6:30 and 8:30 o'clock" there was a brown discoloration 1 to 2 mm. wide. The pupil dilated slightly irregu larly with mydriatics. The lens was clear. Vitreous was quite hazy with floating opacities. Arising apparently from the ciliary body in the lower nasal quadrant and projecting into the vitre ous to such an extent that the nasal edge of the disc was just visible was a dark mass posterior to which was a detachment of the retina, grayish-white in color, quite smooth in contour. Transilhimination was positive for a solid mass under the detached retina. Tension of the eye was 19 by tonom eter. Diagnosis: intraocular tumor of the ciliary body, probably melanotic sarcoma. Immediate enucleation was advised. On July 2, 1930, the eye was sent to the Army Medical Museum at Washington for diagnosis. Following is a copy of the report: "The eye was distorted when re ceived. Melanotic mixed cell sarcoma of choroid in area of ora serrata, slightly pigmented. Deeply pigmented exten sion into the ciliary body. No tumor cells seen outside of globe." Case 7. K. P., a slender, not very healthy appearing young white man of 23 years of age, came to the Infirmary August 7, 1930, complaining of head aches with nausea. He had never worn glasses. His personal history was otherwise negative. His family history was irrelevant.
1250
L. L. McCOY
Examination: Vision was R.E. 20/15— and L.E. 20/15—. Considerable conjunctival congestion was noted with mild marginal blepharitis. The right eye was otherwise normal externally. Irides were grayish or bluish hazel in color. In the left eye there were a few small dilated blood vessels near the limbus at "3:30 o'clock" on the left side. The cornea was clear, the anterior chamber normal in depth except tem porally where it was slightly shallower at about "3:30 o'clock" where there was a small slightly grayish-brown bulging of the iris. This was hardly sufficient to be considered abnormal. However, during the process of dilata tion with homatropin for refraction, the left pupil widened normally and equally in all directions except on the temporal side where the dilatation took place very slowly between "2:00 and 5 :00 o'clock". During refraction noth ing untoward was observed about the right pupil and media but when the light was thrown into the left eye a small, rather thin object appeared pro jecting into the pupillary area from the temporal side at about "3 :30 o'clock". At first, it was thought to be a small macula of the cornea but careful ex amination of the cornea disproved this, the cornea being perfectly clear. The ophthalmoscope revealed a small cyst temporal to which was a brown growth directly posterior to the bulge in the iris, apparently one-half the size of a small pea, and extending above to "1:00 o'clock" and below to "5:00 o'clock"; from this there seemed to be a thickening of the ciliary body. The fundus and media were otherwise nor mal. The patient was kept under ob servation for two months during which time the bulge in the iris increased per ceptibly and the growth became more obvious. The patient's general physical examination was negative. Diaphanoscopy was negative. On October 3 it
was decided to perform a wide iridectomy to include the growth if possible and to examine the frozen section, then proceed accordingly. On October 4 the iridectomy was performed, a piece of iris about 3 mm. by 3 mm. being re moved Mnder local anesthesia and sent to the laboratory. The following report came back: "A frozen section was made and microscopic examination showed an excessive quantity of mela nin scattered throughout the section. There was a thickened area in which the matrix was made of young forms of connective tissue cells. Diagnosis: Melanosarcoma." The patient was giv en a general anesthetic and the eye was enucleated and a Guist's bone sphere inserted. During the operation the globe collapsed. The eye was sent to the Army Medical Museum at Washington, D.C., and the following report was received: "Gross—Opera tive iridectomy, collapsed eye. No tu mor seen. Histological—recent unhealed iridectomy, traumatic cataract, no tumor cells seen, but the eye has a very large amount of pigment, more than occurs in some eyes of the negro race." The patient has been seen numerous times since his operation and to date he is in fine condition. As stated above there seemed to be a thickening or flat growth in the ciliary body from "2 :00 o'clock to 5 :00 o'clock". This was the.reason for enucleation. The patient had expressed his desire to have the eye removed if there was any question at all as to the pos sibility of removing the entire growth by iridectomy or of recurrence. Since receiving the final report from Washington it is apparent that the growth and cyst had slightly dislocated the lens posteriorly bringing the ciliary body more clearly into view and mak ing it appear thickened. 817 Summit avenue.