- Email: [email protected]
Light Coagulation of Intraocular Tumors*
G. A. ELLIOTT AND A. L. SCHUT
1082
ed six times daily for six to 10 days with 0 . 1 % cytarabine HC1 ( C A ) ophthalmicpreparations. However, the use of 0.5 and 1.0% CA preparations was associated with a speckling of rabbit, monkey and human corneas which resembled fine dust particles as seen on retroillumination with the biomicroscope. Histologie examination of eyes of rabbits and monkeys so treated revealed thinning and distortion of the corneal epithelium along with degeneration of individual corneal epithelial cells. Lesions were
restricted to the corneal epithelium and were dose related. Treated corneas returned to normal after the drug was discontinued. T h e results of repeated, intermittent treatment periods in the rabbit indicate that CA is not likely to produce increased tissue sensitivity. Department
of
Pathology.
ACKNOWLEDGMENTS
We gratefully acknowledge the technical assistance of R. N. Weaver and the suggestions of colleagues in preparing the manuscript.
REFERENCES
1. Kaufman, H. E. : Clinical cure of herpes simplex keratitis by 5-iodo-2'-deoxyuridine. Proc. Soc. Exp. Biol. & Med., 109:251-252 (Feb.) 1962. 2. Underwood, G. E. : Activity of 1-ß-D-arabinofuranosylcytosine hydrochloride against herpes simplex keratitis. Proc. Soc. Exp. Biol. &Med., I l l :660-664 (Dec.) 1962. 3. Renis, H. E., and Johnson, H. G. : Inhibition of plaque formation of vaccinia virus by cytosine arabinoside hydrochloride. Bact. Proc, p. 140. 1962. 4. Chu, M. Y., and Fischer, G. A. : A proposed mechanism of action of 1-ß-D-arabinofuranosylcytosine as an inhibitor of the growth of leukemic cells. Biochem. Pharmacol., 11:423-430 (June) 1962. 5. Welch, A. D., and Prusoff, W. H. : A synopsis of recent investigations of 5-iodo-2'-deoxyuridine. Cane. Chem. Rep., 6:29-36 (Feb.) 1960. 6. Kaufman, H. E. : Chemotherapy of herpes keratitis. Invest. Ophth., 2:504-518 (Oct.) 1963. 7. Buthala, D. A. : Cell culture studies on antiviral agents : I. Action of cytosine arabinoside and some comparisons with 5-iodo-2'-deoxyuridine. Proc. Soc. Exp. Biol. & Med., 115:69-77 (Jan.) 1964. 8. Kaufman, H. E., Capella, J. A., Maloney, E. D., Robbins, J. E., Cooper, G. M., and Uotila, M. H. : Corneal toxicity of cytosine arabinoside. Arch. Ophth., 72:535-540, 1964. 9. Sheppard, L. B. : The anatomy and histology of the normal rabbit eye with special reference to the ciliary zone. Arch. Ophth., 66:896-904 (Dec.) 1961 ; 67 :87-100 (Jan.) 1962. 10. Adler, F. H. : Physiology of the Eye : Clinical Application. St. Louis, Mosby, 1953, ed. 2, p. 76.
LIGHT COAGULATION OF INTRAOCULAR T O R R E N C E A.
M A K L E Y , J R . , M.D.,
WILLIAM
AND J A Y NEWBERG,
H.
TUMORS*
HAVENER,
M.D.,
M.D.
Columbus, Ohio In 1952, Meyer-Schwickerath treated a patient with malignant melanoma of the choroid with light coagulation. 1 · 2 In 1955, he began treating retinoblastomas by the same method. H e had such encouraging results in both conditions that he continued clinical trials. Others have utilized light coagulation in treating patients with intraocular neoplasms and reported their results clinically
and histologically. 3,5 It is the purpose of this paper to relate our experiences in treating with the light coagulator four melanomas of the choroid and eight patients with retinoblastomas. In two cases of malignant melanoma, the eye harboring the tumor was enucleated iwhile only one of the eyes with retinoblastoma was ultimately excised. M A L I G N A N T M E L A N O M A OF T H E CHOROID
* From the Department of Ophthalmology, Ohio State University.
O u r method for treating melanomas of the choroid is essentially that employed by
LIGHT COAGULATION OF INTRAOCULAR TUMORS Meyer-Schwickerath. 2 T h e melanoma is first encircled by light coagulations. The outer limits of this treatment ring should extend about 2 mm beyond the tumor tissue. T h e most peripheral part of this ring of coagulation is formed by the "minimum intensity technique" 7 whereby the slightest visible retinal burn is developed slowly with the time of exposure as long as a second. T h e purpose of this cautiously burned peripheral ring is to create firm chorioretinal adhesions involving portions of retina retaining reasonable structural strength. Such peripheral adhesions insure against retinal detachment. One to two weeks are required for these chorioretinal adhesions to become solid and intensive photocoagulation of the tumor should be delayed until that time. A t the first session, however, the surface of the tumor is also treated by the "minimum intensity technique." Despite such careful initial coagulation, an exudative retinal detachment may follow the first light coagulation. If care has been taken to prevent retinal perforation by the avoidance of excessive intensity of photocoagulation at this first session, the detachment will subside in about a week. Once firm chorioretinal adhesions have developed, subsequent photocoagulation will not again cause detachment. Sometimes a low dependent retinal detachment will exist when the melanoma is recognized prior to treatment. Light coagulation will not be effective in this detached area. Surprisingly, minimum intensity coagulation of the tumor surface will result in disappearance of the detachment before the time of the second treatment. T h e second treatment may be as soon as two weeks after the first providing the retinal edema has largely disappeared and there is no detachment. This second treatment is more intense. T h e surgeon adjusts the light to produce the slightest visible shrinkage of the treated tissue. Development of gray discoloration is not a reliable criterion of treatment intensity in previously coagulated
1083
areas. T h e second and subsequent light coagulations should not involve the peripheral edge of the treated area since this might create a retinal tear. If an intense coagulation is inadvertently placed in normal retina, this error will produce a conspicuous dense "snowball." Minimum intensity coagulation about such a "snowball" will guard against hole formation. T h i r d and subsequent sessions of photocoagulation may be scheduled as soon as the hazy media clears, usually within a day or two. These very high intensity treatments, which may utilize the full power of the photocoagulator, cause a definite corneal and vitreous haze which ultimately forces the operator to stop the session of treatment for the day. These intense coagulations are directed upon any visibly elevated masses or any recognizable vessels within the treated area. W i t h very high intensities of treatment the duration of the flash should not be prolonged, lest a choroidal explosion occur. Photocoagulation sessions are repeated until the treated area is a charred, crater-pocked, lifeless-appearing mass. R E S U L T S OF T R E A T M E N T
Of the four patients with malignant melanoma of the choroid treated with the light coagulator, two patients eventually had the eye enucleated. These eyes were studied histologically. In the first case four light coagulation treatments were applied to a tumor in the left eye situated just below and temporal to the macula. I t measured 3 by 4 disc diameters and was only slightly elevated. While the surface of the tumor appeared necrotic, the lesion did not appear inactive. After two months' observation the eye was removed. T h e retina was destroyed over the surface of the tumor but only the very superficial layers of the tumor were necrotic (fig. 1 ) . At the edge of the tumor, retina and choroid were destroyed. T h e rest of the tumor was unaffected (fig. 2 ) . In the other case terminated by excision
MAKLEY, HAVENER AND NEWBERG
1084 4
4
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Fig. 1 (Makley, Havener and Newberg). Case 1. Malignant melanoma of the choroid. The retina has been destroyed and replaced by a thin glial band, showing pigment migration. Only the superficial layers of the tumor have been affected by the light coagulation (χ40). of the globe, 12 treatments with the light coagulator were given over a four-month period. The tumor treated was situated in the midperiphery in the lower temporal quadrant (fig. 3). It was 4 by 5 disc diameters across and was relatively flat. The last six treatments were of maximal intensity. After a six-month observation, it was obvious that not all the tumor had been destroyed (fig. 4). At this time the eye was enucleated. On gross examination there was a craterlike hole in the center of the tumor. Histologically, the retina was completely destroyed over the mass and there was considerable necrosis of the tumor in the craterlike center. However, viable tumor was present between the crater surface and the sciera. At the edge of the mass there was
considerable necrosis. Multiple sections showed that the choroid was not completely destroyed around the tumor and did contain patent blood vessels (fig. 5). The third patient, a 72-year-old white man, presented with a mushroom-shaped tumor in the right eye elevated about 8 diopters and situated in the lower nasal quadrant. There was considerable pigment haze in the vitreous. The chances for any effect from light coagulation seemed remote but the patient refused enucleation. A ring of coagulation was placed around the base of the tumor and the surface treated intensively six times over a period of two months. In spite of this the tumor did not regress and the patient was strongly advised to have an enucleation. He refused, but has been faith-
LIGHT COAGULATION OF INTRAOCULAR TUMORS
1085
disc diameters and relatively flat. Enucleation was refused so four treatments with the light coagulator were given. T h e patient failed to return for the fifth treatment and has not been seen since. T w o years after treatment it was learned indirectly that the patient was living and well. T h e eye had not been removed at that time. COMMENT
O u r experiences of treating malignant melanoma of the choroid indicate that it is almost impossible to destroy the tumor completely. T h e two eyes that were enucleated showed minimal destruction of the tumor. Only 0.5 to 1.0 mm of the surface of the tumor showed necrosis. At the time of clinical diagnosis most choroidal melanomas are much too large to be destroyed by photocoagulation. W e believe that this technique is of limited value in their treatment.
Fig. 2 (Makley, Havener and Newberg). Case 1. Malignant melanoma of the choroid. The deeper parts of the tumor have been unaffected by treatment. (X40). ful about follow-up visits. Vision at the beginning of treatment was 2 0 / 5 0 . At the last follow-up visit vision was 2 0 / 3 0 . Over three years, the tumor seems to remain dormant. It is much the same as when first seen, neither getting larger nor regressing (fig. 6 ) . A wide ring of coagulated area is clearly visible about the tumor base. Perhaps the blood supply has been altered enough to slow down growth. Certainly the tumor has not been destroyed. A recent physical examination revealed the patient to be in good health without evidence of metastasis. The last patient was a 51-year-old white man who had an almond-shaped melanoma in the temporal fundus of the left eye 4 by 3
Curtin and Norton 5 examined four eyes histologically, which had been enucleated 2, 6, 8 and 17 days respectively, after one treatment with light coagulation. They concluded that the flatter lesions were more readily destroyed than the higher ones and that the amount of pigmentation did not influence the degree of tumor necrosis. They concluded, too, that the value of light coagulation is highly limited. RETINOBLASTOMA
Just as in the case of choroidal melanomas, a retinoblastoma is surrounded by a ring of light coagulation in normal retina using the minimal intensity technique (figs. 7 and 8 ) . This ring should be placed for orientation before treatment of the tumor, since, following photocoagulation, the neoplasm cannot be distinguished from surrounding treated retina except where it is elevated. Although a retinoblastoma is very light in color and it would be expected to require very intense photocoagulation, this is not the case. Probably because of the extreme clarity of the infant media and because of the wide pupillary dilatation which
1086
MAKLEY, H A V E N E R AND N E W B E R G
Fig. 3 (Makley, Havener and Newberg). Case 2. Malignant melanoma of the choroid. The photograph on the left shows tumor before treatment. On the right the area has received one treatment with the light coagulator.
Fig. 4 (Makley, Havener and Newberg). Case 2. After 12 sessions of light coagulation, the tumor appeared charred and necrotic.
LIGHT COAGULATION OF INTRAOCULAR
can be achieved, the lowest intensity (green one) must be further reduced by stopping down the diaphragm as much as half way or more. Particular attention should be given to the feeding vessels which should be coagulated directly. Scierai depression during photocoagulation is necessary if the retinoblastoma extends to near the ora serrata. If the retinoblastoma is fairly flat, a single treatment will destroy it. Elevated tumors are a great deal more resistant and seem to respond best to destruction of their arterial supply. If all vessels can be occluded, the tumor mass may literally melt away. Recurrent neoplasm within a treated area appears as a translucent light gray film obscurring the pigmentation. Thorough examination should re-evaluate the status of the tumor at intervals no less frequent than every two weeks until the surgeon is certain the retinoblastoma is destroyed. Of the eight cases of retinoblastoma
Fig. S (Makley, Havener and Newberg). Case 2. Malignant melanoma of the choroid . There is considerable necrosis of the edge and superficial layers in the center of the tumor. The great bulk of the mass has not been destroyed even after intensive treatment. Pigment has migrated to the inner layers of the tumor. The retina has been destroyed.
TUMORS
1087
Fig. 6 (Makley, Havener and Newberg). Case 3. Malignant melanoma of the choroid. Part of a mushroom-shaped tumor is seen in the lower edge of the photograph. It has been little affected by light coagulation. A ring of coagulation is seen around the base of the tumor. Eye retained; patient living and well three years after treatment.
treated with the light coagulator, seven were bilateral and the most involved eye was enucleated. The second eye was treated in three cases with light coagulation alone. One case was treated with light coagulation and TEM and the remaining three cases received irradiation, Cytoxan, and light coagulation. The case of unilateral retinoblastoma treated was seen early and the lesion destroyed by the light coagulator. Of the three cases receiving light coagulation alone, two cases had multiple foci of tumor. These two cases both developed a new focus of tumor while being treated. The new foci were then light coagulated and destroyed. Another case with one large tumor near the disc and two smaller tumors in the periphery below was treated with irradiation (cobalt 60) and Cytoxan. These lesions melted away but in six months a new tumor was noted in the far nasal periphery above. This was treated successfully with the light coagulator. One of the eyes included in this series failed to respond to light coagulation and eventually was enucleated. This child had lost her left eye because of a retinoblastoma. One year after enucleation, a large mass was noted in the inferior temporal quadrant
1088
MAKLEY, HAVENER AND NEWBERG
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Fig. 7 (Makley, Havener and Newberg). Retinoblastoma. Two tumor foci ringed by light coagulation. of the right eye. Two treatments with the light coagulator were given and a week later the sciera and the area of the tumor was cauterized with diathermy. The tumor did show some regression two months later but the residual was treated with the light coagulator two more times three weeks apart. A month later, the tumor again appeared to be growing so, as a last resort, a course of Xray treatments was administered, but in spite of this the tumor did not regress completely and the eye was enucleated. T h i s case raises the question: Should light coagulation be the primary treatment for retinoblastoma? There is no doubt this form of therapy can destroy a malignant tumor if it is not too large. Meyer-Schwickerath concluded that photocoagulation could be used on lesions that involve no more than one third of the retinal surface; this seems
rather large to us. One wonders if the patient just described might have fared better if irradiation and chemotherapy had been tried early. Light coagulation has the disadvantage of all local forms of therapy in that only one small part of the retina is treated. I n two of the treated cases it seemed we were chasing tumors all over the retina as new foci developed. F r o m our experience it would seem that light coagulation should be saved for recurrences and any new tumor foci that might appear after irradiation and chemotherapy. These latter forms of treatment affect the whole retina and being very effective should be used first. SUMMARY
T h e photocoagulation of four choroidal melanomas and seven retinoblastomas has
LTGHT COAGULATION OF INTRAOCULAR TUMORS
1089
Fig. 8 (Makley, Havener and Newberg). Retinoblastoma. Same case as in Figure 7. Note flat scars following three treatments with the light coagulator. been described. None of the four melanomas were completely destroyed despite most intensive treatment. Photocoagulation alone cannot be advocated as a certain treatment for melanoma. Of seven eyes with retinoblastoma treated by photocoagulation only one required enucleation. Photocoagulation
is a very effective means of destroying a small retinoblastoma. However, since irradiation and chemotherapy are so effective, photocoagulation should be reserved for recurrences of retinoblastoma or any new tumors that may appear after treatment. 410 West 10th Avenue (43210).
REFERENCES
1. Meyer-Schwickerath, G. : Light Coagulation (translated by S. W. Drance). St. Louis, Mosby, 1960. 2: The preservation of vision by treatment of intraocular tumors with light coagulation. Arch. Ophth., 66 :458-466 (Oct.) 1961. 3. Wegner, W., and Marquardt, R. : Treatment of melanoblastoma of the choroid with the light coagulator by the Meyer-Schwickerath method from a critical viewpoint. Klin. Mbl. Augenh., 139:800-813. 1961. 4. Lund, O. E. : Histological studies on light-coagulated melanoblastoma of the choroid. Arch. f. Ophth., 164:433-456, 1962. 5. Curtin, V. T., and Norton, E. W. : Pathological changes in malignant melanomas after photocoagulation. Arch. Ophth., 70:150-157 (Aug.) 1963. 6. Westerveld-Brandon, E. R., and Zeeman, W. P. : The prognosis of melanoblastoma of the choroid. Ophthalmologies, 134:20-29 (July) 1957. 7. Havener, W. H. : Clinical experiences with the photocoagulator. Am. T. Ophth., 49:1212-1221 (Mav Pt. II) 1960.
1082
ed six times daily for six to 10 days with 0 . 1 % cytarabine HC1 ( C A ) ophthalmicpreparations. However, the use of 0.5 and 1.0% CA preparations was associated with a speckling of rabbit, monkey and human corneas which resembled fine dust particles as seen on retroillumination with the biomicroscope. Histologie examination of eyes of rabbits and monkeys so treated revealed thinning and distortion of the corneal epithelium along with degeneration of individual corneal epithelial cells. Lesions were
restricted to the corneal epithelium and were dose related. Treated corneas returned to normal after the drug was discontinued. T h e results of repeated, intermittent treatment periods in the rabbit indicate that CA is not likely to produce increased tissue sensitivity. Department
of
Pathology.
ACKNOWLEDGMENTS
We gratefully acknowledge the technical assistance of R. N. Weaver and the suggestions of colleagues in preparing the manuscript.
REFERENCES
1. Kaufman, H. E. : Clinical cure of herpes simplex keratitis by 5-iodo-2'-deoxyuridine. Proc. Soc. Exp. Biol. & Med., 109:251-252 (Feb.) 1962. 2. Underwood, G. E. : Activity of 1-ß-D-arabinofuranosylcytosine hydrochloride against herpes simplex keratitis. Proc. Soc. Exp. Biol. &Med., I l l :660-664 (Dec.) 1962. 3. Renis, H. E., and Johnson, H. G. : Inhibition of plaque formation of vaccinia virus by cytosine arabinoside hydrochloride. Bact. Proc, p. 140. 1962. 4. Chu, M. Y., and Fischer, G. A. : A proposed mechanism of action of 1-ß-D-arabinofuranosylcytosine as an inhibitor of the growth of leukemic cells. Biochem. Pharmacol., 11:423-430 (June) 1962. 5. Welch, A. D., and Prusoff, W. H. : A synopsis of recent investigations of 5-iodo-2'-deoxyuridine. Cane. Chem. Rep., 6:29-36 (Feb.) 1960. 6. Kaufman, H. E. : Chemotherapy of herpes keratitis. Invest. Ophth., 2:504-518 (Oct.) 1963. 7. Buthala, D. A. : Cell culture studies on antiviral agents : I. Action of cytosine arabinoside and some comparisons with 5-iodo-2'-deoxyuridine. Proc. Soc. Exp. Biol. & Med., 115:69-77 (Jan.) 1964. 8. Kaufman, H. E., Capella, J. A., Maloney, E. D., Robbins, J. E., Cooper, G. M., and Uotila, M. H. : Corneal toxicity of cytosine arabinoside. Arch. Ophth., 72:535-540, 1964. 9. Sheppard, L. B. : The anatomy and histology of the normal rabbit eye with special reference to the ciliary zone. Arch. Ophth., 66:896-904 (Dec.) 1961 ; 67 :87-100 (Jan.) 1962. 10. Adler, F. H. : Physiology of the Eye : Clinical Application. St. Louis, Mosby, 1953, ed. 2, p. 76.
LIGHT COAGULATION OF INTRAOCULAR T O R R E N C E A.
M A K L E Y , J R . , M.D.,
WILLIAM
AND J A Y NEWBERG,
H.
TUMORS*
HAVENER,
M.D.,
M.D.
Columbus, Ohio In 1952, Meyer-Schwickerath treated a patient with malignant melanoma of the choroid with light coagulation. 1 · 2 In 1955, he began treating retinoblastomas by the same method. H e had such encouraging results in both conditions that he continued clinical trials. Others have utilized light coagulation in treating patients with intraocular neoplasms and reported their results clinically
and histologically. 3,5 It is the purpose of this paper to relate our experiences in treating with the light coagulator four melanomas of the choroid and eight patients with retinoblastomas. In two cases of malignant melanoma, the eye harboring the tumor was enucleated iwhile only one of the eyes with retinoblastoma was ultimately excised. M A L I G N A N T M E L A N O M A OF T H E CHOROID
* From the Department of Ophthalmology, Ohio State University.
O u r method for treating melanomas of the choroid is essentially that employed by
LIGHT COAGULATION OF INTRAOCULAR TUMORS Meyer-Schwickerath. 2 T h e melanoma is first encircled by light coagulations. The outer limits of this treatment ring should extend about 2 mm beyond the tumor tissue. T h e most peripheral part of this ring of coagulation is formed by the "minimum intensity technique" 7 whereby the slightest visible retinal burn is developed slowly with the time of exposure as long as a second. T h e purpose of this cautiously burned peripheral ring is to create firm chorioretinal adhesions involving portions of retina retaining reasonable structural strength. Such peripheral adhesions insure against retinal detachment. One to two weeks are required for these chorioretinal adhesions to become solid and intensive photocoagulation of the tumor should be delayed until that time. A t the first session, however, the surface of the tumor is also treated by the "minimum intensity technique." Despite such careful initial coagulation, an exudative retinal detachment may follow the first light coagulation. If care has been taken to prevent retinal perforation by the avoidance of excessive intensity of photocoagulation at this first session, the detachment will subside in about a week. Once firm chorioretinal adhesions have developed, subsequent photocoagulation will not again cause detachment. Sometimes a low dependent retinal detachment will exist when the melanoma is recognized prior to treatment. Light coagulation will not be effective in this detached area. Surprisingly, minimum intensity coagulation of the tumor surface will result in disappearance of the detachment before the time of the second treatment. T h e second treatment may be as soon as two weeks after the first providing the retinal edema has largely disappeared and there is no detachment. This second treatment is more intense. T h e surgeon adjusts the light to produce the slightest visible shrinkage of the treated tissue. Development of gray discoloration is not a reliable criterion of treatment intensity in previously coagulated
1083
areas. T h e second and subsequent light coagulations should not involve the peripheral edge of the treated area since this might create a retinal tear. If an intense coagulation is inadvertently placed in normal retina, this error will produce a conspicuous dense "snowball." Minimum intensity coagulation about such a "snowball" will guard against hole formation. T h i r d and subsequent sessions of photocoagulation may be scheduled as soon as the hazy media clears, usually within a day or two. These very high intensity treatments, which may utilize the full power of the photocoagulator, cause a definite corneal and vitreous haze which ultimately forces the operator to stop the session of treatment for the day. These intense coagulations are directed upon any visibly elevated masses or any recognizable vessels within the treated area. W i t h very high intensities of treatment the duration of the flash should not be prolonged, lest a choroidal explosion occur. Photocoagulation sessions are repeated until the treated area is a charred, crater-pocked, lifeless-appearing mass. R E S U L T S OF T R E A T M E N T
Of the four patients with malignant melanoma of the choroid treated with the light coagulator, two patients eventually had the eye enucleated. These eyes were studied histologically. In the first case four light coagulation treatments were applied to a tumor in the left eye situated just below and temporal to the macula. I t measured 3 by 4 disc diameters and was only slightly elevated. While the surface of the tumor appeared necrotic, the lesion did not appear inactive. After two months' observation the eye was removed. T h e retina was destroyed over the surface of the tumor but only the very superficial layers of the tumor were necrotic (fig. 1 ) . At the edge of the tumor, retina and choroid were destroyed. T h e rest of the tumor was unaffected (fig. 2 ) . In the other case terminated by excision
MAKLEY, HAVENER AND NEWBERG
1084 4
4
'1
V
*
4
• ·\
* Ψ
f
: /
Fig. 1 (Makley, Havener and Newberg). Case 1. Malignant melanoma of the choroid. The retina has been destroyed and replaced by a thin glial band, showing pigment migration. Only the superficial layers of the tumor have been affected by the light coagulation (χ40). of the globe, 12 treatments with the light coagulator were given over a four-month period. The tumor treated was situated in the midperiphery in the lower temporal quadrant (fig. 3). It was 4 by 5 disc diameters across and was relatively flat. The last six treatments were of maximal intensity. After a six-month observation, it was obvious that not all the tumor had been destroyed (fig. 4). At this time the eye was enucleated. On gross examination there was a craterlike hole in the center of the tumor. Histologically, the retina was completely destroyed over the mass and there was considerable necrosis of the tumor in the craterlike center. However, viable tumor was present between the crater surface and the sciera. At the edge of the mass there was
considerable necrosis. Multiple sections showed that the choroid was not completely destroyed around the tumor and did contain patent blood vessels (fig. 5). The third patient, a 72-year-old white man, presented with a mushroom-shaped tumor in the right eye elevated about 8 diopters and situated in the lower nasal quadrant. There was considerable pigment haze in the vitreous. The chances for any effect from light coagulation seemed remote but the patient refused enucleation. A ring of coagulation was placed around the base of the tumor and the surface treated intensively six times over a period of two months. In spite of this the tumor did not regress and the patient was strongly advised to have an enucleation. He refused, but has been faith-
LIGHT COAGULATION OF INTRAOCULAR TUMORS
1085
disc diameters and relatively flat. Enucleation was refused so four treatments with the light coagulator were given. T h e patient failed to return for the fifth treatment and has not been seen since. T w o years after treatment it was learned indirectly that the patient was living and well. T h e eye had not been removed at that time. COMMENT
O u r experiences of treating malignant melanoma of the choroid indicate that it is almost impossible to destroy the tumor completely. T h e two eyes that were enucleated showed minimal destruction of the tumor. Only 0.5 to 1.0 mm of the surface of the tumor showed necrosis. At the time of clinical diagnosis most choroidal melanomas are much too large to be destroyed by photocoagulation. W e believe that this technique is of limited value in their treatment.
Fig. 2 (Makley, Havener and Newberg). Case 1. Malignant melanoma of the choroid. The deeper parts of the tumor have been unaffected by treatment. (X40). ful about follow-up visits. Vision at the beginning of treatment was 2 0 / 5 0 . At the last follow-up visit vision was 2 0 / 3 0 . Over three years, the tumor seems to remain dormant. It is much the same as when first seen, neither getting larger nor regressing (fig. 6 ) . A wide ring of coagulated area is clearly visible about the tumor base. Perhaps the blood supply has been altered enough to slow down growth. Certainly the tumor has not been destroyed. A recent physical examination revealed the patient to be in good health without evidence of metastasis. The last patient was a 51-year-old white man who had an almond-shaped melanoma in the temporal fundus of the left eye 4 by 3
Curtin and Norton 5 examined four eyes histologically, which had been enucleated 2, 6, 8 and 17 days respectively, after one treatment with light coagulation. They concluded that the flatter lesions were more readily destroyed than the higher ones and that the amount of pigmentation did not influence the degree of tumor necrosis. They concluded, too, that the value of light coagulation is highly limited. RETINOBLASTOMA
Just as in the case of choroidal melanomas, a retinoblastoma is surrounded by a ring of light coagulation in normal retina using the minimal intensity technique (figs. 7 and 8 ) . This ring should be placed for orientation before treatment of the tumor, since, following photocoagulation, the neoplasm cannot be distinguished from surrounding treated retina except where it is elevated. Although a retinoblastoma is very light in color and it would be expected to require very intense photocoagulation, this is not the case. Probably because of the extreme clarity of the infant media and because of the wide pupillary dilatation which
1086
MAKLEY, H A V E N E R AND N E W B E R G
Fig. 3 (Makley, Havener and Newberg). Case 2. Malignant melanoma of the choroid. The photograph on the left shows tumor before treatment. On the right the area has received one treatment with the light coagulator.
Fig. 4 (Makley, Havener and Newberg). Case 2. After 12 sessions of light coagulation, the tumor appeared charred and necrotic.
LIGHT COAGULATION OF INTRAOCULAR
can be achieved, the lowest intensity (green one) must be further reduced by stopping down the diaphragm as much as half way or more. Particular attention should be given to the feeding vessels which should be coagulated directly. Scierai depression during photocoagulation is necessary if the retinoblastoma extends to near the ora serrata. If the retinoblastoma is fairly flat, a single treatment will destroy it. Elevated tumors are a great deal more resistant and seem to respond best to destruction of their arterial supply. If all vessels can be occluded, the tumor mass may literally melt away. Recurrent neoplasm within a treated area appears as a translucent light gray film obscurring the pigmentation. Thorough examination should re-evaluate the status of the tumor at intervals no less frequent than every two weeks until the surgeon is certain the retinoblastoma is destroyed. Of the eight cases of retinoblastoma
Fig. S (Makley, Havener and Newberg). Case 2. Malignant melanoma of the choroid . There is considerable necrosis of the edge and superficial layers in the center of the tumor. The great bulk of the mass has not been destroyed even after intensive treatment. Pigment has migrated to the inner layers of the tumor. The retina has been destroyed.
TUMORS
1087
Fig. 6 (Makley, Havener and Newberg). Case 3. Malignant melanoma of the choroid. Part of a mushroom-shaped tumor is seen in the lower edge of the photograph. It has been little affected by light coagulation. A ring of coagulation is seen around the base of the tumor. Eye retained; patient living and well three years after treatment.
treated with the light coagulator, seven were bilateral and the most involved eye was enucleated. The second eye was treated in three cases with light coagulation alone. One case was treated with light coagulation and TEM and the remaining three cases received irradiation, Cytoxan, and light coagulation. The case of unilateral retinoblastoma treated was seen early and the lesion destroyed by the light coagulator. Of the three cases receiving light coagulation alone, two cases had multiple foci of tumor. These two cases both developed a new focus of tumor while being treated. The new foci were then light coagulated and destroyed. Another case with one large tumor near the disc and two smaller tumors in the periphery below was treated with irradiation (cobalt 60) and Cytoxan. These lesions melted away but in six months a new tumor was noted in the far nasal periphery above. This was treated successfully with the light coagulator. One of the eyes included in this series failed to respond to light coagulation and eventually was enucleated. This child had lost her left eye because of a retinoblastoma. One year after enucleation, a large mass was noted in the inferior temporal quadrant
1088
MAKLEY, HAVENER AND NEWBERG
(
"il 14
„Ιι'
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Fig. 7 (Makley, Havener and Newberg). Retinoblastoma. Two tumor foci ringed by light coagulation. of the right eye. Two treatments with the light coagulator were given and a week later the sciera and the area of the tumor was cauterized with diathermy. The tumor did show some regression two months later but the residual was treated with the light coagulator two more times three weeks apart. A month later, the tumor again appeared to be growing so, as a last resort, a course of Xray treatments was administered, but in spite of this the tumor did not regress completely and the eye was enucleated. T h i s case raises the question: Should light coagulation be the primary treatment for retinoblastoma? There is no doubt this form of therapy can destroy a malignant tumor if it is not too large. Meyer-Schwickerath concluded that photocoagulation could be used on lesions that involve no more than one third of the retinal surface; this seems
rather large to us. One wonders if the patient just described might have fared better if irradiation and chemotherapy had been tried early. Light coagulation has the disadvantage of all local forms of therapy in that only one small part of the retina is treated. I n two of the treated cases it seemed we were chasing tumors all over the retina as new foci developed. F r o m our experience it would seem that light coagulation should be saved for recurrences and any new tumor foci that might appear after irradiation and chemotherapy. These latter forms of treatment affect the whole retina and being very effective should be used first. SUMMARY
T h e photocoagulation of four choroidal melanomas and seven retinoblastomas has
LTGHT COAGULATION OF INTRAOCULAR TUMORS
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Fig. 8 (Makley, Havener and Newberg). Retinoblastoma. Same case as in Figure 7. Note flat scars following three treatments with the light coagulator. been described. None of the four melanomas were completely destroyed despite most intensive treatment. Photocoagulation alone cannot be advocated as a certain treatment for melanoma. Of seven eyes with retinoblastoma treated by photocoagulation only one required enucleation. Photocoagulation
is a very effective means of destroying a small retinoblastoma. However, since irradiation and chemotherapy are so effective, photocoagulation should be reserved for recurrences of retinoblastoma or any new tumors that may appear after treatment. 410 West 10th Avenue (43210).
REFERENCES
1. Meyer-Schwickerath, G. : Light Coagulation (translated by S. W. Drance). St. Louis, Mosby, 1960. 2: The preservation of vision by treatment of intraocular tumors with light coagulation. Arch. Ophth., 66 :458-466 (Oct.) 1961. 3. Wegner, W., and Marquardt, R. : Treatment of melanoblastoma of the choroid with the light coagulator by the Meyer-Schwickerath method from a critical viewpoint. Klin. Mbl. Augenh., 139:800-813. 1961. 4. Lund, O. E. : Histological studies on light-coagulated melanoblastoma of the choroid. Arch. f. Ophth., 164:433-456, 1962. 5. Curtin, V. T., and Norton, E. W. : Pathological changes in malignant melanomas after photocoagulation. Arch. Ophth., 70:150-157 (Aug.) 1963. 6. Westerveld-Brandon, E. R., and Zeeman, W. P. : The prognosis of melanoblastoma of the choroid. Ophthalmologies, 134:20-29 (July) 1957. 7. Havener, W. H. : Clinical experiences with the photocoagulator. Am. T. Ophth., 49:1212-1221 (Mav Pt. II) 1960.