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Lymphosarcoma of the Choroid
1294
NOTES, CASES, INSTRUMENTS DISCUSSION
A s to the etiology in this case, herpes sim plex has been ruled out. T h e normal Schirmer test rules out keratitis sicca. There is no history of trauma or evidence of recur rent erosion. The retention of corneal sensa tion rules out trophic changes as a possible cause. W i t h our present lack of knowledge, this case falls into the idiopathic group of filamentary keratitis. O n the basis of one patient with an ap parently favorable response to beta radia tion, it is impossible to draw definite con clusions, especially since it is well known that spontaneous remission does occur. O n the other hand, some cases of filamentary keratitis have proven to be most refractory to any form of therapy and the case here re ported would appear to be one of these. This apparent response to beta radiation once again focuses our attention on a type of treat ment that hit its zenith 10 or 12 years ago when advocated by some enthusiasts as a panacea for almost any corneal o r scleral disease. With few exceptions beta radiation
is now generally reserved for treating cor neal vascularization in connection with keratoplasty, recurrent pterygium, rosacea kera titis and severe vernal conjunctivitis. 8 I t s further use in the treatment of idiopathic filamentary keratitis unresponsive to other forms of therapy seems warranted. SUMMARY
A case history of a 38-year-old white man w h o developed persistent filamentary keratitis following a traumatic right subdural hematoma is presented. T h e fila mentary keratitis failed to respond to a num ber of therapeutic measures including local antibiotic and steroid ointment, repeated mechanical denudation, pressure dressings and watchful waiting. Following the applica tion of minimum beta radiation therapy, the filamentary keratitis cleared completely. T h e patient has been entirely symptom free for a 12-month follow-up period.
2325 Vera (13). 718 Carew Tozver (2).
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8.
Benner, R.: Is filamentary keratitis infectious? Ann. ocul., 180:140-141, 1947. Schaeffer, A. J.: Amino acids in corneal healing. Am. J. Ophth., 33:741-750, 1950. Thomas, C. I.: The Cornea. Springfield, 111., Thomas, 1955, pp. 467-470. Berliner, M. L.: Biomicroscopy of the Eye. 1949, v. 1, pp. 490-492. Bossalino, G.: Keratitis filamentosa Boll, ocul., 15:1193-1214, 1936. Westkamp, C : Parenchymatous origin of filamentary keratitis. Am. J. Ophth., 42:115-120, 1956. Thomas, C. I.: The Cornea. Springfield, 111., Thomas, 1955, p. 990. Lehey, B. D.: Beta radiation in ophthalmology. Am. T. Ophth., 49 :7-28, 1960.
LYMPHOSARCOMA O F T H E CHOROID HAROLD BEASLEY,
M.D.
Fort Worth, Texas Primary lymphomatous lesions are un common in the eye and the adnexa and pri mary lymphomatous lesions of the choroid, without systemic involvement, are extremely rare. Stout has classified lymphomatous tumors into the lymphocytic cell type, the giant follicle type and the reticulum cell type.
Lymphatic leukemia and possibly Hodgkin's disease may also be considered in this group. T h e giant follicle type is the least malignant and the reticulum cell type the most malig nant. Since the eye does not contain lymphoid tissue or true lymphatics, intraocular lymphosarcoma of the lymphocytic cell type should be found only as a metastatic lesion. Cells of the reticulo-endothelial system a r e found in the eye, therefore we should expect to see primary lesions of the reticulum cell type. Reese reported three cases of intraocular
NOTES, CASES, INSTRUMENTS
1295
Fig. 1 (Beasley). Cross section of the eye shows a moderately flat tumor, predominately in the pos terior segment. No evidence of extraocular extension is present in this section.
Fig. 3 (Beasley). High-power view of the tu mor shows the lymphocytic structure and many mitotic figures. lymphomatous disease, two of which were in the anterior segment and one in the choroid. Hartshorne reported a case which appar ently involved the choroid primarily. McGavic described a primary lymphocytic cell lymphosarcoma of the iris. I wish to present a case of lymphocytic cell lymphosarcoma of the choroid, which ap pears to be a p r i m a r y process. C A S E REPORT
Fig. 2 (Beasley). Low-power section shows the tumor which is rich in cellular elements. Tumor cells are seen in the small vessels of the sclera.
A 50-year-old white man first presented him self in May, 1956, concerning retinal detachment in the right eye. This had been operated elsewhere four months prior to his first visit and the surgery had failed. Examination revealed the vision to be hand mo tion, R.E., and 20/20, L.E. A complete detachment was present in the right eye with normal tension. The left eye was normal. Transillumination was not informative. Fundus details could not be seen because the retina was behind the lens. With the slitlamp, the anterior chamber was clear and the de-
NOTES, CASES, INSTRUMENTS
12%
tachment appeared to have fluid under it. The pa tient was advised that further detachment surgery was not indicated. In January, 1957, the patient developed absolute glaucoma in the right eye with pain. Enucleation was done January 11, 1957. The sclera appeared intact and there was no gross evidence of tumor or scleral invasion. The pathologic report was lymphosarcoma, lymphocytic type, of the choroid with extension through the sclera. The slides were ex amined by several pathologists, including the Armed Forces Institute of Pathology, and the diagnosis was the same from each examiner (figs. 1, 2 and
3). While the patient was still in the hospital, a thorough physical examination was done by an internist, with lymphomatous disease in mind. No nodes were found and all blood and bone-marrow studies were normal. The right orbit was treated with 1,200 r of X-rays as measured in air, to each of two ports. The patient has had subsequent check-ups in the past three years and still there is no evidence of general lymphogenous disease, and no recurrence of the primary process in the orbit. 1201 West Presidio
Street.
REFERENCES
Benedict, W. L., and Martens. T. G.: Malignant lymphocytic tumors of orbit. S. Clin. North America, 26:871-875, 1946. Forrest, A. W.: Intraorbital tumors; Arch. Ophth., 41:198-232, 1949. Hartshorne, I.: Lymphosarcoma of the orbit: Probably arising in the choroid. Am. J. Ophth., 5:604608, 1922. McGavic, T. S.: Lymphomatoid disease involving the eye and its adnexa. Arch. Ophth., 30:179-189, 1943. Reese, A. B.: Tumors of the Eye. New York, Hoeber, 1951, pp. 453-469. Stout, A. P.: Results of treatment of lymphosarcoma. N.Y. State T. Med., 47:158-164, 1947. ■ : Is lymphosarcoma curable? I.A.M.A., 118:968-970, 1942.
T H E CHOROID A S SITE OF P R I M E MANIFESTATION OF SYSTEMIC INVOLVEMENT I N S K I N MELANOMA
is poor and radical and mutilating surgery is, therefore, not indicated. On the other hand, if the lesion is taken to be another pri mary or a different tumor,3 early surgery is, at present, the treatment of choice.
REPORT OF A CASE CLINICAL REPORT LESTER L. COVELL,
M.D.
Boston, Massachusetts AND H A R R I H . M A R K I E W I T Z , M.D.
Brookline, Massachusetts Ernst Fuchs 1 stated that a metatastic choroidal sarcoma was unknown. A review of the literature and personal communica tions with colleagues confirmed the rarity of a secondary involvement of the eye in malig nant melanoma. A description in detail of such a case therefore seems warranted. 2 Presently accepted views that malignant melanoma can arise from multiple origins adds a therapeutic problem as well as a diag nostic one. T h e assumption that the intra ocular manifestation represents a distant metastasis of a primary lesion elsewhere leads to the conclusion that the life prognosis
H. M., a 43-year-old white carpenter, was first seen by an ophthalmologist on February 11, 1960, with the chief complaint of blurred vision in the right eye. Family history was irrelevant. Past his tory revealed that the patient was originally re jected from military service because of an easily reducible inguinal hernia. Following reduction of this hernia in 1942, he was admitted to active duty and was discharged five months later because of a "nervous condition." The only other medical com plaint consisted of a persistent rash on both legs, diagnosed as lichen planus. The present lesions began over 20 years ago at which time he recalls a "birth-mark" on his left heel. The birth-mark was symptom-free until 1956 when he stated that a callus developed which was diagnosed as a plantar wart and treated by nitric acid, followed by curettage. In 1958, the lesion began draining clear fluid and was painful on wear ing a shoe. It gradually became more prominent and, early in 1959, a biopsy was taken under local anesthesia. At this time the left inguinal lymph nodes became easily palpable and the patient was hospitalized in June, 1959. Examination of the lesion at this time showed
NOTES, CASES, INSTRUMENTS DISCUSSION
A s to the etiology in this case, herpes sim plex has been ruled out. T h e normal Schirmer test rules out keratitis sicca. There is no history of trauma or evidence of recur rent erosion. The retention of corneal sensa tion rules out trophic changes as a possible cause. W i t h our present lack of knowledge, this case falls into the idiopathic group of filamentary keratitis. O n the basis of one patient with an ap parently favorable response to beta radia tion, it is impossible to draw definite con clusions, especially since it is well known that spontaneous remission does occur. O n the other hand, some cases of filamentary keratitis have proven to be most refractory to any form of therapy and the case here re ported would appear to be one of these. This apparent response to beta radiation once again focuses our attention on a type of treat ment that hit its zenith 10 or 12 years ago when advocated by some enthusiasts as a panacea for almost any corneal o r scleral disease. With few exceptions beta radiation
is now generally reserved for treating cor neal vascularization in connection with keratoplasty, recurrent pterygium, rosacea kera titis and severe vernal conjunctivitis. 8 I t s further use in the treatment of idiopathic filamentary keratitis unresponsive to other forms of therapy seems warranted. SUMMARY
A case history of a 38-year-old white man w h o developed persistent filamentary keratitis following a traumatic right subdural hematoma is presented. T h e fila mentary keratitis failed to respond to a num ber of therapeutic measures including local antibiotic and steroid ointment, repeated mechanical denudation, pressure dressings and watchful waiting. Following the applica tion of minimum beta radiation therapy, the filamentary keratitis cleared completely. T h e patient has been entirely symptom free for a 12-month follow-up period.
2325 Vera (13). 718 Carew Tozver (2).
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8.
Benner, R.: Is filamentary keratitis infectious? Ann. ocul., 180:140-141, 1947. Schaeffer, A. J.: Amino acids in corneal healing. Am. J. Ophth., 33:741-750, 1950. Thomas, C. I.: The Cornea. Springfield, 111., Thomas, 1955, pp. 467-470. Berliner, M. L.: Biomicroscopy of the Eye. 1949, v. 1, pp. 490-492. Bossalino, G.: Keratitis filamentosa Boll, ocul., 15:1193-1214, 1936. Westkamp, C : Parenchymatous origin of filamentary keratitis. Am. J. Ophth., 42:115-120, 1956. Thomas, C. I.: The Cornea. Springfield, 111., Thomas, 1955, p. 990. Lehey, B. D.: Beta radiation in ophthalmology. Am. T. Ophth., 49 :7-28, 1960.
LYMPHOSARCOMA O F T H E CHOROID HAROLD BEASLEY,
M.D.
Fort Worth, Texas Primary lymphomatous lesions are un common in the eye and the adnexa and pri mary lymphomatous lesions of the choroid, without systemic involvement, are extremely rare. Stout has classified lymphomatous tumors into the lymphocytic cell type, the giant follicle type and the reticulum cell type.
Lymphatic leukemia and possibly Hodgkin's disease may also be considered in this group. T h e giant follicle type is the least malignant and the reticulum cell type the most malig nant. Since the eye does not contain lymphoid tissue or true lymphatics, intraocular lymphosarcoma of the lymphocytic cell type should be found only as a metastatic lesion. Cells of the reticulo-endothelial system a r e found in the eye, therefore we should expect to see primary lesions of the reticulum cell type. Reese reported three cases of intraocular
NOTES, CASES, INSTRUMENTS
1295
Fig. 1 (Beasley). Cross section of the eye shows a moderately flat tumor, predominately in the pos terior segment. No evidence of extraocular extension is present in this section.
Fig. 3 (Beasley). High-power view of the tu mor shows the lymphocytic structure and many mitotic figures. lymphomatous disease, two of which were in the anterior segment and one in the choroid. Hartshorne reported a case which appar ently involved the choroid primarily. McGavic described a primary lymphocytic cell lymphosarcoma of the iris. I wish to present a case of lymphocytic cell lymphosarcoma of the choroid, which ap pears to be a p r i m a r y process. C A S E REPORT
Fig. 2 (Beasley). Low-power section shows the tumor which is rich in cellular elements. Tumor cells are seen in the small vessels of the sclera.
A 50-year-old white man first presented him self in May, 1956, concerning retinal detachment in the right eye. This had been operated elsewhere four months prior to his first visit and the surgery had failed. Examination revealed the vision to be hand mo tion, R.E., and 20/20, L.E. A complete detachment was present in the right eye with normal tension. The left eye was normal. Transillumination was not informative. Fundus details could not be seen because the retina was behind the lens. With the slitlamp, the anterior chamber was clear and the de-
NOTES, CASES, INSTRUMENTS
12%
tachment appeared to have fluid under it. The pa tient was advised that further detachment surgery was not indicated. In January, 1957, the patient developed absolute glaucoma in the right eye with pain. Enucleation was done January 11, 1957. The sclera appeared intact and there was no gross evidence of tumor or scleral invasion. The pathologic report was lymphosarcoma, lymphocytic type, of the choroid with extension through the sclera. The slides were ex amined by several pathologists, including the Armed Forces Institute of Pathology, and the diagnosis was the same from each examiner (figs. 1, 2 and
3). While the patient was still in the hospital, a thorough physical examination was done by an internist, with lymphomatous disease in mind. No nodes were found and all blood and bone-marrow studies were normal. The right orbit was treated with 1,200 r of X-rays as measured in air, to each of two ports. The patient has had subsequent check-ups in the past three years and still there is no evidence of general lymphogenous disease, and no recurrence of the primary process in the orbit. 1201 West Presidio
Street.
REFERENCES
Benedict, W. L., and Martens. T. G.: Malignant lymphocytic tumors of orbit. S. Clin. North America, 26:871-875, 1946. Forrest, A. W.: Intraorbital tumors; Arch. Ophth., 41:198-232, 1949. Hartshorne, I.: Lymphosarcoma of the orbit: Probably arising in the choroid. Am. J. Ophth., 5:604608, 1922. McGavic, T. S.: Lymphomatoid disease involving the eye and its adnexa. Arch. Ophth., 30:179-189, 1943. Reese, A. B.: Tumors of the Eye. New York, Hoeber, 1951, pp. 453-469. Stout, A. P.: Results of treatment of lymphosarcoma. N.Y. State T. Med., 47:158-164, 1947. ■ : Is lymphosarcoma curable? I.A.M.A., 118:968-970, 1942.
T H E CHOROID A S SITE OF P R I M E MANIFESTATION OF SYSTEMIC INVOLVEMENT I N S K I N MELANOMA
is poor and radical and mutilating surgery is, therefore, not indicated. On the other hand, if the lesion is taken to be another pri mary or a different tumor,3 early surgery is, at present, the treatment of choice.
REPORT OF A CASE CLINICAL REPORT LESTER L. COVELL,
M.D.
Boston, Massachusetts AND H A R R I H . M A R K I E W I T Z , M.D.
Brookline, Massachusetts Ernst Fuchs 1 stated that a metatastic choroidal sarcoma was unknown. A review of the literature and personal communica tions with colleagues confirmed the rarity of a secondary involvement of the eye in malig nant melanoma. A description in detail of such a case therefore seems warranted. 2 Presently accepted views that malignant melanoma can arise from multiple origins adds a therapeutic problem as well as a diag nostic one. T h e assumption that the intra ocular manifestation represents a distant metastasis of a primary lesion elsewhere leads to the conclusion that the life prognosis
H. M., a 43-year-old white carpenter, was first seen by an ophthalmologist on February 11, 1960, with the chief complaint of blurred vision in the right eye. Family history was irrelevant. Past his tory revealed that the patient was originally re jected from military service because of an easily reducible inguinal hernia. Following reduction of this hernia in 1942, he was admitted to active duty and was discharged five months later because of a "nervous condition." The only other medical com plaint consisted of a persistent rash on both legs, diagnosed as lichen planus. The present lesions began over 20 years ago at which time he recalls a "birth-mark" on his left heel. The birth-mark was symptom-free until 1956 when he stated that a callus developed which was diagnosed as a plantar wart and treated by nitric acid, followed by curettage. In 1958, the lesion began draining clear fluid and was painful on wear ing a shoe. It gradually became more prominent and, early in 1959, a biopsy was taken under local anesthesia. At this time the left inguinal lymph nodes became easily palpable and the patient was hospitalized in June, 1959. Examination of the lesion at this time showed