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New England Ophthalmological Society
SOCIETY PROCEEDINGS
548
ties, was based upon the satisfactory correc tion of over 70 cases. The entire paper was published in T H E AMERICAN JOURNAL OF
(January, 1956). William E. Krewson, 3rd, Clerk.
OPHTHALMOLOGY
NEW ENGLAND OPHTHALMOLOGICAL SOCIETY January 19, 1955 W. DIMMITT, presiding The afternoon session of the 422nd meet ing of the New England Ophthalmological Society consisted of the presentation of sev eral interesting clinical cases followed by a Pathology Conference conducted by Dr. Taylor R. Smith. In the evening session, after the business meeting, two original pa pers were presented : the first, a case presen tation, by Dr. J. D. Houghton, Chief of the Laboratory Service for the Veterans' Hos pital in Boston; and the second, a paper on "Success or failure in glaucoma surgery," by Dr. P. Robb McDonald of Philadelphia. DR. FRANK
SOLITARY METASTASIS OF RENAL-CELL CAR CINOMA DR. J. D. HOUGHTON : A 63-year-old night watchman of French-Canadian extraction claimed to have been struck by a light steel chain over a point in the angle between the bridge of the nose and the right eyebrow in November, 1953. Allegedly, a lump appeared at this site two weeks later, and slowly un derwent painless enlargement, spreading up ward over the forehead. In January, a pulsating bruit from this area became audible to the patient, and there was slight downward displacement of the eye and diplopia. Following angiography, a right external carotid ligation was done and the bruit ceased but, after four weeks, enlargement of the
tumor was resumed and the bruit returned. By May 12th, a palpable, pulsating, mod erately firm, low, bulging mass about 8.0 by 6.0 cm. was present over the right medial forehead, extending down over the brow ridge. The edges of a defect in the frontal bone could be felt after emptying the tumor of blood by steady pressure. The globe was pushed anteriorly and to the side, with marked diplopia in all directions of gaze. Fundus was normal and vision 20/20. Im pression, after additional arteriograms, was cirsoid aneurysm. Excision of the mass was performed on August 5th. The tumor was about 11.5 cm. long (vertically), 5.5 cm. wide, and 0.5 to 0.6 cm. thick, encapsulated anteriorly, and bulging from the anterior table of the frontal bone. It was pink-gray, pliable, tough, and highly vascular, with profuse bleeding at op eration. Histologically it showed solid nests of clear cells compartmented by capillaries and slightly larger vascular spaces. This archi tecture closely resembled that of carotidbody tumor, and together with the lack of lumen formation or of fat or glycogen in the cells led to a diagnosis of chemodectoma or nonchromaffin paraganglioma. Since the tu mor was alleged to be primary in the orbit, it was presumed to have arisen in the ciliary paraganglion described by Botar and Pribek (in a chimpanzee). Additional sections of tumor taken from the specimen five months later revealed lu men formation, which is not found in chemo dectoma. Accordingly, renal-cell carcinoma was suspected. Following an intravenous pyelogram, the right kidney was removed on January 28th. It contained a large tumor mass, the whole weighing 550 gm. Large areas of it were histologically identical with the tumor in the frontal bone and orbit, leav ing no doubt that the latter was a metastasis. It should be emphasized that at no time since onset had the patient noted the slightest symptom referable to the genito-urinary tract, although the renal tumor must have
SOCIETY PROCEEDINGS been present for at least a year and two months. At this time, two months after nephrectomy, there is still no evidence of any other metastasis. Only one case (Fisher and Hazard: Can cer, 5 :521, 1952) and two other possible ex amples ( Lattes, McDonald, and Sproul : Ann. Surg., 139:382 [Mar.] 1954; Pendergrass and Kirsh: Am. J. Roentgenol. 57 :517 [Apr.] 1947) of chemodectoma of the orbit have been reported in the literature. The first case was followed for only three months after operation. In each of the other two there was a coexistent carotid-body tumor, raising the possibility that the orbital tumor was metastatic. No ciliary paraganglion has ever been reported as found in a human. In view of the experience here described, it would seem advisable not to report further examples of this entity, if indeed it exists at all, without benefit of bilateral renal explora tion or complete autopsy. SUCCESS OR FAILURE IN GLAUCOMA SURGERY DR. P. ROBB MCDONALD, pointed out that the numbers and variations and types of glaucoma operations merely emphasize what a complex picture we are attempting to re duce to a common denominator, namely, elevated tension. He cited progress in re search which has given us a better under standing of the problem as a whole, and pro ceeded with the discussion of surgery for different types of glaucoma. He considered four groups of glaucoma which are usually subjected to surgery : Acute congestive glaucoma, malignant glau coma, chronic glaucoma, and congenital glau coma. Acute congestive glaucoma was considered to be the most satisfactory to treat, and operation is the treatment of choice except in unusual cases. It was further advised that the other eye should be given a prophylactic iridectomy. He stated that a short trial of medical treatment (about three to six hours) should be given in a case of acute glaucoma and then surgery should be resorted to.
549
A peripheral iridectomy with a tight wound closure was recommended for all cases which can be controlled medically, or when one can be sure it is the first attack. Wound closure was emphasized to promote speedy formation of the anterior chamber and to prevent converting the glaucoma into a chronic type. Also selection of a suitable area for the iridectomy was mentioned since it had been observed that polycoria in some instances produced troublesome diplopia when the iridectomy was below the upper lid margin, even though the tension was well controlled. Complications and failures he attributed to faulty history and examination, in which chronic glaucoma is mistakenly treated as acute narrow-angle glaucoma, although he added that even in chronic glaucoma periph eral iridectomy works well if the tension is controlled by miotics. The second cause for failure, from the patient's point of view, is injury to the lens by a keratome or iris for ceps, thereby producing a poor visual result. Malignant glaucoma was described as es sentially that glaucoma in which there is a narrow angle, in which the pressure cannot be reduced to normal, and in which one gets virtually no aqueous on making a section or entering the anterior chamber. The iris dia phragm is displaced forward and the eye stays hard even after the anterior chamber has been opened. He pointed out that this poses a real problem to the surgeon as to whether to proceed with cataract extraction at that time, or whether to perform a periph eral iridectomy and see if .he chamber will reform. In case cataract extraction is per formed he re-emphasized the fact that it is desirable, in this type of case, to lose vitreous by incising the hyaloid if vitreous is not lost spontaneously, and added that, in a case in which malignant glaucoma has been known to exist in one eye, a prophylactic peripheral iridectomy in the other eye is highly advis able. In discussing the problem of chronic glau coma, Dr. McDonald pointed out that a
550
SOCIETY PROCEEDINGS
peripheral iridectomy is good only when the tension can be controlled by miotics; other wise, a filtering operation is needed. The relative merits of trephination and iridencleisis were discussed, and it was pointed out that trephination is usually a more difficult operation, the danger of hypotony is greater, iritis occurs more frequently, the bleb is usually larger, and when cataract forms, it comes on more rapidly. Also there is greater chance of late secondary infections than with the iridencleisis. However, with iridencleisis, results are usually not very good when the tension is very high. A late complication of trephination is the possibility of acute hypotony. Dr. McDonald discussed opinions as expressed by Kronfeld regarding the increase of outflow by filtering operations as against the evidence presented by DeVoe that in many cases there is suc cessful surgery with no evidence of filtration by gonioscopy. He felt that, probably, DeVoe had been dealing with a group of narrowangle glaucomas which had been cured by the iridectomy and had no need for fistualization. An extremely large filtering bleb was defi nitely considered an undesirable result, and the speaker suggested that the large bleb usually develops in those cases in which Tenon's capsule has not been sutured at the time of the operation. In congenital glaucoma, the operation of choice was considered to be goniotomy, if the diagnosis is made early. The speaker pointed
out that if goniopuncture is done in conjunc tion with goniotomy, one should be careful not to make the puncture too large for fear of prolapse of the iris. It was also pointed out that, in many congenital glaucoma pa tients, the iris tissue cannot be adequately stripped from the angle and kept back. When cyclodiathermy is used for congenital glau coma, the results may be unpredictable. Discussion.
DR. PAUL
A.
CHANDLER
chided Dr. McDonald for astutely recogniz ing a "misery case" and referring him to Dr. Chandler. He stated that, after five opera tions, the tension was still up. This case was used to illustrate the point that, in many in stances, the technique does not seem to make much difference ; that even though operations seem to go very satisfactorily, and from a technical point of view would seem to have everything in their favor, there is some "X" factor which determines whether the patient will get a satisfactory reduction in tension. He agreed with Dr. McDonald's analysis of DeVoe's series, and considered the patients that were cured without filtration had cases of narrow-angle glaucoma. He stated that in the cases of open-angle glaucoma "no filtra tion—no cure." He agreed that iridectomy should be done if the glaucoma is controlled by drops, and that also if it is the first attack, an iridectomy will work even if the drops have not brought the tension down. David H. Scott, Recorder.
548
ties, was based upon the satisfactory correc tion of over 70 cases. The entire paper was published in T H E AMERICAN JOURNAL OF
(January, 1956). William E. Krewson, 3rd, Clerk.
OPHTHALMOLOGY
NEW ENGLAND OPHTHALMOLOGICAL SOCIETY January 19, 1955 W. DIMMITT, presiding The afternoon session of the 422nd meet ing of the New England Ophthalmological Society consisted of the presentation of sev eral interesting clinical cases followed by a Pathology Conference conducted by Dr. Taylor R. Smith. In the evening session, after the business meeting, two original pa pers were presented : the first, a case presen tation, by Dr. J. D. Houghton, Chief of the Laboratory Service for the Veterans' Hos pital in Boston; and the second, a paper on "Success or failure in glaucoma surgery," by Dr. P. Robb McDonald of Philadelphia. DR. FRANK
SOLITARY METASTASIS OF RENAL-CELL CAR CINOMA DR. J. D. HOUGHTON : A 63-year-old night watchman of French-Canadian extraction claimed to have been struck by a light steel chain over a point in the angle between the bridge of the nose and the right eyebrow in November, 1953. Allegedly, a lump appeared at this site two weeks later, and slowly un derwent painless enlargement, spreading up ward over the forehead. In January, a pulsating bruit from this area became audible to the patient, and there was slight downward displacement of the eye and diplopia. Following angiography, a right external carotid ligation was done and the bruit ceased but, after four weeks, enlargement of the
tumor was resumed and the bruit returned. By May 12th, a palpable, pulsating, mod erately firm, low, bulging mass about 8.0 by 6.0 cm. was present over the right medial forehead, extending down over the brow ridge. The edges of a defect in the frontal bone could be felt after emptying the tumor of blood by steady pressure. The globe was pushed anteriorly and to the side, with marked diplopia in all directions of gaze. Fundus was normal and vision 20/20. Im pression, after additional arteriograms, was cirsoid aneurysm. Excision of the mass was performed on August 5th. The tumor was about 11.5 cm. long (vertically), 5.5 cm. wide, and 0.5 to 0.6 cm. thick, encapsulated anteriorly, and bulging from the anterior table of the frontal bone. It was pink-gray, pliable, tough, and highly vascular, with profuse bleeding at op eration. Histologically it showed solid nests of clear cells compartmented by capillaries and slightly larger vascular spaces. This archi tecture closely resembled that of carotidbody tumor, and together with the lack of lumen formation or of fat or glycogen in the cells led to a diagnosis of chemodectoma or nonchromaffin paraganglioma. Since the tu mor was alleged to be primary in the orbit, it was presumed to have arisen in the ciliary paraganglion described by Botar and Pribek (in a chimpanzee). Additional sections of tumor taken from the specimen five months later revealed lu men formation, which is not found in chemo dectoma. Accordingly, renal-cell carcinoma was suspected. Following an intravenous pyelogram, the right kidney was removed on January 28th. It contained a large tumor mass, the whole weighing 550 gm. Large areas of it were histologically identical with the tumor in the frontal bone and orbit, leav ing no doubt that the latter was a metastasis. It should be emphasized that at no time since onset had the patient noted the slightest symptom referable to the genito-urinary tract, although the renal tumor must have
SOCIETY PROCEEDINGS been present for at least a year and two months. At this time, two months after nephrectomy, there is still no evidence of any other metastasis. Only one case (Fisher and Hazard: Can cer, 5 :521, 1952) and two other possible ex amples ( Lattes, McDonald, and Sproul : Ann. Surg., 139:382 [Mar.] 1954; Pendergrass and Kirsh: Am. J. Roentgenol. 57 :517 [Apr.] 1947) of chemodectoma of the orbit have been reported in the literature. The first case was followed for only three months after operation. In each of the other two there was a coexistent carotid-body tumor, raising the possibility that the orbital tumor was metastatic. No ciliary paraganglion has ever been reported as found in a human. In view of the experience here described, it would seem advisable not to report further examples of this entity, if indeed it exists at all, without benefit of bilateral renal explora tion or complete autopsy. SUCCESS OR FAILURE IN GLAUCOMA SURGERY DR. P. ROBB MCDONALD, pointed out that the numbers and variations and types of glaucoma operations merely emphasize what a complex picture we are attempting to re duce to a common denominator, namely, elevated tension. He cited progress in re search which has given us a better under standing of the problem as a whole, and pro ceeded with the discussion of surgery for different types of glaucoma. He considered four groups of glaucoma which are usually subjected to surgery : Acute congestive glaucoma, malignant glau coma, chronic glaucoma, and congenital glau coma. Acute congestive glaucoma was considered to be the most satisfactory to treat, and operation is the treatment of choice except in unusual cases. It was further advised that the other eye should be given a prophylactic iridectomy. He stated that a short trial of medical treatment (about three to six hours) should be given in a case of acute glaucoma and then surgery should be resorted to.
549
A peripheral iridectomy with a tight wound closure was recommended for all cases which can be controlled medically, or when one can be sure it is the first attack. Wound closure was emphasized to promote speedy formation of the anterior chamber and to prevent converting the glaucoma into a chronic type. Also selection of a suitable area for the iridectomy was mentioned since it had been observed that polycoria in some instances produced troublesome diplopia when the iridectomy was below the upper lid margin, even though the tension was well controlled. Complications and failures he attributed to faulty history and examination, in which chronic glaucoma is mistakenly treated as acute narrow-angle glaucoma, although he added that even in chronic glaucoma periph eral iridectomy works well if the tension is controlled by miotics. The second cause for failure, from the patient's point of view, is injury to the lens by a keratome or iris for ceps, thereby producing a poor visual result. Malignant glaucoma was described as es sentially that glaucoma in which there is a narrow angle, in which the pressure cannot be reduced to normal, and in which one gets virtually no aqueous on making a section or entering the anterior chamber. The iris dia phragm is displaced forward and the eye stays hard even after the anterior chamber has been opened. He pointed out that this poses a real problem to the surgeon as to whether to proceed with cataract extraction at that time, or whether to perform a periph eral iridectomy and see if .he chamber will reform. In case cataract extraction is per formed he re-emphasized the fact that it is desirable, in this type of case, to lose vitreous by incising the hyaloid if vitreous is not lost spontaneously, and added that, in a case in which malignant glaucoma has been known to exist in one eye, a prophylactic peripheral iridectomy in the other eye is highly advis able. In discussing the problem of chronic glau coma, Dr. McDonald pointed out that a
550
SOCIETY PROCEEDINGS
peripheral iridectomy is good only when the tension can be controlled by miotics; other wise, a filtering operation is needed. The relative merits of trephination and iridencleisis were discussed, and it was pointed out that trephination is usually a more difficult operation, the danger of hypotony is greater, iritis occurs more frequently, the bleb is usually larger, and when cataract forms, it comes on more rapidly. Also there is greater chance of late secondary infections than with the iridencleisis. However, with iridencleisis, results are usually not very good when the tension is very high. A late complication of trephination is the possibility of acute hypotony. Dr. McDonald discussed opinions as expressed by Kronfeld regarding the increase of outflow by filtering operations as against the evidence presented by DeVoe that in many cases there is suc cessful surgery with no evidence of filtration by gonioscopy. He felt that, probably, DeVoe had been dealing with a group of narrowangle glaucomas which had been cured by the iridectomy and had no need for fistualization. An extremely large filtering bleb was defi nitely considered an undesirable result, and the speaker suggested that the large bleb usually develops in those cases in which Tenon's capsule has not been sutured at the time of the operation. In congenital glaucoma, the operation of choice was considered to be goniotomy, if the diagnosis is made early. The speaker pointed
out that if goniopuncture is done in conjunc tion with goniotomy, one should be careful not to make the puncture too large for fear of prolapse of the iris. It was also pointed out that, in many congenital glaucoma pa tients, the iris tissue cannot be adequately stripped from the angle and kept back. When cyclodiathermy is used for congenital glau coma, the results may be unpredictable. Discussion.
DR. PAUL
A.
CHANDLER
chided Dr. McDonald for astutely recogniz ing a "misery case" and referring him to Dr. Chandler. He stated that, after five opera tions, the tension was still up. This case was used to illustrate the point that, in many in stances, the technique does not seem to make much difference ; that even though operations seem to go very satisfactorily, and from a technical point of view would seem to have everything in their favor, there is some "X" factor which determines whether the patient will get a satisfactory reduction in tension. He agreed with Dr. McDonald's analysis of DeVoe's series, and considered the patients that were cured without filtration had cases of narrow-angle glaucoma. He stated that in the cases of open-angle glaucoma "no filtra tion—no cure." He agreed that iridectomy should be done if the glaucoma is controlled by drops, and that also if it is the first attack, an iridectomy will work even if the drops have not brought the tension down. David H. Scott, Recorder.