- Email: [email protected]
Reflecting Mirror*
NOTES, CASES, INSTRUMENTS
328
lar but an opacity either of the face of the vitreous or a posterior capsule of the lens presented itself. It was difficult to be certain. Needling was necessary. This method is not being advocated at this time as the best way to do a cataract extrac tion, since it has been used on only 12 oc casions. The purpose at this time is to report that it is mechanically possible to remove a cataract by irrigation after the zonule has been dissolved by alpha chymotrypsin. This can be accomplished without loss of vitreous. The lens undoubtedly in some cases could be delivered by external pressure alone, without any irrigation. W e are certain, however, that irrigation is a valuable mechanical aid.
CONCLUSION
This is a preliminary report to demon strate that a cataract can be extracted by ir rigation after using alpha chymotrypsin to dissolve the zonule. It is emphasized at this time that a complete iridectomy be done in all cases. Also, a blunt needle should be used for the introduction of the alpha chymotryp sin. A spoon for external pressure rather than a hook is also recommended. 319 South 16th Street (2). FOOTNOTE
After this work was started, it was noted that K. Hruby advocated simple expression of the lens af ter zonulysis. (Hruby, K. : Expression of cataract after zonulysis with trypsin. Klin. Monatsbl. f. Augenh, 134:527-531, 1959.)
REFERENCES
1. Verhoeff, F. H.: A simple and safe method for removing a cataract dislocated into fluid vitreous. Am. J. Ophth., 25:725, 1942. 2. Vail, D.: Symposium cataract extraction: Intracapsular extraction: mechanics, technique, variations. Tr. Am. Acad. Ophth., 58:367-370 (May-June) 1954. 3. : The zonule of Zinn and ligament of Wieger (Doyne Memorial Lecture, 1957). Tr. Ophth. Soc. U. Kingdom, 77:441-449, 1957. 4. : Zonule membrane and cataract extraction. Am. J. Ophth., 48:405, 1952. 5. Reese, A., and Wadsworth, J.: The adhesion of the lens capsule to the hyaloid membrane and its relation to intracapsular extraction. Tr. Am. Ophth. Soc, 54:709-728, 1956. 6. Barraquer, J.: Enzymatic zonulysis: Contribution to surgery of the lens. 65th Cong. French Ophth. Soc, Paris, May, 1958.
REFLECTING
MIRROR*
FOR T H E SCHEPENS
BINOCULAR
OPHTHALMOSCOPE E N R I Q U E MALBRAN,
M.D.
Buenos Aires, Argentina The indirect binocular ophthalmoscopy obtained through the ophthalmoscope in vented by Schepens is one of the greatest advances made during recent years in ophthalmologic practice. I shall not comment here on the important advantages of this in genious method; I only wish to communi cate the promising possibilities which are * This instrument is manufactured by the Sais Laboratories, Viamonte 2182, Buenos Aires, Argen tina.
offered by a new apparatus which is called a "reflecting mirror." E v e r y ophthalmologist who has used the Schepens indirect binocular ophthalmoscope in a sufficient number of cases to be able to adapt himself to its handling knows the ini tial difficulties in learning how to use it, as well as the impossibility of showing to those who are not familiar with it, or are incredu lous, the enormous advantages it brings for a better examination of the topography of the fundus, especially for retinal detachment diagnosis and surgery. Recently, the firm of Keeler in England announced the creation of a "reflecting plate" for a second observer, adapted to the indirect binocular ophthalmoscope which they manufacture, the Fison model with
NOTES, CASES, INSTRUMENTS which we are already familiar. On not finding any description of this new system in the ophthalmologic literature, I decided to construct, with the invaluable collaboration of Mr. Juan Sais (Sais Lab oratories), an apparatus with which the same possibilities could be obtained. After a short period of necessary tests, we were able to make the new accessory for the ophthal moscope manufactured by the American Optical Company. The apparatus consists of a dark plastic adapter which may be added at will to the original ophthalmoscope and a mirror, 20 by 40 mm. in size, made of white Kraun lenses with a one-way vision, placed at an inclina tion of 45 degrees to the principal line of observation (figs. 1 and 2 ) . This mirror absorbs 60 percent of sunlight and, when actually in use, transmits 40 percent of the beam to the principal observer and reflects 60 percent to the second observer, placed laterally at a right angle to the former. The picture which this second observer receives is very clear. It is inverted vertically but maintains the normal directions horizontally. That is to say that, in contrast to what the main observer sees, the picture in the mirror shows the lower parts of the fundus in the upper part of the mirror and vice versa,
Fig. 1 (Malbran). The reflecting mirror.
329
Fig. 2 (Malbran). Apparatus assembled. while what is to the right or left of the ob server in the fundus remains in the same position in the mirror. The decrease in luminosity caused by the absorbing faculty of the mirror does not create observation difficulties because the illumination power of the Schepens ophthalmoscope is more than sufficient to overcome these inconveniences. It is unnecessary to stress the innumer able advantages that this system offers for teaching, consultations with other colleagues, observation for assistants during the opera tion, and so forth. A transparent plastic arm has also been added which enables one to adapt a Minox camera with which it is hoped to obtain pho tographs of the fundus and the results of which will be published together with our present tests on the filming of the fundus. I believe that this apparatus may be one more way of promulgating the advantages of indirect binocular ophthalmoscopy. In our country, Dr. Escariz has recently made known the adaptation of the "Wesely relascope" for ophthalmoscopy (Arch. Oftal. Buenos Aires, 33: 90-95 [June]
NOTES, CASES, INSTRUMENTS
330
1959). This instrument has two lateral win dows for observation which are used for the same purpose as the reflecting mirror just described. Parera 94.
MALIGNANT MELANOMA OF CHOROID REPORT OF A CASE DISCOVERED AFTER EVISCERATION BYRON S M I T H ,
M.D.
AND DAVID B. SOLL,
M.D.
New York The purpose of this report is to record a case in which the diagnosis of malignant melanoma was established by histologie study of the contents of the eviscerated globe. C A S E REPORT
N. R., a Caucasian man, aged 64 years, noticed the gradual onset of diminished vision of the left eye in April, 19S8. One month later, he was ad vised by an ophthalmologist to use drops in the left eye for the treatment of glaucoma. In spite of the regular use of the prescribed medication, how ever, the visual acuity of the left eye continued to decrease and the eye became congested and pain ful. The patient was first seen by us on June 1, 1958. The vision in the right eye was 20/70, correctible to 20/20. The right eye exhibited no internal or external abnormalities, except for a few small, pigmented areas on the iris. The patient advised us that these spots had not changed in size, shape, or color. The visual field, gonioscopy, and tension of the right eye were normal. The cornea of the left eye was steamy in ap pearance. The conjunctiva and episcleral tissues were congested. The left pupil was partially di lated and fixed. The iris vessels were dilated. Nu merous keratic precipitates were scattered over the lower half of the corneal endothelium. Density and edema of the cornea prevented our determining whether there were any cells in the anterior cham ber. The anterior chamber was so shallow that gonioscopy was nonrevealing. The lens was edematous and opaque. The ocular tension was 60 mm. Hg (Schi^tz). Anterior transillumination failed to reveal any variation in density. A diagnosis of absolute glaucoma of unknown cause was made and the patient was admitted for treatment and observation. Physical examination,
laboratory studies and a series of X-ray studies provided no additional diagnostic information. Ra dioactive-phosphorus studies were not carried out at this time. Antiglaucoma medication failed to normalize the ocular tension or eradicate the pain. In view of the failure of medical treatment and in consideration of statistical evidence that four to 11 percent of blind eyes with opaque media con tain malignant melanomas, histologie analysis of the ocular contents was advised. Under general anesthesia on June 4, 19S8, an in cision was made through the conjunctiva and sclera, parallel to the equator of the globe in the upper nasal quadrant. A long cyclodialysis spatula was inserted to free the uveal tract completely from its scierai attachments. The incision was then extended parallel to the equator from' the 3-o'clock to 9-o'clock positions, anterior to the insertion of the rectus muscles. The uveal tract and its contents were removed in one piece and sent to the labora tory for immediate study. After thorough curettage of the internal surface of the sciera, an 18-mm. plastic sphere was inserted. The sclera was closed with a continuous suture of 4-0 chromic catgut. Twenty-four hours later the laboratory reported that the globe contents exhibited a dense, dark, firm mass histologically characteristic of malignant melanoma. The tumor was of the mixed-cell type, the predominant cells being spindle B and epithelioid cells, (figs. 1 and 2). Forty-eight hours after evisceration, enucleation of the scierai shell was performed under general anesthesia. The conjunctiva, including the wound, was removed together with the sclera. No implant was used because it was felt that a more accurate postoperative follow-up would be possible in the absence of a surgically placed foreign body. Ten on's capsule was closed with 4-0 chromic catgut su tures. The conjunctiva was closed with 6-0 chromic catgut sutures. The postoperative course was un eventful. The patient was discharged from the hos pital on the seventh postoperative day. Histologie study of the optic nerve and Ten on's capsule showed no evidence of neoplastic dis ease. The scierai shell showed no microscopic evi dence of malignant melanoma in the sections ex amined (fig. 3). Three weeks after surgery, an artificial eye was fitted to the socket. Repeated examinations have disclosed no evidence of recurrent disease. Radio active-phosphorus (P32) uptake studies done on November S, 19S8, showed 24 percent the first hour, 27.3 percent in 24 hours, and 28.2 percent in 48 hours. The series of X-ray films taken on the same date revealed no neoplastic growth. The lab oratory considered the report of the radioactivephosphorus uptake studies essentially negative. A second radioactive phosphorus study in July, 1959, was also reported as negative for the superficial sites studied. Melanin tests of the urine taken dur ing November, 1958, and July, 1959, were negative. The patient was last seen on July 28, 1959, and at that time there was no evidence of recurrence (fig. 4).
328
lar but an opacity either of the face of the vitreous or a posterior capsule of the lens presented itself. It was difficult to be certain. Needling was necessary. This method is not being advocated at this time as the best way to do a cataract extrac tion, since it has been used on only 12 oc casions. The purpose at this time is to report that it is mechanically possible to remove a cataract by irrigation after the zonule has been dissolved by alpha chymotrypsin. This can be accomplished without loss of vitreous. The lens undoubtedly in some cases could be delivered by external pressure alone, without any irrigation. W e are certain, however, that irrigation is a valuable mechanical aid.
CONCLUSION
This is a preliminary report to demon strate that a cataract can be extracted by ir rigation after using alpha chymotrypsin to dissolve the zonule. It is emphasized at this time that a complete iridectomy be done in all cases. Also, a blunt needle should be used for the introduction of the alpha chymotryp sin. A spoon for external pressure rather than a hook is also recommended. 319 South 16th Street (2). FOOTNOTE
After this work was started, it was noted that K. Hruby advocated simple expression of the lens af ter zonulysis. (Hruby, K. : Expression of cataract after zonulysis with trypsin. Klin. Monatsbl. f. Augenh, 134:527-531, 1959.)
REFERENCES
1. Verhoeff, F. H.: A simple and safe method for removing a cataract dislocated into fluid vitreous. Am. J. Ophth., 25:725, 1942. 2. Vail, D.: Symposium cataract extraction: Intracapsular extraction: mechanics, technique, variations. Tr. Am. Acad. Ophth., 58:367-370 (May-June) 1954. 3. : The zonule of Zinn and ligament of Wieger (Doyne Memorial Lecture, 1957). Tr. Ophth. Soc. U. Kingdom, 77:441-449, 1957. 4. : Zonule membrane and cataract extraction. Am. J. Ophth., 48:405, 1952. 5. Reese, A., and Wadsworth, J.: The adhesion of the lens capsule to the hyaloid membrane and its relation to intracapsular extraction. Tr. Am. Ophth. Soc, 54:709-728, 1956. 6. Barraquer, J.: Enzymatic zonulysis: Contribution to surgery of the lens. 65th Cong. French Ophth. Soc, Paris, May, 1958.
REFLECTING
MIRROR*
FOR T H E SCHEPENS
BINOCULAR
OPHTHALMOSCOPE E N R I Q U E MALBRAN,
M.D.
Buenos Aires, Argentina The indirect binocular ophthalmoscopy obtained through the ophthalmoscope in vented by Schepens is one of the greatest advances made during recent years in ophthalmologic practice. I shall not comment here on the important advantages of this in genious method; I only wish to communi cate the promising possibilities which are * This instrument is manufactured by the Sais Laboratories, Viamonte 2182, Buenos Aires, Argen tina.
offered by a new apparatus which is called a "reflecting mirror." E v e r y ophthalmologist who has used the Schepens indirect binocular ophthalmoscope in a sufficient number of cases to be able to adapt himself to its handling knows the ini tial difficulties in learning how to use it, as well as the impossibility of showing to those who are not familiar with it, or are incredu lous, the enormous advantages it brings for a better examination of the topography of the fundus, especially for retinal detachment diagnosis and surgery. Recently, the firm of Keeler in England announced the creation of a "reflecting plate" for a second observer, adapted to the indirect binocular ophthalmoscope which they manufacture, the Fison model with
NOTES, CASES, INSTRUMENTS which we are already familiar. On not finding any description of this new system in the ophthalmologic literature, I decided to construct, with the invaluable collaboration of Mr. Juan Sais (Sais Lab oratories), an apparatus with which the same possibilities could be obtained. After a short period of necessary tests, we were able to make the new accessory for the ophthal moscope manufactured by the American Optical Company. The apparatus consists of a dark plastic adapter which may be added at will to the original ophthalmoscope and a mirror, 20 by 40 mm. in size, made of white Kraun lenses with a one-way vision, placed at an inclina tion of 45 degrees to the principal line of observation (figs. 1 and 2 ) . This mirror absorbs 60 percent of sunlight and, when actually in use, transmits 40 percent of the beam to the principal observer and reflects 60 percent to the second observer, placed laterally at a right angle to the former. The picture which this second observer receives is very clear. It is inverted vertically but maintains the normal directions horizontally. That is to say that, in contrast to what the main observer sees, the picture in the mirror shows the lower parts of the fundus in the upper part of the mirror and vice versa,
Fig. 1 (Malbran). The reflecting mirror.
329
Fig. 2 (Malbran). Apparatus assembled. while what is to the right or left of the ob server in the fundus remains in the same position in the mirror. The decrease in luminosity caused by the absorbing faculty of the mirror does not create observation difficulties because the illumination power of the Schepens ophthalmoscope is more than sufficient to overcome these inconveniences. It is unnecessary to stress the innumer able advantages that this system offers for teaching, consultations with other colleagues, observation for assistants during the opera tion, and so forth. A transparent plastic arm has also been added which enables one to adapt a Minox camera with which it is hoped to obtain pho tographs of the fundus and the results of which will be published together with our present tests on the filming of the fundus. I believe that this apparatus may be one more way of promulgating the advantages of indirect binocular ophthalmoscopy. In our country, Dr. Escariz has recently made known the adaptation of the "Wesely relascope" for ophthalmoscopy (Arch. Oftal. Buenos Aires, 33: 90-95 [June]
NOTES, CASES, INSTRUMENTS
330
1959). This instrument has two lateral win dows for observation which are used for the same purpose as the reflecting mirror just described. Parera 94.
MALIGNANT MELANOMA OF CHOROID REPORT OF A CASE DISCOVERED AFTER EVISCERATION BYRON S M I T H ,
M.D.
AND DAVID B. SOLL,
M.D.
New York The purpose of this report is to record a case in which the diagnosis of malignant melanoma was established by histologie study of the contents of the eviscerated globe. C A S E REPORT
N. R., a Caucasian man, aged 64 years, noticed the gradual onset of diminished vision of the left eye in April, 19S8. One month later, he was ad vised by an ophthalmologist to use drops in the left eye for the treatment of glaucoma. In spite of the regular use of the prescribed medication, how ever, the visual acuity of the left eye continued to decrease and the eye became congested and pain ful. The patient was first seen by us on June 1, 1958. The vision in the right eye was 20/70, correctible to 20/20. The right eye exhibited no internal or external abnormalities, except for a few small, pigmented areas on the iris. The patient advised us that these spots had not changed in size, shape, or color. The visual field, gonioscopy, and tension of the right eye were normal. The cornea of the left eye was steamy in ap pearance. The conjunctiva and episcleral tissues were congested. The left pupil was partially di lated and fixed. The iris vessels were dilated. Nu merous keratic precipitates were scattered over the lower half of the corneal endothelium. Density and edema of the cornea prevented our determining whether there were any cells in the anterior cham ber. The anterior chamber was so shallow that gonioscopy was nonrevealing. The lens was edematous and opaque. The ocular tension was 60 mm. Hg (Schi^tz). Anterior transillumination failed to reveal any variation in density. A diagnosis of absolute glaucoma of unknown cause was made and the patient was admitted for treatment and observation. Physical examination,
laboratory studies and a series of X-ray studies provided no additional diagnostic information. Ra dioactive-phosphorus studies were not carried out at this time. Antiglaucoma medication failed to normalize the ocular tension or eradicate the pain. In view of the failure of medical treatment and in consideration of statistical evidence that four to 11 percent of blind eyes with opaque media con tain malignant melanomas, histologie analysis of the ocular contents was advised. Under general anesthesia on June 4, 19S8, an in cision was made through the conjunctiva and sclera, parallel to the equator of the globe in the upper nasal quadrant. A long cyclodialysis spatula was inserted to free the uveal tract completely from its scierai attachments. The incision was then extended parallel to the equator from' the 3-o'clock to 9-o'clock positions, anterior to the insertion of the rectus muscles. The uveal tract and its contents were removed in one piece and sent to the labora tory for immediate study. After thorough curettage of the internal surface of the sciera, an 18-mm. plastic sphere was inserted. The sclera was closed with a continuous suture of 4-0 chromic catgut. Twenty-four hours later the laboratory reported that the globe contents exhibited a dense, dark, firm mass histologically characteristic of malignant melanoma. The tumor was of the mixed-cell type, the predominant cells being spindle B and epithelioid cells, (figs. 1 and 2). Forty-eight hours after evisceration, enucleation of the scierai shell was performed under general anesthesia. The conjunctiva, including the wound, was removed together with the sclera. No implant was used because it was felt that a more accurate postoperative follow-up would be possible in the absence of a surgically placed foreign body. Ten on's capsule was closed with 4-0 chromic catgut su tures. The conjunctiva was closed with 6-0 chromic catgut sutures. The postoperative course was un eventful. The patient was discharged from the hos pital on the seventh postoperative day. Histologie study of the optic nerve and Ten on's capsule showed no evidence of neoplastic dis ease. The scierai shell showed no microscopic evi dence of malignant melanoma in the sections ex amined (fig. 3). Three weeks after surgery, an artificial eye was fitted to the socket. Repeated examinations have disclosed no evidence of recurrent disease. Radio active-phosphorus (P32) uptake studies done on November S, 19S8, showed 24 percent the first hour, 27.3 percent in 24 hours, and 28.2 percent in 48 hours. The series of X-ray films taken on the same date revealed no neoplastic growth. The lab oratory considered the report of the radioactivephosphorus uptake studies essentially negative. A second radioactive phosphorus study in July, 1959, was also reported as negative for the superficial sites studied. Melanin tests of the urine taken dur ing November, 1958, and July, 1959, were negative. The patient was last seen on July 28, 1959, and at that time there was no evidence of recurrence (fig. 4).