VOL. 70, NO. 2
Ophthalmologica 135:565, 1958. 5. Aronson, S. B., and Shaw, R. : Corneal crys tals in multiple myeloma. Arch. Ophth. 61:541, 1959. 6. Laibson, P. R., and Damiano, V. V.: X-ray and electron diffraction of ocular and bone marrow crystals in para proteinemia. Science 163 :581, 1969. 7. Frazier, P. D., and Wong, V. G. : Cystinosis : Histologie and crystallographic examination of crystals in eye tissues. Arch. Ophth. 80:87, 1968. 8. Wong, V. G., Lietman, P. S., and Seegmiller, J. E. : Alterations of pigment epithelium in cystino sis. Arch. Ophth. 77 :361, 1967. 9. Schneider, J. A., Bradley, K., and Seegmiller, J. E. : Increased cystine in leukocytes from individ uals homozygotic and heterozygotic for cystinosis. Science 157:1321, 1967. 10. Schneider, J. A., Rosenbloom, F. M. Bradley, K. H., and Seegmiller, J. E. : Increased free-cystine
content of fibroblasts cultured from patients with cystinosis. Biochem. Biophys. Res. Commun. 29 : 527, 1967. 11. Patrick, A. D., and Lake, B. D. : Cystinosis: Electron microscopic evidence of lysosomal storage of cystine in lymph node. J. Clin. Path. 21:571, 1968. 12. Wong, V. G., Kuwabara, T., Brubaker, R., Olson, W., Schulman, J., and Seegmiller, J. E. : Intralysosomal cystine crystals in cystinosis. Invest. Ophth. In press. 13. Schulman, J. D., Bradley, K. H., and Seeg miller, J. E. : Cystine, compartmentalization within lysomes in cystinotic leukocytes. Science 166 : 1152, 1969. 14. Holtzapple, P. G., Genel, M., Yakovac, W. C, Hummeler, K., and Segal, S. : The diagnosis of cystinosis by rectal biopsy. New Eng. J. Med. 281:143, 1969.
RELIABILITY O F RADIOACTIVE PHOSPHORUS UPTAKE AFTER OCULAR SURGERY O. D A V I D S O L O M O N , M.D.,
281
DIAGNOSIS OF CYSTINOSIS
J E R O M E A . G A N S , M.D.,
TEST
AND B E N N E T T LEVINE,
M.D.
Cleveland, Ohio T h e radioactive phosphorus test for in traocular tumors has limited usefulness in the postoperative period as reported by sev eral investigators. Solomon, Moses and Eig ner 1 showed that the healing surgical wound behaves like neoplastic tissue in its ability to incorporate radioactive phosphorus and thereby produces false positive results in the postoperative period. Carmichael and Leo pold 2 stated that the uptake test is unreliable for six weeks after surgery, and Terner, Leopold, and Eisenberg 3 suggested waiting eight weeks before using the uptake test. Solomon, Gans and Levine 4 published a study in rabbits showing that the radioactive phosphorus test may be used three weeks af ter surgery without the problem of false pos itives. T h e purpose of the present study was to determine when the radioactive phosphoFrom the Department of Ophthalmology (Drs. Solomon and Gans), and the Department of Medi cine (Dr. Levine), Mount Sinai Hospital, Cleveland, Ohio. Reprint requests to O. David Solomon, M.D., 1020 Huron Road, Cleveland, Ohio 44115.
rus uptake test may* be used reliably after surgery in man. MATERIALS AND METHODS
Sixty-six eyes in 64 ambulatory patients who had various types of ocular surgery were given a n intravenous injection of 0.5 millicuries of radioactive phosphorus ( 3 2 P ) and tested at various periods after surgery. Six teen eyes were tested six weeks after sur gery, and 34 were tested 10 weeks after sur gery. I n the first group of 16 eyes, 10 had had cataract procedures, and there was one iridectomy, two strabismus procedures, one retinopexy, one iridocapsulectomy, and one photocoagulation of the iris. A m o n g the 16 eyes tested eight weeks after surgery, 15 procedures w e r e for cataracts a n d one was a photocoagulation of the iris. Of the 34 eyes tested 10 weeks after surgery, surgery was performed for cataracts in 29, two had reti nal detachments, two had peripheral iridectomies and one had strabismus surgery. None of the eyes in any group had been previously tested with the radioactive phosphorus u p -
AMERICAN JOURNAL OF OPHTHALMOLOGY
282
TABLE 1 UPTAKE OF 32P IN SURGICAL WOUNDS SIX WEEKS AFTER SURGERY Surgery
Clinical Remarks
% Uptake*
Cataract Secondary cataract Cataract Iridectomy Cataract Cataract R & R (medial rectus) R & R (lateral rectus) Photocoagulation of iris Cataract Cataract Cataract Iridocapsulectomy Cataract Retinopexy Cataract
164 129 145 110 172 154 205 161 96
Highly inflamed eye
Still injected Still injected
148 191 128 110 100 182 126
take test. Using a miniature Geiger tube* attached to the standard decade sealer, radio active counts were made 24 hours after in jection. Counts were made over the operated area and over the comparable area of the other eye. In the case of individuals with only one eye, or whose other eye had also had re cent surgery, the opposite pole of the same eye was counted. For example, the operated area of a cataract is the upper limbus, so the opposite pole would be the lower limbus. RESULTS
The radioactive phosphorus uptake test is unreliable in the immediate postoperative pe riod as a means of ascertaining the presence or absence of intraocular tumor. This is be cause for at least ten weeks after surgery the operated eye continues to take up the radio active phosphorus at a greater rate than unoperated tissue. It is interesting to note that after photocoagulation of the iris had been performed, these eyes did not show false positive uptakes. The extent of postoperative inflammatory reaction did not seem to influ ence the degree of uptake of radioactive phosphorus. Most of the cataracts showed TABLE 2 UPTAKE OF M P IN SURGICAL WOUNDS EIGHT WEEKS AFTER SURGERY Surgery
The percentages of uptake listed in Table 1 were calculated by comparing the radioac tive counts over the operated site with the counts over the comparable area of the other eye according to the following formula : Counts over operated site X 100 Counts over comparable area of the other eye = percentage of uptake
A reading of 130% or more is usually con sidered positive for this uptake test. In two Electronic
eyes that had had cataract procedures, and in one patient who had had bilateral iridectomy, the opposite pole of the same eye was used as the control area. Tables 1, 2, and 3 list the results for all eyes tested. In every group false positives occurred. In the group tested six weeks after surgery, nine of the 16 eyes showed false positives (56%). Ten of 16 eyes tested were positive in the group tested eight weeks after surgery (63%) and six were positive in the group tested 10 weeks after surgery ( 18% ). DISCUSSION
* Average uptake 145%
* Type 224, Anton Brooklyn, New York.
AUGUST, 1970
Laboratories,
Cataract Cataract Cataract Photocoagulation of iris Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract Cataract
' Average uptake 138%
% Uptake* 103 136 136 119 117 131 191 107 102 163 91 178 147 138 143 184
VOL. 70, NO. 2
283
RADIOACTIVITY TEST AFTER SURGERY
little or no inflammatory reaction, clinically, but despite the quietness of these eyes, most of the positive uptakes were found in this group. Furthermore, in the group tested six weeks after surgery, there was one eye that was still moderately inflamed at the time of the uptake test after an extracapsular cata ract extraction. This particular eye did not
TABLE 4 COMPARISON OF 130% CRITERION WITH 200% CRITERION
(Percentage of Positive Uptakes)
Period Elapsing after Surgery Six weeks Eight weeks Ten weeks
130% Criterion 56 63 18
200% Criterion 6 0 0
TABLE 3 UPTAKE OF 32P IN SURGICAL WOUND 10 WEEKS AFTER SURGERY
Surgery
% Uptake*
Cataract Cataract Cataract Cataract Cataract
93 109 127 98 121
Bilateral peripheral iridectomies Cataract Cataract Cataract
110 120 107 109 107
Cataract Cataract Cataract Cataract Cataract
92 90 104 128 92
Cataract Cataract Cataract Cataract Cataract
102 118 136 113 158
Cataract Cataract Cataract Retinal surgery Strabismus
108 124 101 163 137
Cataract Retina Cataract Cataract Cataract
105 126 146 100 87
Cataract Cataract
165 117
Cataract Cataract
81 96
* Average uptake 115%
Clinical Remarks
Opposite pole used for comparison
show a positive uptake. Yet all of the proce dures involving surgery on the extraocular muscles—the strabismus procedure, and the two retinal detachment operations—pro duced positive uptakes. In the group tested 10 weeks after surgery, two of the five posi tive uptakes occurred after surgery of the extraocular muscles. In reviewing the records of positive up takes that were confirmed pathologically by our isotope laboratory, it was found that in every one of these cases the uptake was 200% or greater. The cases reviewed by Terner, Leopold and Eisenberg 3 also showed uptakes of over 200% for intraocular malig nancies. Because of these findings, it occur red to us to change the criteria of positivity from 130 to 200% (Table 4). On this ba sis, there was only one positive uptake in the six-week group and no positives in the eightweek or 10-week groups. Therefore, we rec ommend (1) that the criterion for positive uptake test be changed to 200% (100% above normal) in the postoperative period, and (2) that the uptake test should be per formed no sooner than eight weeks after ocular surgery. SUMMARY
Opposite pole used because of recent surgery in other eye
When the radioactive phosphorus uptake test was done on 66 eyes six to 10 weeks af ter ocular surgery, positive uptake occurred throughout the 10 weeks. This test for ma lignancy is thus invalid in the postoperative period. However, the test is useful when done eight weeks after surgery and the crite rion for a positive response is raised to 200% from 130%.
284
AMERICAN JOURNAL OF OPHTHALMOLOGY
Using the higher percentage of uptake as the criterion for positivity does not detract from the value of this test for the diagnosis of intraocular neoplasms, because if a neo plasm is the cause of a positive uptake, it always exceeds 200%. REFERENCES
1. Solomon, O. D., Moses, L., and Eigner, E. H. :
AUGUST, 1970
Validity of the radioactive phosphorus uptake test following ocular surgery. Am. J. Ophth. 55:1237, 1963. 2. Carmichael, P. L., and Leopold, I. H. : The ra dioactive phosphorus test in ophthalmology. Am. J. Ophth. 49:484, 1960. 3. Terner, I. S., Leopold, I. H., and Eisenberg, I. J. : The radioactive phosphorus S P uptake test in ophthalmology. Arch. Ophth. 55 :S2, 1956. 4. Solomon, O. D., Gans, J. A., and Levine, B. : Uptake of radioactive phosphorus in surgical wounds of rabbits. Am. J. Ophth. 66:537, 1968.
M E T H O D FOR P E R M A N E N T IN SITU DISPLAY O F R E T I N A L N E R V E FIBER LAYER ANATOMY ALAN M. LATIES,
M.D.
Philadelphia, Pennsylvania
Although the anatomy of the nerve fiber layer of the retina has long attracted the at tention of researchers and clinicians, its dis play has been attended by considerable tech nical difficulties. In large part these difficul ties stem from the necessity of making whole flat mounts of the normally spherical retina and from the vagaries of méthylène blue staining—the most commonly used his tologie stain for this purpose. In the ocular fundus of man, on occasion, the relationship of the sheaves of ganglion cell axons—the fascicles of the nerve fiber layer—can be accurately visualized as a result of aberrant myelinization of the axons beyond the lam ina cribrosa onto the face of the retina. In this paper a method for the permanent in situ display of the nerve layer anatomy in primate eyes is presented in which the form From the Department of Ophthalmology, Univer sity of Pennsylvania Medical School, Philadelphia, Pennsylvania. This study was supported by USPHS Research Grant 2-R01-NB-06092-04, and by a grant from the National Society for the Pre vention of Blindness, Inc., made possible by a con tribution from the Adler Foundation, Inc., and by a Research Professorship from Research to Prevent Blindness, Inc. Reprint requests to Alan M. Laties, M.D., De partment of Ophthalmology, University of Pennsyl vania Medical School, 421 Johnson Pavilion, 36th & Hamilton Walk, Philadelphia, Pennsylvania 19104.
of the retina is unchanged and in which the appearance of aberrant myelinization, as seen with the ophthalmoscope, is simulated. METHOD
Eyes from three owl monkeys (Aotus trivirgatus) and two squirrel monkeys (Saimiri sciurea) were enuclated under deep (40 mg/kg) intraperitoneal pentobarbital anesthesia. In all instances, the eyes were im mediately quenched in isopentane cooled to — 130°C in a liquid nitrogen bath and then freeze-dried for seven days at —3S°C. Once dry, the retina is extremely friable. The dried eyes were bisected coronally with care and then gently placed in a vacuum-dessicator over 1 g of osmium tetroxide. After drawing a vacuum of 10 pounds per square inch, the dessicator was sealed and the eyes were ex posed to osmium vapor for three hours (one owl monkey) or 24 hours (the other four animals). Thereafter the eyes were removed and embedded in a clear plastic (Epon, Shell Chemical Co.). After curing for two days at 60° C, the hardened blocks were cut in a plane coronal to the retinal face and polished. Retinal topography was then viewed through the block surface with a dissecting microscope.