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Sarcoma of Choroid
SARCOMA
O F
CHOROID.
HOWARD F . HANSELL, M . D . , PHILADELPHIA, PA. Five cases are here reported in abstract; o n e of them w a s u n d e r o b s e r v a t i o n ten years before evidence of the sarcoma was noticed, a n d there has been no recurrence in nine years following enucleation. The important points o f diagnosis and the question o f metastasis are discussed. Read before the Section on Ophthalmology o f the College o f Physicians o f Phila delphia, January, 1924,
The diagnosis o f the presence o f tumor o f the choroid presents no especial difficulty. T h e patient complains only of partial loss o f vision and his attention is attracted to his eyes solely f o r this reason. H e has no pain and singularly no photopsia. T h e eye is not congested and its appearances are unaltered. With the ophthalmoscope the detached retina, fixed over most o f its extent if not en tirely, seen with convex lenses o f vary ing strength because o f the diflferent levels o f the tumor, with the transillumihator, when the growth is not limited to the posterior portion o f the fundus; with the perimeter which outlines graph ically the extent o f the invasion, the diagnosis is made. Case 1. M r . B., aged 41, came un der my care in November, 1904, for the relief o f accommodative asthenopia. T h e media were clear and the eye grounds normal. In 1908, the eyes were healthy and vision, with correcting glass, o f full acuity. In 1913 no change except a slight increase in hyperopia. In 1915, V . o f L . was reduced from 2 0 / 1 5 to 2 0 / 2 0 . T h e retina over a small area be low was detached. The diagnosis o f choroidal tumor was made. Enuclea tion advised and refused. S i x months later vision was reduced to perception o f light in the lower field, A yellow vas cular growth was easily seen occupying a large part o f the vitreous. Tension normal. O n December 27, 1915, the eye was enucleated and a gold sphere im planted in Tenon's capsule. Nearly 9 years have elapsed and he is in appar ently perfect health. Pathologic exam ination : Spindle celled sarcoma. Case 2. (Reported in the Trans, A m . Oph. S o c . 1919.) Mrs. P., aged 39, loss of vision in left eye during past few weeks; no pain, no inflammation. T e n sion normal. Diagnosis, choroidal tumor. T h e ball was enucleated and a gold sphere implanted in Tenon's cap 359
sule. Pathologic examination showed the growth to be melanotic spindle celled sarcoma. Case 3. M r . P., aged 69, consulted me October 15, 1923, stating that for 6 months V . o f R . eye had been declining and n o w equals hand movements on nasal side. L . V . with correcting glass o f full acuity. N o pain. Health g o o d . Large round tumor involving the entire nasal fundus readily seen with ophthal moscope. Dense shadow in transillumi nation. T h e eye was enucleated the fol lowing day. Path, r e p o r t : Spindle celled sarcoma. Case 4. D . age 40. T u m o r project ing forward from the nasal section o f the choroid concealing the disc f r o m ophthalmoscopic view. S h a d o w cast by transillumination. N o light perception on large part o f the temporal field. T e n sion normal. N o evidence of metastasis. Case 5. M r s . H . T h e only symptom was decline in vision. T h e entire lower third o f retina o f left eye was detached. Tension normal. N o pain. Enucleation with implantation o f gold sphere. Path ologic examination; Melanotic sarcoma. T h e t w o points o f especial interest in connection with these and all cases c f choroidal malignant growth are 1st, the tension, and 2nd, metastasis. T h e first point was discussed in the paper above referred to. T h e writer has found no reason to m o d i f y the view there e x pressed, namely that the tension o f the eyeball is not raised until the crystal line lens is pushed forward, the anterior chamber annihilated and the angle o f the anterior chamber choked with iris tissue. T h e only plausible explanation is that the vitreous humor is absorbed as the tumor g r o w s and the normal relation be tween intraocular secretion and excre tion is not disturbed. Plus tension there fore is not a diagnostic sign o f the pres ence o f intraocular tumor per se. O n the contrary hypotony may be present.
360
H O W A R D F. H A N S E L L
Franz, ( K l i n . Monats, f. A u g . V . 64. 1920) describes 3 cases all o f which were tumors affecting the ciliary body. H e says the hypotony may be due to the resulting decrease in the secretion of the aqueous. L. M . Francis ( T r a n s , .-^mer. O p h . S o c . 1920) reports a case o f choroidal melanosarcoma in which the tension taken at four different times showed a steady decrease from 20 m m . to 5 mm. during 2Υι years. Heymans, ( A r c h . Ophthal. V . 38, 1921) showed 12 cases o f which four had hypotension, two normal tension, and six plus tension. N o definite relation was observed be tween the tension and the size or location of the t u m o r ; but in all with hyperten sion the filtration angle was m o r e o r less completely effaced. 2. Metastasis. T h e p o i n t is an i m portant o n e and unfortunately w e have few facts b y w h i c h w e m a y b e g u i d e d in g i v i n g an o p i n i o n as t o the origin of the original disease. T h e m e a n s of transmission o f the g e r m s o r t o x i n s o r cells are the b l o o d streams or the l y m p h streams o r b o t h . M a n y cases are recorded of the metastasis from other organs o f the body to the eye and in one recent instance from one eye to the other. Doesschat ( A . J. O . V . 4, 1921) reported the case o f a woman w h o had been operated on six years before for melanosarcoma o f the mamma. Three years later both eyes contained choroidal tumors. A t postmortem a large tumor was found in the left eye and five separate tumors in the retina o f the right eye, m i x e d leucosarcoma and melanosarcoma. This is stated to be an instance o f metastasis from the breast to the e y e s and from the left to the right e y e . A n e x a m p l e of metastasis from the e y e to the liver is the case o f Velhagen ( K l i n . Monats f. Augenh. V . 64, 1 9 2 0 ) . A f t e r enucleation the e y e s h o w e d t w o sar c o m a t a , the larger o n e c o m p o s e d of small, round cells probably secondary to the other. T h e patient died after eight m o n t h s , of metastasis to the liver. Instances of metastasis are c o m m o n in the literature. If w e admit metastasis from the liver to the e y e it is l o g i c a l to assume metastasis from
the e y e to the liver. M y o w n o p i n i o n , h o w e v e r , b a s e d o n m y experience, is that the f o r m e r is far m o r e c o m m o n , and that in s o m e in w h i c h it is stated that the c h o r o i d w a s the site o f the original tumor, I am inclined to b e l i e v e that the cells w e r e inplanted first in s o m e o t h e r o r g a n and that this earliest collection was undiscovered. Post mortem examinations depended on to demonstrate multiple tumors, d o not p r o v e that metastasis p r o c e e d e d from the e y e . In o r d e r to d e c i d e the q u e s tion, thoro analytical tests must be m a d e of as m a n y o f the b o d i l y secre tions and o r g a n s as m a y be available. T h e question is o n e of a c a d e m i c rather than o f practical interest b e c a u s e it is the usual c u s t o m t o practice early enu cleation after a p o s i t i v e d i a g n o s i s o f c h o r o i d a l t u m o r s that are p r e s u m e d not to b e syphilitic. A s stated in m y paper previously referred to, early enu cleation c a n n o t prevent metastasis b e cause a b s o r p t i o n and transference o f t u m o r cells m a y take p l a c e at any time after the cells have appeared in the c h o r o i d . E a r l y enucleation is r e c o m m e n d e d to prevent pain, and i n v o l v m e n t of the other orbital tissues and to rid the b o d y of a malignant g r o w t h . In c o n c l u s i o n , I desire to q u o t e a few passages from the splendid treatise of E w i n g o n N e o p l a s t i c D i s e a s e w h i c h , while n o t c o n t r i b u t i n g to o u r k n o w l e d g e of metastasis from the c h o r o i d to other organs, are of interest. H e says the rather c o m m o n o c c u r r e n c e of t w o or m o r e t u m o r s in different o r g a n s of the s a m e subject s u g g e s t n o t h i n g m o r e than the accidental c o i n c i d e n c e in several o r g a n s of the general e t i o l o g i c factors in the genesis o f t u m o r s . M e tastasis is accomplished thru the lym phatics either thru "continuous per meation" o r the development o f a secondary growth at the end o f a chain of c a n c e r cells filling the d e e p l y m phatics or thru "cell emboli" lodging at diflferent points in a l y m p h a t i c chain. It m a y g r o w in b o t h directions and after a time fill the l y m p h a t i c c o m pletely. T h e c o m p a r a t i v e i m m u n i t y of l y m p h a t i c s against invasion of s a r c o m a cells is p r o b a b l y t o b e explained chiefly
SAHíOOMA O F C H O R O I D
b y the greater local fixation o f s a r c o m a cells as c o m p a r e d w i t h the m o b i l e and s o m e t i m e s a m e b o i d c a n c e r cell. T h e b l o o d vessels are the chief chan nel o f the extension of s a r c o m a . M e t astasis is o b s e r v e d in the a d v a n c e d stages o f m o s t s a r c o m a s and it is
361
characteristic of the disease that, w i t h rare e x c e p t i o n s , e m b o l i c cells travel thru the blood vessels. T h e metas tasis often o c c u r s m u c h earlier than is g e n e r a l l y c o n c e i v e d and this fact adds to the g r a v i t y o f the p r o g n o s i s after surgical operations.
M U S C L E R E T R O P L A C E M E N T IN T H E C O R R E C T I O N O F S Q U I N T . SIMPLIFIED TECHNIC.
R E P O R T O F CASES A N D R E S U L T S . *
S I G M U N D A . AGATSTON, M . D . N E W YORK, N . Y . T h e operation here described seeks to secure exact results by ensuring the adhesion o f the tenotomized tendon to a definite selected place o n the sclera. T h e special technic for accomplishing this is described and tabulated details regarding fifty-five cases submitted to it are reported. T h e cases were treated at Bellevue Hospital and the N e w Y o r k Eye and Ear Infirmary.
In reporting this series o f cases it is m y p u r p o s e to p o i n t o u t the value o f the operation of r e t r o p l a c e m e n t o f the overacting muscle in preference to tenotomy and guarded tenotomy, and also in place o f m u s c l e a d v a n c e m e n t , or resection in squints o f m o d e r a t e degree. R e c e n t l y , P. C . J a m e s o n re p o r t e d a n u m b e r o f cases in w h i c h a similar operation w a s d o n e w i t h g o o d results. T h e o l d c o n t r o l ligature after c o m p l e t e t e n o t o m y , w i t h o u t suture to the episclera s e e m s t o m e rather uncer tain, just as is the o p e r a t i o n of c o m plete t e n o t o m y , for, w h i l e it is n o t likely to b e f o l l o w e d b y c o m p l e t e loss of p o w e r , the m u s c l e s t u m p m a y b e c o m e attached t o o near the original in sertion, or o v e r t o o b r o a d an area. A c o n t r o l suture is intended t o h o l d the t e n o t o m i z e d m u s c l e fastened t o the original insertion, the m u s c l e b e i n g al l o w e d to r e c e d e as far b a c k as n e c e s sary. I t appeared to m e , that this simple procedure could be made m o r e exact b y p i c k i n g up the episclera at the point t o w h i c h it w a s d e c i d e d t o retroplace the insertion o f the muscle, so as to p r e v e n t the cut end from slid ing up w h e n t y i n g the ligature, at the same time k e e p i n g it in c l o s e a p p o s i tion with the episclera. •Reported at the meeting of the section on ophfhalology of the N. Y. Acadamy of Medicine March 19, 1923.
T E C H N I C OF T H E OPERATION.
1. Vertical incision thru the conjunc tiva over the attachment o f the muscle. 2. O p e n i n g of T e n o n ' s capsule at the l o w e r level o f the a t t a c h m e n t . 3. Muscle h o o k passed thru the o p e n i n g , u n d e r the m u s c l e , to the u p p e r level o f the attachment. 4. O p e n i n g o f T e n o n ' s capsule at the upper level o f the attachment. 5. C o n j u n c t i v a and c a r u n c l e dis sected a w a y from the m u s c l e . 6. Parallel i n c i s i o n s thru T e n o n ' s capsule at upper and l o w e r b o r d e r s of the muscle. 7. D o u b l e - a r m e d suture passed thru the m u s c l e with l o o p o n the scleral side. T h i s is best a c c o m p l i s h e d w i t h o n e o f the needles, w h i c h enters at a p o i n t 1 m m . b e l o w the upper b o r d e r o f the m u s c l e ; and, disappearing u n d e r the m u s c l e , e m e r g e s at a p o i n t 1 m m . a b o v e the l o w e r b o r d e r of the m u s c l e . T h e ligature is passed 3 m m . beyond t h e l i n e o f insertion o f the m u s c l e . 8. C o m p l e t e t e n o t o m y . 9. T h e m u s c l e h o o k is passed u n d e r the m u s c l e o n each side, t o m a k e sure that the t e n o t o m y is c o m p l e t e . 10. A t a p o i n t o n the line t o w h i c h it has been d e c i d e d to r e c e d e the m u s c l e , p i c k u p the episclera, passing the needle h o r i z o n t a l l y t o w a r d the original insertion for a distance of a b o u t 1 m m . , u n d e r the episclera, then e m e r g i n g pass the needle thru the
O F
CHOROID.
HOWARD F . HANSELL, M . D . , PHILADELPHIA, PA. Five cases are here reported in abstract; o n e of them w a s u n d e r o b s e r v a t i o n ten years before evidence of the sarcoma was noticed, a n d there has been no recurrence in nine years following enucleation. The important points o f diagnosis and the question o f metastasis are discussed. Read before the Section on Ophthalmology o f the College o f Physicians o f Phila delphia, January, 1924,
The diagnosis o f the presence o f tumor o f the choroid presents no especial difficulty. T h e patient complains only of partial loss o f vision and his attention is attracted to his eyes solely f o r this reason. H e has no pain and singularly no photopsia. T h e eye is not congested and its appearances are unaltered. With the ophthalmoscope the detached retina, fixed over most o f its extent if not en tirely, seen with convex lenses o f vary ing strength because o f the diflferent levels o f the tumor, with the transillumihator, when the growth is not limited to the posterior portion o f the fundus; with the perimeter which outlines graph ically the extent o f the invasion, the diagnosis is made. Case 1. M r . B., aged 41, came un der my care in November, 1904, for the relief o f accommodative asthenopia. T h e media were clear and the eye grounds normal. In 1908, the eyes were healthy and vision, with correcting glass, o f full acuity. In 1913 no change except a slight increase in hyperopia. In 1915, V . o f L . was reduced from 2 0 / 1 5 to 2 0 / 2 0 . T h e retina over a small area be low was detached. The diagnosis o f choroidal tumor was made. Enuclea tion advised and refused. S i x months later vision was reduced to perception o f light in the lower field, A yellow vas cular growth was easily seen occupying a large part o f the vitreous. Tension normal. O n December 27, 1915, the eye was enucleated and a gold sphere im planted in Tenon's capsule. Nearly 9 years have elapsed and he is in appar ently perfect health. Pathologic exam ination : Spindle celled sarcoma. Case 2. (Reported in the Trans, A m . Oph. S o c . 1919.) Mrs. P., aged 39, loss of vision in left eye during past few weeks; no pain, no inflammation. T e n sion normal. Diagnosis, choroidal tumor. T h e ball was enucleated and a gold sphere implanted in Tenon's cap 359
sule. Pathologic examination showed the growth to be melanotic spindle celled sarcoma. Case 3. M r . P., aged 69, consulted me October 15, 1923, stating that for 6 months V . o f R . eye had been declining and n o w equals hand movements on nasal side. L . V . with correcting glass o f full acuity. N o pain. Health g o o d . Large round tumor involving the entire nasal fundus readily seen with ophthal moscope. Dense shadow in transillumi nation. T h e eye was enucleated the fol lowing day. Path, r e p o r t : Spindle celled sarcoma. Case 4. D . age 40. T u m o r project ing forward from the nasal section o f the choroid concealing the disc f r o m ophthalmoscopic view. S h a d o w cast by transillumination. N o light perception on large part o f the temporal field. T e n sion normal. N o evidence of metastasis. Case 5. M r s . H . T h e only symptom was decline in vision. T h e entire lower third o f retina o f left eye was detached. Tension normal. N o pain. Enucleation with implantation o f gold sphere. Path ologic examination; Melanotic sarcoma. T h e t w o points o f especial interest in connection with these and all cases c f choroidal malignant growth are 1st, the tension, and 2nd, metastasis. T h e first point was discussed in the paper above referred to. T h e writer has found no reason to m o d i f y the view there e x pressed, namely that the tension o f the eyeball is not raised until the crystal line lens is pushed forward, the anterior chamber annihilated and the angle o f the anterior chamber choked with iris tissue. T h e only plausible explanation is that the vitreous humor is absorbed as the tumor g r o w s and the normal relation be tween intraocular secretion and excre tion is not disturbed. Plus tension there fore is not a diagnostic sign o f the pres ence o f intraocular tumor per se. O n the contrary hypotony may be present.
360
H O W A R D F. H A N S E L L
Franz, ( K l i n . Monats, f. A u g . V . 64. 1920) describes 3 cases all o f which were tumors affecting the ciliary body. H e says the hypotony may be due to the resulting decrease in the secretion of the aqueous. L. M . Francis ( T r a n s , .-^mer. O p h . S o c . 1920) reports a case o f choroidal melanosarcoma in which the tension taken at four different times showed a steady decrease from 20 m m . to 5 mm. during 2Υι years. Heymans, ( A r c h . Ophthal. V . 38, 1921) showed 12 cases o f which four had hypotension, two normal tension, and six plus tension. N o definite relation was observed be tween the tension and the size or location of the t u m o r ; but in all with hyperten sion the filtration angle was m o r e o r less completely effaced. 2. Metastasis. T h e p o i n t is an i m portant o n e and unfortunately w e have few facts b y w h i c h w e m a y b e g u i d e d in g i v i n g an o p i n i o n as t o the origin of the original disease. T h e m e a n s of transmission o f the g e r m s o r t o x i n s o r cells are the b l o o d streams or the l y m p h streams o r b o t h . M a n y cases are recorded of the metastasis from other organs o f the body to the eye and in one recent instance from one eye to the other. Doesschat ( A . J. O . V . 4, 1921) reported the case o f a woman w h o had been operated on six years before for melanosarcoma o f the mamma. Three years later both eyes contained choroidal tumors. A t postmortem a large tumor was found in the left eye and five separate tumors in the retina o f the right eye, m i x e d leucosarcoma and melanosarcoma. This is stated to be an instance o f metastasis from the breast to the e y e s and from the left to the right e y e . A n e x a m p l e of metastasis from the e y e to the liver is the case o f Velhagen ( K l i n . Monats f. Augenh. V . 64, 1 9 2 0 ) . A f t e r enucleation the e y e s h o w e d t w o sar c o m a t a , the larger o n e c o m p o s e d of small, round cells probably secondary to the other. T h e patient died after eight m o n t h s , of metastasis to the liver. Instances of metastasis are c o m m o n in the literature. If w e admit metastasis from the liver to the e y e it is l o g i c a l to assume metastasis from
the e y e to the liver. M y o w n o p i n i o n , h o w e v e r , b a s e d o n m y experience, is that the f o r m e r is far m o r e c o m m o n , and that in s o m e in w h i c h it is stated that the c h o r o i d w a s the site o f the original tumor, I am inclined to b e l i e v e that the cells w e r e inplanted first in s o m e o t h e r o r g a n and that this earliest collection was undiscovered. Post mortem examinations depended on to demonstrate multiple tumors, d o not p r o v e that metastasis p r o c e e d e d from the e y e . In o r d e r to d e c i d e the q u e s tion, thoro analytical tests must be m a d e of as m a n y o f the b o d i l y secre tions and o r g a n s as m a y be available. T h e question is o n e of a c a d e m i c rather than o f practical interest b e c a u s e it is the usual c u s t o m t o practice early enu cleation after a p o s i t i v e d i a g n o s i s o f c h o r o i d a l t u m o r s that are p r e s u m e d not to b e syphilitic. A s stated in m y paper previously referred to, early enu cleation c a n n o t prevent metastasis b e cause a b s o r p t i o n and transference o f t u m o r cells m a y take p l a c e at any time after the cells have appeared in the c h o r o i d . E a r l y enucleation is r e c o m m e n d e d to prevent pain, and i n v o l v m e n t of the other orbital tissues and to rid the b o d y of a malignant g r o w t h . In c o n c l u s i o n , I desire to q u o t e a few passages from the splendid treatise of E w i n g o n N e o p l a s t i c D i s e a s e w h i c h , while n o t c o n t r i b u t i n g to o u r k n o w l e d g e of metastasis from the c h o r o i d to other organs, are of interest. H e says the rather c o m m o n o c c u r r e n c e of t w o or m o r e t u m o r s in different o r g a n s of the s a m e subject s u g g e s t n o t h i n g m o r e than the accidental c o i n c i d e n c e in several o r g a n s of the general e t i o l o g i c factors in the genesis o f t u m o r s . M e tastasis is accomplished thru the lym phatics either thru "continuous per meation" o r the development o f a secondary growth at the end o f a chain of c a n c e r cells filling the d e e p l y m phatics or thru "cell emboli" lodging at diflferent points in a l y m p h a t i c chain. It m a y g r o w in b o t h directions and after a time fill the l y m p h a t i c c o m pletely. T h e c o m p a r a t i v e i m m u n i t y of l y m p h a t i c s against invasion of s a r c o m a cells is p r o b a b l y t o b e explained chiefly
SAHíOOMA O F C H O R O I D
b y the greater local fixation o f s a r c o m a cells as c o m p a r e d w i t h the m o b i l e and s o m e t i m e s a m e b o i d c a n c e r cell. T h e b l o o d vessels are the chief chan nel o f the extension of s a r c o m a . M e t astasis is o b s e r v e d in the a d v a n c e d stages o f m o s t s a r c o m a s and it is
361
characteristic of the disease that, w i t h rare e x c e p t i o n s , e m b o l i c cells travel thru the blood vessels. T h e metas tasis often o c c u r s m u c h earlier than is g e n e r a l l y c o n c e i v e d and this fact adds to the g r a v i t y o f the p r o g n o s i s after surgical operations.
M U S C L E R E T R O P L A C E M E N T IN T H E C O R R E C T I O N O F S Q U I N T . SIMPLIFIED TECHNIC.
R E P O R T O F CASES A N D R E S U L T S . *
S I G M U N D A . AGATSTON, M . D . N E W YORK, N . Y . T h e operation here described seeks to secure exact results by ensuring the adhesion o f the tenotomized tendon to a definite selected place o n the sclera. T h e special technic for accomplishing this is described and tabulated details regarding fifty-five cases submitted to it are reported. T h e cases were treated at Bellevue Hospital and the N e w Y o r k Eye and Ear Infirmary.
In reporting this series o f cases it is m y p u r p o s e to p o i n t o u t the value o f the operation of r e t r o p l a c e m e n t o f the overacting muscle in preference to tenotomy and guarded tenotomy, and also in place o f m u s c l e a d v a n c e m e n t , or resection in squints o f m o d e r a t e degree. R e c e n t l y , P. C . J a m e s o n re p o r t e d a n u m b e r o f cases in w h i c h a similar operation w a s d o n e w i t h g o o d results. T h e o l d c o n t r o l ligature after c o m p l e t e t e n o t o m y , w i t h o u t suture to the episclera s e e m s t o m e rather uncer tain, just as is the o p e r a t i o n of c o m plete t e n o t o m y , for, w h i l e it is n o t likely to b e f o l l o w e d b y c o m p l e t e loss of p o w e r , the m u s c l e s t u m p m a y b e c o m e attached t o o near the original in sertion, or o v e r t o o b r o a d an area. A c o n t r o l suture is intended t o h o l d the t e n o t o m i z e d m u s c l e fastened t o the original insertion, the m u s c l e b e i n g al l o w e d to r e c e d e as far b a c k as n e c e s sary. I t appeared to m e , that this simple procedure could be made m o r e exact b y p i c k i n g up the episclera at the point t o w h i c h it w a s d e c i d e d t o retroplace the insertion o f the muscle, so as to p r e v e n t the cut end from slid ing up w h e n t y i n g the ligature, at the same time k e e p i n g it in c l o s e a p p o s i tion with the episclera. •Reported at the meeting of the section on ophfhalology of the N. Y. Acadamy of Medicine March 19, 1923.
T E C H N I C OF T H E OPERATION.
1. Vertical incision thru the conjunc tiva over the attachment o f the muscle. 2. O p e n i n g of T e n o n ' s capsule at the l o w e r level o f the a t t a c h m e n t . 3. Muscle h o o k passed thru the o p e n i n g , u n d e r the m u s c l e , to the u p p e r level o f the attachment. 4. O p e n i n g o f T e n o n ' s capsule at the upper level o f the attachment. 5. C o n j u n c t i v a and c a r u n c l e dis sected a w a y from the m u s c l e . 6. Parallel i n c i s i o n s thru T e n o n ' s capsule at upper and l o w e r b o r d e r s of the muscle. 7. D o u b l e - a r m e d suture passed thru the m u s c l e with l o o p o n the scleral side. T h i s is best a c c o m p l i s h e d w i t h o n e o f the needles, w h i c h enters at a p o i n t 1 m m . b e l o w the upper b o r d e r o f the m u s c l e ; and, disappearing u n d e r the m u s c l e , e m e r g e s at a p o i n t 1 m m . a b o v e the l o w e r b o r d e r of the m u s c l e . T h e ligature is passed 3 m m . beyond t h e l i n e o f insertion o f the m u s c l e . 8. C o m p l e t e t e n o t o m y . 9. T h e m u s c l e h o o k is passed u n d e r the m u s c l e o n each side, t o m a k e sure that the t e n o t o m y is c o m p l e t e . 10. A t a p o i n t o n the line t o w h i c h it has been d e c i d e d to r e c e d e the m u s c l e , p i c k u p the episclera, passing the needle h o r i z o n t a l l y t o w a r d the original insertion for a distance of a b o u t 1 m m . , u n d e r the episclera, then e m e r g i n g pass the needle thru the