- Email: [email protected]
The Research Study Club
860
EDITORIALS
their membership since it is earned after many years of endeavor in research, teach ing and clinical work. In addition, after nomination and careful scrutiny by its pow erful Council, an applicant for membership may be invited to submit a thesis. This is indeed a formidable hurdle; when accom plished, it leads to election as an associate member. This is a sort of probationary pe riod, during which time the neophyte is ex pected to contribute to the success of the scientific program. The annual Transactions of the Society are printed, bound and distributed to its members. The papers, and particularly the accepted theses, have been outstanding con tributions to ophthalmology. The roster of the members during these hundred years contains the names of the most eminent ophthalmologists and leaders of ophthalmol ogy of this country. The affection between the members and their families, engendered over many years of work and play together during the annual sessions, ripens like vin tage wine, and brings increasing dividends of joy throughout the passing years. We of T H E JOURNAL join our voices with those of all nations in sending Happy Birth day greetings to the Society and all good wishes for increasing success through the ups and downs of the next hundred years. Derrick Vail.
T H E RESEARCH STUDY CLUB For the readers of T H E JOURNAL, a few of the contributions of the guest speaker at the 33rd midwinter convention of the Re search Study Club of Los Angeles might be of interest. In discussing preoperative preparation, Dr. Charles E. Iliff, Baltimore, showed a new plastic drape that covers the operative field and can be slit to cover the brow and lashes and even go under the speculum to
give a completely sterile field. Dr. Howard House, Los Angeles otologist, has been using such a drape for some time and he preps over the drape. For akinesia and retrobulbar, Dr. Iliff mentioned the trick of injecting while inserting the needle, push ing the vessels aside as fluid is injected. He uses inferior and superior rectus traction sutures to lift and steady the eye. For cataract extraction, he makes an ab externo incision just in front of the limbus, rather vertically, one-half to three-fourths through the cornea, inserts preplaced sutures and finishes with scissors, slanting slightly toward the pupil, giving a broken type in cision. This wound seals with corneal epithelium and becomes watertight quickly. There is no bleeding and the angle is not impaired. The incidence of prolapse or fistulization is less than with a more poste riorly placed incision that has to seal with granulation tissue. He did show instances of the vitreous syndrome due to rupture of the vitreous face late in the postoperative period with adhesions of the vitreous to the wound. Vision then often deteriorates. Dr. Iliff does not hesitate, under these circumstances, to put a 30-gauge needle, bent at a 90-degree angle, into the anterior chamber, injecting air or saline to keep the chamber full while hooking the adhesion with the needle, pulling it out and incising it. This would be done weeks or months after surgery if vision were decreasing. Better results might be ob tained with use of a Sato needle. Dr. Iliff uses nonsiliconized silk, as it is softer and does not "cheese-wire" the tis sue. As an expert with capsule forceps, he prefers these to an erisophake and rarely uses alpha chymotrypsin. His technique would be preferred by older surgeons used to grasping the lens at the equator, lifting it and tearing the zonular fibers as one would tear along the perforations of a perforated paper. Surgeons using alpha chymotrypsin more routinely would have to gain experi ence with this technique and it might be wiser for them to continue to use Chymar
EDITORIALS
861
if the vitreous is not fluid and if they close the wound adequately with four, five, or even seven sutures. With the sharper needles now available, sutures are easily postplaced. Iliff showed a number of cases of corneal opacities, due to vitreous touching the cornea, cured by corneal transplant. This consequence of vitreous touch can be pre vented if the patient is observed carefully postoperatively, by doing peripheral iridectomies, and, if necessary, posterior sclerotomy and air injection and even incision of the hyaloid, to obtain good communication between vitreous and anterior chambers when the posterior chamber has been oblit erated because of adherence of vitreous to the under surface of the iris and the iridectomy closed by a hyalinized vitreous mem brane. He ties sutures snugly but not so snugly as to cause buckling or posterior gaping of the wound. He leaves them in place three weeks or more.
situ. Neurofibroma, "bag of worms," may be satisfactorily handled by partial excision and the lid elevated by a ptosis procedure, or, what this editor prefers, a GuytonFriedenwald tantalum wire-sling operation. Papillomas are excised and occasionally radi ated. Abscess of the orbit, in children, may be caused by infected toothbuds and most ab scesses respond to antibiotic therapy. He mentioned a number of general conditions, as eosinophilic granuloma, often diagnosed and treated by X-rays, as well as by scoop ing out involved bone, and medulloblastoma, arising from the kidney, usually associated with marked ecchymosis of the lids. En countering such a condition, palpation for evidence of kidney enlargement and urologie studies to rule out origin of the tumor in the kidney region are indicated. Cancer chemotherapeutic agents and X-rays are used in treatment.
Dr. Iliff lectured also on tumors of the orbit in children. He said that simple angi oma, present at birth, tends to regress, es pecially if there is a family history of a similar tumor with regression. Nevus flammeus is corrected, for the cosmetic effect, by tattoo, and, for the glaucoma, by a filter ing operation. Unfortunately, even after this, enucleation may be necessary. Progres sive, relatively localized angioma may re spond to radiation. The differentiation from sarcoma is not always possible. An gioma of the conjunctiva can usually be excised unless there is extension into the orbit, and then he suggests a large Krönlein type exposure for proper removal. Lymphangiomas are removed surgically; they do not respond to X-rays but in the future the "cold-probe" may be of value.
Pseudotumors are rare in children. They often involve both orbits and respond well to steroids. Dr. Iliff discussed correction of muscles fibrosed as a result of thyroid dis ease. The inferior rectus is often the target. Amazing relief is obtained by recessing the inferior rectus and, if there is marked lid retraction, recessing the levator. In these cases, the levator is easy to identify and recess. Plastic procedures developed by Dr. Iliff, as well as his ptosis operation, were well illustrated. The audience was delighted to hear an authority with such extensive personal experience in the procedures dis cussed. Dr. Lester T. Jones gave superb lectures on the anatomy of orbit and lids. He sug gests that the corrugator muscle, arising as part of the orbicularis, nasally, could be brought down and used in ptosis procedures. Drs. Maumenee, Warren Wilson and others are working on this concept. Before the for mal lectures, Dr. Jones gave a course which was so well attended that it may be repeated in successive years. Dr. Jones demonstrated his operation for
Dr. Iliff excises pigmented nevi of lids and conjunctiva and dermoids but he is in clined to leave lipodermoids alone if they extend back into the orbit. His trick, in treat ing dermoids under the brow, is to keep the sac intact as the contents are irritating. He makes a large incision to remove them in
862
EDITORIALS
correction of closure of the canaliculi. He makes a Toti-Mosher exposure of the sac and the lacrimai fossa, anastomosing the medial wall of the sac to the mucous mem brane of the nose, inserting a polyethylene tube through the region of the caruncle that has been excised. Later, this is replaced by a glass tube. Dr. Jones has more than a hundred cases of persistent tearing cured by this procedure. I am happy to report that the case he did in demonstration also has a good result. Two details of the technique merit em phasis as essential to a good result: First, the incision is made rather high on the nose but so superficially that he is able to identify the angular vein and pull it aside without severing it. Second, he does not cut the internal canthai ligament but works under it and, with a periosteal elevator, peels the periosteum off the lacrimai fossa, pulling the lacrimai sac nasally. The nose has previously been packed and shrunk with cocaine and adrena lin. The bone is then carefully removed from the lacrimai fossa, with rongeur or chisel or drill, preserving the nasal mucous mem brane. The opening, about one cm. by one cm., is just opposite the sac and sufficiently inferior so that the tubercle of bone medial to the entrance to the nasal lacrimai duct is removed. The mucous membrane of the sac is then incised horizontally, making two flaps and, opposite this, the mucous membrane of the sac is incised. The lower nasal and lacrimai flaps, as well as the upper, are sutured to gether with fine gut sutures on half-circle needles. The caruncle is then excised and a 25-gauge needle inserted through the car uncle into the lacrimai sac and into the nose. A von Graefe knife is pushed along the course of the needle, the latter acting as a guide, to make a small horizontal incision that allows introduction of the tube through the lacrimai sac into the nose. This is all a relatively bloodless procedure as done by Dr. Jones.
A small bit of umbilical tape, covered with Neodecadron ointment to cut down in flammation, is so inserted as to keep the flaps of sutured mucous membrane apart. Otherwise, they might fall down and close the opening. This is left in place for 10 days. I would advise every study group to get the motion pictures and study the procedure carefully, as it can be done by any good surgeon if he is aware of the fine details emphasized by Dr. Jones. This procedure is a real contribution. Articles in which Dr. Jones has described the procedure are: Am. J. Ophth., 38:824 (Dec.) 1954; Am. J. Ophth., 43:203 (Feb.) 1957; Tr. Am. Acad. Ophth., July, 1961. Dr. Bayard H. Colyear, Jr., gave a beauti ful discussion on detachment of the retina, telling the advantages of retinopexy versus scierai buckling procedures, using infolding methods as well as silicon bands and pillows. He also lectured on the light coagulator with which he has had extensive experience. He emphasized the importance of combining the principles of old techniques, such as retin opexy, with newer infolding and buckling techniques. We still do not know the cause of massive viterous retraction but it does seem to be related to overmanipulation of the globe. The younger men are overindoctrinated with infolding and buckling band and pillow procedures and may not agree with some of Dr. Colyear's ideas until they have had more experience and can better evaluate the final results and actually know how many cases achieve successful reattachment as well as preservation of central vision. The loss of central vision is not just a question of the macula being off at the time of surgery but is also related to manipulation of the eye and interference with the blood supply, and this is often due to lack of understanding of diathermy currents and of the effects of light coagulation. We have, as yet, no actual experience or absolute data that give us clinical proof as to the best type of dia thermy or galvanic current to use other than
CORRESPONDENCE realization that the current should be the minimal amount that will achieve adherence without harmful spreading effects. More re search in biophysics and instrumentation is needed. Too many cases are pronounced cured which have no macular vision remain ing when this vision might have been pre served had less tedious procedures been tried. Dr. Raynold N. Berke, with lectures and movies, illustrated his beautiful ptosis tech niques. He and Dr. Jones do not agree com pletely on the anatomy of the lids, proving that even in such a basic subject as anatomy there is room for research. Dr. Poul Braendstrup, professor of oph thalmology and chief of the ophthalmologic department of the City Hospital of Copen hagen, was the foreign guest. He discussed primarily medical ophthalmology, amblyopia ex anopsia of extinction and regression as can be demonstrated in varying degrees of infantile cataract, thrombosis of the central retinal vein and hemorrhagic glaucoma. He illustrated retinal disturbances associated with various blood dyscrasias, particularly those altering the viscosity of the blood, re lated to abnormally large molecules from aggregation of molecules of albumin or globulin, as in macroglobulinemia. This is a new field in which problems will be solved with the newer techniques of electrophoresis, paper chromotography and ultracentri fugation of blood serum. The vessels resemble those seen in leukemia and these cases might be studied to advantage in the university centers where these special microtechniques can be employed. In the round-table discussions, the mem bers of the course were most anxious to quiz Dr. Braendstrup about socialized medi cine in the Scandinavian countries. He told us that, for specialists in contrast to gen eral practitioners, the plan worked quite well but is extremely costly, taking 22 per cent of the entire government budget. He was impressed by the eagerness with which private practitioners here attend courses and
863
participate in seminars to improve them selves in contrast to the Scandinavian coun tries where only university personnel show evidence of such ambition. The discussions led the listeners and this writer to fear that socialization in this country would divert the mainstream of potential talent from medicine into other careers where a man's ambition, expression of individuality, free dom from bureaucracy would not be thwart ed as it would be under a plan of socialized medicine. S. Rodman Irvine.
CORRESPONDENCE CONGENITAL MELANOSIS
Editor, American Journal of Ophthalmology: In a recent article in T H E JOURNAL, "Clin ical pathology of iris tumors," by L. E. Zimmerman (August, 1963, pp. 183-195), there is a discussion of the differential diag nosis between diffuse malignant melanoma of the iris and congenital melanosis (mela nosis oculi). The statement is made con cerning congenital melanosis that "on slitlamp examination the iris markings are not obscured." I would like to point out that in the usual case of congenital melanosis (melanosis oculi) the surface texture of the iris is usually obscured almost completely by fine granular pigment, often associated with small nodules scattered over the surface of the iris. This is also true for partial melan osis involving a sector of the iris, although the normal markings may be less obscured, especially at the margins of the area of hyperpigmentation. It is my feeling that this point is most important. The clinician must be aware of the usual appearance of the iris in melanosis oculi to avoid mistaking this entity for dif fuse or localized malignant melanoma of the
EDITORIALS
their membership since it is earned after many years of endeavor in research, teach ing and clinical work. In addition, after nomination and careful scrutiny by its pow erful Council, an applicant for membership may be invited to submit a thesis. This is indeed a formidable hurdle; when accom plished, it leads to election as an associate member. This is a sort of probationary pe riod, during which time the neophyte is ex pected to contribute to the success of the scientific program. The annual Transactions of the Society are printed, bound and distributed to its members. The papers, and particularly the accepted theses, have been outstanding con tributions to ophthalmology. The roster of the members during these hundred years contains the names of the most eminent ophthalmologists and leaders of ophthalmol ogy of this country. The affection between the members and their families, engendered over many years of work and play together during the annual sessions, ripens like vin tage wine, and brings increasing dividends of joy throughout the passing years. We of T H E JOURNAL join our voices with those of all nations in sending Happy Birth day greetings to the Society and all good wishes for increasing success through the ups and downs of the next hundred years. Derrick Vail.
T H E RESEARCH STUDY CLUB For the readers of T H E JOURNAL, a few of the contributions of the guest speaker at the 33rd midwinter convention of the Re search Study Club of Los Angeles might be of interest. In discussing preoperative preparation, Dr. Charles E. Iliff, Baltimore, showed a new plastic drape that covers the operative field and can be slit to cover the brow and lashes and even go under the speculum to
give a completely sterile field. Dr. Howard House, Los Angeles otologist, has been using such a drape for some time and he preps over the drape. For akinesia and retrobulbar, Dr. Iliff mentioned the trick of injecting while inserting the needle, push ing the vessels aside as fluid is injected. He uses inferior and superior rectus traction sutures to lift and steady the eye. For cataract extraction, he makes an ab externo incision just in front of the limbus, rather vertically, one-half to three-fourths through the cornea, inserts preplaced sutures and finishes with scissors, slanting slightly toward the pupil, giving a broken type in cision. This wound seals with corneal epithelium and becomes watertight quickly. There is no bleeding and the angle is not impaired. The incidence of prolapse or fistulization is less than with a more poste riorly placed incision that has to seal with granulation tissue. He did show instances of the vitreous syndrome due to rupture of the vitreous face late in the postoperative period with adhesions of the vitreous to the wound. Vision then often deteriorates. Dr. Iliff does not hesitate, under these circumstances, to put a 30-gauge needle, bent at a 90-degree angle, into the anterior chamber, injecting air or saline to keep the chamber full while hooking the adhesion with the needle, pulling it out and incising it. This would be done weeks or months after surgery if vision were decreasing. Better results might be ob tained with use of a Sato needle. Dr. Iliff uses nonsiliconized silk, as it is softer and does not "cheese-wire" the tis sue. As an expert with capsule forceps, he prefers these to an erisophake and rarely uses alpha chymotrypsin. His technique would be preferred by older surgeons used to grasping the lens at the equator, lifting it and tearing the zonular fibers as one would tear along the perforations of a perforated paper. Surgeons using alpha chymotrypsin more routinely would have to gain experi ence with this technique and it might be wiser for them to continue to use Chymar
EDITORIALS
861
if the vitreous is not fluid and if they close the wound adequately with four, five, or even seven sutures. With the sharper needles now available, sutures are easily postplaced. Iliff showed a number of cases of corneal opacities, due to vitreous touching the cornea, cured by corneal transplant. This consequence of vitreous touch can be pre vented if the patient is observed carefully postoperatively, by doing peripheral iridectomies, and, if necessary, posterior sclerotomy and air injection and even incision of the hyaloid, to obtain good communication between vitreous and anterior chambers when the posterior chamber has been oblit erated because of adherence of vitreous to the under surface of the iris and the iridectomy closed by a hyalinized vitreous mem brane. He ties sutures snugly but not so snugly as to cause buckling or posterior gaping of the wound. He leaves them in place three weeks or more.
situ. Neurofibroma, "bag of worms," may be satisfactorily handled by partial excision and the lid elevated by a ptosis procedure, or, what this editor prefers, a GuytonFriedenwald tantalum wire-sling operation. Papillomas are excised and occasionally radi ated. Abscess of the orbit, in children, may be caused by infected toothbuds and most ab scesses respond to antibiotic therapy. He mentioned a number of general conditions, as eosinophilic granuloma, often diagnosed and treated by X-rays, as well as by scoop ing out involved bone, and medulloblastoma, arising from the kidney, usually associated with marked ecchymosis of the lids. En countering such a condition, palpation for evidence of kidney enlargement and urologie studies to rule out origin of the tumor in the kidney region are indicated. Cancer chemotherapeutic agents and X-rays are used in treatment.
Dr. Iliff lectured also on tumors of the orbit in children. He said that simple angi oma, present at birth, tends to regress, es pecially if there is a family history of a similar tumor with regression. Nevus flammeus is corrected, for the cosmetic effect, by tattoo, and, for the glaucoma, by a filter ing operation. Unfortunately, even after this, enucleation may be necessary. Progres sive, relatively localized angioma may re spond to radiation. The differentiation from sarcoma is not always possible. An gioma of the conjunctiva can usually be excised unless there is extension into the orbit, and then he suggests a large Krönlein type exposure for proper removal. Lymphangiomas are removed surgically; they do not respond to X-rays but in the future the "cold-probe" may be of value.
Pseudotumors are rare in children. They often involve both orbits and respond well to steroids. Dr. Iliff discussed correction of muscles fibrosed as a result of thyroid dis ease. The inferior rectus is often the target. Amazing relief is obtained by recessing the inferior rectus and, if there is marked lid retraction, recessing the levator. In these cases, the levator is easy to identify and recess. Plastic procedures developed by Dr. Iliff, as well as his ptosis operation, were well illustrated. The audience was delighted to hear an authority with such extensive personal experience in the procedures dis cussed. Dr. Lester T. Jones gave superb lectures on the anatomy of orbit and lids. He sug gests that the corrugator muscle, arising as part of the orbicularis, nasally, could be brought down and used in ptosis procedures. Drs. Maumenee, Warren Wilson and others are working on this concept. Before the for mal lectures, Dr. Jones gave a course which was so well attended that it may be repeated in successive years. Dr. Jones demonstrated his operation for
Dr. Iliff excises pigmented nevi of lids and conjunctiva and dermoids but he is in clined to leave lipodermoids alone if they extend back into the orbit. His trick, in treat ing dermoids under the brow, is to keep the sac intact as the contents are irritating. He makes a large incision to remove them in
862
EDITORIALS
correction of closure of the canaliculi. He makes a Toti-Mosher exposure of the sac and the lacrimai fossa, anastomosing the medial wall of the sac to the mucous mem brane of the nose, inserting a polyethylene tube through the region of the caruncle that has been excised. Later, this is replaced by a glass tube. Dr. Jones has more than a hundred cases of persistent tearing cured by this procedure. I am happy to report that the case he did in demonstration also has a good result. Two details of the technique merit em phasis as essential to a good result: First, the incision is made rather high on the nose but so superficially that he is able to identify the angular vein and pull it aside without severing it. Second, he does not cut the internal canthai ligament but works under it and, with a periosteal elevator, peels the periosteum off the lacrimai fossa, pulling the lacrimai sac nasally. The nose has previously been packed and shrunk with cocaine and adrena lin. The bone is then carefully removed from the lacrimai fossa, with rongeur or chisel or drill, preserving the nasal mucous mem brane. The opening, about one cm. by one cm., is just opposite the sac and sufficiently inferior so that the tubercle of bone medial to the entrance to the nasal lacrimai duct is removed. The mucous membrane of the sac is then incised horizontally, making two flaps and, opposite this, the mucous membrane of the sac is incised. The lower nasal and lacrimai flaps, as well as the upper, are sutured to gether with fine gut sutures on half-circle needles. The caruncle is then excised and a 25-gauge needle inserted through the car uncle into the lacrimai sac and into the nose. A von Graefe knife is pushed along the course of the needle, the latter acting as a guide, to make a small horizontal incision that allows introduction of the tube through the lacrimai sac into the nose. This is all a relatively bloodless procedure as done by Dr. Jones.
A small bit of umbilical tape, covered with Neodecadron ointment to cut down in flammation, is so inserted as to keep the flaps of sutured mucous membrane apart. Otherwise, they might fall down and close the opening. This is left in place for 10 days. I would advise every study group to get the motion pictures and study the procedure carefully, as it can be done by any good surgeon if he is aware of the fine details emphasized by Dr. Jones. This procedure is a real contribution. Articles in which Dr. Jones has described the procedure are: Am. J. Ophth., 38:824 (Dec.) 1954; Am. J. Ophth., 43:203 (Feb.) 1957; Tr. Am. Acad. Ophth., July, 1961. Dr. Bayard H. Colyear, Jr., gave a beauti ful discussion on detachment of the retina, telling the advantages of retinopexy versus scierai buckling procedures, using infolding methods as well as silicon bands and pillows. He also lectured on the light coagulator with which he has had extensive experience. He emphasized the importance of combining the principles of old techniques, such as retin opexy, with newer infolding and buckling techniques. We still do not know the cause of massive viterous retraction but it does seem to be related to overmanipulation of the globe. The younger men are overindoctrinated with infolding and buckling band and pillow procedures and may not agree with some of Dr. Colyear's ideas until they have had more experience and can better evaluate the final results and actually know how many cases achieve successful reattachment as well as preservation of central vision. The loss of central vision is not just a question of the macula being off at the time of surgery but is also related to manipulation of the eye and interference with the blood supply, and this is often due to lack of understanding of diathermy currents and of the effects of light coagulation. We have, as yet, no actual experience or absolute data that give us clinical proof as to the best type of dia thermy or galvanic current to use other than
CORRESPONDENCE realization that the current should be the minimal amount that will achieve adherence without harmful spreading effects. More re search in biophysics and instrumentation is needed. Too many cases are pronounced cured which have no macular vision remain ing when this vision might have been pre served had less tedious procedures been tried. Dr. Raynold N. Berke, with lectures and movies, illustrated his beautiful ptosis tech niques. He and Dr. Jones do not agree com pletely on the anatomy of the lids, proving that even in such a basic subject as anatomy there is room for research. Dr. Poul Braendstrup, professor of oph thalmology and chief of the ophthalmologic department of the City Hospital of Copen hagen, was the foreign guest. He discussed primarily medical ophthalmology, amblyopia ex anopsia of extinction and regression as can be demonstrated in varying degrees of infantile cataract, thrombosis of the central retinal vein and hemorrhagic glaucoma. He illustrated retinal disturbances associated with various blood dyscrasias, particularly those altering the viscosity of the blood, re lated to abnormally large molecules from aggregation of molecules of albumin or globulin, as in macroglobulinemia. This is a new field in which problems will be solved with the newer techniques of electrophoresis, paper chromotography and ultracentri fugation of blood serum. The vessels resemble those seen in leukemia and these cases might be studied to advantage in the university centers where these special microtechniques can be employed. In the round-table discussions, the mem bers of the course were most anxious to quiz Dr. Braendstrup about socialized medi cine in the Scandinavian countries. He told us that, for specialists in contrast to gen eral practitioners, the plan worked quite well but is extremely costly, taking 22 per cent of the entire government budget. He was impressed by the eagerness with which private practitioners here attend courses and
863
participate in seminars to improve them selves in contrast to the Scandinavian coun tries where only university personnel show evidence of such ambition. The discussions led the listeners and this writer to fear that socialization in this country would divert the mainstream of potential talent from medicine into other careers where a man's ambition, expression of individuality, free dom from bureaucracy would not be thwart ed as it would be under a plan of socialized medicine. S. Rodman Irvine.
CORRESPONDENCE CONGENITAL MELANOSIS
Editor, American Journal of Ophthalmology: In a recent article in T H E JOURNAL, "Clin ical pathology of iris tumors," by L. E. Zimmerman (August, 1963, pp. 183-195), there is a discussion of the differential diag nosis between diffuse malignant melanoma of the iris and congenital melanosis (mela nosis oculi). The statement is made con cerning congenital melanosis that "on slitlamp examination the iris markings are not obscured." I would like to point out that in the usual case of congenital melanosis (melanosis oculi) the surface texture of the iris is usually obscured almost completely by fine granular pigment, often associated with small nodules scattered over the surface of the iris. This is also true for partial melan osis involving a sector of the iris, although the normal markings may be less obscured, especially at the margins of the area of hyperpigmentation. It is my feeling that this point is most important. The clinician must be aware of the usual appearance of the iris in melanosis oculi to avoid mistaking this entity for dif fuse or localized malignant melanoma of the