Gilbert Urbain Guillaumin.

The Annals of ophthalmology online

. (page 41 of 76)
Online LibraryGilbert Urbain GuillauminThe Annals of ophthalmology → online text (page 41 of 76)
Font size
QR-code for this ebook


the iris. Direct illumination by the ophthalmoscopic
mirror showed the retina detached at the lower half,
beginning under optic disc. Under this there was a
greenish area, due to the sub -retinal exudate. The whole
lower portion of the field was occupied by a rounded
purplish mass, over which coursed blood vessels; there
being a well defined space between the apex of the tumor
and the retina. (See Fig. 2.)

Despite the fact that the eye had no pain, little tension,
and could yet see, the ophthalmoscopic picture was so
perfect that I did not hesitate to make a diagnosis qt intra-
ocular tumor, of probable sarcomatous nature. After
some correspondence with her physician, she returned to
me three weeks later, when the vision was found
reduced to counting fingers at three meters, with visual
field and the iris reaction more hemianopic. The patient
had no pain, although the tension was now perceptible.
Enucleation under ether was done April 20, the location
of the tumor being marked by a black thread in the con-
junctiva. Patient had uninterrupted recovery, and was
fitted later with an artificial eye. Since the operation she
has had no symptoms.

*IlluBtrative cases showing the indications for enucleation of the
eyeball, etc., H. V. Wiirdemann, M. D., Annals op Ophthalmol-
ogy, Oct , 1897.



Digitized by VjOOQ IC



Pig. 2. Fundus Oculi by Direct Ophthalmoscopy in Sarcoma of
the Chorioid. (This picture also well illustrates the ophthalmic
appearances of Dr. Krauss^ case and of Wiirdemann'sCase II.)



Digitized by VjOOQ IC



Digitized by VjOOQ IC



CHORIOIDAL SARCOBIA. 441

The macroscopic specimens are of an eyeball normal in
size and shape, and in relation to ocular structures, except
as shown. Especially noticeable are the vense vorticosse
and the chorioidal fetal cleft. (See Fig. 3.) This is the
larger section, the eye being cut a little out of the median
line, although through the center of the tumor. The latter
is the size of a large pea, arising from the chorioid near
the ciliary body, at the lower portion. The growth is
white, although covered by the dark pigment coat of the
chorioid and the retina. It has as yet disturbed none of
the intimate relations of the ocular structures, except
the chorioid and retina. The latter is detached back to
the optic disc, this space being filled by a subretinal



Fig. 3. Lateral half of eyeball Fig, 4. Lateral half of eyeball

with sarcoma of the chorioid, with sarcoma of the chorioid ,

showing normal relations of showing extensive retinal

the ocular structures and the detachment and the tumor,
tumor.

exudate which in section appeared of a colloid nature, and
of a firmer consistency than the vitreous.

In the opposite section, the retina is extensively
detached by reason of the exudate, and thrown in folds.
It retains its normal appearance in other respects, and the
macula lutea shows distinctly to the naked eye. (See

Pig: 4.)

The microscopic section shows that the tumor is made
up almost entirely of typical non -pigmented, small round
cells, there i^being but little connective tissue
stroma, l^he chorioidal tissue itself is entirely replaced
by the new formation. The sarcoma cells are limited to
the tumor itself, none being found in the vitreous or other
structures, which retain their normal microscopic appear-
ances. The subretinal exudate is of a homogeneous col-
loid nature.



Digitized by VjOOQ IC



442 CHORIOIDAL SARCOMA.

June 24, 1902. The patient is alive and has had no
recurrence of sarcoma growth.

Case II. June 21, 1900. Mr. K., aged52, of Milwaukee,
Wis., manufacturer, (referred by Dr. L. Webster Fox, of
Philadelphia), negative general history except that he
remembered receiving a blow upon the left side of the head
about a year before; since that time and a few months ago
had noticed that the sight of that eye was failing ; no history
of pain or inflammation ; stat. praes. — strong healthy man;
eyes: R., V. — 5/VIII; refraction, R., + .25 3 + 1.00
— 180° = 6/VI add + 2.25 for near; L., V. = fingers 1
m., could see better downward; V. P. hemianopic, of the
same character as in Case I; pupillary reflex normal; the
ophthalmoscopic appearances were much the same as in
Case I, there being a rounded bluish mass easily observ-
able by oblique examination and by the ophthalmoscope.
I did not hesitate to make immediate diagnosis of intra-
ocular tumor of probable sarcomatous nature. He then
acknowledged that Dr. L. Webster Fox, of Philadelphia,
had seen him the week before and had made the same
diagnosis and had referred him to me for operation. He
also stated that he did not come direct to me and had been
to a specialist in this city who told him he had "detach-
ment of the retina," which, of course, was self-evident,
but no diagnosis of the tumor was there given him. I ad-
vised enucleation at as early a time as possible. He did
not return to me again until July 7th: during the interval
he had been to several physicians in consultation, all of
whom had given him the same diagnosis, with the exception
of the one to whom he had been before, to whom he had
had again gone and who insisted he had simple detachment
of the retina. He finally decided that the opinion of the
majority should prevail, but even then was suspicious
that we might have been mistaken and insisted that the
eyeball be put in possession of a friend at the time of the
operation. I acquiesced in this idiosyncrasy and per-
formed enucleation allowing his friend to take the eye in
a sealed bottle. (This extraordinary procedure would not
have been allowed were the diagnosis not so plain.) One
week later the eye was frozen, divided in his presence
and a marked circumscribed tumor was found, a little lar-



Digitized by VjOOQ IC



CHORIOIDAL SARCOMA. 443

ger and more irregular than that which is illustrated in
the first case, but springing from the same location, i. e.,
from the anterior portion of the chorioid in the lower half
near the ciliary region ; the retina was detached over and
behind the tumor, there being a subretinal exudate of the
same character. Microscopic section showed that the tu-
mor was made up of typical pigmented, small-round-
cells, there being considerable connective tissue
stroma. The chorioidal tissue itself was entirely replaced
by the neoplasm. The sarcoma cells were likewise, in
this case, limited to the tumor itself, none being found in
the other structures of the eye.

Of particular interest is the fact that there has been no
recurrence of sarcomatous growth in either of these ca-
ses ; case I. having been under observation 6 years, case II.
for 2 years.

New growths of the uveal tract. are relatively uncom-
mon, occurring in 0,0375 to 0,066 per cent, of eye cases;
of these sarcoma is relatively common and most often
found in the chorioid itself , it is usually pigmented and its
course is such that four distinct stages may be observed.
If occurring in the chorioid in the first stage, the tumor is
small and does not at first affect the visual acuity; it
gives rise to defect in the visual field from circumscribed
detachment of the retina. The diagnosis is usually read-
ily made by the ophthalmoscope although not always upon
first examination, as it is to be differentiated from simple
detachment of the retina. As the tumor grows the retina
becomes more and more detached from the chorioid, the
space between it and the chorioid containing a thickened
jelly mass infiltrated by connective tissue and ameboid
cells but no tumor tissue. The growth itself is usually
circumscribed, the chorioid remaining in contact with the
sclera in its full extent. Externally the eye looks
normal. There are as a rule no symptoms of pain
or inflammation, which come on in the second stage,
when the eye becomes blind and ophthalmoscopic
examination is impossible on account of disturbances of
the media. In the second stage symptoms of increased
tension set in. In the third stage perforation of the eye-
ball and extra -orbital growth of the tumor occurs and in
this and in the fourth or last stage the tumor grows ra-



Digitized by VjOOQ IC



444 CHORIOIDAL SARCOBIA.

pidly, filling the orbit, projecting out cauliflower-like
excrescences and as a rule metastasis into other organs
with death occurs.*

Sarcoma affects both the uveal tract and the orbit in
males and females in about equal proportions. The ave-
rage in uveal sarcoma is forty- eight and one- half years,
and in primary orbital cases the growth first appeared, on
the average, at twenty-eight and one-sixth years. There
is but little tendency for one side to be affected more fre-
quently than the other. In only four cases out of 103 was
there history of tumors in near relatives. In three out of
seven cases that recurred there were metastatic growths.
Recurrence took place locally from a week to three years
after operation. In every case in which recurrence took
place the patient died of sarcoma. In the primary orbital
cases recurrence was reported to have occurred in 58.6
per cent. The average time elapsing between operation
and recurrence was twenty months. Stirling'sf results
show a difference between growths primarily affecting the
uveal tract an those beginning in the orbit. In the for-
mer 8.86 per cent, recurred in the region of the orbit, and
death in 32 per cent, was due to metastasis. In the latter,
when recurrence took place at all, the orbit was always
affected, even when other organs were attacked.'' t

*Wurdemann, Part VI in Posey and Wright's System Dis. of
Eye, Ear, Nose and Throat (in press, 1902).

tStirling, A. W., Sarcoma of the Orbit, Ophth. Rec, 1898, Vol.
VII, pp. 331-336.

t Wiirdemann. * * A Study of Multiple Metastatic Angio-Sarcoma,"
Amer. Jour. Med. Sciences, June, 1899.



Digitized by VjOOQ IC



A REMARKABLE VASCULAR GROWTH INTO
THE VITREOUS.

By J. E. Jennings, M. D.,

ST. LOUIS, MO.

ILLU8T&ATBD.

Mrs. L. J. C, a woman in good health, aged 72,
consulted me Oot. 11, 1901, complaining of failing sight.

History: At thirty-five years, began wearing glasses
for close work, otherwise sight was good. About five
years ago, was considerably run down in health from
nursing a case of scarlet fever. One day while engaged
in laundry work she noticed a sudden blindness in the left
eye, which her physician. Dr. Benj. F. Hall, of Rock
Island, 111., writes me was the result of hemorrhagic reti-
nitis. According to the statement of the patient ''vision
of left eye slowly improved," though from the findings of
my examination this is not at all likely.

About three months ago the vision of the right eye was
noticed to be failing so that she was no longer able to read.
Thinking a new pair of glasses might be of benefit she
presented herself at my office.

Refraction. V. O. D. s/eo + LOO D. sph. - V20.

V. O. S. counts fingers at one foot, if the
hand is held to the temporal side.

Retinoscopy under homatropin. Right, + 2.00. Left,
+ 2.50.

ophthalmoscopic examination.

Right eye. Media clear, optic disc possibly a little paler
than normal, but no marked change observed. Retinal
veins and arteries normal. No disease of other parts of
fundus.

Left eye. By the indirect method a moving mass of
vessels was seen which suggested detachment of the retina.
By the direct method the optic disc and retina were found

445



Digitized by VjOOQ IC



446 VASCULAR GROWTH INTO THE VITREOUS.

to be normal and there were no evidences of retinal or
vitreous hemorrhages.

At the temporal edge of the disc a macular branch of the
retinal artery turned abruptly at a right angle and together
with two vessels which issued from the depth of the nerve
passed directly forward to a small patch of semi -transpar-
ent connective tissue situated in the vitreous 2V2 nam. in
front of the disc. At this point the three vessels subdi-
vided into a dozen or more tortuous branches which
spread outward into transparent vitreous like spokes of a
wheel. Finally these vessels anastomosed with one another
(see figure), forming a beautifully, delicate and extensive
meshwork of fine vessels. Situated at various points of



this meshwork, usually at the junction of two vessels,
were minute patches of membranous tissue, represented
by black dots in the drawing.

Heart and kidneys were found to be normal.

Treatment consisted in the use of ^/i2 of a grain of
bichlorid of mercury with 5 grains of iodid of potassium,
.three times a day.

Nov. 6, 1901. The only change noted at this visit was
an improvement in vision of the right eye from ^/^o to s/jj.

Dec. 31, 1901. Vision of the right eye improved to Vii-

Vision of the left eye was reduced to light perception.
Patient said that about a week ago she noticed a web-like
film in front of the left eye which, the next day, took the



Digitized by VjOOQ IC



VASCULAR GROWTH INTO THE VITREOUS. 447

form of a ball-like cloud attached at one point and moving
about.

An ophthalmoscopic examination showed a dense haze
of the vitreous so that only a faint outline of the disc
could be obtained. With a + 8 D lens I could make out
the small patch of connective tissue at the hub of the
wheel, ^but, to my surprise, the beautiful meshwork of
vessels had entirely disappeared with the exception of a
few fine hazy lines no doubt remnants of the delicate walls
of the empty vessels.

Vascular growths into a relatively healthy vitreous are
extremely rare of the countless thousands of eyes exam-
ined by observers all over the world; since 1851 only about
twenty cases are on record. A history of these cases is
given by Dr. Wilbur B. Marple in a paper entitled, **A
Contribution to the Pathology of Vascular Growths into
the Vitreous," and published in the Transactions of the
American Ophthalmological Society, 1901. The cause of
these peculiar formations is, no doubt, hemorrhage into
the retina and vitreous. The process is identical with
retinitis proliferans in which new formed vessels are seen
on the surface of masses of white connective tissue which
develop into the retina and extend out into the vitreous.
In retinitis proliferans, however, the condition is apt to
remain stationary while in some cases of vascular growths
without connective tissue formation the delicate vessels
may ultimately disappear leaving a useful eye or, as in
my case, the vitreous becomes disorganized and the sight
is lost.

507 Carleton Building.



Digitized by VjOOQ IC



AMYLOID DEGENERATION OF THE CONJUNCTIVA/
By L. a. W. Allebian, A. M., M. D.,

BROOKLYN, N. T.

ILLUSTRATED.

The patient, the history of whose case is here presented,
Rosalia Cascia, an Italian, 54 years of age, came under my
observation in February, 1899, in the Long Island College
hospital, where she had been sent by the United States
Immigration authorities for detention, on account of the
condition of her left eye.

Her own statement of the case, kindly given me by Dr.
J. W. Tappan, Interne in Charge United States Immigra-
tion service, was that, several years ago, she lost one of
her children, and cried a great deal; one morning she
awoke and found the left eye red and swollen ; it grad-
ually grew worse, until it reached it present condition.

Even this meagre history is unreliable, owing to the
patient's lack of intelligence, and to the misrepresenta-
tion by immigrants of all facts of their physical history,
seeing in the questions some trap to exclude them from the
country. She denied ever having had any pain in the
eye previous to her arrival in this country, but she ad-
mitted that,of late, there had been some pain and photo-
phobia.

PRESENT CONDITION.

The patient's physical condition seems to be good. She
looks much older than her alleged years, but this is usual
among immigrants of her class. The right eye appears to
be normal and shows no evidence of trachoma, and there
are neither corneal nor conjunctival scars.

The left eye presents a most unusual picture : both lids
are enormously thickened and the palprebral fissure
much narrowed. (See Fig.) The skin shows a bluish-
red discoloration. No enlarged vessels are visible. On

*Read before the Ophthalmological Section of the Medical Society
of the County of Kings, March 23, 1900.

448



Digitized by VjOOQ IC



AMYLOID DEGENERATION OF THE CONJUNCTIVA. 449

palpation, a hard mass is felt beneath the skin of the
upper lid; this mass presents two prominences, with a
central depression. The skin of the lid is freely movable
over the mass, which is slightly resilient, but not com-
pressible; nor is it movable, save with the lid.

The impression given to the examining finger is of a
thickening of the tissues of the lid, rather than a new
growth in the lid substance.

In the lower lid a crescentic mass is discovered, which
seems similar to that in the upper lid.

The induration involves the major portion of both lids,
and is thickest in the center of lids, and slopes oft grad-
ually toward the edges.

It is impossible to evert the upper lid, and an attempt to
separate the lids produces slight hemorrhage. The lower
lid can be pulled a little way from the globe, showing a
shortened lower cul-de-sac.

The conjunctival sxirface is smooth and glistening, and
looks as if tightly stretched over a waxy mass of an inde-
scribable yellowish-red color.

The cornea is surrounded by a wall of similar appear-
ance, which, save for the color, reminds one of the picture
sometimes seen in extreme chemosis.

The cornea shows a small point of ulceration at its infe-
rior temporal margin. The iris does not react to light, and
an opaque lens prevents any examination of the interior
of the eye. The globe is depressed by the mass above,
and motility is restricted in all directions. No enlarged
glands can be found in any part of the body.

An examination of the nose and naso -pharynx was
made for me, by Dr. H. M. Smith, and no appreciable
thickening of the lymphoid tissue in the pharyngeal vault,
nor at the base of the tongue, was discovered.

A small portion of the diseased tissue was removed for
examination. This operation occasioned little pain and
but the slightest reaction.

Unfortunately, further operation or observation of the
case was prevented by the death of the patient, which oc-
curred a few days later, from pneumonia.

The portion of the mass which was removed was exam-
ined by Dr. J: H. Van Cott, who reported as follows:

**Herewith, I beg to report findings from my microscopic



Digitized by VjOOQ IC



460 AMYLOID DEGENERATION OP THE CONJUNCTIVA.

examination of sections made by my colleague, Dr. Mur-
ray, from tissue removed from the conjunctiva of a woman
in your care, in the Immigrant service, at the Long Island
College Hospital. The tissue examined was removed by
myself, from a markedly bulging portion at the inferior
region of the inner canthus.

''In situ, it presented a pale,« semi- translucent appear-
ance and was fairly jBrm in consistence. Very little pain
was occasioned by its ablation, with scissors, and only
moderate hemorrhage.

'*The microscope revealed a typical amyloid degenera-
tion, originating in and around the arteries, capillaries
and venules and extending to all the subjacent tissues.

"There was a small amount of round cell infiltration.
No normal structures were found.

'Trusting this may be of service to you, I am,

"Yours faithfully,

"Joshua M. Van Cott."

Amyloid degeneration of the conjunctiva, or, more
properly, of the lid and subjunctival tissues, is a disease
but very infrequently observed, at least, in this country.

Russia seerbs to be the habitat of this disease, and most
of the recorded cases are from Northern Europe ; yet, this
case, occurring in an Italian, shows that it is not strictly
confined to northern latitudes:

The disease is said to begin in the retro -tarsal fold and
to pass over to the lid and eyeball.

The typical picture of a case of long standing, as given
by Fuchs,* is as follows:

"The patient cannot open the eye, because the lids,
transformed into large, misshapen swellings, cover it up.
If the lids are drawn as far apart as possible, the wax-like
conjunctiva is seen rising up under the form of a rigid
prominence, all about the cornea, which latter is either clear
or is covered by pannus. This swelling, belonging to the
fold of transmission, protrudes between the lids and the
eyeball, the plica semilunaris, also, is enlarged until it
forms a misshapen mass."

The progress of the disease, in typical cases, is said to
be very slow, and is attended with little inflammatory dis-

*Text Book of Oph., p. 99.

Digitized by VjOOQ IC



AMYLOID DEGENERATION OF THE CONJUNCTIVA. 451

turbance. It attacks, as a rule, patients in middle life
and, sometimes, is present in both eyes.

The degenerative process may be confined to a discrete
mass or nodule, but it mope often occurs as a diffuse infil-
tration.

Raehlmann,* who has made a very careful study of
the disease, makes out a clear clinical picture, which has
been further amplified by Kubli.t Kubli agrees with
Raehlmann that the disease is a purely local affection and
usually begins in the upper fold and neighboring por-
tions of the tarsal conjunctiva, where the normal sub-
conjunctival tissue most nearly resembles adenoid tissue.

The disease passes through four stages: —

1. Simple adenoid proliferation in the sub-conjunctival
tissue.

2. Hyaline degeneration.

3. Exquisite amyloid degeneration. «

4. Calcification and ossification.

First Phase. (Kubli) ^'Consists in a proliferation of
pure adenoid tissue in the sub-mucus layer of the con-
junctiva, or, in other words, hypertrophy of the normal
adenoid tissue of the region." .... **In appearance, if
the neoplasm is poorly supplied with vessels, it is gener-
ally of a bright yellow, glassy color and of a coarse, but
very elastic consistency; but, if highly vascular, its color
varies from an indescribably diaphanous reddish yellow
to a reddish brown, with a delicate, elastic consistency,"
etc.

Second Phase. "Is characterized by the smooth and
glistening surface of the tumor. When slightly vascular,
the tumor is generally brownish yellow and wax-like, with

numerous vessels unmistakably diaphanous The

tumors in this phase are harder than those in the first
phase and more elastic than those in the third."

Third Phase. * *Is characterized by a few, but important,
symptoms. The color of the tumor remains about the
same; it varies in consistency from hard to gelatinous,
but, even in the latter condition, the tissue is not elastic."

Fourth Phase. "Is characterized by calcification and

*Arch. Oph., X, p. 171; XI, p. 446.
tArch. Oph., X, p. 149.



Digitized by VjOOQ IC



452 AMYLOID DEGENERATION OP THE CONJUNCTIVA.

ossification, in addition to pronounoed amyloid degenera-
tion, as in the previous phases."

These calcified or ossified portions, Kubli remarks, are
often overlooked, as they may He deep in the tumor, and
are only discoverable on section, and are then not always
visible to the unaided eye.

The picture as here given is sufficiently definite, to be
easily recognizable, clinically, yet it is difficult to include
all the cases reported under this head, in the same group.
Dr. Chas. Steadman Bull* has described a case of '^Amyl-
oid Infiltration of the Lid and Orbit" of an active inflam-
matory type, which occured in a child 4^2 years old, of
Spanish parents, and markedly strumous. It began about
three weeks before the case presented itself, with a slight
redness, and swelling of the outer part of left upper lid,
and when first seen appeared to be a low grade cellulitis
of^the lid and its attachments. The swelling gradually
increased until it occupied the entire lid and invaded the
orbit, depressing the globe and causing exophthalmos.

The child complained of pain in the orbit and forehead,
and showed a decided rise in temperature. After the case
had been under observation for about 5 weeks a deep in-
cision was made, through the tissues of the lid and orbit,
but no pus was evacuated and the hemorrhage was but a
few drops, and this mostly from the vessels of the skin.
The child died several weeks later, but no autopsy was ob-
tained. The tissue removed at the time of operation, gave
the reaction of amyloid tissue, and proved on examination
to be infiltrated.

The infiltration involved the vessel walls and extending
for some distance into the connective tissue.

Amyloid degeneration of the conjunctiva has been held
by many authors to be a result of trachoma. A review of
the reported cases shows clearly that trachoma does not



Online LibraryGilbert Urbain GuillauminThe Annals of ophthalmology → online text (page 41 of 76)