332
KIPP: Sarcoma of the Choroid.
A CASE OF SARCOMA OF THE CHOROID, FOLLOWED BY PHTHISIS BULBI, AND TWENTY YEARS LATER BY PERFORATION OF THE ANTERIOR PART OF THE GLOBE AND RAPID GROWTH OF THE NEOPLASM. By CHARLES J. KIPP, M. D., NEWARK, N. J.
The patient from whom this eye was removed was first seen by me in I877, twenty-two years before I enucleated the eye. The patient was at that time sixty-four years old and in good health. A few days before she consulted me she had noticed for the first time that she was unable to see with her right eye. Some weeks before, this eye had suddenly become very red, but as she had no.pain she paid no attention to it and the redness passed away in a few days. When I saw her there was no injection of the conjunctiva and there were no other inflammatory symptoms. The cornea was clear, the anterior chamber of normal dimension, the iris normal in appearance. The pupil was small. After dilating the pupil by atropine the retina was found to be detached totally, but still transparent, and in the posterior part of the eye were seen two semi-globular masses of dark color, one springing from below and inwards and the other from outward and above. Each projected toward the axis of the eye with its convexity. Vessels could not be made out on the surface of the dark colored masses. The disk could not be made out, and onlv a red reflex could be obtained from the parts not hidden by the dark masses. The tension of the eye was normal. The other eye was healthy. I made the diagnosis of tumor of the choroid and told her to come again soon for another examination. She returned in about three months. At this time several opaque bands with smaller vessels on them were seen in the anterior part of the vitreous by oblique illumination. The detached retina
KIpP: Sarcoma of the Choroid.
.333'
was now opaque and the dark masses could no longer be seen. Otherwise there was no change in the appearance of the eye. I advised enucleation, but my advice was not accepted. Sixteen years later the patient consulted me again because her left eye was becoming blind. The notes made at this time stated that the right eye was atrophic, the cornea opaque and flat, that this eye is often painful but is not tender to the touch. The left eye I found to have incipient cataract, and the vitreous was full of floating membranous opacities. The disk and retina, as far as could be made out, were normal. Vision was reduced to 5/60. I was unable to ascertain from her just when the shrinking of the right eye had commenced. All that I could learn was that her eye had been very red and painful about a year after I saw the patient, that the inflammation had lasted many months, and that the eyeball had been smaller since then. It is therefore impossible to say whether a secondary glaucoma or a iridocyclitis caused the shrinking of the globe, and the appearance of the cornea did not enable me to make out whether it had been perforated or not. I again advised enucleation of this eye and prescribed iodide of potassium for the other. After this consultation I did not see the patient again for six years. She returned in November, I899, and her reason for visiting me was that she was fast losing strength in consequence of persistent heniorrhage from the right eye. At this time I found a large fungoid mass, somewhat of the shape of a mushroom, protruding through the palpebral fissure of the right eye, which on closer exAmination was found to be adherent to the anterior part of the shrunken globe and to move with it. The left eye was in fairly good condition. The cataract had not progressed much, and the vitreous was much clearer than at the previous visit. On inquiiry I learned that a darkish mass was seen on the anterior part of the eye about a year before, that is, twenty-one years after her first visit to me; that it had grown steadily since that time, and that it had bled a good deal for the last three months. She was now willing to have the eye removed. I enucleated under ether on the following day. The wound healed in a week,
334
Kipp: Sarcoma of the Choroid
and since then there has been no local relapse (July, I9OI). She had an attack of hemiplegia last year, but has partially regained the use of the paralyzed arm since then and is otherwise in fair health. Since the operation she has been entirely free from the pain in the head from which she had suffered for more than twenty years. The anatomical examination of the enucleated globe shows it to be greatly shrunken, most so in its anterior portion. The sclera is in part greatly thickened and wrinkled and the lamina cribrosa is also much thickened. The cornea, iris, and ciliary body are totally destroyed, and no trace can be found of the retina and choroid. The short globe is completely filled with a melanotic mass which seems to have perforated the sclero-corneal junction and spread out on the exterior part of the globe in the shape of a mushroom. The growth is a melano sarcoma in which spindle cells prevail. A more detailed microscopical examination will be published. We have here, then, a case of sarcoma of the choroid which caused phthisis bulbi. There is of course a possibility that the dark colored semi-globular mass projecting into the vitreous chamber from the sides of the fundjis which I saw on her first visit to me may have been masses- of blood, but it is much more probable that it was a new growth. I do not think that blood clots would have that shape and be situated behind the detached floating retina. The case throws no light on the cause of the phthisis, and it must remain unsettled whether it was due to secondary glaucoma or an iridochoroiditis or to perforation of the cornea. Whether the growth of the neoplasm was hindered by the phthisis is also uncertain. It certainly was of an uncommonly slow growth for over twenty years, though it grew with great rapidity after it had perforated the anterior part of the globe. It is not my intention to review the literature of this subject at this time, but shall only mention that Leber and Krahnstover (Archiv. fur Ophthalmologie, Band 45, p. 64) have lately studied the cause of phthisis of eyes containing sarcoma, and while thev
.
F:.F.
~~/
F.:
W.:: aweS:
t: : ^S
.:: i::;: l
j
,. 1
i-Globe.
Lower half. Globe and
2-
Tumor.
extra-ocular tumor.
KiPP. -Sarcoma choroid (%
natural size).
JACKSON: Double Panophthalnitis and Septicemia. 335 are inclined to the belief that it is due to an iridochoroiditis which is caused by the products of decay and degeneration of the neoplasm and by micro-organisms, they say that further evidence is necessary to prove this. As yet no one has been able to prove the presence of micro-organisms in such cases. Evetzky (ibid, p. 563), who studied this subject about the same time as Leber and Krahnstover, but independently of them, holds similar opinions as to the cause of the phthisis. 'His fifth case was somewhat similar in its history to the one related here, but the growth had caused greater destruction of the eyeball when it was removed.
DOUBLE PANOPHTHALMITIS AND SEPTICEMIA FROM ABSCESS OF THE KNEE. By EDWARD JACKSON, M.D., DENVER, COLO.
It is rare in rapidly fatal disease to have the ocular symptoms overshadow all others, and give the most positive and valuable evidence of the impending danger to life. The following case was of this character. It occurred at the Arapahoe County Hospital during my last term of service, and was at first regarded by the interne and others who saw it as a case of purulent conjunctivitis, a diagnosis that had a good deal to excuse it. P. P., female, aged about 45, a light mulatto, a native of South Carolina, was admitted to my service January 25, 1901. The only history obtainable was of inflammation beginning simultaneously in both eyes nine days previously. Within five days she had become absolutely blind. She was said otherwise not to have been sick; but we subsequently learned that she had been ailing for a couple of weeks. The left knee was somewhat swollen and painful; and there were several large blebs on the right foot and ankle. There was a fetid, purulent discharge from the vagina, but the patient denied any history of venereal disease.
KIPP: Sarcoma of the Choroid.
A CASE OF SARCOMA OF THE CHOROID, FOLLOWED BY PHTHISIS BULBI, AND TWENTY YEARS LATER BY PERFORATION OF THE ANTERIOR PART OF THE GLOBE AND RAPID GROWTH OF THE NEOPLASM. By CHARLES J. KIPP, M. D., NEWARK, N. J.
The patient from whom this eye was removed was first seen by me in I877, twenty-two years before I enucleated the eye. The patient was at that time sixty-four years old and in good health. A few days before she consulted me she had noticed for the first time that she was unable to see with her right eye. Some weeks before, this eye had suddenly become very red, but as she had no.pain she paid no attention to it and the redness passed away in a few days. When I saw her there was no injection of the conjunctiva and there were no other inflammatory symptoms. The cornea was clear, the anterior chamber of normal dimension, the iris normal in appearance. The pupil was small. After dilating the pupil by atropine the retina was found to be detached totally, but still transparent, and in the posterior part of the eye were seen two semi-globular masses of dark color, one springing from below and inwards and the other from outward and above. Each projected toward the axis of the eye with its convexity. Vessels could not be made out on the surface of the dark colored masses. The disk could not be made out, and onlv a red reflex could be obtained from the parts not hidden by the dark masses. The tension of the eye was normal. The other eye was healthy. I made the diagnosis of tumor of the choroid and told her to come again soon for another examination. She returned in about three months. At this time several opaque bands with smaller vessels on them were seen in the anterior part of the vitreous by oblique illumination. The detached retina
KIpP: Sarcoma of the Choroid.
.333'
was now opaque and the dark masses could no longer be seen. Otherwise there was no change in the appearance of the eye. I advised enucleation, but my advice was not accepted. Sixteen years later the patient consulted me again because her left eye was becoming blind. The notes made at this time stated that the right eye was atrophic, the cornea opaque and flat, that this eye is often painful but is not tender to the touch. The left eye I found to have incipient cataract, and the vitreous was full of floating membranous opacities. The disk and retina, as far as could be made out, were normal. Vision was reduced to 5/60. I was unable to ascertain from her just when the shrinking of the right eye had commenced. All that I could learn was that her eye had been very red and painful about a year after I saw the patient, that the inflammation had lasted many months, and that the eyeball had been smaller since then. It is therefore impossible to say whether a secondary glaucoma or a iridocyclitis caused the shrinking of the globe, and the appearance of the cornea did not enable me to make out whether it had been perforated or not. I again advised enucleation of this eye and prescribed iodide of potassium for the other. After this consultation I did not see the patient again for six years. She returned in November, I899, and her reason for visiting me was that she was fast losing strength in consequence of persistent heniorrhage from the right eye. At this time I found a large fungoid mass, somewhat of the shape of a mushroom, protruding through the palpebral fissure of the right eye, which on closer exAmination was found to be adherent to the anterior part of the shrunken globe and to move with it. The left eye was in fairly good condition. The cataract had not progressed much, and the vitreous was much clearer than at the previous visit. On inquiiry I learned that a darkish mass was seen on the anterior part of the eye about a year before, that is, twenty-one years after her first visit to me; that it had grown steadily since that time, and that it had bled a good deal for the last three months. She was now willing to have the eye removed. I enucleated under ether on the following day. The wound healed in a week,
334
Kipp: Sarcoma of the Choroid
and since then there has been no local relapse (July, I9OI). She had an attack of hemiplegia last year, but has partially regained the use of the paralyzed arm since then and is otherwise in fair health. Since the operation she has been entirely free from the pain in the head from which she had suffered for more than twenty years. The anatomical examination of the enucleated globe shows it to be greatly shrunken, most so in its anterior portion. The sclera is in part greatly thickened and wrinkled and the lamina cribrosa is also much thickened. The cornea, iris, and ciliary body are totally destroyed, and no trace can be found of the retina and choroid. The short globe is completely filled with a melanotic mass which seems to have perforated the sclero-corneal junction and spread out on the exterior part of the globe in the shape of a mushroom. The growth is a melano sarcoma in which spindle cells prevail. A more detailed microscopical examination will be published. We have here, then, a case of sarcoma of the choroid which caused phthisis bulbi. There is of course a possibility that the dark colored semi-globular mass projecting into the vitreous chamber from the sides of the fundjis which I saw on her first visit to me may have been masses- of blood, but it is much more probable that it was a new growth. I do not think that blood clots would have that shape and be situated behind the detached floating retina. The case throws no light on the cause of the phthisis, and it must remain unsettled whether it was due to secondary glaucoma or an iridochoroiditis or to perforation of the cornea. Whether the growth of the neoplasm was hindered by the phthisis is also uncertain. It certainly was of an uncommonly slow growth for over twenty years, though it grew with great rapidity after it had perforated the anterior part of the globe. It is not my intention to review the literature of this subject at this time, but shall only mention that Leber and Krahnstover (Archiv. fur Ophthalmologie, Band 45, p. 64) have lately studied the cause of phthisis of eyes containing sarcoma, and while thev
.
F:.F.
~~/
F.:
W.:: aweS:
t: : ^S
.:: i::;: l
j
,. 1
i-Globe.
Lower half. Globe and
2-
Tumor.
extra-ocular tumor.
KiPP. -Sarcoma choroid (%
natural size).
JACKSON: Double Panophthalnitis and Septicemia. 335 are inclined to the belief that it is due to an iridochoroiditis which is caused by the products of decay and degeneration of the neoplasm and by micro-organisms, they say that further evidence is necessary to prove this. As yet no one has been able to prove the presence of micro-organisms in such cases. Evetzky (ibid, p. 563), who studied this subject about the same time as Leber and Krahnstover, but independently of them, holds similar opinions as to the cause of the phthisis. 'His fifth case was somewhat similar in its history to the one related here, but the growth had caused greater destruction of the eyeball when it was removed.
DOUBLE PANOPHTHALMITIS AND SEPTICEMIA FROM ABSCESS OF THE KNEE. By EDWARD JACKSON, M.D., DENVER, COLO.
It is rare in rapidly fatal disease to have the ocular symptoms overshadow all others, and give the most positive and valuable evidence of the impending danger to life. The following case was of this character. It occurred at the Arapahoe County Hospital during my last term of service, and was at first regarded by the interne and others who saw it as a case of purulent conjunctivitis, a diagnosis that had a good deal to excuse it. P. P., female, aged about 45, a light mulatto, a native of South Carolina, was admitted to my service January 25, 1901. The only history obtainable was of inflammation beginning simultaneously in both eyes nine days previously. Within five days she had become absolutely blind. She was said otherwise not to have been sick; but we subsequently learned that she had been ailing for a couple of weeks. The left knee was somewhat swollen and painful; and there were several large blebs on the right foot and ankle. There was a fetid, purulent discharge from the vagina, but the patient denied any history of venereal disease.
