NOTES, CASES, I N S T R U M E N T S 253

no recurrence of the tumor has been noted.

CASE 2

A white man, aged 83 years, who is afflicted

with Parliinson's disease, complained of a

growth on his left eye for over one year.

Examination revealed visual acuity to be

limited to light perception in both eyes. A

diffuse, hyperplastic, mulberry-type lesion

was seen at the limbal margin of the left eye

on the temporal aspect. This growth involved

approximately five mm. of the corneal sur­

face. The patient had bilateral senile cataracts

which were responsible for the impairment

of vision. A biopsy showed the lesion to be

epidermoid carcinoma, grade I I I .

After due consideration, it was decided to

enucleate the left eye. The patient has been

carefully followed for the past nine months.

His condition is good, with no external evi­

dence of recurrence of the tumor.

SUMMARY

Epitheliomas of the eye are slow growing

and of a low-grade malignancy, as compared

with epitheliomas elsewhere.

In adults, malignant tumors of the con­

junctiva occur as frequently as benign

tumors. This is most important to the physi­

cian who must decide, after careful study of

the patient and the existing lesion, what type

of therapy is best in each individual case.

711 South Jefferson Street.

R E G R E S S I O N O F R U B E O S I S

I R I D I S F O L L O W I N G

C Y C L O D I A T H E R M Y *

PHILIP P . ELLIS, M.D.

Iowa City, Iowa

The exact mechanism of action of cyclodi­athermy in lowering intraocular pressure is not completely understood. Whether it acts primarily to destroy the secretory function of the ciliary body by interfering with its vas-

• From the Department of Ophthalmology, Uni­versity of Nebraska, Omaha, Nebraska.

cular supply or whether it serves to stimulate

the formation of a new anastomotic group of

vessels and thus affect aqueous outflow has

not been established.

I t has previously been observed that, at

the time of surgery, there may be a tempo­

rary disappearance of rubeosis iridis when

the cyclodiathermy needle is introduced.^

Presumably this was due to a temporary

vasoconstrictor effect.

The following case is reported because it

is believed unique in that in a follow-up

period of 10 months after cyclodiathermy the

rubeosis iridis has not yet returned and be­

cause the disappearance of the rubeosis de­

veloped several weeks after surgery.

CASE REPORT

History. G. L., a 57-year-old white

woman, was first seen in the University Eye

Clinic on December 3, 1953, with pain, red­

ness, halos in the left eye for one month. She

had consulted an out-of-state ophthalmologist

who told her she had glaucoma and gave her

some drops to use ; this medication did not

relieve her symptoms.

She had been a known diabetic since 1942,

and was fairly well controlled on 25 units

of insulin daily. In the past two to three

years she had been told that she had high

blood pressure. The vision in her right eye

became poor several years ago ; a diagnosis

of an intraocular hemorrhage had been made.

Examination. Vision in the right eye was

counting fingers at two feet and in the left

eye hand movements only. Tension in the

right eye was 14 mm. H g and in the left

eye, 57 mm. H g (Schiøtz) . Externally, on

the right, no rubeosis was noted; on the left,

advanced rubeosis iridis (fig. 1 ) , corneal

edema, and ciliary congestion were observed.

Ophthalmoscopic examination. I n the

right eye, a large subhyaloid hemorrhage was

seen below the macula extending across the

entire retina. In addition a few scattered

round hemorrhages (microaneurysms) and

hard, yellow, waxy exudates were observed.

The vessels showed a moderate amount of

254 NOTES, CASES, I N S T R U M E N T S

I I

I \

\ \ \

\ I

t I

/ I / '

/ /

A. 6. C. Fig. 1 (Ellis). ( A ) Initial examination in December, 1953. (B) Three weeks after cyclodiathermy.

(C) Seven weeks after cyclodiathermy.

sclerosis. In the left eye, there were oc­

casional microaneurysms and hard yellow

exudates. The nerve was slightly pale with

some early cupping below.

Hospital course. The patient was started

on intensive miotic therapy, and the pressure

fell only to 50 mm. Hg. Retrobulbar injec­

tion of 1.5 cc. of two-percent procaine with

epinephrine lowered the tension to 39 mm.

H g but it rose in about 12 hours to 72 mm.

Hg. The patient developed severe nausea and

vomiting.

On December 7, 1953, the patient had a

cyclodiathermy performed on the left eye in

the inferior quadrants. The technique used

was as fol lows: After a conjunctival flap was

made from 3- to 9-o'clock positions below,

approximately six mm. from the limbus, two

rows of partial penetrating 0.5-mm. dia­

thermy punctures were made between the

medial and inferior rectus and between the

lateral and inferior rectus six and eight mm.,

respectively, from the limbus. T w o 1.5-mm.

perforating punctures were placed between

the two rows of diathermy on each side.

There was some fluid loss and the eye was

quite soft at the close of the procedure.

Postoperatively the eye showed only a

slight reaction. The cornea stayed clear; the

conjunctiva healed well. The pressure was

17 mm. H g (Schiøtz) on the third day and

began to rise a week later until it reached

42 mm. H g three weeks after surgery.

On December 31, 1953, the patient had

cyclodiathermy, performed as described, on

the left eye in the superior quadrants. Fol­

lowing this procedure the pressure stabilized

at about 18 mm. H g and remained there for

the next three weeks of the hospital stay.

The patient's blood sugars ranged from

150 to 295 mg. percent. The blood pressure

was 170/70 mm. Hg. Urinalysis showed one-

plus albumin and occasional white cells. The

liver function tests were normal. The electro­

cardiogram was normal, and the P.S.P. test

showed 25- to 30-percent dye retention.

Follow-up record. The patient was seen in

the clinic on January 20, 1954, and at that

time the vision of the right eye was hand

movements, and of the left eye 5/200. The

tension of the right eye was 14 mm. Hg, and

the left, 10 mm. Hg. On slitlamp examination

the rubeosis was seen to be regressing (fig.

1 ) . The peripupillary vessels were com­

pletely gone and only a few vessels on the

outer portion of the iris remained.

On ophthalmoscopic examination the right

eye was the same as before hospitalization.

The left eye showed fresh hemorrhages in

the macular region.

On February 3rd, tension in the right eye

was 12 mm. H g and in the left, 16 mm. Hg .

There was further decrease in the amount

of rubeosis. The patient began to get some

proliferative retinopathy with fibrotic bands

radiating from the disc about one to two disc

diameters from the optic nerve.

On February 14th, tension in the right eye

was 10 mm. H g and in the left, 15 mm. Hg .

The rubeosis had completely disappeared ex-

NOTES, CASES. I N S T R U M E N T S 255

cept for one small vessel at the 8-o'clock position (fig. I ) . The proliferative retinop­athy had increased. The patient was re­ferred for posterior X-ray irradiation of the globes. This course of treatment was com­pleted, and the patient was not seen again until May, 1954, at which time her vision was reduced to hand movements in each eye. The appearance of the left iris was the same as on the last visit. Ophthalmoscopically both eyes showed extensive retinitis proliferans. Tension on the right was 17 mm. H g and on the left, 12 mm. Hg.

The patient was last seen in October, 1954. Her eyes remained unchanged. Tension on the left was down to 10 mm. Hg . Her gen­eral health was failing; her diabetes was be­coming more resistant to treatment, she showed renal damage and was presumed to have Kimmelstiel-Wilson's disease.

COMMENT

In view of the positioning of the diathermy points—six and eight mm. from the limbus between the recti muscles—it must be pre­sumed that the anastomotic vessels of the anterior ciliary and the posterior long ciliary arteries were at least partially destroyed. This destruction apparently involved the direct source of the vessels forming the rubeosis iridis.

University Hospitals.

REFERENCE

1. Rubin, E., Romig, J., and Molloy, J. H . : Early results in perforating cyclodiathermy in glaucoma. Am. J. Ophth., 35:1035 (July) 1952.

R E M O V A B L E G U A R D F O R B A R D - P A R K E R K N I F E B L A D E *

ROBERT A. SILLS, M.D. San Diego, California

The use of a guard on a knife blade for controlled depth of incisions is not new. The guard here presented has the advantage of being adapted to the Bard-Parker No. 15 disposable blade.

A protecting shelf approximately one mm. in width is made 0.5 mm. from the cutting edge, per­mitting a controlled incision of this depth for any pur­pose, such as pre-placed grooves for McLean sutures, and so forth. It should be noted that the shelf is limited

Fig. 1 (Sills). Guard for , · j r Bard-Parker knife blade. ^0 one side of the

blade so that the other side may be used not only to sight the line of incision but also to permit the blade to be placed directly against a conjunctival flap if necessary.

The method of preparation of the guard was that of a routine dental investment cast­ing procedure done by practically all dental laboratories. Cost of the gold was approxi­mately four dollars.

Front Street (3).

•From the San Diego County General Hospital.