KIPP: Four Cases of Sarcoma of the Uveal Tract.
557
FOUR CASES OF SARCOMA OF THE UVEAL TRACT. (With Woodcut.)
BY CHARLES J. KIPP, MI.D., NEWARK, N. J.
CASE I. MlVelano-Sarcoma of Ciliary Body and Adlacent Choroid and Iris.-Mrs. H. H., of American birth, seventy years of age, was first seen July 3, I882. Is in pretty good health. Is not aware that the eye about which she wishes advice has ever been injured. The right eye is apparently normal in every respect; the left eye has been blind for six months. There is not now, and there never has been, any pain in the eye itself. Occasionally she has had a " drawing" pain about the eye. On examination of the left (blind) eye, the anterior parts were found to be healthy; there were no signs of irritation; pupil was of medium size; the lens was not very clear. After dilating the pupil with atropine, examination with oblique illumination showed, not far behind lens, in temporal half of vitreous chamber, a large yellowish-white mass of nearly round form, on the anterior surface of which were a number of small red patches (hemorrhages). On nasal side the retina seemed detached and floating about. The eye could not be illuminated with ophthalmo. scope; the eye was totally blind. Tn. The mobility of the eye was unimpaired in every direction. Enucleation of globe was advised but not accepted. Six weeks later the patient returned with the statenlent that she had suffered very great pain ever since her visit to me. There was now great chemosis and injection of the whole ocular conjunctiva. The swelling around the cornea was so great that the cornea was almost hidden by it; the
558 KIPP: Four Casesv of Sarcoma of the Uveal Tract. cornea was steamy. The anterior chamber was very shallow and the pupil very widely dilated. T. +2. The eye was enucleated on following day and the wound healed kindly and rapidly. Six weeks later there was no relapse. On opening the eye two-thirds of the vitreous chamber was found to be occupied by a round tumor, of a dark color, which sprang from the ciliary body and the anterior part of the choroid. The anterior surface of the tumor was loosely covered by the thickened and opaque retina. After the tumor had been hardened it was examined microscopically and was found to be made up of large spindle-shaped cells, many of which contained pigment. There was scarcely any intercellular substance. Numerous blood-vessels and many free masses of pigment were found all through the tumor. The retina had undergone connective-tissue degeneration. The base of the tumor was in close contact with the sclerotic throughout, and in several places the inner layer of the sclerotic only was invaded by round and oval cells. The iris adjoining the tumor was much thickened by the infiltration of round and oval cells. CASE II. Melano-Sarcoma of Choroid in an Eye which Twenty Years before had Suffered from Chorio-Retinitis.W. P. R., American, thirty-four years of age, was first seen at Newark Charitable Eye and Ear Infirnmary, August 21, j882. With the exception of an ozwna was in good health. States that twenty years ago he had a severe eye trouble, since which time his vision has been somewhat impaired in both, but more especially in the left eye. Since two months he has noticed gradual failure of sight in the right, which formerly was his best eye. The eye has not been injured. It is emmetropic, S. W, The visual field was defective in outer half and much contracted in all other directions. Tn. On examination nothing abnormal was detected in anterior half of eye; the media were perfectly clear. On looking into the vitreous chamber after the pupil was dilated the attention was at once arrested by a semi-globular tumor which nearly filled the nasal half of the chamber. The most projecting part of
KIPP: Four Cases of Sarcoma of the Uveal Tract. 559 the tumor reached nearly the vistial axis of the eye. The surface of the tumor was perfectly smooth and of a yellowishred, mottled appearance; it was covered by the transparent retina, the vessels of which could be readily distinguished from those of the tumor. With the exception of a slight detachment at the base of the tumor, the retina was in its place. The optic disk was white and opaque and its margin was slightly blurred; the vessels were very thin. A little below the disk there was an atropic patch in the choroid. The left eye showed a white opaque disk, small retinal vessels, numerous small atrophic spots in choroid, especially at periphery, and numerous pigment deposits of irregular form in different parts of the retina, S. . Field concentrically contracted. Hemeralopia. Although the sight of the right eye was still tolerably good, I advised immediate enucleation of this eye, which advice the patient declined to follow. On May 12, I883, I saw the patient again. He was now nearly frantic with pain in the right eye and the whole head. His eye presented the appearance of an acute inflammatory glaucoma. The media were so turbid that the interior of the eye could not be illunminated. T. + 2. I enucleated the eye on the same day; the wound healed rapidly. Up to date there are no signs of a relapse. The eye was opened immediately after enucleation, and presented the following appearance: Retina detached in the form of a funnel. On nasal side a large dark tumor of irregular form, which was attached to choroid by a moderately broad base. In the choroid, especially at periphery, were many spots of much lighter color than the rest of this membrane. The microscopical examination of the tumor showed it to be made up of small spindle-shaped cells, very few of which contained pigment. The tumor was very vascular and contained many free masses of pigment. The tumor probably originated in the outer layer of the choroid, as the chorio capillaris could be more or less distinctly made out in different parts of the tumor. The base of the tumor was in close con-
560 KiPP: Four Cases of Sarcomna of the Uveal Tract. tact with the sclerotic, which was, however, free from sarcomatous elements. CASE III. Sarcoma of Choroid, originating in the Region of the Macula.-Mrs. I., American, forty-one years of age, a large, healthy-looking woman, consulted me for the first time February 12, I882. Loss of sight of right eye was her only complaint. Impairment of vision was first noticed a year ago, but located ih right eye by accidental closing of the left only three months ago. There was no pain; the eye had not been injured. The anterior half of eye presented nothing abnormal. Refractive media were perfectly clear. The only abnormity visible was an opacity and a projection of the retina in the region of the macula. The retina was of a grayish hue over a round space equal to perhaps three diameters of the disk. At the periphery of this space the grayish tint gradually faded. Running horizontally across this space were several lines of somewhat lighter color, which did not, however, change their places with movements of the eye. The retinal vessels were of normal. number and regularly distributed. They were uncommonly distinct in the opaque retina. The summit of the protuberance was best seen with a + 4 dioptrics glass, while the rest of the fundus was best seen without a convex glass by the emmetropic eye. The sides of the elevation sloped gradually to the normal level. No fluid could be discovered behind the opaque retina, and there were no signs of a cysticerqus. The remainder of the retina was entirely normal, and the choroid was apparently healthy. The disk was normal. There was a large central scotoma corresponding to the opaque area in the retina. Peripheral vision was about the same as in the other (good) eye. Tn. I suspected a choroidal tumor, and so informed my associates at the Infirmary, but did not inform the patient of my suspicions. She was kept under observation for several months, during which time she took considerable quantities of the iodide of potassium, which greatly relieved her headaches but had no appreciable effect on the eye. As she did not improve under treatment, she discontinued her visits to me
KiPP: Four Cases of Sarcoma of the Uveal Tract.
56i
in May of the same year. During the three months she was under observation I examined the eye carefully about once a week, but was not able to discover at any time a change in the eye. About fifteen months after her last visit she called on me again. She had then been suffering great pain in eye and head for several weeks. The eye presented the ordinary symptoms of acute inflammatory glaucoma. T. + 2. I enucleated the eye July 8, I883. The operation was performed in the usual way, and the7wound healed in six days. The eye was divided by a horizontal section. The retina was detached everywhere, except at the optic nerve entrance and at region of ora serrata. A large tumor, dark in color, and irregularly pyramidal in form, was connected with choroid from the optic nerve entrance to the equator. It consisted of spindle-shaped cells, and contained but little pigment. It probably started from the outer layer of the choroid, as the chorio capillaris was tolerably well preserved in many parts of the surface of the tumor. Although in contact with the sclerotic over a large space, no sarcomatous cells were found in this membrane. In a paper on the " Diagnosis of Intra-ocular Sarcomata,"' Becker says: " Choroidal sarcomata originating in the region of the macula seem from- the very beginning to have but little disposition to proliferate in the interior of the eye, but are prone to develop posteriorly in the orbit." That this does not always occur is proved by the above case. CASE IV. Melano-Sarcoma of Ciliary Body and Iris.Mrs. C. D., a healthy-looking woman, forty-two years of age, consulted me for the first time in August, I875, for the purpose of obtaining relief from great pain in her left eye. According to her statement, this eye had never been injured and its sight was good till a few mnonths ago, when she accidentally noticed that she was unable to recognize large objects with it. Up to a fortnight before she came to me the eye had never been uneasy, but since then she has suffered I
Archives of Ophthalmology and Otology, vol. i., page 694.
562 KIPP: Four Cases of Sarcoma of the Uveal Tract. very much from pain in and about the eye. On examination it was found that she had only perception of light. The tension was markedly increased (T. + 2). The-lids were healthy. The eye was of normal size and form, and its mobility was unimpaired. The conjunctiva was healthy. Around the cornea was a zone of enlarged subconjunctival veins, several of which pierced the sclerotic about 3 mm. from cornea. The cornea was normal, the anterior chamber of nor, mal depth, and the aqueous quite clear. The pupil was widely dilated and almost immovable.' On looking at the iris, attention was at once attracted to the middle part of the temporal half, which was swollen and of a dark slate color. This swelling extended about two millimetres above and below the horizontal meridian, and from the periphery to within I mm. of the pupillary margin. The anterior surface of the swelling was in contact with Descemet's membrane. The remaining part of the iris was of same color as the other eye, and of normal texture. The lens was transparent, and apparently in its proper place. The vitreous body was somewhat hazy. The fundus oculi presented the usual appearances of chronic inflammatory glaucoma, viz., a kettle-form excavation reaching to the margin of the disk, distention and tortuosity of the retinal veins, and spontaneous pulsation of the arteries on the papilla. The choroid was normal. When the eye was abducted as far as possible, an indistinct, circumscribed, dark, reflex was obtained from the outer ciliary region, on a line with the swelling of the iris. With the oblique illumination a similar reflex was observed in the same position. Believing the case to be one of sarcoma of the iris and ciliary body, with secondary glaucoma, I advised the enucleation of the eyeball, and performed the operation in the usual manner three days later. The wound healed by first intention, and four days after the operation the patient was discharged from the hospital. Nearly nine years have now passed since the eye was removed, and as yet there are no signs of a relapse. The patient is in good general health. An examination of the eyeball by transmitted sunlight, im-
KIPP: Four Cases of Sarcoma of the Uveal Tract.
563
mediately after the operation, show'ed it to be perfectly transpaient, except at the outer ciliary region, where a dark mass was seen to project toward the axis of the eye. The eye was hardened in Muller's fluid, and opened by a section passing through the middle of the tumor. The cornea and sclera were apparently normal. In contact with the inner surface of the cornea and sclera, on the temporal side of the eye, was seen a growth of irregular form, occupying the place of the ciliary body and extending into the anterior chamber. This growth extended backward to the junction of the ciliary body and the choroid, and anteriorly about three millimetres into the anterior chamber; it occupies about eight millimetres of the circumference of the ciliary body, and measures at its most projecting point (immediately posterior to the equator of the lens) about four millimetres in thickness. Its posterior s9rface is convex, of a dark color, and closely covered by the membrana ciliaris retinae. After the removal of the latter it is seen that whilst on the middle portion of the posterior surface the ciliary processes had entirely disappeared in the growth, they were preserved near the nmargins of the tumor. In its forward growth the tumor had detached the iris from its connection with the cornea for a space measuring about six millimetres in width, so that the iris appeared to grow out of the tuinor. The iris itself was greatly swollen when it was in immediate connection with the tumor, but in every other part it appeared normal. Of the zonula zinnii, the part in contact with the tumor had almost entirely disappeared, probably by atrophy from pressure. The lens was perfectly transparent, and in its proper place, but its form has undergone a change in such a way that the antero-posterior diameter of the outer half was increased at the expense of its equatorial diameter. The nasal half of the 'lens was apparently of normal curvature. The vitreous body showed no abnormity. The ciliary body appeared healthy outside of the region occupied by the
564
KIPP: Case of Ossification of the Clhoroid.
tumor., The choroid and retina were in normal position, and showed no abnormity. The optic papilla was deeply excavated. The microscopic examination showed the growth to be a very vascular melano-sarcoma, which had probably originated in the inter-muscular conjunctive tissue of the ciliary muscle, and subsequently invaded the iris. REMARKS.
DR. MITTENDORF asked Dr. Kipp if he had seen metastatic sarcoma of the choroid ? DR. KiPP replied that he had not. THE PRESIDENT remarked that in relation to these tumors of the choroid, there was a point which might deserve consideration, that is, under what circumstances the tension might be increased or diminished, or the eye remain normal. The clinical history in such cases in this particular is very vague, and we can scarcely predict when that condition may be expected to arise.
CASE OF OSSIFICATION OF THE CHOROID. BY CHARLES J. KIPP, M.D., NEWARK, N. J.
THE eye was removed from a young man, twenty-two years of age, who was first seen ten years before the eye was enucleated. At that time the eye was free from all signs of irritation. There was an adherent chalky cataract, which, according to statements of the child's parents, was first noticed by them shortly after birth. The iris was atrophic. The eye diverged, and had but imperfect perception of light. As the case was hopeless so far as the restoration of sight was concerned no treatment was advised. Ten years later the patient was seen again. He was now suffering great pain in the. eye. There was much circumcorneal injection. The cornea was clear, the anterior chamber of normal dimensions, and the aqueous clear. The iris
557
FOUR CASES OF SARCOMA OF THE UVEAL TRACT. (With Woodcut.)
BY CHARLES J. KIPP, MI.D., NEWARK, N. J.
CASE I. MlVelano-Sarcoma of Ciliary Body and Adlacent Choroid and Iris.-Mrs. H. H., of American birth, seventy years of age, was first seen July 3, I882. Is in pretty good health. Is not aware that the eye about which she wishes advice has ever been injured. The right eye is apparently normal in every respect; the left eye has been blind for six months. There is not now, and there never has been, any pain in the eye itself. Occasionally she has had a " drawing" pain about the eye. On examination of the left (blind) eye, the anterior parts were found to be healthy; there were no signs of irritation; pupil was of medium size; the lens was not very clear. After dilating the pupil with atropine, examination with oblique illumination showed, not far behind lens, in temporal half of vitreous chamber, a large yellowish-white mass of nearly round form, on the anterior surface of which were a number of small red patches (hemorrhages). On nasal side the retina seemed detached and floating about. The eye could not be illuminated with ophthalmo. scope; the eye was totally blind. Tn. The mobility of the eye was unimpaired in every direction. Enucleation of globe was advised but not accepted. Six weeks later the patient returned with the statenlent that she had suffered very great pain ever since her visit to me. There was now great chemosis and injection of the whole ocular conjunctiva. The swelling around the cornea was so great that the cornea was almost hidden by it; the
558 KIPP: Four Casesv of Sarcoma of the Uveal Tract. cornea was steamy. The anterior chamber was very shallow and the pupil very widely dilated. T. +2. The eye was enucleated on following day and the wound healed kindly and rapidly. Six weeks later there was no relapse. On opening the eye two-thirds of the vitreous chamber was found to be occupied by a round tumor, of a dark color, which sprang from the ciliary body and the anterior part of the choroid. The anterior surface of the tumor was loosely covered by the thickened and opaque retina. After the tumor had been hardened it was examined microscopically and was found to be made up of large spindle-shaped cells, many of which contained pigment. There was scarcely any intercellular substance. Numerous blood-vessels and many free masses of pigment were found all through the tumor. The retina had undergone connective-tissue degeneration. The base of the tumor was in close contact with the sclerotic throughout, and in several places the inner layer of the sclerotic only was invaded by round and oval cells. The iris adjoining the tumor was much thickened by the infiltration of round and oval cells. CASE II. Melano-Sarcoma of Choroid in an Eye which Twenty Years before had Suffered from Chorio-Retinitis.W. P. R., American, thirty-four years of age, was first seen at Newark Charitable Eye and Ear Infirnmary, August 21, j882. With the exception of an ozwna was in good health. States that twenty years ago he had a severe eye trouble, since which time his vision has been somewhat impaired in both, but more especially in the left eye. Since two months he has noticed gradual failure of sight in the right, which formerly was his best eye. The eye has not been injured. It is emmetropic, S. W, The visual field was defective in outer half and much contracted in all other directions. Tn. On examination nothing abnormal was detected in anterior half of eye; the media were perfectly clear. On looking into the vitreous chamber after the pupil was dilated the attention was at once arrested by a semi-globular tumor which nearly filled the nasal half of the chamber. The most projecting part of
KIPP: Four Cases of Sarcoma of the Uveal Tract. 559 the tumor reached nearly the vistial axis of the eye. The surface of the tumor was perfectly smooth and of a yellowishred, mottled appearance; it was covered by the transparent retina, the vessels of which could be readily distinguished from those of the tumor. With the exception of a slight detachment at the base of the tumor, the retina was in its place. The optic disk was white and opaque and its margin was slightly blurred; the vessels were very thin. A little below the disk there was an atropic patch in the choroid. The left eye showed a white opaque disk, small retinal vessels, numerous small atrophic spots in choroid, especially at periphery, and numerous pigment deposits of irregular form in different parts of the retina, S. . Field concentrically contracted. Hemeralopia. Although the sight of the right eye was still tolerably good, I advised immediate enucleation of this eye, which advice the patient declined to follow. On May 12, I883, I saw the patient again. He was now nearly frantic with pain in the right eye and the whole head. His eye presented the appearance of an acute inflammatory glaucoma. The media were so turbid that the interior of the eye could not be illunminated. T. + 2. I enucleated the eye on the same day; the wound healed rapidly. Up to date there are no signs of a relapse. The eye was opened immediately after enucleation, and presented the following appearance: Retina detached in the form of a funnel. On nasal side a large dark tumor of irregular form, which was attached to choroid by a moderately broad base. In the choroid, especially at periphery, were many spots of much lighter color than the rest of this membrane. The microscopical examination of the tumor showed it to be made up of small spindle-shaped cells, very few of which contained pigment. The tumor was very vascular and contained many free masses of pigment. The tumor probably originated in the outer layer of the choroid, as the chorio capillaris could be more or less distinctly made out in different parts of the tumor. The base of the tumor was in close con-
560 KiPP: Four Cases of Sarcomna of the Uveal Tract. tact with the sclerotic, which was, however, free from sarcomatous elements. CASE III. Sarcoma of Choroid, originating in the Region of the Macula.-Mrs. I., American, forty-one years of age, a large, healthy-looking woman, consulted me for the first time February 12, I882. Loss of sight of right eye was her only complaint. Impairment of vision was first noticed a year ago, but located ih right eye by accidental closing of the left only three months ago. There was no pain; the eye had not been injured. The anterior half of eye presented nothing abnormal. Refractive media were perfectly clear. The only abnormity visible was an opacity and a projection of the retina in the region of the macula. The retina was of a grayish hue over a round space equal to perhaps three diameters of the disk. At the periphery of this space the grayish tint gradually faded. Running horizontally across this space were several lines of somewhat lighter color, which did not, however, change their places with movements of the eye. The retinal vessels were of normal. number and regularly distributed. They were uncommonly distinct in the opaque retina. The summit of the protuberance was best seen with a + 4 dioptrics glass, while the rest of the fundus was best seen without a convex glass by the emmetropic eye. The sides of the elevation sloped gradually to the normal level. No fluid could be discovered behind the opaque retina, and there were no signs of a cysticerqus. The remainder of the retina was entirely normal, and the choroid was apparently healthy. The disk was normal. There was a large central scotoma corresponding to the opaque area in the retina. Peripheral vision was about the same as in the other (good) eye. Tn. I suspected a choroidal tumor, and so informed my associates at the Infirmary, but did not inform the patient of my suspicions. She was kept under observation for several months, during which time she took considerable quantities of the iodide of potassium, which greatly relieved her headaches but had no appreciable effect on the eye. As she did not improve under treatment, she discontinued her visits to me
KiPP: Four Cases of Sarcoma of the Uveal Tract.
56i
in May of the same year. During the three months she was under observation I examined the eye carefully about once a week, but was not able to discover at any time a change in the eye. About fifteen months after her last visit she called on me again. She had then been suffering great pain in eye and head for several weeks. The eye presented the ordinary symptoms of acute inflammatory glaucoma. T. + 2. I enucleated the eye July 8, I883. The operation was performed in the usual way, and the7wound healed in six days. The eye was divided by a horizontal section. The retina was detached everywhere, except at the optic nerve entrance and at region of ora serrata. A large tumor, dark in color, and irregularly pyramidal in form, was connected with choroid from the optic nerve entrance to the equator. It consisted of spindle-shaped cells, and contained but little pigment. It probably started from the outer layer of the choroid, as the chorio capillaris was tolerably well preserved in many parts of the surface of the tumor. Although in contact with the sclerotic over a large space, no sarcomatous cells were found in this membrane. In a paper on the " Diagnosis of Intra-ocular Sarcomata,"' Becker says: " Choroidal sarcomata originating in the region of the macula seem from- the very beginning to have but little disposition to proliferate in the interior of the eye, but are prone to develop posteriorly in the orbit." That this does not always occur is proved by the above case. CASE IV. Melano-Sarcoma of Ciliary Body and Iris.Mrs. C. D., a healthy-looking woman, forty-two years of age, consulted me for the first time in August, I875, for the purpose of obtaining relief from great pain in her left eye. According to her statement, this eye had never been injured and its sight was good till a few mnonths ago, when she accidentally noticed that she was unable to recognize large objects with it. Up to a fortnight before she came to me the eye had never been uneasy, but since then she has suffered I
Archives of Ophthalmology and Otology, vol. i., page 694.
562 KIPP: Four Cases of Sarcoma of the Uveal Tract. very much from pain in and about the eye. On examination it was found that she had only perception of light. The tension was markedly increased (T. + 2). The-lids were healthy. The eye was of normal size and form, and its mobility was unimpaired. The conjunctiva was healthy. Around the cornea was a zone of enlarged subconjunctival veins, several of which pierced the sclerotic about 3 mm. from cornea. The cornea was normal, the anterior chamber of nor, mal depth, and the aqueous quite clear. The pupil was widely dilated and almost immovable.' On looking at the iris, attention was at once attracted to the middle part of the temporal half, which was swollen and of a dark slate color. This swelling extended about two millimetres above and below the horizontal meridian, and from the periphery to within I mm. of the pupillary margin. The anterior surface of the swelling was in contact with Descemet's membrane. The remaining part of the iris was of same color as the other eye, and of normal texture. The lens was transparent, and apparently in its proper place. The vitreous body was somewhat hazy. The fundus oculi presented the usual appearances of chronic inflammatory glaucoma, viz., a kettle-form excavation reaching to the margin of the disk, distention and tortuosity of the retinal veins, and spontaneous pulsation of the arteries on the papilla. The choroid was normal. When the eye was abducted as far as possible, an indistinct, circumscribed, dark, reflex was obtained from the outer ciliary region, on a line with the swelling of the iris. With the oblique illumination a similar reflex was observed in the same position. Believing the case to be one of sarcoma of the iris and ciliary body, with secondary glaucoma, I advised the enucleation of the eyeball, and performed the operation in the usual manner three days later. The wound healed by first intention, and four days after the operation the patient was discharged from the hospital. Nearly nine years have now passed since the eye was removed, and as yet there are no signs of a relapse. The patient is in good general health. An examination of the eyeball by transmitted sunlight, im-
KIPP: Four Cases of Sarcoma of the Uveal Tract.
563
mediately after the operation, show'ed it to be perfectly transpaient, except at the outer ciliary region, where a dark mass was seen to project toward the axis of the eye. The eye was hardened in Muller's fluid, and opened by a section passing through the middle of the tumor. The cornea and sclera were apparently normal. In contact with the inner surface of the cornea and sclera, on the temporal side of the eye, was seen a growth of irregular form, occupying the place of the ciliary body and extending into the anterior chamber. This growth extended backward to the junction of the ciliary body and the choroid, and anteriorly about three millimetres into the anterior chamber; it occupies about eight millimetres of the circumference of the ciliary body, and measures at its most projecting point (immediately posterior to the equator of the lens) about four millimetres in thickness. Its posterior s9rface is convex, of a dark color, and closely covered by the membrana ciliaris retinae. After the removal of the latter it is seen that whilst on the middle portion of the posterior surface the ciliary processes had entirely disappeared in the growth, they were preserved near the nmargins of the tumor. In its forward growth the tumor had detached the iris from its connection with the cornea for a space measuring about six millimetres in width, so that the iris appeared to grow out of the tuinor. The iris itself was greatly swollen when it was in immediate connection with the tumor, but in every other part it appeared normal. Of the zonula zinnii, the part in contact with the tumor had almost entirely disappeared, probably by atrophy from pressure. The lens was perfectly transparent, and in its proper place, but its form has undergone a change in such a way that the antero-posterior diameter of the outer half was increased at the expense of its equatorial diameter. The nasal half of the 'lens was apparently of normal curvature. The vitreous body showed no abnormity. The ciliary body appeared healthy outside of the region occupied by the
564
KIPP: Case of Ossification of the Clhoroid.
tumor., The choroid and retina were in normal position, and showed no abnormity. The optic papilla was deeply excavated. The microscopic examination showed the growth to be a very vascular melano-sarcoma, which had probably originated in the inter-muscular conjunctive tissue of the ciliary muscle, and subsequently invaded the iris. REMARKS.
DR. MITTENDORF asked Dr. Kipp if he had seen metastatic sarcoma of the choroid ? DR. KiPP replied that he had not. THE PRESIDENT remarked that in relation to these tumors of the choroid, there was a point which might deserve consideration, that is, under what circumstances the tension might be increased or diminished, or the eye remain normal. The clinical history in such cases in this particular is very vague, and we can scarcely predict when that condition may be expected to arise.
CASE OF OSSIFICATION OF THE CHOROID. BY CHARLES J. KIPP, M.D., NEWARK, N. J.
THE eye was removed from a young man, twenty-two years of age, who was first seen ten years before the eye was enucleated. At that time the eye was free from all signs of irritation. There was an adherent chalky cataract, which, according to statements of the child's parents, was first noticed by them shortly after birth. The iris was atrophic. The eye diverged, and had but imperfect perception of light. As the case was hopeless so far as the restoration of sight was concerned no treatment was advised. Ten years later the patient was seen again. He was now suffering great pain in the. eye. There was much circumcorneal injection. The cornea was clear, the anterior chamber of normal dimensions, and the aqueous clear. The iris
