statistical study of our follow-up data, we concluded that if tumors of medium size ( 11-15 mm in greatest diameter) were left untreated, there would be a greater survival during the first seven years, but after seven years, patients treated by enucleation would have the greater survival. 11

We have not presented dogma but rather a hypothesis that needs to be studied and tested. We are continuing to test our hypothesis with the aid of mathematical models and are continuing to monitor work done on animal models; however, the final test will have to involve human subjects. We have continually advocated that controlled clinical trials are the best way to test our hypothesis. 12

•13 Unfortunately, so many ophthalmologists

assume they know what is best therapy for uveal mela­nomas that most controlled clinical trials appear ethically unfeasible. What we have instead is a series of uncon­trolled studies by advocates of different therapies. While uncontrolled studies do not have the statistical power of controlled studies, the results should not be discounted. Based on the work of Gass, 14 we believe that small asymptomatic and minimally symptomatic tumors can safely be observed for growth. We have found histolog­ically that a significant portion of similarly small tumors are nevi and that clinically it is impossible to determine whether they are nevi or melanomas.

We advocate that most growing tumors and larger symptomatic tumors be treated and that the results obtained from treatments other than enucleation be carefully monitored and compared with matched tumors treated by enucleation.

Several years ago we advocated a prospective study that would compare the results of enucleation with a comparable series in which enucleation was preceded by a course of external beam irradiation. External beam therapy in such cases would seem more logical because it avoids the additional surgical trauma involved in placing markers for proton beam therapy and in sewing on plaques. The rationale for such a study is that a suitable preoperative dose of radiation should devitalize the melanoma cells sufficiently so that even if they were released into the circulation they would be incapable of producing metastasis.

To date, the preliminary results we have seen with other forms of radiation therapy and eyewall resection have not indicated that these procedures increase the risk of metastasis. We are particularly interested in the results with radiation therapy because of the work of Neiderkorn. 10 His work indicates that external beam

Dear Editor:

In reference to our publication concerning argon laser destruction of anterior chamber implantation cysts (Ar­gon laser destruction of anterior chamber implantation cysts. Ophthalmology 1984; 91: 1040-43), the subsequent course of two patients has prompted us to submit this

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therapy may have the potential to prevent dissemination of viable tumor cells without eliminating immunity to metastasis conferred on the host by the presence of devitalized tumor cells within the eye. We continue to believe that a controlled clinical trial of radiation therapy vs. enucleation for large tumors should be ethical, and hope that the ophthalmic community will undertake such a study.

References

IAN W. MCLEAN, COL, MC, USA LORENZ E. ZIMMERMAN, MD

1. Zimmerman LE, Mclean JW. Metastatic disease from untreated uveal melanomas. Am J Ophthalmol 1979; 88:524-34.

2. Tyzzer EE. Factors in the production and growth of tumor metastases. J Med Res 1913; 28:309-33.

3. Schatten WE. An experimental study of postoperative tumor metas­tases. I. Growth of pulmonary metastases following total removal of primary leg tumor. Cancer 1958; 11 :455-9.

4. Cole WH, McDonald GO, Roberts SS, Southwick HW. Dissemination of Cancer; Prevention and Therapy. New York: Appleton-Century­Crofts, 1961.

5. Romsdahl MM. Influence of surgical procedures on development of spontaneous lung metastases. J Surg Res 1964; 4:363-70.

6. Wexler H, Chretien PB, Ketcham AS, Sindelar WF. Induction of pulmonary metastases in both immune and nonimmune mice; effect of the removal of a transplanted primary tumor. Cancer 1975; 36: 2042-7.

7. Fraunfelder FT, Boozman FW IV, Wilson RS, Thomas AH. No-touch technique for intraocular malignant melanomas. Arch Ophthalmol 1977; 95:1616-20.

8. Lundy J, Lovett EJ Ill, Hamilton S, Conran P. Halothane, surgery, immunosuppression and artificial pulmonary metastases. Cancer 1978; 41:827-30.

9. Paste G, Fidler JJ. The pathogenesis of cancer metastasis. Nature 1980; 283:19-46.

10. Niederkorn JY. Enucleation-induced metastasis of intraocular mela­nomas in mice. Ophthalmology 1984; 91:692-700.

11. Mclean IW, Foster WD, Zimmerman LE, Martin DG. Inferred natural history of uveal melanoma. Invest Ophthalmol Vis Sci 1980; 19: 760-70.

12. Zimmerman LE, Mclean IW. An evaluation of enucleation in the management of uveal melanomas. Am J Ophthalmol1979; 87:741-60.

13. Zimmerman LE. Metastatic disease from uveal melanomas; a review of current concepts with comments concerning future research and prevention. Trans Ophthalmol Soc UK 1980; 100:34-54.

14. Gass JDM. Observation of suspected choroidal and ciliary body melanomas for evidence of growth prior to enucleation. Ophthal­mology 1980; 87:523-8.

letter as an addendum. Case 2 in that publication, a woman who developed an iris cyst following penetrating keratoplasty for keratoconus, developed a recurrence of her iris cyst 14 months after the treatment reported in our initial publication. This was photocoagulated in a manner identical to the initial treatment and there has been no recurrence in the subsequent 10 months of

follow-up. Case 5, who underwent iridocyclectomy after unsuccessful argon laser destruction of an anterior chamber implantation cyst, had initial visual acuity of 20/30 after surgery. Subsequently he has had chronic inflammation and cystoid macular edema as well as the growth of an irregular membrane on the posterior surface of his cornea. He was treated with vitrectomy and corneal cryotherapy. Biopsies at the time of the procedure failed to show the presence of epithelium in

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Daniel Nelson, MD, J. Douglas Cameron, MD (1981-82), Investigators; Pat Williams, COT, Clinic Coordinator.

Mount Sinai School of Medicine, Department of Ophthal­mology, New York, New York: Stephen A. Obstbaum, MD, Principal Investigator; Penny Asbell, MD, Steven M. Podos, MD, Michael J. Newton, MD (1981-82), and George Pardos, MD (1981-82), Investigators; Norma Justin, COA, Clinic Coordinator.

University of Oklahoma, McGee Eye Institute, Oklahoma City, Oklahoma: J. James Rowsey, MD, Principal Investigator; Hal D. Balyeat, MD, James C. Hays, MD, Wayne F. March, MD (1981-83), Investigators; Jack Whiteside, COT (from 1983), Becky Hewett, COA (1982-83), Douglas Corley (1982), Beth Kuns (1981-82), Clinic Coordinators.

University of Southern California, Estelle Doheny Eye Foundation, Los Angeles, California: David J. Schanzlin, MD, and Ronald E. Smith, MD, Co-principal Investigators; James J. Salz, MD, Douglas L. Steel, MD, and Richard A. Villasenor, MD, Investigators; Jenny Garbus, COT, Jan Reinig, LVN, COT (until 1984), Clinic Coordinators.

William Beaumont Eye Clinic, Royal Oak, Michigan: Wil­liam D. Myers, MD, Principal Investigator; Robert C. Arends, MD, John W. Cowden, MD, William T. Sallee, MD, Robert L. Stephenson, MD, Paul Fecko, MD (from 1982), and Henry J. Spiro, MD (1981-82), Investigators; Vicki Roszka-Duggan, CO, COMT, Clinic Coordinator.

Wills Eye Hospital, Philadelphia, Pennsylvania: Peter R. Laibson, MD, Principal Investigator; Juan J. Arentsen, MD, Michael A. Naidotf, MD, and Elisabeth Cohen, MD ( 1983-present), Investigators; Nubia Cantillo, CO, Clinic Coordinator.

Corneascope Reading Center: University of Oklahoma, Oklahoma City, Oklahoma: J. James Rowsey, MD, Principal Investigator; Roy Monlux, Digitizer (from 1983); Michael Isaac, BSC, Digitizer (1981-82).

Psycometric Testing Center: University of California, Los Angeles, School of Public Health, Los Angeles, California: Linda B. Bourque, PhD, Principal Investigator; Beverly Cosand, BA, Assistant Programmer.

the anterior chamber of the eye although we still suspect that this was the case. The eye remains inflammed.

As Dr. Bergstrom mentioned in his discussion of our paper, laser intervention in anterior chamber implanta­tion cysts may not necessarily be permanent or benign in its effect. Only further time and follow-up will tell.

JOEL SUGAR, MD LEE M. JAMPOL, MD

MORTON F. GOLDBERG, MD

Specular Microscopy Center: Emory University, Atlanta, Georgia: George 0. Waring, MD, Principal Investigator; Shari Swift, Digitizer (from 1984); Darrl Clark, Digitizer (1983-84); Vicki Shadix, Digitizer ( 1982-83).

Clinic Monitoring Group: Jay H. Krachmer, MD, (Chair­person, 1980-present), Department of Ophthalmology, Uni­versity of Iowa; Ceretha S. Cartwright, Dr. PH, Department of Ophthalmology, Emory University; Robert J. Hardy, PhD, University of Texas School of Public Health; James P. Mc­Culley, MD, Department of Ophthalmology, Southwestern Medical School; Robert D. Sperduto, MD, Scientific Project Officer, National Eye Institute; Walter J. Stark, MD, Wilmer Eye Institute, Johns Hopkins Hospital; Michael J. Lynn, MS, Director of Coordinating Center, Emory University (from 1984); Steven D. Moffitt, PhD, Director of Coordinating Center, Emory University (1980-83).

Data and Safety Monitoring Board: Richard A. Thoft, MD (Chairperson, 1980-present), Chairman of Department of Ophthalmology, Eye and Ear Hospital; James V. Aquavella, MD; Jules L. Baum, MD, Department of Ophthalmology, Tufts Medical School; Robert J. Hardy, PhD, University of Texas School of Public Health; Jay H. Krachmer, MD, De­partment of Ophthalmology, University of Iowa; Robert D. Sperduto, MD, Scientific Project Officer, National Eye Institute; Joel Sugar, MD, Illinois Eye and Ear Infirmary, University of Illinois; James Ware, PhD, Department of Biostatistics, Harvard School of Public Health; George 0. Waring, MD, Project Chairperson, Emory University Department of Ophthalmology; Michale J. Lynn, MS, Emory University (from 1984); Aran Safir, MD, Department of Ophthalmology, University of Con­necticut Health Center (from 1984); Steven D. Moffitt, PhD, Department of Biometry, Emory University (1980-83).

National Eye Institute, Bethesda, Maryland: Robert D. Sperduto, MD, Scientific Project Officer; Ronald G. Geller, PhD, Associate Director for Extramural and Collaborative Programs; Ralph J. Helmsen, PhD, Administrative Project Officer.

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