74 NOTES, CASES, INSTRUMENTS
Our improvement on the after-image test, making use of a linear electronic flash tube as a light source, elicits useful responses approximately twice as often as does the old test, which makes use of an elongated incandescent filament or slides in a major amblyo-scope. In spite of its short duration, the electronic flash provides such great light intensity that the after-image it produces may persist for 20 to 30 minutes. The after-image produced by the electronic flash is so vivid that there is little difficulty experienced by the examiner in making the subject understand what is expected of him.
Because only momentary fixation is needed with the electronic flash method, many children (some as young as three years) who cannot be tested by the old technique respond satisfactorily with the improved method;
RETINAL TEARS ASSOCIATED WITH TUMORS
EDWARD O. BIERMAN, M.D. Santa Monica, California
In Volume III of his textbook, Duke-Elder says, "Once the diagnosis of retinal detachment is established, the essential point is the decision as to whether the detachment is simple or complicated by a tumor. It is sometimes not an easy matter to establish this with certainty, and since on the differential diagnosis depend decisions of the highest importance, the distinguishing points merit the closest attention." And, he continues, "The statement that the presence of retinal holes excludes a neoplasm (Lister, 1924) has never been contradicted."
The case to be reported and one now in
with, the old method successful results are unusual under the age of six years.
Because the improved after-image is so persistent that it may prove distracting to the patient, all other orthoptic diagnostic procedures should be carried out before exposing the patient to the electronic flash.
No injury to the eye, external or internal, is produced by exposure to the flash-tube employed in the improved after-image tester. It is not necessary to have the patient dark adapted in order to elicit an after-image by the improved method.
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A light-weight, compact, hand-held instrument (fig. 3) is available from the Penn-East Engineering Corporation, South Willow Street, Kutztown, Pennsylvania. Trial of a prototype in our Ocular Motility Clinic has given very satisfactory results.
the literature contradict this statement; even the presence of a tear does not definitely rule out a tumor.
History. M. N., an 80-year-old white woman, complained of gradual blindness of the left eye. She had been told by one doctor that she had glaucoma. Later she was told by another doctor that she had developed a tumor in the left eye. Surgery was not advised because of her age.
Examination. Visual acuity was: R.E., 20/20, uncorrected; L.E., no light perception. The chamber was somewhat shallow in both eyes but no more than would be expected at this age. The conjunctiva was slightly pale. Ophthalmoscopic examination showed the vessels of the right eye to be displaced nasally at the disc; a moderate amount of cupping was present. Grade 2 arteriosclerosis was present. The left eye had a giant tear temporally and inferiorly, associated with small hemorrhages. A large retinal detachment was present. Not
1. Bielschowsky, A.: Lectures on Motor Anomalies. Hanover, N.H., Dartmouth College Publications, 1945, p. 2.
2. Duke-Elder: Textbook of Ophthalmology. The Neurology of Vision; Motor and Optical Anomalies. St. Louis, Mosby, 1949, v. 4, p. 3884.
3. Wahlgren, R., and Swan, K. C.: A simplified after-image test for retinal correspondence. Am. Orthop. T., 5:109-110, 1955.
NOTES, CASES, INSTRUMENTS 75 solid in appearance, it was too far posterior to be adequately transilluminated. The disc could not be seen because of the retinal elevation. Tension was normal but the patient was on pilocarpine (two percent) in both eyes.
Three months after her first visit the patient developed an acute glaucoma in the left eye. The eye had to be enucleated when all else failed to relieve the pain. The enucleated eye was sent to Doheny Eye Laboratory where a diagnosis of malignant melanoma of the choroid was made. The retina was elevated by fluid which had disguised the tumor.
CASE 2 Kirk and Petty of the Illinois Eye and Ear In
firmary reported one case of serous detachment with retinal tear in malignant melanoma of the choroid. This one case was found in a series of 74 cases.
I have seen one case in which a tumor was probably mistaken for a detachment with tear. Detachment surgery was successful for a short period of time, when a solid detachment occurred. By that time other secondary lesions of hypernephroma had been found. The case could not be considered definitely one of tumor, because the eye was not obtained for study. However, from all clinical appearances it was later typically tumor, and the history suggests the diagnosis.
Retinal tears are thought to be due to two factors, the amount of pull exerted by the vitreous and the resistance of the retinal elements to separation. Both factors are present in most patients suffering from retinal tears. Other factors should also be considered.
The pushing up of a tumor also exerts a force on a diseased retina. In the case herein reported, the patient's age indicates that retinal weakness probably was a factor in the tear. Either a push or a pull may tear the retina, if either exerts adequate force.
Other forces may cause tears, forces within the retina itself. The frequency of showers of vitreous floaters simultaneous with retinal tearing and detachment probably represents a retinal hemorrhage forcing its way through the retina into the vitreous.
The shock waves of trauma, the swelling of an inflammatory reaction, the traction of scar tissue both in the retina and the vitreous may result in tears. In fact, any force might cause a separation if properly applied. Retinal tearing does not, however, mean that the retina will detach. Tears are seen with no detachment. Sometimes retinal tears cannot be found in detachment even after a most thorough search. The causal relationship is not present. Tears do not necessarily cause detachments.
Retinal separation probably represents a far more complex mechanism than is commonly believed. I suggest that a biochemical reaction, possibly similar to any contact type allergenic reaction, might be the final cause of detachment in many cases. The subretinal fluid could be due to an attempt of the body to resist the irritation of the vitreous as it presents itself through the tear into a foreign area. In the absence of a tear, any foreign protein could provoke a retinal separation. The efforts of nature to block further separation seem to point to this. It may also be that, in some cases, the tear is a result of such biochemical reactions. Just as the malignant tumor caused a secondary tear, so also could any swelling. Consideration of this possibility would be justified.
Retinal tear can occur with tumor. It is suggested that routine chest X-ray films be included in the preliminary study of detachment patients in order to rule out secondary lesions of the area, as well as to aid in evaluation of the patient as a surgical risk.
A discussion of the relationship between retinal tumors, retinal tears, and retinal detachments is presented. The present concepts of retinal detachment do not apply in some cases.
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