“INTRAOCULAR TUMORS.” 
BY 
YV. F. NORRIS, M.D. THREE CASES 
OF 
INTRAOCULAR TUMOR. 
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W. F. NORRIS, M.D., 
CLINICAL PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF PENNSYLVANIA. 
I.—GLIOMA OF THE RETINA, WITH NUMEROUS METASTASES. 
II.—SARCOMA OF THE CHOROID. 
III.—SARCOMA OF THE CHOROID. 
PHILADELPHIA: 
J. B. LIPPINCOTT & CO. 
1 874. THREE CASES OF INTRAOCULAR TUMOR 
HE ID BEFORE THE PATHOLOGICAL 80C1ETT OF PHILADELPHIA, JAMJAR! 9, 1873. 
I. Glioma of the retina, with numerous mctastascs. 
B. N—, aged 2$ years, was brought by his parents to the clinic of the 
University of Pennsylvania in October, 1870, with the statement that in 
the winter previous they had noticed a yellowish reflex from the right 
pupil. The right eye was slightly prominent, lid a little swollen but not 
reddened, the eyeball very tense (T,), commencing opacities in the cornea, 
a small quantity of pus in the anterior chamber, the lens yellowish and so 
far opaque that nothing could be seen behind it. 
The case having been recognized as one of glioma, enucleation of the 
eyeball was performed October 20th, 1870. The wound healed rapidly, 
and in ten days the child returned to his home. 
The eyeball was laid in Muller’s fluid to harden, and, when a section 
was made of it, a tumor was seen 
filling the posterior half of the ball, 
the anterior portion being filled with 
pus. To the outer upper side of the 
ball was a tumor firmly adhering to 
the sclera, shaped as if moulded to 
it, about one-half inch in length by 
one-fourth of an inch in thickness; 
and from this another nodule, about 
the size of a hazel-nut ($" in diam- 
eter), projected still farther into the 
orbital tissues. The continuity of the 
sclerotica between the external and in- 
ternal tumor was unbroken, it having 
been infiltrated by the tumor but not ruptured by it. A microscopic 
section of it showed the characteristic structure of glioma,—viz., numer- 
ous small round cells, imbedded in a finely granular material, each cell 
being about the size of the granules of the granular layers of the retina. 
The child soon returned to the clinic with a button of granulations 
A. Intraocular tumor. 
B. Episcleral growth. 
C. Optic nerve. 4 
springing from the bottom of the conjunctival sac. This rapidly increased 
in size, and, having filled the orbit, projected from the eyelids as a flat- 
tened round mass nearly three inches in diameter. Sloughs now formed 
on the exterior surface of the mass, which separated and fell off, materially 
reducing its size and allowing the distended eyelids once more to close over 
it. It, however, soon repullulated. 
A. Cells from intraocular tumor. 
B. Infiltration of the sclerotic. 
C. Section of secondary tumor between dura mater and skull. 
About this period several lumps appeared on the child’s head, and one 
at the angle of the jaw (left side). Two of these attained considerable 
size; one near the vertex being a flattened hemisphere about three inches 
by two in diameter, and the one at the angle of the jaw ulcerating into 
the cavity of the mouth and causing a constant fetid discharge. 
The child, at first very irritable, became heavy and soporose, and died 
December 14th, 1870. 
The autopsy showed that the tumors on the outside of the cranium had 
sprung apparently from the periosteum, leaving, when forcibly pulled off, 
the bones bare and rough. On removing the calvarium, numerous flat- 
tened ovoid lumps were found between the dura mater and the bone, that 
membrane firmly adhering to them. Some of these were as large as half 
a walnut. Opposite them were corresponding depressions in the cerebral 
convolutions. The brain-substance at these points presented no trace of 
the gliomatous degeneration. 
It was also seen that the tumor filling the right orbit had extended 5 
backwards through the sphenoidal fissure into the cranium, and, crossing 
over through the sella turcica, extended to the vicinity of the sphenoidal 
fissure of the left side. 
The case is interesting clinically from its extreme malignancy, and the 
inefficiency of the operation undertaken at a period when the tumor has 
filled the ball and caused inflammation and greatly increased intra-ocular 
pressure, to arrest even temporarily the progress of the disease. Scleral 
tumors, if small and formed at the posterior surface of the ball, are not to 
be diagnosticated before enucleation. Having found them, according to 
many authorities it is proper to destroy by cauterization the entire con- 
tents of the orbit; but the statistics of this procedure were not sufficiently 
encouraging to cause a decision in favor of so serious an operation. 
The prognosis of all such tumors is eminently unfavorable, and the 
recorded cases in which the return has not been rapid are all instances in 
which the extirpation was undertaken early. In the foregoing example 
the yellow reflex from the cyeground had been observed by the parents 
for nearly a year before they considered it worth while to submit the child 
to medical examination. 
The statistics of the subject have been carefully compiled by Ilirschberg.* 
Out of seventy-seven cases he gives five cures (t.e. 6.5 per cent.). One of 
these was observed seven years after the operation, one six, and in the other 
three from one to one and a quarter years had passed without a return of 
the disease. They were all operated on in the earliest stage of the disease. 
I have reported the above history partly in the hope of inducing the 
members of the Society to use their influence to cause all such cases, as 
soon as observed, to be carefully examined with the ophthalmoscope, and, 
if the presence of an intraocular tumor be proved by it, to urge instant 
extirpation. Moreover, they will contribute essentially to the statistics 
of the subject if they will report the return or metastases of any such 
cases as fall under their notice. For here, if ever, we have a chance to 
prove the value of the knife in the treatment of malignant disease. By 
the ophthalmoscope the disease may be diagnosticated in its very incipiency; 
and while the abnormal mass measures only a millimetre or two in diame- 
ter, and while it is yet shut off from the rest of the organism by the firm 
fibrous capsule of the sclerotica, we have surely better means of deciding 
the question whether malignant disease can be eradicated by the knife, and, 
if not, whether life can be prolonged by the operation, than is presented to 
us in any other organ of the body. 
* Dur Uarkfcliwamm der Netzbaut, Berlin, 1S69. 6 
II. Sarcoma of the choroid. 
E. O'C—, aged 60 years, presented herself at the clinic of the Univer- 
sity of Pennsylvania, April 1st, 1872, 
with a tumor of the right eye the size 
of a small hen’s-egg. It was everywhere 
covered by conjunctiva, hard and nodu- 
lated. Some years previously an opera- 
tion for staphyloma had been performed 
on the eye, and a section of the growth 
proved that it had its origin in the cica- 
trix of the shrunken ball. 
Microscopic examination showed a 
net-work of very small spindle cells 
closely felted together, and consequent- 
ly a comparatively favorable prognosis 
was made. It was enucleated April 4th, 
1872, and up to the present date there has been no recurrence.* 
Equatorial section of shrunken ball and of 
the tumor. 
Section of above, magnified two hundred and fifty diameters. 
III. Sarcoma of the choroid. 
J. II—, aged 25 years, a hcaltliy-looking farmer, presented himself at 
the Wills Hospital with a hard lobulated tumor growing from the right 
e/e and pushing the cornea upwards and outwards. The lids can still be 
closed over it; but it has grown much lately, and causes severe liemicrania. 
* Patient now, March IfOth, 1874, in good health, and no symptom of recurrence. 7 
The ball and adherent tumor were removed May 5th, 1872. A section of 
the ball showed the inner wall of it occupied by a pigmented tumor, which 
presented a mottled appearance, owing 
to some portions of it being less pig- 
mented than others, while some were 
entirely uncolored. The retina, ad- 
herent to the tumor on that side, 
although pushed inward by it, was on 
the other side entirely detached from 
the choroid and separated from it by a 
mass of pus. The sclera was nowhere 
ruptured, but outside of it, opposite the 
choroidal tumor, was an unpigmented 
hemispherical mass about three-fourths 
of an inch in its longest diameter. 
Micro-examination showed that the 
choroid tumor was a mixed form of 
sarcoma, consisting partly of round and 
ovoid, and partly of spindle-shaped cells. 
In some places these were pigmented, in others entirely free from it. Most 
of the cells had more than one nucleus, and many of the large ovoid pig- 
mented cells contained as many as six or eight. An examination of the 
A. Pigmented tumor. 
B. Episcleral growth. 
C. Subretinal pus. 
D. Optic nerve. 
E. Retina. 
F. Lens dislocated by the section. 
A. Large polynueleated pigmented cells from intraocular tumor. 
B. Other large cells lying in a slightly deeper layer, the nuclei hidden by the 
numerous superficial pigment granules. 
0. Round and spiudle cells from the orbital growth. 
D. Stroma of orbital growth as seen under a lower power. 8 
episcleral growth and its edges showed that the fat-tissue of the orbit 
had been irritated by the presence of the neighboring tumor; that the 
trabeculae of fibrous tissue pervading it and bounding its areolae had been 
hypertrophied, and that then the place occupied usually by the fat-cells 
had been infiltrated by a mass of spindle and round cells, resembling those 
of the original tumor, except in their not being pigmented. This anatom- 
ical arrangement, of course, gives a marked areolar appearance to the tumor. 
In this orbital growth the round and ovoid cells constituted the bulk of 
the tumor, the spindle cells being far less numerous. 
A most unfavorable prognosis was made, which has been only too accu- 
rately verified by the course of the case. Within a few days (i.e. about 
seven months after the removal of the tumor) he has reappeared at the 
hospital with a recurrence of the growth in situ. 
Dr. R. M. Bertolet asked whether, in pigmented sarcomata of the 
choroid, the metastases were also pigmented. 
Dr. Norris replied that even with regard to sarcomata of the choroid, 
although the greater number were pigmented, certain tumors occurred 
which, notwithstanding the marked pigmentation of the mother-tissue, 
were entirely composed of white cells. These are, however, rare. Dr. 
N. said that metastases were most frequent in the lungs and liver, and 
that some were pigmented and some not. This circumstance, he said, 
was claimed by the advocates of each of the two theories as supporting 
their own view. Those who believe in the metastasis of cells themselves 
consider the pigmented secondary deposits vindications of their theory; 
while those who believe in the constitutional origin of morbid growths 
affirm that their occurrence is evidence in favor of the view that the same 
cause produces the same effects even in different localities.