A CLINICAL AND HISTOLOGIC STUDY OF A 
CASE OF EPITHELIOMA OF THE CORNEO- 
SCLERAL JUNCTION. 
BY 
CHARLES A. OLIVER, A.M., M.D., 
ONE OF THE ATTENDING SURGEON'S TO THE WILLS EYE HOSPITAL; ONE OF THE OPHTHALMIC 
SURGEONS TO THE PHILADELPHIA HOSPITAL, ETC. 
(IVith J drawings on text-plate III.) 
Reprinted from the Archives of Ophthalmology, Vol. xxvi., No. 2, 1897. Arch, of Ophthalmology, XXVI. 
Text Plate III. 
FIG. I. 
FIG. 2. 
FIG. 3. A CLINICAL AND HISTOLOGIC STUDY OF A 
CASE OF EPITHELIOMA OF THE CORNEO- 
SCLERAL JUNCTION? 
By CHARLES A. OLIVER, A.M., M.D., 
ONE OF THE ATTENDING SURGEONS TO THE WILLS EYE HOSPITAL; ONE OF THE OPHTHALMIC 
SURGEONS TO THE PHILADELPHIA HOSPITAL, ETC. 
( With 3 drawings on text-plate III.') 
On the 30th of October, 1895, J- $•> a sixty-nine-year-old la- 
borer was referred to my clinic at Wills Eye Hospital by Dr. 
James D. Madeira of Reading, Pa. The patient stated that one 
year previously, without any history of traumatism, a " small pim- 
ple " appeared at the lower outer corneal border of the right eye ; 
the growth, which had been painlessly though slowly and steadily 
increasing in size, having been repeatedly cauterized by caustics 
for several months previous to his first visit. 
As can be seen in Fig. No. 1, reproduced from a water-color 
sketch made at the time by Miss Margaretta Washington of this 
city, there was a fleshy and wart-like-looking mass about the size 
of a large pea, embracing an area equal to almost the lower outer 
quadrant of the cornea. The growth seemed to start from a broad 
base in the conjunctiva just beyond the corneo-scleral margin. It 
was highly vascular in places, and its surface, which was rough 
and irregular, seemed to be infiltrated with sago-like particles. 
Running along the base, upon the conjunctival level, there were 
numerous vascular twigs which connected with several engorged 
conjunctival vessels. The conjunctiva in this region appeared, 
upon careful focussing with strong illumination, to be permeated 
with offshoots and narrow prolongations from the growth itself. 
1 Read before the November, 1896, meeting of the Section on Ophthalmology 
of the College of Physicians of Philadelphia. 
Reprinted from the Archives of Ophthalmology, Vol. xxvi., No. 2, 1897. 271 
Epithelioma of the Corneo-Scleral Junction. 
The cornea beyond the area occupied by the tumor was trans- 
parent, the pupil was round, and the iris was unaffected and mo- 
bile. Intraocular tension was apparently slightly increased. The 
eye-ground revealed no gross changes. Vision was reduced to 
three-fortieths of the normal. 
The left eye, with the exception of hyperopia and presbyopia, 
was unaffected in any way. 
The patient was admitted to the hospital and the tumor-mass 
was removed. The involved portions of the conjunctiva were ex- 
cised, the entire denuded area being lightly though effectually cau- 
terized by heat. The scarification and cauterization were carried 
as far around the limbus of the cornea as there seemed to be any 
blood supply to the tumor-area. A few drops of a weak solution 
of atropine were instilled and the field of operation was covered 
with several turns of a roller bandage. 
Two days later the entire area of denudation seemed to be 
covered with a thick and whitish membrane, and the burned 
points were granulating. The pupil was evenly and almost fully 
dilated. The eyeball and lids were freely mobile, and there was 
no pain. 
Microscopic examination of some of the removed portions of the 
growth showed that it was epitheliomatous in character. 
The patient was allowed to return home with the request to 
report in about two months' time. 
On the 31st of January, 1896, he came back to the hospital, 
when it was found that the growth had assumed a size which was 
somewhat greater than before, and the conditions were apparently 
more malignant than when he was first seen. He was admitted 
to the hospital, and with the assistance of my colleague, Dr. 
George C. Harlan, every vestige of the mass was shaved from the 
underlying cornea and sclera with a Beer's knife, the raw surface 
left being situated deeply in the corneal lamella. All of the re- 
lated blood-vessel stems were excised and their tips cauterized as 
freely as possible. During this operative procedure, as well as 
during the first operation, there was almost constant oozing of 
blood as the successive layers of the growth were excised, this at 
times being so pronounced that it was impossible to get any view 
of the field of operation. The tumor-mass itself seemed to be 
composed of a densely packed and friable material very similar 
to that seen in papillomatous formations. 
The eye was dressed in the same manner as was done at the 
first operation. Charles A Oliver. 
272 
Two weeks later, when the exposed corneal membrane became 
covered with thin layers of almost transparent epithelium, cor- 
rected vision rose to one-sixth of normal 
In spite of these two radical procedures the mass again recurred 
until, in four months' time, it had become so great in size and so 
angry in appearance that in spite of the good vision it was de- 
termined to sacrifice the organ. 
On the 27th of May, 1896, the eye was enucleated whilst under 
the local anaesthetic influence of hydrochlorate of cocaine, this 
being necessary on account of gross organic cardiac and renal 
disease. The patient was very weak and feeble. During the 
operation he did not express any discomfiture until the optic 
nerve was severed, when he experienced a slight deep-seated pain- 
ful sensation without the appearance of any phosphenes. The 
operation was performed as quickly as possible, I being assisted 
by my house surgeon, Dr. D. E. Esterly. All of the doubtful 
portions of the bulbar conjunctiva left after the eyeball had been 
removed, were looked over with a strong magnifying lens and 
freely excised, leaving only those parts that were apparently unin- 
volved. The patient was profoundly shocked, requiring the free 
use of whiskey and aromatic spirits of ammonia after the opera- 
tion. The cavity was thoroughly cleansed with bichloride solu- 
tion and closed with gauze, cotton, and a roller bandage. 
In several days' time a deep and well-formed socket was obtained. 
The patient was discharged from the hospital a few days later. 
At the present writing, April 1, 1897, there are no signs of re- 
currence. 
The specimen (see Figs. 2 and 3 the originals of which 
were made for me by my friend and assistant Dr. £reautgig 
E. Gillespie) was then carefully cut by my friend, Dr. Ada 
Howard Audenried, of this city. Study of them shows the 
characteristic polynuclear cell-formation with numerous un- 
covered epithelial nests which at places fuse and sink into 
the deeper corneal and scleral layers and the surrounding 
tumor structures. The external epithelial layers plainly dip 
into the surface-fissures of the tumor-mass. After a most 
extended and painstaking search, no appearance of any 
basement membrane can be found-thus proving the epi- 
theliomatous character of the growth. 
Remarks.-From a clinical standpoint the case is most in- 273 
Epithelioma of the Corneo-Scleral function. 
teresting. Commencing as a " pimple " in the epithelial 
structures of the conjunctiva at the transition-border be- 
tween the cornea and sclera, as is almost universal in such 
cases, it gradually and painlessly increased in size until it 
assumed the papillomatous variety of epithelial growth. It 
then extended into and beneath the epithelium of the cornea 
far in towards the summit of the membrane. In other 
words, the tumor-mass evinced its development and growth 
in a manner that is eminently characteristic of epithelioma- 
tous formations. 
The quick recurrence and steady increase of the growth in 
defiance of the extreme radical measures employed for ex- 
tirpation, plainly evidenced the necessity of removal of the 
entire field of malignancy. The almost uncontrollable ooz- 
ing of blood experienced during the operative procedure 
plainly showed the extreme vascularity of the neoplasm. 
Microscopically, the specimen is exceedingly instructive, 
not only by reason of presenting the characteristic appear- 
ance of epitheliomatous formation in the region involved, 
but upon account of the undoubted protrusion of the epi- 
thelial cells into the interlamellar corneal spaces (which 
possibly might have been produced or rendered more easy 
by the operative procedure? pursued in the early stages of 
the disease), and the insertion of the same form of malignant 
cells into the superficial layers of the sclera (layers which 
were untouched by operation), but is also of interest in 
substantiating the view that the deepest penetrations of 
the epithelial cells into the outermost tunics of the eye are 
in the transition zone between the cornea and the sclera- 
that is, at the cornea-scleral junction. 
Explanation of the Drawings on Text-plate III. 
Fig. i.-Macroscopic appearance of the tumor at the corneo- 
scleral junction. 
Fig. 2.-Microscopic section showing position and extent of 
the growth. 
Fig. 3. -Microscopic section showing infiltration of epithelial 
cells into the corneal lamellae. Ube IRnicfcetbocfccr press, Ittew jijorh