420 AMERICAN JOURNAL O F OPHTHALMOLOGY MARCH, 1978

Fig. 2 (Jampol and Nagpal). Dilated channels are now filled with lymph. Lymphangiectasia (arrow) is apparent in areas.

submandibular nodes. On rare occa­sions,3-8 spontaneous or posttraumatic entrance of blood into these channels— hemorrhagic lymphangiectasia of the conjunctiva—has been noted. Some pa­tients demonstrate repeated hemorrhages in these channels. The possibility of this occurrence should be noted by ophthal­mologists as it is very easy to confuse a blood-filled lymphatic channel with an abnormal dilated conjunctival blood ves­sel. Similar hemorrhage into conjunctival lymphangiomas9 has been described. In most cases hemorrhage into the lymphatic channels clears promptly without treat­ment, although in cases with repeated hemorrhages, superficial diathermy or ex­cision of the lymph vessels may be neces­sary to prevent recurrence.

SUMMARY

A 41-year-old man developed a sponta­neous hemorrhage in his conjunctival lymphatic system in one eye. These abnormal channels were initially inter­preted as blood vessels, which led to confusion in diagnosis. Fluorescein an-giography and follow-up examination disclosed the true nature of the lesions. Hemorrhagic lymphangiectasia of the conjunctiva must be included in the dif­

ferential diagnosis of dilated, tortuous, blood-filled conjunctival vessels.

REFERENCES 1. Sugar, H. S., Riazi, A., and Schaffner, R.: The

bulbar conjunctival lymphatics and their clinical significance. Trans. Am. Acad. Ophthalmol. Otolar-yngol. 61:212, 1957.

2. Hogan, M. J., Alvarado, J. A., and Weddell, J. E.: Histology of the Human Eye. Philadelphia, W. B. Saunders, 1971, pp. 121-126.

3. Awdry, P.: Lymphangiectasia haemorrhagica conjunctivae. Br. J. Ophthalmol. 53:274, 1969.

4. Leffertstra, L. J.: Lymphangiectasia haemor­rhagica' conjunctivae (Leber). Ophthalmologica 143:133, 1962.

5. Duke-Elder, S.: Diseases of the Outer Eye. Conjunctiva. In System of Ophthalmology, vol. 8, pt. 1. St. Louis, C. V. Mosby, 1965, pp. 40-42.

6. Em6dy, J.: Lymphangiectasia haemorrhagica conjunctivae. Klin. Monatsbl. Augenheilkd. 161: 342, 1972.

7. Donders, P. C : Haemorrhagic lymphangiecta­sia of the conjunctiva. Ophthalmologica 155:308, 1968.

8. Awdry, P.: Leber's lymphangiectasia haemor­rhagica conjunctivae. (Feature photograph). Arch. Ophthalmol. 81:278, 1969.

9. Reese, A. B., and Howard, G. M.: Unusual manifestations of ocular lymphangioma and lymph­angiectasia. Surv. Ophthalmol. 18:226, 1973.

AN ENDOSCOPE FOR OPHTHALMOLOGY

JOHN L. NORRIS, M.D., AND GILBERT W. CLEASBY, M.D.

San Francisco, California

New wave guide technology has made possible the development of an endo-scope* (Fig. 1) useful to the ophthalmol­ogist.1-3 The lens and wave guide view­ing system is 1.7 mm wide, surrounded by a ring of fibers for illumination, and

From the Department of Ophthalmology, Pacific Medical Center, Presbyterian Hospital, San Francis­co, California.

Reprint requests to John L. Norris, M.D., 2400 Clay St., San Francisco, CA 94115.

Th i s instrument is available from Dyonics Inc., 71 Pine St., Woburn, MA 01801.

VOL. 85, NO. 3 NOTES,

wrapped in a stainless steel sheath for strength. The field of view is 70 degrees. The lens system has two unique proper­ties, in addition to its size, that make it useful for intraocular surgery. First, the observer's view is always in focus, wheth­er the object is at the tip of the en-doscope or infinitely far. Secondly, mag­nification of up to X 30 is available. Magnification is inversely proportional to the distance from the object of regard.

For orbital surgery, a cannula placed over the lens system increases the size of the shaft to 2 X 3 mm. A clear view is obtained by irrigation introduced through a cannula (Fig. 2). Forceps for foreign body removal or biopsy are also intro­duced through channels in a cannula (Fig. 3). Manipulation of tissue or foreign material is done at the endoscope tip under direct observation.

Intraocular surgery is performed under endoscopic control by making a 1.7-mm sclerotomy in the pars plana. As the endo-

AND INSTRUMENTS 421

Fig. 1 (Norris and Cleasby) The endoscope with 1.7-mm diameter stainless steel shaft containing lens, wave guide system, and fiberoptic ring for illumination.

scope enters the eye, the view is panoram­ic, everything appears small, upright, and in focus, thus permitting ready orienta­tion. As the endoscope lens approaches the object of interest, the area viewed is smaller, but magnified. A 1-mm viewing distance provides x 20 magnification, permitting detailed study of such struc­tures as preretinal membranes, blood ves­sels, and optic nerve.

Illumination for intraocular surgery is provided through the fiberoptic ring sur­rounding the wave guide and lens. Any standard light source currently used for vitrectomy can be used by obtaining the correct adapter.

Practice and an awareness of the rela­tion between working space and magnifi­cation is necessary to use endoscopy within the eye safely. The loss of stereop-sis in a monocular system is partially re­placed by developing a sense of location based on relative magnification of differ­ent objects in view. This ability can only

Fig. 3 (Norris and Cleasby) A 2 x 3-mm oval Fig. 2 (Norris and Cleasby) The 2.2-mm cannula, cannula with side port for introducing instruments

with irrigation port, fits over a 1.7-mm shaft. into visual field.

422 AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH, 1978

be obtained by practice with animal sur­gery.

The endoscope is used in the orbit with the cannular attachment to study orbital tumors and to remove foreign bodies. We are using it in the eye without the cannula to guide removal of intraocular foreign bodies and to facilitate vitrectomy. 4

SUMMARY

An endoscope with a 1.7-mm diameter shaft has unique properties of focus, mag­nification, and large field of view that

OPHTHALMIC MINIATURE

On a marble Stele from the Asklepieon in Epidaurus Timon, wounded by a spear under his eye. While sleeping in the

temple he saw a dream. It seemed to him that the god rubbed down an herb and poured it into his eye and he became well.

Guido Majno, The Healing Hand Cambridge, Harvard University Press, 1975

make it useful for both orbital and intra­ocular surgery.

REFERENCES 1. Uchida, T., Furukawa, M., Kitano, I., Koizumi,

K., and Matsumura, H.: Optical characteristics of a light-focusing fiber quide and its applications. IEEE J. Quant. Electron. 6:606, 1970.

2. Prescott, R: Optical principles of endoscopy. J. Med. Primatol. 5.133, 1976.

3. Kita,H.,andUchida,T.:Auniquelight-focusing glass fiber. Optical Spectra 4:80, 1970.

4. Norris, J. L., Cleasby, G. W., and Nakanishi, A. S.: Use of ultrasound guidance in removing retained intraocular foreign bodies. Presented at the first meeting of the American Society of Ophthalmic Ultrasound, Oct. 3, 1977, Dallas, Texas.