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A Simplified Scleral Reinforcement Technique
A S I M P L I F I E D SCLERAL R E I N F O R C E M E N T T E C H N I Q U E F R A N K B. T H O M P S O N , Pasadena,
In the past eight years I have operated on 52 eyes for myopic degeneration by using the simplified reinforcement tech nique. In ten cases, the operation was preceded or followed by cataract extrac tion, without complications. In two cases, reoperation was necessary because a scleral strip had been incorrectly placed during previous surgery. The follow-up time extended from one month to seven years. M A T E R I A L AND M E T H O D S
The type and size of scleral graft have been described previously. 1 I obtained two grafts from each donor eye by con touring the grafts posteriorly from the cornea on either side of the optic nerve in a curvilinear pattern. This procedure dou bled the amount of material available, and took less time to perform. Whole donor eyes were used because it was necessary to include the corneal tis sue to obtain a sufficient length, as the myopic eyes requiring reinforcement needed all the donor tissue available. I attempted to use eyes from which the cornea or corneoscleral button had been removed, by taking a spiral graft from anterior to posterior. However, these grafts were difficult to place and keep flat against the globe, because they did not follow the normal contour of the eyeball. Eye bank specimens that have been kept refrigerated under sterile conditions, but which are slightly too old for use as corneal grafting material, may be used. Since the scleral graft is only for rein forcement and does not depend on the From the Department of Ophthalmology, Univer sity of Southern California School of Medicine, Los Angeles, California. Reprint requests to Frank B. Thompson, M.D., 206 E. Los Tunas Ave., San Gabriel, CA 91776. 782
M.D.
California
viability of cellular structure, specimens can be seven to eight days old. The specific details of placement were described previously, 1 but some changes have evolved (Fig. 1). No canthotomy is generally necessary even on Oriental eyes, which have much smaller palpebral fissures and tighter eyelids. However, if visibility of the strip posteriorly is a prob lem, a canthotomy should be performed because accurate placement of the strip is crucial. Placement of the strip over the posteri or pole was made easier by using an instrument I made by bending the tip of a flat iris repositor in a stair-step fashion, and then curving the instrument to fit the contour of the globe (Fig. 2). The cottontipped applicator used previously for placement would frequently pull the strip forward as it was withdrawn; the shaped tip of the new instrument held the strip in place. In those cases where the muscle was divided into two strips, it was important that the strip be placed in back of both bundles of the inferior oblique muscle. The oblique tendon must not be split. When this occurs a reoperation is neces sary. The inferior oblique muscle was the key to the entire operation, because the insertion of this muscle held the strip over the macula without suturing. The dissection was done so as to avoid tearing of the vortex veins, both to prevent choroidal edema and hemorrhage and to fa cilitate surgery because an actively bleed ing vortex vein is difficult to control and makes posterior visibility extremely diffi cult. When the strip was in position and the inferior oblique muscle was released from its traction suture, an anectine drip
AMERICAN JOURNAL O F OPHTHALMOLOGY 86:782-790, 1978
VOL. 86, NO. 6
SCLERAL REINFORCEMENT
783
AT RECTUS
2r<=>t=r*='>^c^J*-vss3a: INF RECTUS
Fig. 1 (Thompson). Placement of a scleral homograft in the right eye. A, View from above showing graft placement nasal to the superior oblique muscle insertion. B, Posterior view showing graft held over macular area by insertion of inferior oblique muscle. C, View from below showing insertion of strip nasal to inferior rectus muscle insertion. D, Donor eye showing scleral grafts being dissected and including corneal tissue to obtain sufficient length.
Fig. 2 (Thompson). Instrument for placement of strip over posterior pole. A, View showing curves of repositor to fit the contour of the globe. B, Larger view showing stair-step bend in tip. C, Magnified view of the tip. D, View of the opposite uncurved end of iris repositor.
was started on the patient to contract the extraocular muscles and pull the strip in place. Instead of the 4-0 polyester fiber su tures used to fix the strip superiorly and inferiorly, 5-0 chromic collagen sutures were used. The polyester sutures re mained indefinitely, but occasionally, they extruded or caused postoperative in flammation. By the time the collagen su tures were absorbed, the strip was firmly fixed to the underlying sclera. It was not necessary to dissect a scleral bed for the strip.
784
AMERICAN JOURNAL OF OPHTHALMOLOGY
If further ocular surgery was anticipat ed, then minor modifications in the tech nique were necessary. In many cases, scleral reinforcement has been performed on patients with fairly dense cataracts. As long as the posterior pole and periphery of the retina were apparent with the indi rect ophthalmoscope, the scleral rein forcement was done first, followed by the cataract surgery, because the loss of visu al acuity from macular deterioration was usually permanent and irreversible, whereas the loss of vision from the cata ract was reversible. The myopia surgery, therefore, takes precedence. When cata ract surgery was anticipated after scle ral reinforcement, the superior conjunctival incision was placed as posterior as possible (4 to 5 mm) so as not to disturb the limbal area if a limbal-based flap was used in the cataract technique. Because the routine detachment of extraocular muscles for visualization of the posterior portion of the globe is not necessary, anterior segment necrosis is not a complication. In the occasional case where muscle surgery is needed for a preoperative strabismus, the muscle sur gery can be done at the same time as scleral reinforcement as long as two adja cent muscles are not operated on. Resection-recession of medial and lateral rectiis muscles have been successful. Sur gery on the inferior oblique muscle is not desirable, however, because this muscle keeps the strip in place. In many cases cryosurgery to areas of peripheral degeneration after placement of the strip is beneficial because small open operculated retinal breaks have been detected and treated during the sur gery, which were not visible on the pre operative examination (either because of poor patient cooperation, especially in younger patients, or poor visibility, or both). We believe this maneuver may have prevented retinal detachments in our cases.
DECEMBER, 1978 RESULTS
The ultimate value of the procedure can be finally evaluated only after careful clinical comparison of a large number of patients, treated and untreated, over a long follow-up period (20 to 40 years). The first patients in this study have been observed from five to seven years (Table). For those not lost to follow-up, the vision in almost all cases has remained at the level at which surgery was performed, or it has improved. In one case (Case 6) the patient suffered a macular hemorrhage two years after surgery similar to the hemorrhage seen in high myopia. The patient was treated with argon laser, and the condition stabilized. This patient had no increase in staphyloma. In some cases eyes were operated on at a lower level of myopia than the guideline indicates. These patients, however, showed posterior staphyloma, severe macular deterioration, or fluorescein angiography changes compatible with a higher degree of myopia. These changes were sometimes inexplicably seen at lower levels of myopia than were ex pected. DISCUSSION
Since the original description by Borley and Snyder 2,3 of the use of a scleral homograft to preserve vision, and the subse quent report by Borley and Miller, 4 the popularity of the procedure seems to have waned in the United States. It is, howev er, being performed by an increasing number of surgeons outside of the United States. Bulyaev and Ilyina 5 used both fascial (eight cases) and scleral homografts in 102 cases, with good results. Fydorov (personal communication, June 1977) used our technique 1 in 150 cases, obtaining a 98.1% effectiveness with no serious complications. Reasons for the unpopularity of this procedure in the United States may be (1) the difficulty in selecting patients who
oo
-11.25
6/9 (20/30) 6/7.5 (20/25) 6/15 (20/50) 6/21 (20/70)
6/15 (20/50) 6/7.5 (20/25) 6/24 (20/80) 6/24 (20/80)
4/11/73
3/3/72
12/11/74
7, M, 50
8, M, 33
(Table
-13.00
6/60 (20/200)
6/15 (20/50)
2/6/74
36
-21.50 - 16.50 continued on next page.)
62
48
60
52
64
38
No record
- 12.00
-16.00
-5.50
-6.75
51
54
60
66
3
7
80
84
Follow-up (mos)
-17.50
- 17.50
-17.00
-5.75
-7.00
-11.00
No recent refraction No recent refraction
-10.00
-9.00 - 12.50
-12.50
-9.75
2/18/72
6, F , 40
1/21/72
3/16/73
12/6/72
12/17/71
11/1/71
1/12/73
5, M, 63
4, M, 55
3, F , 21
6/7.5 (20/25) 6/45 (20/150)
-21.00
-21.00
6/7.5 (20/25) 6/30 (20/100)
-21.00
-21.50
6/12 (20/40) 6/12 (20/40)
6/12 (20/40) 6/12 (20/40)
6/18 (20/60) 6/9 (20/30)
-11.00
-10.50
Post operative -11.00
Myopia
-11.00
6/9 (20/30) 6/9 (20/30)
6/12 (20/40) 6/9 (20/30)
6/60 (20/200) 6/12 (20/40)
Preoperative
6/6 (20/20) 6/6 (20/20)
4/2/71
12/15/70
Post operative
Preoperative
Visual Acuity
C F 7 ft. 6/12 (20/40)
2, M, 8
6/26/70
1, M, 47
11/4/70
Date of Surgery
Patient No., Sex, Age (yrs)
TABLE R E S U L T S O F SCLERAL R E I N F O R C E M E N T SURGERY O N 52 E Y E S *
Surgery done elsewhere Developed postoperative choroidal hemorrhage
None
None
Retinal edema and hemorrhages in 1974 treated with argon laser
None
None
None
None
None
Laser to L.E. 1973 (retinal tear)
None
None
Patient had bilateral cataract Cataract surgery in 1976 (+2.75) (+3.00)
Pertinent Information
oo
6/7.5 (20/25) 6/18 (20/60) 6/12 (20/40) 6/6 (20/20) 6/12 (20/40) 6/7.5 (20/25) 6/24 (20/80) 6/60 (20/200) 6/9 (20/30) 6/15 (20/50)
6/60 (20/200) 6/21 (20/70) 6/9 (20/30) 6/9 (20/30) 6/15 (20/50) 6/9 (20/30) 6/15 (20/50) 6/120 (20/400) 6/18 (20/60) 6/12 (20/40)
1/7/76
2/4/76
5/4/76
8/18/72
14, F , 63
15, F , 61
16, M, 5
17, F , 31
1/26/73
12/3/75
12/18/75
7/10/75
8/27/75
6/17/75
6/12 (20/40)
6/18 (20/60)
8/6/75
13, M, 73
12, F , 8
11, F , 6 0
6/21 (20/70)
6/60 (20/200)
5/21/75
10, F , 60
6/12 (20/40)
6/15 (20/50)
1/22/75
9, M, 10
Post operative
Visual Acuity Preoperative
Date of Surgery
Patient No., Sex, Age (yrs)
TABLE
(continued)
-16.50
-14.50
-14.00
-12.75
With another physician
-7.25
-8.75
-8.00
- 10.75
- 11.00
-20.00
-20.00
-9.00
Preoperative
-8.75
Post operative
-15.50
-15.50
-12.50
Not checked since surgery
With another physician
With another physician
-9.00
-8.00
+ 3.00 due to cataracts + 2.75 due to cataracts
Would be A+ due to aphakia Would be A+ due to aphakia
Myopia
52
57
12
15
15
15
14
19
20
22
21
24
10
Follow-up (mos)
R E S U L T S O F SCLERAL R E I N F O R C E M E N T SURGERY ON 52 E Y E S *
None
PSC cataracts both eyes
None
Cataract surgery 4/26/77
None
PSC cataract R.E.
None
None
Cataract surgery 2/19/76 Cataract surgery 3/1/76
Cataract surgery 1975
Cataract surgery 1976
None
Pertinent Information
~4 00
6/15 (20/50) 6/9 (20/30) 6/9 (20/30) 6/15 (20/50) 6/12 (20/40) 6/9 (20/30) 6/9 (20/30) 6/7.5 (20/25) 6/45 (20/150) 6/12 (20/40) 6/12 (20/40)
6/9 (20/30) 6/18 (20/60) 6/18 (20/60) 6/18 (20/60) 6/15 (20/50) 6/18 (20/60) 6/18 (20/60) 6/9 (20/30) 6/60 (20/200) 6/18 (20/60) 6/12 (20/40)
7/20/73
1/15/74
4/3/74
6/19/74
6/8/76
22, F , 28
23, M, 13
24, F , 18
25, F , 75
21, M, 7
20, F , 13
19, M, 21
12/2/73
7/19/73
7/19/73
6/13/73
9/26/73
4/20/73
6/15 (20/50)
6/18 (20/60)
2/2/73
18, F , 12
Post operative
Date of Surgery
Preoperative
Patient No., Sex, Age (yrs)
TABLE
(continued)
-12.25
No refraction since surgery
(Table continued on next page.)
Would be A+ due to aphakia
-12.50
-11.25
-10.50
-7.75
-7.50 - 10.25
-10.50
-12.50
-8.75
-12.25
- 15.00
-15.00
-15.25 -15.00
-15.50
-11.50
-11.00
Post operative
-16.00
-12.75
- 11.00
Preoperative
10
32
4
28
45
40
22
23
20
25
46
51
Follow-up (mos)
R E S U L T S O F SCLERAL R E I N F O R C E M E N T SURGERY O N 52 E Y E S *
Cataract surgery before scleral surgery
None
None
None
None
None
None
None
None
None
None
None
Pertinent Information
00
-a
TABLE
(continued)
-12.50
- 15.50 -13.00
6/21 (20/70)
6/18 (20/60) 6/60 (20/200) 6/9 (20/30)
6/60 (20/200)
6/18 (20/60)
6/60 (20/200)
6/12 (20/40)
6/22/77
8/31/77
9/13/77
32, F , 75
33, M, 44
*PSC designates posterior subcapsular cataract.
6/15/77
-18.25
Temporary glasses
6/30 (20/100)
6/60 (20/200)
5/3/77
4/19/77 -20.00
-20.00
6/120 (20/400) 6/45 20/150
CF6ft 6/45 20/150
2/22/77
31, M, 34
30, F , 72
29, F , 35
- 15.50
Temporary glasses
No refraction
No refraction
No refraction
-20.00
6/9 (20/30)
1
3
1
1
3
6
None
Dense PSC cataract
None
Cataract surgery 1977 Now aphakic
PSC cataracts and preoperative esotropia PSC cataracts and preoperative esotropia
None
None
6/21 (20/70)
8/17/76
6
-25.00
6/9 (20/30)
6/15 (20/50) No refraction
None
2
-11.00
8/12/76
28, F , 44
11/2/76
Cataract surgery 4/13/73
Pertinent Information
None
17
Follow-up (mos)
7
6/21 (20/70) 6/7.5 (20/25)
6/30/76
27, M, 38
Post operative
-12.00
-7.50
6/7.5 (20/25)
6/60 (20/200)
11/1/72
26, F , 54
Myopia
6/15 (20/50) 6/7.5 (20/25)
Preoperative
Post operative
Preoperative
Date of Surgery
Patient No., Sex, Age (yrs)
Visulal Acuity
R E S U L T S O F SCLERAL R E I N F O R C E M E N T SURGERY O N 52 E Y E S *
VOL. 86, NO. 6
SCLERAL REINFORCEMENT
* * * ! Fig. 3 (Thompson). Fluorescein angiogram of the eye illustrating a severe posterior staphyloma and deterioration of choroid and retina (too late for scleral reinforcement).
require surgery; (2) concern over serious complications; and (3) a general misun derstanding of the objective of the sur gery. Patient selection—Since most near sighted patients stop progressing at the —5.00 to —7.00 diopter range and do not progress into the range of high myopia
789
(-9.00 or greater) or malignant myopia, most myopic patients do not require sur gery. In degenerative myopia there is de terioration of the connective tissue of the globe with fewer and thinner scleral fi bers. The end result of the process is severe posterior staphyloma with choroidal and retinal deterioration (Fig. 3). The patient for whom surgery is most necessary is the individual over 20 years of age, in whom (1) the myopia is greater than - 1 0 . 0 0 diopters and the vision is decreasing (Fig. 4, left); (2) a posterior staphyloma is present; and (3) the macula is undergoing degenerative changes ob served either directly or by fluorescein angiography (Fig. 4, right). In the patient 55 to 60 years of age or older, the degree of myopia does not usually increase rap idly. However, there is frequently a marked deterioration of the retina and choroid over the staphyloma, which is probably secondary to the more pro nounced vascular changes in this age group. Surgery may also be indicated for the younger patient under 20 years of age with (1) myopia greater than - 1 2 . 0 0 to — 13.00 and a yearly increase in the myopia of greater than —2.00 diopters
-k
Fig. 4 (Thompson). Left, Fluorescein angiogram of deterioration around macula taken two months prior to scleral reinforcement. Right, Fluorescein angiogram taken five years after operation showing little change in macular deterioration and maintenance of good visual acuity.
790
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 5 (Thompson). Fluorescein angiogram taken four years after operation revealing no increase in the previously noted loss of pigment epithelium and lacquer cracks in macula with maintenance of im proved vision.
DECEMBER, 1978
capsule must be meticulously carried out to prevent later scarring. Surgical objectives—Many patients and surgeons still view the scleral rein forcement as a method of decreasing the degree of myopia. The objective of the procedure is to strengthen the sclera over the posterior pole to prevent further staphylomatous changes, and increase the circulation by stopping the progressive thinning of the choroid. Although visual improvement may be dramatic in some cases (as from counting fingers to 6/6 (20/20) in patient No. 3), the thrust of surgery is toward stopping the degenerative process, rather than revers ing it (Fig. 5). One can, therefore, realisti cally expect only to stop the process at the point at which surgery is performed, thus making early surgery in younger patients more desirable. SUMMARY
(Fig. 5); (2) a posterior staphyloma; and (3) even if the present vision is good, with no observable fluorescein changes (this contradicts previous reports in which sur gery was believed not to be indicated until demonstrable changes in vision had occurred). The objective of the surgery, however, is to prevent further visual loss (without necessarily improving present vision). Serious complications—In the present study, and in the cases reported by Fydorov and Bulyaev and Ilyvina, 5 the incidents of serious complications have been near zero. There have been cases of severe conjunctival edema, transient mus cle imbalance, subconjunctival hemor rhages, and the like, but no complication effecting visual acuity or ocular function. Permanent muscle imbalance can be produced by the malposition of the strip, as was the case in one patient in whom the strip was incorrectly positioned in relation to the inferior oblique muscle, necessitating a reoperation. Additionally, the stripping of the muscles of their check ligaments and attachments to Tenon's
A simplified scleral reinforcement tech nique performed on 52 eyes with myopic degeneration prevented further visual loss by strengthening of the sclera over the posterior pole. This scleral homograft was useful not only in older patients with high myopia and posterior staphyloma, but also in younger patients in whom the degenerative process could be stopped at an earlier stage. In all cases in which follow-up was possible, the visual acuity remained at the preoperative level before surgery was performed or it improved. REFERENCES 1. Snyder, A. A, and Thompson, F. B.: A simpli fied technique for surgical treatment of degenerative myopia. Am. J. Ophthalmol. 74:273, 1972. 2. Borley, W. E., and Snyder, A. A.: Surgical treatment of degenerative myopia. Combined lamel lar scleral reinforcement using donor eye. Trans. Pac. Coast Otoophthalmol. Soc. 275, 1958. 3. : Surgical treatment of high myopia. Trans. Am. Acad. Ophthalmol. Otolaryngol. 62:791, 1958. 4. Miller, W., and Borley, W. E.: Surgical treat ment of degenerative myopia. Scleral reinforcement. Am. J. Ophthalmol. 57:796, 1964. 5. Bulyaev, V. S., and Ilyina, T. S.: Late results of scleroplasty in surgical treatment of progressive myopia. Eye Ear Nose Throat Mon. 54:109, 1975.
In the past eight years I have operated on 52 eyes for myopic degeneration by using the simplified reinforcement tech nique. In ten cases, the operation was preceded or followed by cataract extrac tion, without complications. In two cases, reoperation was necessary because a scleral strip had been incorrectly placed during previous surgery. The follow-up time extended from one month to seven years. M A T E R I A L AND M E T H O D S
The type and size of scleral graft have been described previously. 1 I obtained two grafts from each donor eye by con touring the grafts posteriorly from the cornea on either side of the optic nerve in a curvilinear pattern. This procedure dou bled the amount of material available, and took less time to perform. Whole donor eyes were used because it was necessary to include the corneal tis sue to obtain a sufficient length, as the myopic eyes requiring reinforcement needed all the donor tissue available. I attempted to use eyes from which the cornea or corneoscleral button had been removed, by taking a spiral graft from anterior to posterior. However, these grafts were difficult to place and keep flat against the globe, because they did not follow the normal contour of the eyeball. Eye bank specimens that have been kept refrigerated under sterile conditions, but which are slightly too old for use as corneal grafting material, may be used. Since the scleral graft is only for rein forcement and does not depend on the From the Department of Ophthalmology, Univer sity of Southern California School of Medicine, Los Angeles, California. Reprint requests to Frank B. Thompson, M.D., 206 E. Los Tunas Ave., San Gabriel, CA 91776. 782
M.D.
California
viability of cellular structure, specimens can be seven to eight days old. The specific details of placement were described previously, 1 but some changes have evolved (Fig. 1). No canthotomy is generally necessary even on Oriental eyes, which have much smaller palpebral fissures and tighter eyelids. However, if visibility of the strip posteriorly is a prob lem, a canthotomy should be performed because accurate placement of the strip is crucial. Placement of the strip over the posteri or pole was made easier by using an instrument I made by bending the tip of a flat iris repositor in a stair-step fashion, and then curving the instrument to fit the contour of the globe (Fig. 2). The cottontipped applicator used previously for placement would frequently pull the strip forward as it was withdrawn; the shaped tip of the new instrument held the strip in place. In those cases where the muscle was divided into two strips, it was important that the strip be placed in back of both bundles of the inferior oblique muscle. The oblique tendon must not be split. When this occurs a reoperation is neces sary. The inferior oblique muscle was the key to the entire operation, because the insertion of this muscle held the strip over the macula without suturing. The dissection was done so as to avoid tearing of the vortex veins, both to prevent choroidal edema and hemorrhage and to fa cilitate surgery because an actively bleed ing vortex vein is difficult to control and makes posterior visibility extremely diffi cult. When the strip was in position and the inferior oblique muscle was released from its traction suture, an anectine drip
AMERICAN JOURNAL O F OPHTHALMOLOGY 86:782-790, 1978
VOL. 86, NO. 6
SCLERAL REINFORCEMENT
783
AT RECTUS
2r<=>t=r*='>^c^J*-vss3a: INF RECTUS
Fig. 1 (Thompson). Placement of a scleral homograft in the right eye. A, View from above showing graft placement nasal to the superior oblique muscle insertion. B, Posterior view showing graft held over macular area by insertion of inferior oblique muscle. C, View from below showing insertion of strip nasal to inferior rectus muscle insertion. D, Donor eye showing scleral grafts being dissected and including corneal tissue to obtain sufficient length.
Fig. 2 (Thompson). Instrument for placement of strip over posterior pole. A, View showing curves of repositor to fit the contour of the globe. B, Larger view showing stair-step bend in tip. C, Magnified view of the tip. D, View of the opposite uncurved end of iris repositor.
was started on the patient to contract the extraocular muscles and pull the strip in place. Instead of the 4-0 polyester fiber su tures used to fix the strip superiorly and inferiorly, 5-0 chromic collagen sutures were used. The polyester sutures re mained indefinitely, but occasionally, they extruded or caused postoperative in flammation. By the time the collagen su tures were absorbed, the strip was firmly fixed to the underlying sclera. It was not necessary to dissect a scleral bed for the strip.
784
AMERICAN JOURNAL OF OPHTHALMOLOGY
If further ocular surgery was anticipat ed, then minor modifications in the tech nique were necessary. In many cases, scleral reinforcement has been performed on patients with fairly dense cataracts. As long as the posterior pole and periphery of the retina were apparent with the indi rect ophthalmoscope, the scleral rein forcement was done first, followed by the cataract surgery, because the loss of visu al acuity from macular deterioration was usually permanent and irreversible, whereas the loss of vision from the cata ract was reversible. The myopia surgery, therefore, takes precedence. When cata ract surgery was anticipated after scle ral reinforcement, the superior conjunctival incision was placed as posterior as possible (4 to 5 mm) so as not to disturb the limbal area if a limbal-based flap was used in the cataract technique. Because the routine detachment of extraocular muscles for visualization of the posterior portion of the globe is not necessary, anterior segment necrosis is not a complication. In the occasional case where muscle surgery is needed for a preoperative strabismus, the muscle sur gery can be done at the same time as scleral reinforcement as long as two adja cent muscles are not operated on. Resection-recession of medial and lateral rectiis muscles have been successful. Sur gery on the inferior oblique muscle is not desirable, however, because this muscle keeps the strip in place. In many cases cryosurgery to areas of peripheral degeneration after placement of the strip is beneficial because small open operculated retinal breaks have been detected and treated during the sur gery, which were not visible on the pre operative examination (either because of poor patient cooperation, especially in younger patients, or poor visibility, or both). We believe this maneuver may have prevented retinal detachments in our cases.
DECEMBER, 1978 RESULTS
The ultimate value of the procedure can be finally evaluated only after careful clinical comparison of a large number of patients, treated and untreated, over a long follow-up period (20 to 40 years). The first patients in this study have been observed from five to seven years (Table). For those not lost to follow-up, the vision in almost all cases has remained at the level at which surgery was performed, or it has improved. In one case (Case 6) the patient suffered a macular hemorrhage two years after surgery similar to the hemorrhage seen in high myopia. The patient was treated with argon laser, and the condition stabilized. This patient had no increase in staphyloma. In some cases eyes were operated on at a lower level of myopia than the guideline indicates. These patients, however, showed posterior staphyloma, severe macular deterioration, or fluorescein angiography changes compatible with a higher degree of myopia. These changes were sometimes inexplicably seen at lower levels of myopia than were ex pected. DISCUSSION
Since the original description by Borley and Snyder 2,3 of the use of a scleral homograft to preserve vision, and the subse quent report by Borley and Miller, 4 the popularity of the procedure seems to have waned in the United States. It is, howev er, being performed by an increasing number of surgeons outside of the United States. Bulyaev and Ilyina 5 used both fascial (eight cases) and scleral homografts in 102 cases, with good results. Fydorov (personal communication, June 1977) used our technique 1 in 150 cases, obtaining a 98.1% effectiveness with no serious complications. Reasons for the unpopularity of this procedure in the United States may be (1) the difficulty in selecting patients who
oo
-11.25
6/9 (20/30) 6/7.5 (20/25) 6/15 (20/50) 6/21 (20/70)
6/15 (20/50) 6/7.5 (20/25) 6/24 (20/80) 6/24 (20/80)
4/11/73
3/3/72
12/11/74
7, M, 50
8, M, 33
(Table
-13.00
6/60 (20/200)
6/15 (20/50)
2/6/74
36
-21.50 - 16.50 continued on next page.)
62
48
60
52
64
38
No record
- 12.00
-16.00
-5.50
-6.75
51
54
60
66
3
7
80
84
Follow-up (mos)
-17.50
- 17.50
-17.00
-5.75
-7.00
-11.00
No recent refraction No recent refraction
-10.00
-9.00 - 12.50
-12.50
-9.75
2/18/72
6, F , 40
1/21/72
3/16/73
12/6/72
12/17/71
11/1/71
1/12/73
5, M, 63
4, M, 55
3, F , 21
6/7.5 (20/25) 6/45 (20/150)
-21.00
-21.00
6/7.5 (20/25) 6/30 (20/100)
-21.00
-21.50
6/12 (20/40) 6/12 (20/40)
6/12 (20/40) 6/12 (20/40)
6/18 (20/60) 6/9 (20/30)
-11.00
-10.50
Post operative -11.00
Myopia
-11.00
6/9 (20/30) 6/9 (20/30)
6/12 (20/40) 6/9 (20/30)
6/60 (20/200) 6/12 (20/40)
Preoperative
6/6 (20/20) 6/6 (20/20)
4/2/71
12/15/70
Post operative
Preoperative
Visual Acuity
C F 7 ft. 6/12 (20/40)
2, M, 8
6/26/70
1, M, 47
11/4/70
Date of Surgery
Patient No., Sex, Age (yrs)
TABLE R E S U L T S O F SCLERAL R E I N F O R C E M E N T SURGERY O N 52 E Y E S *
Surgery done elsewhere Developed postoperative choroidal hemorrhage
None
None
Retinal edema and hemorrhages in 1974 treated with argon laser
None
None
None
None
None
Laser to L.E. 1973 (retinal tear)
None
None
Patient had bilateral cataract Cataract surgery in 1976 (+2.75) (+3.00)
Pertinent Information
oo
6/7.5 (20/25) 6/18 (20/60) 6/12 (20/40) 6/6 (20/20) 6/12 (20/40) 6/7.5 (20/25) 6/24 (20/80) 6/60 (20/200) 6/9 (20/30) 6/15 (20/50)
6/60 (20/200) 6/21 (20/70) 6/9 (20/30) 6/9 (20/30) 6/15 (20/50) 6/9 (20/30) 6/15 (20/50) 6/120 (20/400) 6/18 (20/60) 6/12 (20/40)
1/7/76
2/4/76
5/4/76
8/18/72
14, F , 63
15, F , 61
16, M, 5
17, F , 31
1/26/73
12/3/75
12/18/75
7/10/75
8/27/75
6/17/75
6/12 (20/40)
6/18 (20/60)
8/6/75
13, M, 73
12, F , 8
11, F , 6 0
6/21 (20/70)
6/60 (20/200)
5/21/75
10, F , 60
6/12 (20/40)
6/15 (20/50)
1/22/75
9, M, 10
Post operative
Visual Acuity Preoperative
Date of Surgery
Patient No., Sex, Age (yrs)
TABLE
(continued)
-16.50
-14.50
-14.00
-12.75
With another physician
-7.25
-8.75
-8.00
- 10.75
- 11.00
-20.00
-20.00
-9.00
Preoperative
-8.75
Post operative
-15.50
-15.50
-12.50
Not checked since surgery
With another physician
With another physician
-9.00
-8.00
+ 3.00 due to cataracts + 2.75 due to cataracts
Would be A+ due to aphakia Would be A+ due to aphakia
Myopia
52
57
12
15
15
15
14
19
20
22
21
24
10
Follow-up (mos)
R E S U L T S O F SCLERAL R E I N F O R C E M E N T SURGERY ON 52 E Y E S *
None
PSC cataracts both eyes
None
Cataract surgery 4/26/77
None
PSC cataract R.E.
None
None
Cataract surgery 2/19/76 Cataract surgery 3/1/76
Cataract surgery 1975
Cataract surgery 1976
None
Pertinent Information
~4 00
6/15 (20/50) 6/9 (20/30) 6/9 (20/30) 6/15 (20/50) 6/12 (20/40) 6/9 (20/30) 6/9 (20/30) 6/7.5 (20/25) 6/45 (20/150) 6/12 (20/40) 6/12 (20/40)
6/9 (20/30) 6/18 (20/60) 6/18 (20/60) 6/18 (20/60) 6/15 (20/50) 6/18 (20/60) 6/18 (20/60) 6/9 (20/30) 6/60 (20/200) 6/18 (20/60) 6/12 (20/40)
7/20/73
1/15/74
4/3/74
6/19/74
6/8/76
22, F , 28
23, M, 13
24, F , 18
25, F , 75
21, M, 7
20, F , 13
19, M, 21
12/2/73
7/19/73
7/19/73
6/13/73
9/26/73
4/20/73
6/15 (20/50)
6/18 (20/60)
2/2/73
18, F , 12
Post operative
Date of Surgery
Preoperative
Patient No., Sex, Age (yrs)
TABLE
(continued)
-12.25
No refraction since surgery
(Table continued on next page.)
Would be A+ due to aphakia
-12.50
-11.25
-10.50
-7.75
-7.50 - 10.25
-10.50
-12.50
-8.75
-12.25
- 15.00
-15.00
-15.25 -15.00
-15.50
-11.50
-11.00
Post operative
-16.00
-12.75
- 11.00
Preoperative
10
32
4
28
45
40
22
23
20
25
46
51
Follow-up (mos)
R E S U L T S O F SCLERAL R E I N F O R C E M E N T SURGERY O N 52 E Y E S *
Cataract surgery before scleral surgery
None
None
None
None
None
None
None
None
None
None
None
Pertinent Information
00
-a
TABLE
(continued)
-12.50
- 15.50 -13.00
6/21 (20/70)
6/18 (20/60) 6/60 (20/200) 6/9 (20/30)
6/60 (20/200)
6/18 (20/60)
6/60 (20/200)
6/12 (20/40)
6/22/77
8/31/77
9/13/77
32, F , 75
33, M, 44
*PSC designates posterior subcapsular cataract.
6/15/77
-18.25
Temporary glasses
6/30 (20/100)
6/60 (20/200)
5/3/77
4/19/77 -20.00
-20.00
6/120 (20/400) 6/45 20/150
CF6ft 6/45 20/150
2/22/77
31, M, 34
30, F , 72
29, F , 35
- 15.50
Temporary glasses
No refraction
No refraction
No refraction
-20.00
6/9 (20/30)
1
3
1
1
3
6
None
Dense PSC cataract
None
Cataract surgery 1977 Now aphakic
PSC cataracts and preoperative esotropia PSC cataracts and preoperative esotropia
None
None
6/21 (20/70)
8/17/76
6
-25.00
6/9 (20/30)
6/15 (20/50) No refraction
None
2
-11.00
8/12/76
28, F , 44
11/2/76
Cataract surgery 4/13/73
Pertinent Information
None
17
Follow-up (mos)
7
6/21 (20/70) 6/7.5 (20/25)
6/30/76
27, M, 38
Post operative
-12.00
-7.50
6/7.5 (20/25)
6/60 (20/200)
11/1/72
26, F , 54
Myopia
6/15 (20/50) 6/7.5 (20/25)
Preoperative
Post operative
Preoperative
Date of Surgery
Patient No., Sex, Age (yrs)
Visulal Acuity
R E S U L T S O F SCLERAL R E I N F O R C E M E N T SURGERY O N 52 E Y E S *
VOL. 86, NO. 6
SCLERAL REINFORCEMENT
* * * ! Fig. 3 (Thompson). Fluorescein angiogram of the eye illustrating a severe posterior staphyloma and deterioration of choroid and retina (too late for scleral reinforcement).
require surgery; (2) concern over serious complications; and (3) a general misun derstanding of the objective of the sur gery. Patient selection—Since most near sighted patients stop progressing at the —5.00 to —7.00 diopter range and do not progress into the range of high myopia
789
(-9.00 or greater) or malignant myopia, most myopic patients do not require sur gery. In degenerative myopia there is de terioration of the connective tissue of the globe with fewer and thinner scleral fi bers. The end result of the process is severe posterior staphyloma with choroidal and retinal deterioration (Fig. 3). The patient for whom surgery is most necessary is the individual over 20 years of age, in whom (1) the myopia is greater than - 1 0 . 0 0 diopters and the vision is decreasing (Fig. 4, left); (2) a posterior staphyloma is present; and (3) the macula is undergoing degenerative changes ob served either directly or by fluorescein angiography (Fig. 4, right). In the patient 55 to 60 years of age or older, the degree of myopia does not usually increase rap idly. However, there is frequently a marked deterioration of the retina and choroid over the staphyloma, which is probably secondary to the more pro nounced vascular changes in this age group. Surgery may also be indicated for the younger patient under 20 years of age with (1) myopia greater than - 1 2 . 0 0 to — 13.00 and a yearly increase in the myopia of greater than —2.00 diopters
-k
Fig. 4 (Thompson). Left, Fluorescein angiogram of deterioration around macula taken two months prior to scleral reinforcement. Right, Fluorescein angiogram taken five years after operation showing little change in macular deterioration and maintenance of good visual acuity.
790
AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 5 (Thompson). Fluorescein angiogram taken four years after operation revealing no increase in the previously noted loss of pigment epithelium and lacquer cracks in macula with maintenance of im proved vision.
DECEMBER, 1978
capsule must be meticulously carried out to prevent later scarring. Surgical objectives—Many patients and surgeons still view the scleral rein forcement as a method of decreasing the degree of myopia. The objective of the procedure is to strengthen the sclera over the posterior pole to prevent further staphylomatous changes, and increase the circulation by stopping the progressive thinning of the choroid. Although visual improvement may be dramatic in some cases (as from counting fingers to 6/6 (20/20) in patient No. 3), the thrust of surgery is toward stopping the degenerative process, rather than revers ing it (Fig. 5). One can, therefore, realisti cally expect only to stop the process at the point at which surgery is performed, thus making early surgery in younger patients more desirable. SUMMARY
(Fig. 5); (2) a posterior staphyloma; and (3) even if the present vision is good, with no observable fluorescein changes (this contradicts previous reports in which sur gery was believed not to be indicated until demonstrable changes in vision had occurred). The objective of the surgery, however, is to prevent further visual loss (without necessarily improving present vision). Serious complications—In the present study, and in the cases reported by Fydorov and Bulyaev and Ilyvina, 5 the incidents of serious complications have been near zero. There have been cases of severe conjunctival edema, transient mus cle imbalance, subconjunctival hemor rhages, and the like, but no complication effecting visual acuity or ocular function. Permanent muscle imbalance can be produced by the malposition of the strip, as was the case in one patient in whom the strip was incorrectly positioned in relation to the inferior oblique muscle, necessitating a reoperation. Additionally, the stripping of the muscles of their check ligaments and attachments to Tenon's
A simplified scleral reinforcement tech nique performed on 52 eyes with myopic degeneration prevented further visual loss by strengthening of the sclera over the posterior pole. This scleral homograft was useful not only in older patients with high myopia and posterior staphyloma, but also in younger patients in whom the degenerative process could be stopped at an earlier stage. In all cases in which follow-up was possible, the visual acuity remained at the preoperative level before surgery was performed or it improved. REFERENCES 1. Snyder, A. A, and Thompson, F. B.: A simpli fied technique for surgical treatment of degenerative myopia. Am. J. Ophthalmol. 74:273, 1972. 2. Borley, W. E., and Snyder, A. A.: Surgical treatment of degenerative myopia. Combined lamel lar scleral reinforcement using donor eye. Trans. Pac. Coast Otoophthalmol. Soc. 275, 1958. 3. : Surgical treatment of high myopia. Trans. Am. Acad. Ophthalmol. Otolaryngol. 62:791, 1958. 4. Miller, W., and Borley, W. E.: Surgical treat ment of degenerative myopia. Scleral reinforcement. Am. J. Ophthalmol. 57:796, 1964. 5. Bulyaev, V. S., and Ilyina, T. S.: Late results of scleroplasty in surgical treatment of progressive myopia. Eye Ear Nose Throat Mon. 54:109, 1975.