- Email: [email protected]
Brooklyn Ophthalymological Society
476
SOCIETY PROCEEDINGS
PARTICIPANTS
Mansour F. Armaly, M.D., associate pro fessor of ophthalmology, State University of Iowa, College of Medicine, Iowa City, Iowa. Elmer J. Ballintine, M.D., assistant clin ical professor of ophthalmology, Western Reserve University, Cleveland, Ohio. Ernst Bârâny, M.D., professor of phar macology, University of Uppsala, Uppsala, Sweden. Bernard Becker, M.D., professor of oph thalmology, Washington University School of Medicine, St. Louis, Missouri. Sjoerd L. Bonting, Ph.D., Ophthalmol ogy Branch, National Institute of Neuro logical Diseases and Blindness, Bethesda, Maryland. David F. Cole, Ph.D., Institute of Oph thalmology, University of London, London, England. Marguerite A. Constant, Ph.D., associate professor of ophthalmology, Washington University School of Medicine, St. Louis, Missouri. Hans Goldmann, M.D., professor of oph thalmology, University Eye Clinic, Bern, Switzerland. W. Morton Grant, M.D., associate pro fessor of ophthalmology, Harvard Univer sity Medical School, Boston, Massachusetts. V. Everett Kinsey, Ph.D., professor of ophthalmic biochemistry, Kresge Eye Insti tute, Detroit, Michigan. Peter C. Kronfeld, M.D., professor of opthalmology, University of Illinois College of Medicine, Chicago, Illinois. Carl Kupfer, M.D., instructor in oph thalmology, Harvard University Medical School, Boston, Massachusetts. Maurice E. Langham, Ph.D., associate professor of ophthalmology, Johns Hopkins University Medical School, Baltimore, Maryland. Irving H. Leopold, M.D., professor of ophthalmology, Graduate School of Medi cine, University of Pennsylvania, Phila delphia, Pennsylvania.
Ralph Z. Levene, M.D., assistant profes sor of ophthalmology, New York Univer sity School of Medicine, New York, New York. Frank J. Macri, Ph.D., head, Pharma cology Section, Ophthalmology Branch, National Institute of Neurological Diseases and Blindness, Bethesda, Maryland. Thomas H. Maren, M.D., professor of pharmacology and therapeutics, University of Florida College of Medicine, Gainesville, Florida. D. Venkat Reddy, Ph.D., associate pro fessor of ophthalmic biochemistry, Kresge Eye Institute, Detroit, Michigan. Bernard Schwartz, M.D., Ph.D., assistant professor of ophthalmology, State Univer sity of New York, Brooklyn, New York. Marvin L. Sears, M.D., assistant profes sor of surgery, Yale School of Medicine, New Haven, Connecticut. Robert N. Shaffer, M.D., clinical pro fessor of ophthalmology, University of California School of Medicine, San Fran cisco, California. George K. Smelser, M.D., professor of anatomy, College of Physicians and Sur geons of Columbia University, New York, New York. Lorenz E. Zimmerman, M.D., chief, Oph thalmic Pathology Branch, Armed Forces Institute of Pathology, Washington, D.C. Recorder. Earle H. McBain, M.D., assist ant clinical professor of ophthalmology, University of California School of Medi cine, San Francisco, California. BROOKLYN OPHTHALMOLOGICAL SOCIETY March 26, 1962 SURGERY OF GLAUCOMA
H. SAUL SUGAR, M.D., Detroit, consid
ered three of the four classes of operations used in the surgical treatment of the adult primary glaucomas: (1) the iridectomy, con cerned with freedom of the chamber angle
SOCIETY PROCEEDINGS drainage channels in angle-closure glau coma; (2) the externally fistulizing opera tions; (3) cyclodialysis. The fourth class, cyclodiathermy, was not considered. 1. Iridectomy is used to prevent or re lieve pupil block and angle-closure glaucoma when no significant permanent angle block is present. The most significant factor in the ease of performance of this operation is the use of an incision which is perpendicular to the sclerolimbus. If the incision is bevelled, it becomes necessary to enter the anterior chamber with forceps, making possible com plications much more likely. Location of the incision in the upper temporal quadrant makes it easier to do any necessary future filtering operation nasally, still leaving the temporal area without a filtering bleb, should future cataract surgery ever be necessary. A study of 84 eyes in which peripheral iridec tomy was performed was reviewed. 2. Filtering operations. Iridencleisis. The factors which determine why one particular iridencleisis operation will result in continu ous aqueous outflow through the new chan nel while another does not depends, at least to a large extent, on the following factors: a. The angle of the incision in relation to the scierai or limbal plane. The use of a keratome is associated with a bevelled inci sion which promotes self-closure of the wound since the intraocular pressure itself tends to press the posterior lip against the anterior one. A perpendicular incision avoids this disadvantage. b. Increasing the length of the incision, up to about four mm., tends to decrease the pressure of the lips against the included iris. c. Double pillar incarceration tends to hold the scierai lips apart better than a sin gle one if the pillars are jammed into the ends of the linear wound. d. An intact pigment epithelium on the incarcerated iris helps to prevent adhesions and closure of the fistula. Cautery sclerectomy. This operation, de scribed by Scheie in this country, has been widely used. In principle it does not differ
477
from other forms of sclerolimbal excision. A review of a series of 24 cases performed at two Detroit Hospitals indicated a percentage of success of 65. A review of the anterior chamber reformation was possible in 20 cases. Of these, 16 were flat for an average of 3.7 days (range 1-10days). The impression from this small series was that the operation is as sociated with a slightly greater incidence of flat chamber and early hypotony than other procedures. Trephination. Recently, Sugar has de scribed the limboscleral trephination, a modi fication of the original method of Fergus and Elliot. This procedure avoids the dan ger of conjunctival buttonholing and the thin portion of the bleb which is probably responsible for the high incidence of late in fection following the standard corneoscleral trephination of Elliot. The results in a series of over 50 cases, observed nip to two years, appear to justify its use wherever sclerec tomy is the desired operation. Cyclodialysis. Recently, Maumenee and Chandler have suggested that hypotony, at least in some cases, is due to hyposecretion of aqueous as a result of detachment of the anterior portion of the ciliary body and that the normalization of intraocular pressure after cyclodialysis is due to the same proc ess. Clinical and, especially, experimental ex periences in animals tend to refute this. In a series of six rabbit eyes and 16 cat eyes aqueous was transferred from the an terior chamber to the suprachoroidal space under general anesthesia and the changes in intraocular pressure were observed. It was found that presence of separation of the ciliary body and choroid does not, per se, cause hypotony except when accidental per foration of the choroid co-exists. These and other clinical observations on choroidal hem orrhage during retinal detachment surgery fit the theory that there is a rapid absorption of fluid from the subretinal and supracho roidal spaces into the choroidal vessels. In cases of cyclodialysis this is suggested clin ically by the fact that even with hypotony
SOCIETY PROCEEDINGS
478
sudden closure of the cleft raises the intra ocular pressure almost immediately to its preoperative level. Cylodialysis in dogs shows the typical choroidal separation ex tending all around the globe, especially over the ciliary body. This area of aqueous out flow is yet to be explored.
APPLANATION TONOMETRY MILES A. GALIN, M.D., New York: Ap planation tonometry although reducing er rors caused by ocular rigidity has not elimi nated them. Data was presented indicating that applanation measurements obtained from patients in the supine position may significantly differ from similar measure ments obtained in the erect position. Con sequently, calculations of rigidity although of dubious quantitative significance should be obtained with patients in similar posi tions. This is readily carried out by adapting the applanation tonometer for use on pa tients in the supine position by removing the front grill of the Haag-Streit slitlamp. In this manner an applanation and Schi^tz reading are obtained with patients in essen tially identical positions and estimates of oc ular rigidity become more meaningful.
CLINICAL MANAGEMENT OF GLAUCOMA
BERNARD
SCHWARTZ,
M.D.,
Brooklyn:
One of the main diagnostic indications for tonography is for the diagnosis of chronic simple (open-angle) glaucoma by the use of tonography combined with a water provoca tive test. For angle-closure glaucoma tonog raphy combined with the mydriatic or dark room test will again establish a diagnosis in terms of a drop in the "C" value in the pres ence of a negative or borderline rise of pres sure. Similarly the main indications for to nography in the management of glaucoma appear primarily for chronic simple glau coma in the establishment of a Po/C ratio below 100. Once the tensions have been nor malized then the use of tonography on medi cation will indicate whether the Po/C ratio is adequate and whether the medication should be increased or maintained at the same level. By maintenance of an adequate Po/C ratio, prevention and delay of future field loss can be obtained. In angle-closure glaucoma tonography will indicate whether a peripheral iridectomy or filtering proced ure is required on the basis of an adequate outflow. A. Benedict Rizzuti, Recording Secretary.
OPHTHALMIC MINIATURE
Dr. B. Alex Randall wished to add his testimony to the importance of treating with alternatives the cases of incipient cataract, as he had seen many cases of prompt cessation of all advance in the cataractous process, which had before seemed rapidly progressive. Opacities are generally first and most markedly seen down and in, because this is the worst part of the choroid, being the most exposed to excess of light. Tr. Ophth. Section, A.M.A., 1891, p. 102.
SOCIETY PROCEEDINGS
PARTICIPANTS
Mansour F. Armaly, M.D., associate pro fessor of ophthalmology, State University of Iowa, College of Medicine, Iowa City, Iowa. Elmer J. Ballintine, M.D., assistant clin ical professor of ophthalmology, Western Reserve University, Cleveland, Ohio. Ernst Bârâny, M.D., professor of phar macology, University of Uppsala, Uppsala, Sweden. Bernard Becker, M.D., professor of oph thalmology, Washington University School of Medicine, St. Louis, Missouri. Sjoerd L. Bonting, Ph.D., Ophthalmol ogy Branch, National Institute of Neuro logical Diseases and Blindness, Bethesda, Maryland. David F. Cole, Ph.D., Institute of Oph thalmology, University of London, London, England. Marguerite A. Constant, Ph.D., associate professor of ophthalmology, Washington University School of Medicine, St. Louis, Missouri. Hans Goldmann, M.D., professor of oph thalmology, University Eye Clinic, Bern, Switzerland. W. Morton Grant, M.D., associate pro fessor of ophthalmology, Harvard Univer sity Medical School, Boston, Massachusetts. V. Everett Kinsey, Ph.D., professor of ophthalmic biochemistry, Kresge Eye Insti tute, Detroit, Michigan. Peter C. Kronfeld, M.D., professor of opthalmology, University of Illinois College of Medicine, Chicago, Illinois. Carl Kupfer, M.D., instructor in oph thalmology, Harvard University Medical School, Boston, Massachusetts. Maurice E. Langham, Ph.D., associate professor of ophthalmology, Johns Hopkins University Medical School, Baltimore, Maryland. Irving H. Leopold, M.D., professor of ophthalmology, Graduate School of Medi cine, University of Pennsylvania, Phila delphia, Pennsylvania.
Ralph Z. Levene, M.D., assistant profes sor of ophthalmology, New York Univer sity School of Medicine, New York, New York. Frank J. Macri, Ph.D., head, Pharma cology Section, Ophthalmology Branch, National Institute of Neurological Diseases and Blindness, Bethesda, Maryland. Thomas H. Maren, M.D., professor of pharmacology and therapeutics, University of Florida College of Medicine, Gainesville, Florida. D. Venkat Reddy, Ph.D., associate pro fessor of ophthalmic biochemistry, Kresge Eye Institute, Detroit, Michigan. Bernard Schwartz, M.D., Ph.D., assistant professor of ophthalmology, State Univer sity of New York, Brooklyn, New York. Marvin L. Sears, M.D., assistant profes sor of surgery, Yale School of Medicine, New Haven, Connecticut. Robert N. Shaffer, M.D., clinical pro fessor of ophthalmology, University of California School of Medicine, San Fran cisco, California. George K. Smelser, M.D., professor of anatomy, College of Physicians and Sur geons of Columbia University, New York, New York. Lorenz E. Zimmerman, M.D., chief, Oph thalmic Pathology Branch, Armed Forces Institute of Pathology, Washington, D.C. Recorder. Earle H. McBain, M.D., assist ant clinical professor of ophthalmology, University of California School of Medi cine, San Francisco, California. BROOKLYN OPHTHALMOLOGICAL SOCIETY March 26, 1962 SURGERY OF GLAUCOMA
H. SAUL SUGAR, M.D., Detroit, consid
ered three of the four classes of operations used in the surgical treatment of the adult primary glaucomas: (1) the iridectomy, con cerned with freedom of the chamber angle
SOCIETY PROCEEDINGS drainage channels in angle-closure glau coma; (2) the externally fistulizing opera tions; (3) cyclodialysis. The fourth class, cyclodiathermy, was not considered. 1. Iridectomy is used to prevent or re lieve pupil block and angle-closure glaucoma when no significant permanent angle block is present. The most significant factor in the ease of performance of this operation is the use of an incision which is perpendicular to the sclerolimbus. If the incision is bevelled, it becomes necessary to enter the anterior chamber with forceps, making possible com plications much more likely. Location of the incision in the upper temporal quadrant makes it easier to do any necessary future filtering operation nasally, still leaving the temporal area without a filtering bleb, should future cataract surgery ever be necessary. A study of 84 eyes in which peripheral iridec tomy was performed was reviewed. 2. Filtering operations. Iridencleisis. The factors which determine why one particular iridencleisis operation will result in continu ous aqueous outflow through the new chan nel while another does not depends, at least to a large extent, on the following factors: a. The angle of the incision in relation to the scierai or limbal plane. The use of a keratome is associated with a bevelled inci sion which promotes self-closure of the wound since the intraocular pressure itself tends to press the posterior lip against the anterior one. A perpendicular incision avoids this disadvantage. b. Increasing the length of the incision, up to about four mm., tends to decrease the pressure of the lips against the included iris. c. Double pillar incarceration tends to hold the scierai lips apart better than a sin gle one if the pillars are jammed into the ends of the linear wound. d. An intact pigment epithelium on the incarcerated iris helps to prevent adhesions and closure of the fistula. Cautery sclerectomy. This operation, de scribed by Scheie in this country, has been widely used. In principle it does not differ
477
from other forms of sclerolimbal excision. A review of a series of 24 cases performed at two Detroit Hospitals indicated a percentage of success of 65. A review of the anterior chamber reformation was possible in 20 cases. Of these, 16 were flat for an average of 3.7 days (range 1-10days). The impression from this small series was that the operation is as sociated with a slightly greater incidence of flat chamber and early hypotony than other procedures. Trephination. Recently, Sugar has de scribed the limboscleral trephination, a modi fication of the original method of Fergus and Elliot. This procedure avoids the dan ger of conjunctival buttonholing and the thin portion of the bleb which is probably responsible for the high incidence of late in fection following the standard corneoscleral trephination of Elliot. The results in a series of over 50 cases, observed nip to two years, appear to justify its use wherever sclerec tomy is the desired operation. Cyclodialysis. Recently, Maumenee and Chandler have suggested that hypotony, at least in some cases, is due to hyposecretion of aqueous as a result of detachment of the anterior portion of the ciliary body and that the normalization of intraocular pressure after cyclodialysis is due to the same proc ess. Clinical and, especially, experimental ex periences in animals tend to refute this. In a series of six rabbit eyes and 16 cat eyes aqueous was transferred from the an terior chamber to the suprachoroidal space under general anesthesia and the changes in intraocular pressure were observed. It was found that presence of separation of the ciliary body and choroid does not, per se, cause hypotony except when accidental per foration of the choroid co-exists. These and other clinical observations on choroidal hem orrhage during retinal detachment surgery fit the theory that there is a rapid absorption of fluid from the subretinal and supracho roidal spaces into the choroidal vessels. In cases of cyclodialysis this is suggested clin ically by the fact that even with hypotony
SOCIETY PROCEEDINGS
478
sudden closure of the cleft raises the intra ocular pressure almost immediately to its preoperative level. Cylodialysis in dogs shows the typical choroidal separation ex tending all around the globe, especially over the ciliary body. This area of aqueous out flow is yet to be explored.
APPLANATION TONOMETRY MILES A. GALIN, M.D., New York: Ap planation tonometry although reducing er rors caused by ocular rigidity has not elimi nated them. Data was presented indicating that applanation measurements obtained from patients in the supine position may significantly differ from similar measure ments obtained in the erect position. Con sequently, calculations of rigidity although of dubious quantitative significance should be obtained with patients in similar posi tions. This is readily carried out by adapting the applanation tonometer for use on pa tients in the supine position by removing the front grill of the Haag-Streit slitlamp. In this manner an applanation and Schi^tz reading are obtained with patients in essen tially identical positions and estimates of oc ular rigidity become more meaningful.
CLINICAL MANAGEMENT OF GLAUCOMA
BERNARD
SCHWARTZ,
M.D.,
Brooklyn:
One of the main diagnostic indications for tonography is for the diagnosis of chronic simple (open-angle) glaucoma by the use of tonography combined with a water provoca tive test. For angle-closure glaucoma tonog raphy combined with the mydriatic or dark room test will again establish a diagnosis in terms of a drop in the "C" value in the pres ence of a negative or borderline rise of pres sure. Similarly the main indications for to nography in the management of glaucoma appear primarily for chronic simple glau coma in the establishment of a Po/C ratio below 100. Once the tensions have been nor malized then the use of tonography on medi cation will indicate whether the Po/C ratio is adequate and whether the medication should be increased or maintained at the same level. By maintenance of an adequate Po/C ratio, prevention and delay of future field loss can be obtained. In angle-closure glaucoma tonography will indicate whether a peripheral iridectomy or filtering proced ure is required on the basis of an adequate outflow. A. Benedict Rizzuti, Recording Secretary.
OPHTHALMIC MINIATURE
Dr. B. Alex Randall wished to add his testimony to the importance of treating with alternatives the cases of incipient cataract, as he had seen many cases of prompt cessation of all advance in the cataractous process, which had before seemed rapidly progressive. Opacities are generally first and most markedly seen down and in, because this is the worst part of the choroid, being the most exposed to excess of light. Tr. Ophth. Section, A.M.A., 1891, p. 102.