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Cataract Extraction Following Iridencleisis*
258
F. M. KAPETANSKY, T. SUIE, A. D. GRACY AND J. L. BITONTE SUMMARY
1. Potentially pathogenic organisms were found in 35 percent of individuals wearing contact lenses, either in their cul-de-sac, carrying cases or wetting and soaking solu tions. 2. The pathogens most frequently recov ered were those with the ability to produce corneal lesions which progress rapidly and are extremely destructive. These include Staphylococci, Streptococci, Pseudomonas,
Klebsiella, as well as yeasts and fungi. 3. The prescribed length of wearing time did not change the microflora qualitatively; however, the incidence of pathogens recov ered rose sharply in patients who had worn contact lenses for six months or more. 4. Precautions which may prevent ocular infections in contact lens wearers are out lined. 410 West 10th Avenue
(10).
REFERENCES
1. Suie, T., et al.: Bacterial corneal ulcers: With special reference to those caused by Proteus vulgaris. Am. J. Ophth., 48:775, 1959. 2. Vaughan, O. G.: Corneal ulcers. Survey Ophth., 3:203, 1958. 3. Dixon, J. M., Lawaczeck, E., and Winkler, C. H.: Pseudomonas contamination of contact lens con tainers: Preliminary report. Am. J. Ophth., 54:461, 1962. 4. Fitzgerald, J. R., Kapustiak, W., and McCarthy, J. L.: Contact lens corneal ulcer. Am. J. Ophth., 54: 307, 1962. 5. Suie, T., and Havener, W. H.: Mycology of the eye. Am. J. Ophth., 56:63, 1963. 6. Allen, H. F.: To wet or not to wet. AMA Arch Ophth., 67:25, 1962.
CATARACT EXTRACTION FOLLOWING IRIDENCLEISIS* ELTON YASUNA,
M.D.
Worcester, Massachusetts Iridencleisis filtration for open-angle glau coma has been the most popular approach in the United States during the past genera tion. With the prolongation of life expect ancy an increasing number of patients who have had filtering operations now present themselves with cataracts. Nano and his co-workers1 believe that 35 percent of patients with fistulizing surgery develop central nuclear cataracts which pro gress to cortical involvement. Arruga 2 states that the frequency of lens opacities is the same in eyes which have or do not have fil tering procedure. He feels the process fol lows the same slow course, beginning in the nucleus. Arruga further states: "The existence of a filtering scar is no obstacle to cataract ex traction through the same site, and some col* From the Departments of Ophthalmology, Tufts Medical School and Worcester City Hospital.
leagues even pass the cataract knife through the scar. However, a corneal section may be performed, so the filtering scar is not touched." Cataract development may follow one of three courses following iridencleisis : 1. Immediately following surgery. This is due to lens damage incurred during the op eration. 2. Within several months postoperatively. In these instances an incipient or partial cataract existed and showed rapid develop ment following surgery. 3. Delayed formation occurring after many years. These patients may be following their normal pattern of cataract formation or per haps the ocular metabolism has been dis turbed by the glaucoma surgery. If the cataract surgery in patients with functioning blebs is performed by the classi cal route, the superior limbal incision will
259
CATARACT EXTRACTION AFTER IRIDENCLEISIS
cut through the filtering area. Theoretically this would destroy the bleb and return the eye to a state of glaucoma. Therefore, a host of approaches have been described3"13 to avoid the filtering area. Incisions have been recommended either above or below the bleb. Both of these pro cedures create difficulties in the cataract ex traction and assume that the filtration will be undisturbed. In a further attempt to avoid the site of glaucoma surgery, incisions have been de scribed in the lateral or inferior portions of . the limbus. This too adds difficulty to the cataract procedure and creates iridectomies not coyered by the upper lid. Variations have been reported, such as doing a limbal incision on each side of the bleb but cut ting a keyhole below the areas of filtration. This procedure would cause cornea healing to be considerably irregular. The problem which has not been fully solved is what happens to the pressure of an eye if the filtering bleb is opened by a cata ract incision. If the ocular tension main tains its same level, there is no need to change the technique in cataract surgery. During the past nine years a series of 26 eyes in 20 patients had cataract surgery fol lowing previous iridencleisis. In all instances 53 32 31 30 29
htì I
li'i
I Î [ I 1 1 I ' ■! I 1 1 I
Y
1 I 1 I ! I I
ΤΓΤΤΓΓ779ΤΤΓΓΓΠΤΤΓΪΪ Chart 1 (Yasuna). Ocular tension range preceding and following cataract surgery. . . . Preoperative ocular tensions. Postoperative ocular tensions.
Λ · of eues
7 6 5
* Ï 21 0 1 jrr (or loos)
1-» jre
5-8 jr«
o r « 8 jr».
Chart 2 (Yasuna). Interval between iridencleisis and cataract extraction.
the cataract incision was performed through the site of the filtering bleb. ANALYSIS OF CASES
Age and sex. The patients ranged in age from 54 to 72 years. Sixteen of the 26 eyes were in women. Ocular tension preceding cataract surgery (chart 1). In all but two instances the ocu lar tension, was controlled except for occa sional elevation. Various antiglaucomatous drugs were used in some patients in order to accomplish full control. No cases of hypotony were experienced. Interval between iridencleisis and cataract extraction (chart 2 ) . This interval varied between four months and 18 years. In 16 of the 26 cases the interval was five years or longer. In six patients the time interval was less than two years, suggesting that a pre existing cataract had become exacerbated by the glaucoma surgery. There were no in stances of "immediate" cataract formation, such as within a four-week interval. Ocular tension following cataract surgery (Chart 1). The follow-up period ranged be tween four months and nine years. Eighteen of the 26 eyes were observed for four years or longer. Four cases had follow-up for less than one year.
ELTON YASUNA
260
The glaucoma in all patients could be con trolled (below 24 mm. Kg), although two of the patients showed definite elevations on occasions. Some required antiglaucoma med ication. In 18 eyes (70 percent) the ocular ten sion was somewhat lower than the preopera tive levels. Three eyes (12 percent) had higher pressures than previously, while the remaining five eyes were unchanged. DISCUSSION
This study of 26 glaucomatous eyes in 20 patients with existing filtering blebs from iridencleisis was of individuals with openangle glaucoma. This was confirmed by gonioscopy in most cases. Early in the series it was hoped that the ocular tension levels would not be disturbed when cataract extraction incisions were per formed through the filtering bleb. Actually the tension levels were reduced in 70 per cent of the patients and increased in only 12 percent. This improvement in ocular ten sion could be explained by the removal of the lens and subsequent deepening of the anterior chamber. Varying amounts of antiglaucoma medica tion, such as local miotics, epinephrine bi chloride and oral carbonic anhydrase in hibitors were required in some patients. This was true both before and after the cataract extractions. The technique of the cataract extraction was classical except for a few modifications. Tract sutures were used but none were placed through the site of the filtering bleb. A tract suture was inserted on each side of the bleb and two additional postplaced su tures were inserted peripherally, one on each side. In some instances the iridencleisis had been combined with sclerectomy which resulted in the scierai tissue adjacent to the bleb being rather friable. This finding would make suture placement difficult. It was necessary to free posterior synechiae. This was done gently with an iris re-
positor and presented no problem. A "full iridectomy" result was obtained since the original iridencleisis had cut through the iris sphincter. In general the cataract extractions were easily performed. The zonules seemed to be weaker than usual. Alpha chymotrypsin was not used and is not recommended in these cases. The conjunctival flap was fornix based. A varying amount of careful dissection had to be performed because of the previous sur gery at this site. In some eyes the conjunc tival dissection presented a minor problem since the tissue elasticity had been dimin ished or lost. Individual variations had to be' employed in order to obtain a satisfactory conjunctival flap over the wound. The most surprising result was the con tinuation of the filtering bleb after the cata ract surgeiy. This is best explained by the fact that a certain amount of scar tissue had formed about the bleb during the years of filtration. With careful point-to-point clo sure, such as is obtained by tract sutures, the anatomy of the bleb is maintained even though the cataract incision went through the site. Also, no suture was placed through the bleb and therefore the area was not flattened. Complications consisted of vitre ous loss in one eye and mild endothelial clouding in two other eyes. One other finding should be mentioned. In some patients the aphakic vision ob tained was considerably greater than had been anticipated. During the years of ob servation between the iridencleisis and the cataract extraction, the pupils usually were small and the amount of nuclear opacity was not fully appreciated. The slow but relent less diminution of vision was accepted by both the patient and the ophthalmologist. CONCLUSIONS
1. After iridencleisis, cataract extraction incisions can be performed through the fil tering bleb.
CATARACT EXTRACTION AFTER IRIDENU.EISIS 2. Ocular tensions were lower in 70 per cent of eyes after cataract extraction per formed in this manner. 3. This technique is simple and safe.
261
4. Careful, anatomically accurate wound closure makes possible the continuing func tion of the filtering bleb. 507 Main Street (8).
REFERENCES
1. Nano, H., Pagano, R., and Beraza, H.: A method of extraction of cataracts after fistulizing opera tions. Sem. Med., 117:359-364 (Aug.) 1960. 2. Arruga, H. : Ocular Surgery. New York, McGraw-Hill, 1952. 3. Scheie, H. G., and Muirhead, F. J.: Cataract extraction after filtering operations. AMA Arch. Ophth., 68:37-41 (July) 1962. 4. Scheie, H. G.: A method of cataract extraction following filtering operations for glaucoma. 55:818, 1956. 5. Magdalena, J.: Cataract extraction by the lateral route. Arch. Soc. Oftal. hispano-am., 21:398-402 (May) 1961. 6. Weekers, R., and Pivont, A.: Extraction of cataract after fistulizing antiglaucomatous operations. Arch, opht., 20:252-264 (Apr.-May) 1960. 7. Fry, W. E.: Proceedings N.Y. Soc. Clin. Ophth., Am. J. Ophth., 47:250 (Feb.) 1959. 8. Rizzutti, A. B.: Cataract following glaucoma surgery. Am. J. Ophth., 47:548-556 (Apr.) 1959. 9. McPherson, S. D., and Fisher, G. W.: Results of cataract extraction following filtering operations for glaucoma. Southern M.J., 51:99-102 (Jan.) 1958. 10. Rizzutti, A. B.: Cataract extraction following fistulizing glaucoma operations. Acta XVII Cone. Ophth. 1954, 3:1831,1955. 11. Agarwal, L. P.: Cataract extraction after postplaced valvular iridencleisis. Ophthalmologica, 135: 91-94 (Feb.) 1958. 12. Fitzgerald, R. A., and McCarthy, J. L.: Surgery of the filtering bleb. AMA Arch. Ophth., 68:453467 (Oct.) 1962. 13. Callahan, A.: Surgery of the Eye. Springfield, 111., Charles C Thomas, 1956, p. 287.
HISTOPATHOLOGIC FINDINGS FOLLOWING SCLERAL
BUCKLING*
I N A N EYE 18 DAYS AFTER A C I R C L I N G - B U C K L I N G OPERATION W I T H P O L Y E T H Y L E N E T U B E W I T H PARTICULAR REFERENCE TO T H E AREA W H E R E T H E P O L Y E T H Y L E N E T U B E I N D E N T E D UNRESECTED A N D U N D I A T H E R M I Z E D SCLERA W A L T E R K O R N B L U E T H , M.D.,
A L B E R T B E H A R , M.D.,
AND C H . ZAUBERMAN,
M.D.
Jerusalem, Israel T h e reports dealing with the histologiec findings following scierai buckling opera itions with a polyethylene tube pay little at ttention to the pathologic findings over thee area of scierai indentation where no lamellarr resection or diathermy applications were 'e performed. 1 ' 2 Only one report describes the ie histologie changes in rabbit eyes following g partial buckling with a polyethylene tube, in n r an area of lamellar scierai resection. 3 It seemed, therefore, interesting to investigate :e id * From the Departments of Ophthalmology and sPathology, Rothschild-Hadassah University Hos pital.
the histologie changes caused by pressure of the polyethylene tube on the "undisturbed" sclera in a case of retinal detachment where a successful scierai buckling operation had been performed. C A S E REPORT
H. C, a 48-year-old man suffering from myopia, was admitted to hospital because of retinal detachment of the right eye. One month prior to his admission he had been hit on the right side of his head. At the time of admission the ophthalmologic examinations revealed: Right eye. The visual acuity was finger counting at the distance of half a meter. The cornea was clear, but the lens showed a small posterior polar
F. M. KAPETANSKY, T. SUIE, A. D. GRACY AND J. L. BITONTE SUMMARY
1. Potentially pathogenic organisms were found in 35 percent of individuals wearing contact lenses, either in their cul-de-sac, carrying cases or wetting and soaking solu tions. 2. The pathogens most frequently recov ered were those with the ability to produce corneal lesions which progress rapidly and are extremely destructive. These include Staphylococci, Streptococci, Pseudomonas,
Klebsiella, as well as yeasts and fungi. 3. The prescribed length of wearing time did not change the microflora qualitatively; however, the incidence of pathogens recov ered rose sharply in patients who had worn contact lenses for six months or more. 4. Precautions which may prevent ocular infections in contact lens wearers are out lined. 410 West 10th Avenue
(10).
REFERENCES
1. Suie, T., et al.: Bacterial corneal ulcers: With special reference to those caused by Proteus vulgaris. Am. J. Ophth., 48:775, 1959. 2. Vaughan, O. G.: Corneal ulcers. Survey Ophth., 3:203, 1958. 3. Dixon, J. M., Lawaczeck, E., and Winkler, C. H.: Pseudomonas contamination of contact lens con tainers: Preliminary report. Am. J. Ophth., 54:461, 1962. 4. Fitzgerald, J. R., Kapustiak, W., and McCarthy, J. L.: Contact lens corneal ulcer. Am. J. Ophth., 54: 307, 1962. 5. Suie, T., and Havener, W. H.: Mycology of the eye. Am. J. Ophth., 56:63, 1963. 6. Allen, H. F.: To wet or not to wet. AMA Arch Ophth., 67:25, 1962.
CATARACT EXTRACTION FOLLOWING IRIDENCLEISIS* ELTON YASUNA,
M.D.
Worcester, Massachusetts Iridencleisis filtration for open-angle glau coma has been the most popular approach in the United States during the past genera tion. With the prolongation of life expect ancy an increasing number of patients who have had filtering operations now present themselves with cataracts. Nano and his co-workers1 believe that 35 percent of patients with fistulizing surgery develop central nuclear cataracts which pro gress to cortical involvement. Arruga 2 states that the frequency of lens opacities is the same in eyes which have or do not have fil tering procedure. He feels the process fol lows the same slow course, beginning in the nucleus. Arruga further states: "The existence of a filtering scar is no obstacle to cataract ex traction through the same site, and some col* From the Departments of Ophthalmology, Tufts Medical School and Worcester City Hospital.
leagues even pass the cataract knife through the scar. However, a corneal section may be performed, so the filtering scar is not touched." Cataract development may follow one of three courses following iridencleisis : 1. Immediately following surgery. This is due to lens damage incurred during the op eration. 2. Within several months postoperatively. In these instances an incipient or partial cataract existed and showed rapid develop ment following surgery. 3. Delayed formation occurring after many years. These patients may be following their normal pattern of cataract formation or per haps the ocular metabolism has been dis turbed by the glaucoma surgery. If the cataract surgery in patients with functioning blebs is performed by the classi cal route, the superior limbal incision will
259
CATARACT EXTRACTION AFTER IRIDENCLEISIS
cut through the filtering area. Theoretically this would destroy the bleb and return the eye to a state of glaucoma. Therefore, a host of approaches have been described3"13 to avoid the filtering area. Incisions have been recommended either above or below the bleb. Both of these pro cedures create difficulties in the cataract ex traction and assume that the filtration will be undisturbed. In a further attempt to avoid the site of glaucoma surgery, incisions have been de scribed in the lateral or inferior portions of . the limbus. This too adds difficulty to the cataract procedure and creates iridectomies not coyered by the upper lid. Variations have been reported, such as doing a limbal incision on each side of the bleb but cut ting a keyhole below the areas of filtration. This procedure would cause cornea healing to be considerably irregular. The problem which has not been fully solved is what happens to the pressure of an eye if the filtering bleb is opened by a cata ract incision. If the ocular tension main tains its same level, there is no need to change the technique in cataract surgery. During the past nine years a series of 26 eyes in 20 patients had cataract surgery fol lowing previous iridencleisis. In all instances 53 32 31 30 29
htì I
li'i
I Î [ I 1 1 I ' ■! I 1 1 I
Y
1 I 1 I ! I I
ΤΓΤΤΓΓ779ΤΤΓΓΓΠΤΤΓΪΪ Chart 1 (Yasuna). Ocular tension range preceding and following cataract surgery. . . . Preoperative ocular tensions. Postoperative ocular tensions.
Λ · of eues
7 6 5
* Ï 21 0 1 jrr (or loos)
1-» jre
5-8 jr«
o r « 8 jr».
Chart 2 (Yasuna). Interval between iridencleisis and cataract extraction.
the cataract incision was performed through the site of the filtering bleb. ANALYSIS OF CASES
Age and sex. The patients ranged in age from 54 to 72 years. Sixteen of the 26 eyes were in women. Ocular tension preceding cataract surgery (chart 1). In all but two instances the ocu lar tension, was controlled except for occa sional elevation. Various antiglaucomatous drugs were used in some patients in order to accomplish full control. No cases of hypotony were experienced. Interval between iridencleisis and cataract extraction (chart 2 ) . This interval varied between four months and 18 years. In 16 of the 26 cases the interval was five years or longer. In six patients the time interval was less than two years, suggesting that a pre existing cataract had become exacerbated by the glaucoma surgery. There were no in stances of "immediate" cataract formation, such as within a four-week interval. Ocular tension following cataract surgery (Chart 1). The follow-up period ranged be tween four months and nine years. Eighteen of the 26 eyes were observed for four years or longer. Four cases had follow-up for less than one year.
ELTON YASUNA
260
The glaucoma in all patients could be con trolled (below 24 mm. Kg), although two of the patients showed definite elevations on occasions. Some required antiglaucoma med ication. In 18 eyes (70 percent) the ocular ten sion was somewhat lower than the preopera tive levels. Three eyes (12 percent) had higher pressures than previously, while the remaining five eyes were unchanged. DISCUSSION
This study of 26 glaucomatous eyes in 20 patients with existing filtering blebs from iridencleisis was of individuals with openangle glaucoma. This was confirmed by gonioscopy in most cases. Early in the series it was hoped that the ocular tension levels would not be disturbed when cataract extraction incisions were per formed through the filtering bleb. Actually the tension levels were reduced in 70 per cent of the patients and increased in only 12 percent. This improvement in ocular ten sion could be explained by the removal of the lens and subsequent deepening of the anterior chamber. Varying amounts of antiglaucoma medica tion, such as local miotics, epinephrine bi chloride and oral carbonic anhydrase in hibitors were required in some patients. This was true both before and after the cataract extractions. The technique of the cataract extraction was classical except for a few modifications. Tract sutures were used but none were placed through the site of the filtering bleb. A tract suture was inserted on each side of the bleb and two additional postplaced su tures were inserted peripherally, one on each side. In some instances the iridencleisis had been combined with sclerectomy which resulted in the scierai tissue adjacent to the bleb being rather friable. This finding would make suture placement difficult. It was necessary to free posterior synechiae. This was done gently with an iris re-
positor and presented no problem. A "full iridectomy" result was obtained since the original iridencleisis had cut through the iris sphincter. In general the cataract extractions were easily performed. The zonules seemed to be weaker than usual. Alpha chymotrypsin was not used and is not recommended in these cases. The conjunctival flap was fornix based. A varying amount of careful dissection had to be performed because of the previous sur gery at this site. In some eyes the conjunc tival dissection presented a minor problem since the tissue elasticity had been dimin ished or lost. Individual variations had to be' employed in order to obtain a satisfactory conjunctival flap over the wound. The most surprising result was the con tinuation of the filtering bleb after the cata ract surgeiy. This is best explained by the fact that a certain amount of scar tissue had formed about the bleb during the years of filtration. With careful point-to-point clo sure, such as is obtained by tract sutures, the anatomy of the bleb is maintained even though the cataract incision went through the site. Also, no suture was placed through the bleb and therefore the area was not flattened. Complications consisted of vitre ous loss in one eye and mild endothelial clouding in two other eyes. One other finding should be mentioned. In some patients the aphakic vision ob tained was considerably greater than had been anticipated. During the years of ob servation between the iridencleisis and the cataract extraction, the pupils usually were small and the amount of nuclear opacity was not fully appreciated. The slow but relent less diminution of vision was accepted by both the patient and the ophthalmologist. CONCLUSIONS
1. After iridencleisis, cataract extraction incisions can be performed through the fil tering bleb.
CATARACT EXTRACTION AFTER IRIDENU.EISIS 2. Ocular tensions were lower in 70 per cent of eyes after cataract extraction per formed in this manner. 3. This technique is simple and safe.
261
4. Careful, anatomically accurate wound closure makes possible the continuing func tion of the filtering bleb. 507 Main Street (8).
REFERENCES
1. Nano, H., Pagano, R., and Beraza, H.: A method of extraction of cataracts after fistulizing opera tions. Sem. Med., 117:359-364 (Aug.) 1960. 2. Arruga, H. : Ocular Surgery. New York, McGraw-Hill, 1952. 3. Scheie, H. G., and Muirhead, F. J.: Cataract extraction after filtering operations. AMA Arch. Ophth., 68:37-41 (July) 1962. 4. Scheie, H. G.: A method of cataract extraction following filtering operations for glaucoma. 55:818, 1956. 5. Magdalena, J.: Cataract extraction by the lateral route. Arch. Soc. Oftal. hispano-am., 21:398-402 (May) 1961. 6. Weekers, R., and Pivont, A.: Extraction of cataract after fistulizing antiglaucomatous operations. Arch, opht., 20:252-264 (Apr.-May) 1960. 7. Fry, W. E.: Proceedings N.Y. Soc. Clin. Ophth., Am. J. Ophth., 47:250 (Feb.) 1959. 8. Rizzutti, A. B.: Cataract following glaucoma surgery. Am. J. Ophth., 47:548-556 (Apr.) 1959. 9. McPherson, S. D., and Fisher, G. W.: Results of cataract extraction following filtering operations for glaucoma. Southern M.J., 51:99-102 (Jan.) 1958. 10. Rizzutti, A. B.: Cataract extraction following fistulizing glaucoma operations. Acta XVII Cone. Ophth. 1954, 3:1831,1955. 11. Agarwal, L. P.: Cataract extraction after postplaced valvular iridencleisis. Ophthalmologica, 135: 91-94 (Feb.) 1958. 12. Fitzgerald, R. A., and McCarthy, J. L.: Surgery of the filtering bleb. AMA Arch. Ophth., 68:453467 (Oct.) 1962. 13. Callahan, A.: Surgery of the Eye. Springfield, 111., Charles C Thomas, 1956, p. 287.
HISTOPATHOLOGIC FINDINGS FOLLOWING SCLERAL
BUCKLING*
I N A N EYE 18 DAYS AFTER A C I R C L I N G - B U C K L I N G OPERATION W I T H P O L Y E T H Y L E N E T U B E W I T H PARTICULAR REFERENCE TO T H E AREA W H E R E T H E P O L Y E T H Y L E N E T U B E I N D E N T E D UNRESECTED A N D U N D I A T H E R M I Z E D SCLERA W A L T E R K O R N B L U E T H , M.D.,
A L B E R T B E H A R , M.D.,
AND C H . ZAUBERMAN,
M.D.
Jerusalem, Israel T h e reports dealing with the histologiec findings following scierai buckling opera itions with a polyethylene tube pay little at ttention to the pathologic findings over thee area of scierai indentation where no lamellarr resection or diathermy applications were 'e performed. 1 ' 2 Only one report describes the ie histologie changes in rabbit eyes following g partial buckling with a polyethylene tube, in n r an area of lamellar scierai resection. 3 It seemed, therefore, interesting to investigate :e id * From the Departments of Ophthalmology and sPathology, Rothschild-Hadassah University Hos pital.
the histologie changes caused by pressure of the polyethylene tube on the "undisturbed" sclera in a case of retinal detachment where a successful scierai buckling operation had been performed. C A S E REPORT
H. C, a 48-year-old man suffering from myopia, was admitted to hospital because of retinal detachment of the right eye. One month prior to his admission he had been hit on the right side of his head. At the time of admission the ophthalmologic examinations revealed: Right eye. The visual acuity was finger counting at the distance of half a meter. The cornea was clear, but the lens showed a small posterior polar