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Conjunctival Closure in Strabismus Surgery
750
O C T O B E R , 1968
AMERICAN JOURNAL OF O P H T H A L M O L O G Y
Fig. 3 (Gtom^T^hktra ready for use
Fig. 4 (Grom). Trephines viewed from above. Note the black lines on the tape (sterilization sign).
W e find these trephines very sharp, cheap, and easy to produce. Instituto Medico del Este Avenida Casanova
modified Snellen chart designed to equalize the perceptive areas used and to employ letters related to astigmatism is proposed. The letters are non-serif, so-called Gothic. This is a practical variation inasmuch as so many patients drive and road signs are designed with this type. Selection of letters is confined to N, Z, V , T, L, U, E and O. The first five letters comprise diverse angles. Faulty recognition of one or another of these suggests astigmatic defect. Since Z is simply N on its side, and L and T have similar correspondence, they are isometric in detection of astigmatism. An effort has been made to equalize the ratio of black and white to facilitate prompt identification. The 11 rows of letters on this chart include the complete range from 20/200 to 20/10. Figure 1 represents the 20/20 line, the eighth line on the chart. 1133 S.W. Second Avenue (33130)
C O N J U N C T I V A L CLOSURE IN S T R A B I S M U S SURGERY JOSEPH H . GOLDSTEIN, M.D. Brooklyn, New
York
CARLTON DEEDERER, M . D . Miami, Florida
In long-standing cases of large-angle strabismus and in those cases in which reoperation is necessary, it is frequently difficult to close the conjunctiva, which has become shortened. In both instances it becomes apparent that the results of surgery may be significantly reversed by closing tight the conjunctiva, thereby inducing some degree of mechanical limitation. In such cases, one may use a free conjunctival graft as described by Callahan, which requires more extensive surgery, or leave bare sclera, as
Standard eye charts for testing central visual acuity are usually printed in Gothic Boston Breton type adorned by serifs. A
From the Department of Surgery, Division of Ophthalmology, State University of New York, Downstate Medical Center.
ACKNOWLEDGEMENT I wish to thank Dr. L. Cerrolaza for his technical help.
ISOMETRIC OPHTHALMIC CHART
1
N Z V T L U
E O H
Fig. 1 (Deederer). Isometric type of letters in Line 8,20/20.
V O L . 66, N O . 4
NOTES, CASES,
INSTRUMENTS
751
Fig. 1 (Goldstein). Closure of the conjunctiva. A shows the conjunctival wound after completion of muscle surgery. Starting at the center of the distal edge of the conjunctiva, the wound is closed horizontally with a continuous mattress suture as shown in B, C, and D. One reaches a point at which it is difficult to close the wound any farther horizontally as shown in D. The remaining edges lie almost touching and one may then easily close them vertically, as shown in E.
suggested by Cole and Cole. Papolczy has SUMMARY suggested routinely closing the conjunctiva To close the conjunctiva in reoperations vertically. If the entire wound is closed in for strabismus, a T-closure is recommended. this manner, however, undermining must be Initially the wound is closed horizontally, and carried deeply into the fornices. A n alternathen vertically. tive approach, which is easy and yet effec450 Clarkson Avenue (11203) tive, is to convert the center of the wound from an oval into a T closure (fig. 1 ) . T o do REFERENCES this, one starts from the center of the wound and closes it horizontally as far as can be 1. Callahan, A. : The arrangement of the coneasily performed, at which time the vertical junctiva in surgery for oculomotor paralysis and edges are practically touching. The remain- strabismus. Arch. Opth. 66:241, 1961. 2. Cole, J. G. and Cole, H . G. : Recession of the ing margins are closed vertically. In this conjunctiva in complicated eye muscle operations. way, one may easily close the wound and yet Am. J. Ophth. 53:618, 1962. 3. Papolczy, F.: The significance of lengthening avoid traction, which tends to pull the eye of the conjunctiva in squint operations. Acta X V I I back into the position of original deviation. Concilium Ophthalmologicum (1958). 2:1670, 1959. 2
3
O C T O B E R , 1968
AMERICAN JOURNAL OF O P H T H A L M O L O G Y
Fig. 3 (Gtom^T^hktra ready for use
Fig. 4 (Grom). Trephines viewed from above. Note the black lines on the tape (sterilization sign).
W e find these trephines very sharp, cheap, and easy to produce. Instituto Medico del Este Avenida Casanova
modified Snellen chart designed to equalize the perceptive areas used and to employ letters related to astigmatism is proposed. The letters are non-serif, so-called Gothic. This is a practical variation inasmuch as so many patients drive and road signs are designed with this type. Selection of letters is confined to N, Z, V , T, L, U, E and O. The first five letters comprise diverse angles. Faulty recognition of one or another of these suggests astigmatic defect. Since Z is simply N on its side, and L and T have similar correspondence, they are isometric in detection of astigmatism. An effort has been made to equalize the ratio of black and white to facilitate prompt identification. The 11 rows of letters on this chart include the complete range from 20/200 to 20/10. Figure 1 represents the 20/20 line, the eighth line on the chart. 1133 S.W. Second Avenue (33130)
C O N J U N C T I V A L CLOSURE IN S T R A B I S M U S SURGERY JOSEPH H . GOLDSTEIN, M.D. Brooklyn, New
York
CARLTON DEEDERER, M . D . Miami, Florida
In long-standing cases of large-angle strabismus and in those cases in which reoperation is necessary, it is frequently difficult to close the conjunctiva, which has become shortened. In both instances it becomes apparent that the results of surgery may be significantly reversed by closing tight the conjunctiva, thereby inducing some degree of mechanical limitation. In such cases, one may use a free conjunctival graft as described by Callahan, which requires more extensive surgery, or leave bare sclera, as
Standard eye charts for testing central visual acuity are usually printed in Gothic Boston Breton type adorned by serifs. A
From the Department of Surgery, Division of Ophthalmology, State University of New York, Downstate Medical Center.
ACKNOWLEDGEMENT I wish to thank Dr. L. Cerrolaza for his technical help.
ISOMETRIC OPHTHALMIC CHART
1
N Z V T L U
E O H
Fig. 1 (Deederer). Isometric type of letters in Line 8,20/20.
V O L . 66, N O . 4
NOTES, CASES,
INSTRUMENTS
751
Fig. 1 (Goldstein). Closure of the conjunctiva. A shows the conjunctival wound after completion of muscle surgery. Starting at the center of the distal edge of the conjunctiva, the wound is closed horizontally with a continuous mattress suture as shown in B, C, and D. One reaches a point at which it is difficult to close the wound any farther horizontally as shown in D. The remaining edges lie almost touching and one may then easily close them vertically, as shown in E.
suggested by Cole and Cole. Papolczy has SUMMARY suggested routinely closing the conjunctiva To close the conjunctiva in reoperations vertically. If the entire wound is closed in for strabismus, a T-closure is recommended. this manner, however, undermining must be Initially the wound is closed horizontally, and carried deeply into the fornices. A n alternathen vertically. tive approach, which is easy and yet effec450 Clarkson Avenue (11203) tive, is to convert the center of the wound from an oval into a T closure (fig. 1 ) . T o do REFERENCES this, one starts from the center of the wound and closes it horizontally as far as can be 1. Callahan, A. : The arrangement of the coneasily performed, at which time the vertical junctiva in surgery for oculomotor paralysis and edges are practically touching. The remain- strabismus. Arch. Opth. 66:241, 1961. 2. Cole, J. G. and Cole, H . G. : Recession of the ing margins are closed vertically. In this conjunctiva in complicated eye muscle operations. way, one may easily close the wound and yet Am. J. Ophth. 53:618, 1962. 3. Papolczy, F.: The significance of lengthening avoid traction, which tends to pull the eye of the conjunctiva in squint operations. Acta X V I I back into the position of original deviation. Concilium Ophthalmologicum (1958). 2:1670, 1959. 2
3